For a lot of hospitalists, routinely starting rounds earlier would be OK as long as they can finish earlier. But there are some for whom this is really tough or impossible, such as those who need to take their kids to school before work each morning. Rounding early won’t do any good if the hospital doesn’t ensure test results and other information is available early.
A practice could choose to undertake an initiative as simple as the following steps to support improvements in writing most discharge orders early in the day:
- Encourage starting rounds earlier (e.g., 7 a.m.) on most days;
- Whenever possible, prepare discharge summaries the day before;
- As often as possible, write in the order section “probable discharge tomorrow” one day before planned discharges;
- Keep routine morning conferences, such as signout, as short as possible; move it to later in the day, or eliminate it entirely, if feasible; and
- If you have routine, sit-down rounds with case managers each morning, think about whether they get in the way of early-in-the-day discharges. If so, consider moving them to the afternoons, and focus on discussing the next day’s potential discharges rather than discharges for the current day.
Consider establishing targets for each of these metrics and audit performance compared with a historical baseline. For example, the goal might be that the “probable discharge tomorrow” order appears the day before discharge in 50% of hospitalist patients, and the discharge summary is prepared the day before in 30%. These things help ensure other hospital staff members realize discharge is possible or likely and can significantly reduce discharges that are a surprise to nurses and others.
There is nothing magic about the bulleted protocol above. I’m offering it as only one potential idea to improve throughput, and you might want to pursue an entirely different strategy.
The Flip Side
Two closely related issues come up when working on getting discharge orders written early in the day. The first is that some late-afternoon discharges are in reality very early discharges that might have otherwise waited until the next day. It is important to stress that not all discharge orders are written early, and that hospitalists should not hold on to patients who could be discharged late in the day and instead release them the next morning to make their statistics look better.
The other related point is that a declining length of stay and discharging early in the day begin to compete with each other at some point. From a bed management perspective, the theoretical optimal length of stay means discharging patients the moment they are ready and not waiting until the next morning. This means discharging around the clock without regard to the time of day, and that would look terrible when analyzed from the perspective of the portion of discharge orders written early in the day—not to mention it would be very unpleasant for patients asked to leave at night. So I’m not suggesting that we should be discharging patients around the clock, but I just want to point out the tension between length of stay and writing discharge orders early in the day. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospital practice management consulting firm. He is part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official SHM position.