title: Systematic identification and management of barriers to vascular surgery patient discharge time of day.
abstract: OBJECTIVE
  Length of stay fails to completely capture the clinical and economic effects of patient progression through the phases of inpatient care, such as admission, room placement, procedures, and discharge. Delayed hospital throughput has been linked to increased time spent in the emergency department and postanesthesia care unit, delayed time to treatment, increased in-hospital mortality, decreased patient satisfaction, and lost hospital revenue. We identified barriers to vascular surgery inpatient care progression and instituted defined measures to positively impact standardized metrics.
  
  
  METHODS
  The study was divided into three periods: preintervention, "wash-in," and postintervention. During the preintervention phase, barriers to patient flow were quantified by an interdisciplinary team. Suboptimal provider communication emerged as the key barrier. An enhanced communication intervention consisting of face-to-face and mobile application-based education on key patient flow metrics, explicit discussion of individual patient barriers to progression at rounds and interdisciplinary huddles, and communication of projected discharge and potential barriers via e-mail was developed with input from all stakeholders. Following a 4-week wash-in implementation phase, data collection was repeated.
  
  
  RESULTS
  The pre- and postintervention patient cohorts accounted for 244.3 and 238.1 inpatient days, respectively. Both groups had similar baseline demographic, clinical characteristics, and procedures performed during hospitalization. The postintervention group was discharged 78 minutes earlier (14:00:32 vs 15:18:37; P = .03) with a trend toward increased discharge by noon (94% vs 88%; P = .09). Readmission rates did not differ (P = .44).
  
  
  CONCLUSIONS
  Implementation of a focused, interdisciplinary, frontline provider-driven, enhanced communication program can be feasibly incorporated into existing specialty surgical workflow. The program resulted in improved timeliness of discharge and projected cost savings, without increasing readmission rates.
authors.affiliation: Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass.
authors.forename: Gaurav
authors.initials: G
authors.lastname: Sharma
authors.affiliation: Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass.
authors.forename: Danny
authors.initials: D
authors.lastname: Wong
authors.affiliation: Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass.
authors.forename: Dean J
authors.initials: DJ
authors.lastname: Arnaoutakis
authors.affiliation: Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass.
authors.forename: Samir K
authors.initials: SK
authors.lastname: Shah
authors.affiliation: Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass.
authors.forename: Alice
authors.initials: A
authors.lastname: O'Brien
authors.affiliation: Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass.
authors.forename: Stanley W
authors.initials: SW
authors.lastname: Ashley
authors.affiliation: Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass. Electronic address: ckozaki@partners.org.
authors.forename: C Keith
authors.initials: CK
authors.lastname: Ozaki
mesh_terms: D000046:Academic Medical Centers; D000368:Aged; D000369:Aged, 80 and over; D001900:Boston; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D019033:Delivery of Health Care, Integrated / Q000191:economics / Q000458:organization & administration; D017598:Efficiency, Organizational; D005240:Feasibility Studies; D005260:Female; D006302:Health Services Research; D017721:Hospital Costs; D006801:Humans; D033183:Interdisciplinary Communication; D007902:Length of Stay / Q000191:economics; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team / Q000191:economics / Q000458:organization & administration; D010351:Patient Discharge / Q000191:economics; D010359:Patient Readmission; D010865:Pilot Projects; D015397:Program Evaluation; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000191:economics / Q000458:organization & administration; D057188:Workflow