Quality officers tackle pandemic throughput with discharge improvement

In early 2021, Dr. Brian Parker knew his health system was in trouble. As chief quality and learning officer at Allegheny Health Network, he and the executive team made the call in 2020 to pause several discharge-related quality improvement projects. Patient volumes had declined dramatically because of a statewide order suspending all elective procedures and surgeries.

By late 2020, elective surgeries had resumed, the hospital system was swamped by COVID-19 patients. Admitting and discharging patients as quickly as possible loomed as a threat to quality and safety. That led the Pittsburgh-based not-for-profit system to renew its readmissions prevention work.

“Once we saw what was coming—what we thought was that light at the end of the tunnel but it was a train, it was delta (variant)—that’s when we really made the determination that discharge work needed to be reinvigorated again, because we were going to have gridlock,” Parker said.

The 14-hospital system separated COVID-19 patients from the others. As the executive responsible for tracking metrics such as readmissions, Parker played a vital role in ensuring patients in hospitals for reasons other than the novel coronavirus could get appropriate, safe care.

Discharge work has always been important, because patients are flooded with information hours before going home. Once they’re on their own, how well a patient follows those directions can make or break recovery.

“Each time a patient has another (chronic obstructive pulmonary disease) or congestive heart failure exacerbation, it reduces their lung or heart function,” and that in turn creates a sicker patient who is harder to treat, said Dr. David Burwell, chief quality officer for UPMC facilities in central Pennsylvania and western Maryland. “Making sure that they continue to be successful (at home) is really important.”

Quality teams had to manage the push and pull of maximizing the discharge process to create bed space while ensuring patients went home with everything they needed to prevent them from ending up back in one of those beds.

Allegheny revamped reviews of social determinants risk profiles for patients without COVID-19 before discharge. The health system considered factors at home that could create a higher risk for readmission, such as transportation access and food insecurity. Patients were also connected with nurses two days after discharge instead of the usual seven.

ChristianaCare, a two-hospital system based in Wilmington, Delaware, already had experience with throughput issues related to stroke patients before the pandemic. When it became apparent that their standard admission criteria would result in care delays because of bed capacity, the not-for-profit system looked to the telemedicine system already used for its stroke program.

Certain patients who previously would have been admitted instead went home. ChristianaCare connects them with remote nurses and other caregivers who supervise them via at-home equipment the hospital provides. The health system hasn’t seen bumps in readmissions, post-surgical complications or infections, said Chief Medical Officer Dr. Kert Anzilotti.

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“That was a real quality and safety challenge, because we had to make sure they got their rehab, they got their physical therapy, they were going to do all those steps that they would have done as an inpatient toward the rehab,” Anzilotti said. “We really had no choice during COVID-19 but to do things differently and innovate.”

The discharge period is usually the most risky for patients, because they go from a highly controlled environment to homes or other environments without equivalent oversight. Recognizing this, UPMC’s Burwell got involved.

“It’s become even more vital to really help make sure that our patients are going to the right level of care, and safely and effectively,” Burwell said. “That transition is so significant and significantly variable that we know there are multiple areas where people can fall through the cracks.”

UPMC created a discharge readiness checklist that asks patients questions such as if they can afford new prescription medications and if they have adequate home support. Nurses also take patients’ vital signs within two hours of discharge.

Quality teams also drilled down into disease-specific reasons why patients came back.

For instance, COVID-19 patients with subsiding sepsis cases often were readmitted because of an acute kidney injury, readmission reviews found. UPMC established a protocol to give these patients gallon jugs with directions on how much water to drink and when to refill the containers. The health system has seen readmissions decline from 4.51% in 2019 to 4% in 2021 because of these targeted efforts.

Clarification: This story has been updated to reflect Allegheny Health Network's patient load as it paused discharge-related quality programs in the pandemic.