A Tricky Proposition
It is pretty easy for administrators to think that the time of day a discharge order is written is nearly always up to the doctor and how they organize their day. To them, it might seem reasonable to expect more than 50% of discharge orders to be written before 10 a.m. or earlier. But wait … it is more complicated than that.
The same administrators care a lot about LOS, which is most commonly reported in days but can also be measured in hours. So the time of day a discharge order is written, arguably the most important determinant of when a patient will vacate a room, is a determinant of LOS. If we’re really managing LOS optimally, we should discharge a patient at the first moment it is clinically appropriate, which means discharging at any hour of the day or night. (Of course, no one is proposing that we discharge and expect patients to vacate rooms in the middle of the night. Yet.)
But that would mean only a small portion of patients would end up with early-morning discharge orders. So excellent LOS management and a high portion of discharge orders written early in the day are incompatible. Setting the target percentage of early-a.m. discharge orders too high probably will increase LOS and defeat the original objective.
Benefits and Costs of Improved Throughput
Let’s say you’re sold on the value of improving throughput. It should lead to improved efficiency and financial performance for your hospital. I suspect it will improve quality and reduce iatrogenesis for some patients, but risk more readmissions and quality lapses or errors for others. And as every department tries to improve their own throughput, there will be a tendency to push problems off on others. For example, it is easy to improve ED throughput if the ED doctor just does a lot less evaluation and sends patients upstairs without much of a workup. Example: “The patient has fever and low sats, so I know he’s going to be admitted. Why should I keep him in the ED to do a workup?”
In fact, I think we should move away from using the ED as a triage unit and send some patients directly from ED triage to the inpatient unit. But we’ll need to put in place systems that make that safe and ensure good care. I don’t think any hospital has such systems in place now.
Let’s say that by 2013 most hospitals have dramatically improved their throughput, have short ED admit decision time to ED departure, and many patients are discharged and vacate their rooms early in the day. And let’s say we’ve been able to do that while maintaining or improving quality of care (we must!). We’ll then have happy patients and hospital administrators, and can bring up this improved performance when negotiating for hospital financial support for our practice. Everyone is happy, right?
Well, won’t this increase marginal or unnecessary admissions and readmissions, and lead to overall increased hospital utilization? After all, if it becomes really quick and easy to admit a patient to the hospital, won’t we do it more often? I think we will, but would never propose that we maintain poor throughput to keep a lid on costs and inappropriate utilization. But we’d better come up with other ways, or improved throughput will just be one more factor contributing to escalating healthcare costs.
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 Hospital Medicine Consultants, a national hospitalist practice management consulting firm.