Preparing for discharge shortly after admission to reduce length of stay

At Nemours Children's Hospital in Orlando, Fla., the daily census hovers around 75 patients. But as recently as two years ago, the hospital was frequently filling all 100 available beds.

Concerned about how crowded the hospital was, coupled with the fact that average length of stay was on the rise, hospital leaders set out to find ways to decrease the amount of time patients spent in the hospital unnecessarily.

In the summer of 2017, an interdisciplinary team of physicians, nurses, nurse navigators, nutritionists and social workers was formed. They found that 78% of discharge delays were caused by unresolved or unidentified barriers that Nemours could address. 

“That was an eye-opening moment,” said Kellie Olmstead, operational vice president of continuous improvement at Nemours. “If we do things differently, we can have an impact on this and get the patients home as soon as they are clinically ready.” 

The team opted to address the problem in the medical-surgical unit because it’s where most patients receive some  treatment. “The unit is like Grand Central Terminal, so if there is a jam there is going to be a jam everywhere else,” said Monica Nebel, nurse manager of the unit at Nemours.

The team implemented Path to Home, a process in which the barriers to a successful discharge are identified within the first few hours of admission to the unit and then addressed throughout the patient’s stay. 

The program has led to a drop in delayed discharged days in the medical-surgical unit from an average of 1.04 days in 2017 to 0.69 in December 2018. Nemours estimated the system has saved about $425,000 as a result. 

Before Path to Home, nurses and navigators didn’t ask patients or parents about barriers to successful discharge until the physician was ready to release the patient, Nebel said. That led to delays because it was during that last-minute conversation with the family when the team would discover the patient needed additional resources such as a home health referral, new equipment or transportation.

“It was decided we should ask these discharge questions, not waiting until” the physician says it’s time to go home, Nebel said. “Let’s ask these questions at the get-go.” 

Now, nurses ask the patient and their parents within the first two hours of admission about problems they may face when leaving the facility. And the questions are specific. Previously, nurses were vague with their questions, asking “Is everything OK?” or “What are your other medical needs?” 

The broad questions usually meant real barriers were missed, Nebel said. “When you are panicking or stressed out and someone asks you, ‘Do you need any help?’ Your response is usually, ‘No, I’m OK.’ It’s that question that takes you by surprise.” 

The nurses on the unit helped design the new questions, which ask about specific barriers like, “Is your medical equipment working?” Patient and family input was also gathered. 

The questions have been implemented into the electronic health record so nurses can reference them during conversations. And nurses are expected to follow up on the questions every 12 hours.

The nurses initially struggled to adopt the questions into their workflow because it was an added priority, but the fact that they created the questions helped with buy-in, Nebel said. 

“It was key to have front-line staff be part of it,” she said. 

Along with the new questions, daily rounding with the entire interdisciplinary team and parents was added to ensure discharge planning stayed top of mind. The patient’s expected discharge is mentioned as well as any problems that might lead to a discharge delay. 

Nebel said Nemours is looking into how it can implement the program beyond just the medical-surgical unit.