Using Discharge Milestones to Avoid Hospitals 'Patient Stacking'

Imagine what happens to the domino effect if the last domino doesn’t drop. That’s exactly what happens in a hospital when a patient isn’t discharged on time.

In a recent interview with Becker’s Hospital Review, TeleTracking clinical product specialist Maria Romano, RN, outlined what can be done about this “patient stacking,” which disrupts patient flow throughout the institution, by using discharge milestones.

For one thing, hospitals should adopt a checklist of discharge milestones for the key phases of the discharge process.  Most organizations now use one broad metric – “time from physician order to actual discharge” – to measure the success of their discharge initiatives. But there are many intervals within that measurement which can be improved.

Then, they need to adopt tools which can record those milestones and display them in a transparent manner so everyone who handles the patient sees who is accountable for meeting them.  Often, it’s a test that wasn’t completed, an order that wasn’t placed, a physician who didn’t sign the patient release form, etc.  Whatever the hold-up, time-stamped milestones can help determine who caused it and why, so it can be avoided in the future.

This information can then be used to set reasonable standards for meeting each milestone within specific time constraints, so that medical providers and staff can be held to those standards. Time-stamped milestones provided in the form of a processing time analysis can help shorten those intervals and thereby the overall discharge process.

TeleTracking’s pending and confirmed discharge tool was designed for just this need. It features enhanced discharge planning notification by adding a list of milestones to be checked off as tasks are completed. The record of completion and reasons for delay are captured electronically for summary reports, which later can be used to determine root causes of discharge delay.

Configuring Hospital Discharge Milestones

Here is an example of a possible hospital discharge milestone configuration:

• Notify Patient & Family of Discharge

Ideally, the family is notified the night before the patient is to be discharged so that they may arrange to pick up the patient and provide care at home. This often over-looked step can result in delayed discharge because the family isn’t given time to make arrangements for pick up and home care.

It also can delay Discharge Teaching, which often must include the family member who may deliver post-discharge care.

After notification, the patient must be physically prepared for discharge, which can be a tremendous transition for someone who has spent an extended time in a hospital bed. A common example of discharge preparation is the removal of peripheral devices such as Foley catheters, intravenous lines, and telemetry monitors. Then the patient’s condition must be assessed without those devices.

• Secure Physician order

If a pending discharge has not been entered, the CPOE order will apply the discharge tracking milestones to this patient and subsequently complete this milestone automatically. The attending physician must write the order for discharge along with the detailed discharge instructions including medications to be delivered at home, follow-up appointments and required diagnostic testing to be completed either before discharge or on an outpatient basis.

• Complete Diagnostic Testing

Physicians may not write discharge orders if certain tests are required, or they may write the order with discharge contingent upon completed testing. If it is indicated that a specialist must see the patients before discharge, further diagnostic testing may be needed, including: Infectious disease, Cardiology, Neurology.

• Complete Patient Teaching

This can be the lengthiest part of the discharge process and will vary according to clinical specialty and/or type of diagnosis. The family needs to be present to learn home care needs, and a consult may be required for certain disease conditions.

For example, a newly diagnosed diabetic requires teaching on insulin injection administration, use of glucometer to test blood sugar, and nutritional education. Post open heart surgery in-hospital education sessions include cardiac care diet, cardiac rehab and instruction for post-discharge cardiac rehab.

• Arrange transportation

This can be problematic if the family is not available to pick up a patient until the evening, in which case a taxi voucher or ambulance service may be necessary.

• Arrange home or destination patient bed disposition

Since 70% of patient discharges are to “home,” it is important that home care needs be arranged prior to discharge, in addition to transportation needs. It is recommended that case management be the one to complete this milestone as they are typically the ones arranging the post-acute care bed or home care need.

Using Hospital Discharge Milestones Positively Impacts Entire Patient Flow Process!

The “milestones” feature was designed to positively impact the entire patient flow process by addressing overcrowding problems at both ends of the institution. By tracking discharge milestones electronically, the progress of each discharge can be automatically displayed throughout the institution for anyone with a need to know. That information is displayed in multiple TeleTracking software applications by a status bar graphic which appears directly under a discharge candidate’s room number.

By electronically charting the progress of a discharge, “milestones” helps employees along the entire patient flow continuum anticipate needs and opportunities well in advance, thus expediting the entire process.

While discharges are complex, the process can be more manageable if tasks are coordinated more efficiently between caregivers, communication barriers are eliminated and real-time actions are taken to resolve delays. Discharge Tracking Milestones streamline communications, provide valuable data for flow improvement and ensure that required tasks are completed in an orderly and timely fashion.

Ms. Romano says that even reducing a patient’s length of stay by half a day will have a domino effect and reduce the average length of stay in a hospital, leading to efficient use of space and resources.

For example, the case management department, which usually regulates patient discharges, will be able to ensure discharges are taking place on time. They will be able to fix any broken processes. Efficient patient throughputs are also beneficial for the patients themselves, particularly for elderly patients or small children. Knowing when they will be discharged can help the healing process for these groups. It is also easier for them to plan ahead and notify their families about when to pick them up.

One of the cornerstones of hospital efficiency is patient throughput. To be able to bring in more patients, hospitals need to ensure that the average length of stay at their facility isn’t unnecessarily long. Maria Romano says that to improve patient throughput, hospitals need to ensure they are treating and discharging patients in a timely manner.

Using tools that record milestones in the care a patient receives is one way to achieve efficient patient throughput. This ensures that everyone is on the same page. Hospital staff will know if a metric was reached or not, and why. Use of these tools also results in less waste, as the hospital staff will know how many beds they have for new patients, says Ms. Romano.

Are you using discharge milestones in your hospital?