Out by noon—a winning strategy to reduce crowding, shorten stays

In early 2011, NYU Langone Medical Center aimed to get 30% of its discharged patients out the door before noon in an effort to reduce bottlenecks and ease patient flow.

One year later, discharge-before-noon rates for the New York hospital's medicine service lagged far behind that target. Discharges were delayed because test results weren't ready or transportation hadn't been arranged. Residents were behind filling out discharge orders or patients and their families hadn't received post-discharge education. Some patients just wanted to stay for lunch.

“It seemed like the moons had to be aligned to get patients out by noon,” said Dr. Katherine Hochman, director of the hospitalist program and associate chair for quality at NYU Langone. “To me, it was a marker that everyone was not on the same page.”

Discharging patients late in the day is linked to emergency-department overcrowding, longer lengths of stay and lower patient-satisfaction scores. Like 791-bed NYU Langone, many hospitals are looking at setting early discharge targets as a way to avoid gridlock and make it easier for discharged patients to access same-day services such as primary-care appointments and home health.

“Patients get home early enough so that if there are challenges, they can address them right away,” said Scott Croonquist, associate chief nursing officer of the University of Virginia Health System, Charlottesville, which undertook an early discharge initiative several years ago. “It's much better for them.”

Because discharge-before-noon rates on NYU Langone's medicine units were at or near 7%, the lowest in the hospital, Hochman and her colleagues started there. Unlike surgery, where admissions and discharges tend to follow typical schedules, medicine discharges are harder to predict. “If the medicine service could succeed at a discharge-before-noon initiative, anyone could,” she said.

Hochman and Martha Bailey, NYU Langone's manager of operational initiatives, focused their efforts on the 17th floor of Tisch Hospital, which consists of two 35-bed inpatient medical units, each led by a hospitalist. A four-week assessment found no one factor accounted for most delayed discharges.

Beginning in March 2012, Hochman and her colleagues instituted afternoon multidisciplinary rounds, used to identify patients likely to be discharged the next day. They made a checklist of all discharge-related tasks and the staff member responsible for each one. Nurses, for example, do patient education and social workers or care managers arrange at-home services.

The team also created a website with the names of patients expected to be discharged the next morning. At 4:30 p.m. each day, the site generates automated e-mails to more than 200 key staffers listing the next day's discharges and indicating barriers that need to be addressed. Updates of the list go out to the listserv at 7 p.m. and again at 7 the next morning.

“If we knew a patient was going home tomorrow and was going to need oxygen, we placed orders the day before with the DME company,” said Dr. Ramon Jacobs, the hospitalist in charge of one of the medical units.

Finally, the units instituted daily leadership meetings at 11 a.m. to identify missed opportunities in the previous day's discharges. “If there was a problem with transportation, why did it happen?” said Dr. Benjamin Wertheimer, leader of the other unit.

Within a month discharge-before-noon rates in the two units rose sharply and averaged 38% over the 13-month initiative. The average discharge time moved one hour and 31 minutes earlier in the day, from 3:43 p.m. to 2:13 p.m. Average observed/expected length of stay also fell 10% to 0.96 from 1.06.

To dispel concerns that earlier discharges would lead to more re-hospitalizations or harried patients, Hochman and Bailey measured 30-day readmission rates and patient-satisfaction scores at the beginning and end of the initiative. Readmission rates fell from 14.3% to 13.1% and scores improved on several HCAHPS measures, including discharge instructions and communication with nurses.

“I think they've done well,” said Croonquist, whose own approach to early discharges at the University of Virginia Health System served as a model for NYU Langone leaders. “Success depends so much on the culture of the hospital.”

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