Using quality improvement to optimise paediatric discharge efficiency.
BACKGROUND
Bed capacity management is a critical issue facing hospital administrators, and inefficient discharges impact patient flow throughout the hospital. National recommendations include a focus on providing care that is timely and efficient, but a lack of standardised discharge criteria at our institution contributed to unpredictable discharge timing and lengthy delays. Our objective was to increase the percentage of Hospital Medicine patients discharged within 2 h of meeting criteria from 42% to 80%.


METHODS
A multidisciplinary team collaborated to develop medically appropriate discharge criteria for 11 common inpatient diagnoses. Discharge criteria were embedded into electronic medical record (EMR) order sets at admission and could be modified throughout a patient's stay. Nurses placed an EMR time-stamp to signal when patients met all discharge goals. Strategies to improve discharge timeliness emphasised completion of discharge tasks prior to meeting criteria. Interventions focused on buy-in from key team members, pharmacy process redesign, subspecialty consult timeliness and feedback to frontline staff. A P statistical process control chart assessed the impact of interventions over time. Length of stay (LOS) and readmission rates before and after implementation of process measures were compared using the Wilcoxon rank-sum test.


RESULTS
The percentage of patients discharged within 2 h significantly improved from 42% to 80% within 18 months. Patients studied had a decrease in median overall LOS (from 1.56 to 1.44 days; p=0.01), without an increase in readmission rates (4.60% to 4.21%; p=0.24). The 12-month rolling average census for the study units increased from 36.4 to 42.9, representing an 18% increase in occupancy.


CONCLUSIONS
Through standardising discharge goals and implementation of high-reliability interventions, we reduced LOS without increasing readmission rates.
Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, , Cincinnati, Ohio, USA.
Christine M
CM
White
Angela M
AM
Statile
Denise L
DL
White
Dena
D
Elkeeb
Karen
K
Tucker
Diane
D
Herzog
Stephen D
SD
Warrick
Denise M
DM
Warrick
Julie
J
Hausfeld
Amanda
A
Schondelmeyer
Pamela J
PJ
Schoettker
Pamela
P
Kiessling
Michael
M
Farrell
Uma
U
Kotagal
Frederick C
FC
Ryckman
D001509:Bed Occupancy / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data; D002648:Child; D017598:Efficiency, Organizational; D057286:Electronic Health Records; D006776:Hospitals, Pediatric / Q000458:organization & administration* / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D010348:Patient Care Team / Q000458:organization & administration / Q000592:standards / Q000706:statistics & numerical data; D010351:Patient Discharge / Q000592:standards; D010359:Patient Readmission / Q000706:statistics & numerical data; D058996:Quality Improvement / Q000458:organization & administration
Communication; Healthcare Quality Improvement; Hospital Medicine; Paediatrics; Teamwork