O2164: Decreasing Time to Discharge for Hospital Medicine Patients

Purpose/Objectives: Our site is a free-standing children’s hospital with 44 med/surg beds. When bed capacity is limited discharges from med/surg can be a bottle neck for patient flow. The discharge process is complex, and we found there was often a large gap between when a patient was medically ready for discharge until they were able to physically leave the hospital. Our objective was to increase the percentage of patients with discharge orders within 4 hours of being medically ready from 52% to 67% from June 2023 to February 2025.

Design/Methods: We formed a multidisciplinary team including physicians, nursing, pharmacy, case management, and respiratory within our unit and utilized the DMAIC system of Quality Improvement to develop an intervention. Based on root cause analysis, the most impactful barriers to discharge orders being placed within 4 hours were: provider still needing to round, provider unaware the patient has met discharge criteria, and the patient sleeping/being ready overnight. Based on these barriers, we used planned sequential interventions including providers placing discharge orders before or during morning rounds and placing conditional discharge orders before end of day shift. Medical readiness was defined as the patient meeting discharge criteria agreed upon during family centered rounding. We utilized an i-chart and standard rules for special cause deviation to assess for improvement over time. We used MiniTab to run a two-proportion test on the baseline and post intervention data to confirm a statistically significant improvement.

Results: After our interventions, our baseline time between medically ready and discharged decreased from a mean of 510 minutes to 207 minutes with less variability (Figure 1). In our baseline data, 52% of patients reviewed had a discharge order placed within four hours of being medically ready. Post-intervention this increased to 86% (p=0.001). There was no increase in ED visits or readmissions in the post-intervention group (Table 1). Our minimum time to order placement decreased from –2 minutes to –349 minutes, indicating increased use of conditional discharge orders. Our median dropped by over 2.5 hours. Our standard deviation decreased from 432 minutes to 209 minutes indicating a statistically significant decrease in process variability. Additionally, we found that decreasing the time to order placement coincided with an increase in the percentage of patients out the door within 6 hours of being medically ready from 56% to 86% (Figure 1).

Conclusion/Discussion: The project team was able to take processes utilized by our most efficient providers and standardize them across the group to improve discharge efficiency. Barriers to implementation include difficulty of measuring and documentation of medical readiness, provider autonomy, and control over workflow.