Influencing Discharge Efficiency: Addressing Interdisciplinary Communication, Transportation, and COVID-19 as Barriers.

PURPOSE: At one tertiary, academic medical center, two general medicine units averaged 94% and 97% occupancy causing strain on patient throughput. This project was implemented at these two comparable general medicine units, totaling 64 beds. On each of these units, Pareto analyses on causal factors related to discharge order to exit time (DOTE) were performed. DOTE was defined as the period in minutes from when a provider orders a discharge to when the patient actually exits a room. Prime DOTE reduction opportunities were elicited that highlighted the need to address coordination of hospital discharge transportation; that is, arriving family members averaged 120 and 129 min for the two units, and medicars and ambulances averaged 122 and 156 min, which fell above the established 90-min overall strategic DOTE goal. Coordinating efficient discharges decreases the likelihood of hospital bottlenecking and improves patient satisfaction. CASE MANAGEMENT SETTING: The health care team is composed of physician and provider services, nursing, and case management, as well as the patient and family. Team-focused interventions aimed at reducing DOTE included leveraging interdisciplinary communication technology and messaging for efficiency and accuracy within the health care team and proactive scheduling of hospital discharge transportation arrival. Process objectives measured included percentage of the health care team educated and utilization of the discharge suite. Outcome objectives measured included median DOTE times, patient satisfaction, and emergency department boarding volume and times. Significantly, admissions for coronavirus disease-2019 (COVID-19) cases were also rapidly increasing early on during program implementation resulting in one of the two general medicine units to be designated for COVID-19 overflow. RESEARCH METHODOLOGY: Using Lean methodology, the project design was formed based on the Institute for Healthcare Improvement's work on improving hospital-wide patient flow and the Agency for Healthcare Research and Quality's (AHRQ) IDEAL patient discharge framework to better achieve the well-known, triple aim. In response to COVID-19 demands, the Plan-Do-Study-Act process was warranted to be able to manage acute changes, using iterative processing. RESULTS AND IMPLICATIONS: This program evaluation study assessed whether a communication training program that taught an interdisciplinary team of case managers, nurses, physicians, and related staff how to reduce DOTE was useful. The program had a material impact on the DOTE metric knowing that the hospital's ultimate strategic goal is to reduce DOTE to 90 min or less. A reduction in discharge time was documented when using weekly data from the hospital's discharge dashboard powered by the Maestro database. More specifically, nurses fully trained in the interdisciplinary communications program aimed to reduce DOTE had significantly lower DOTE outcomes on their discharges compared with untrained staff (i.e., average untrained = 127 min, average trained = 93 min). In addition, the fully trained nurses had 14% more of their discharges fall at or below the 90-min goal compared with untrained staff (i.e., untrained = 40%, trained = 54%). Supplemental research also suggested that the content of the communication training program was very relevant (e.g., empowering families to pick up the patients and using scheduling vs. will-call transportation strategies with patients lowered the DOTE metric). Corollary analyses showed that readmissions were also lowered, and patient satisfaction ratings increased. In addition, the interdisciplinary communications training program can benefit from being updated to include content on how COVID-19 issues adversely impact discharge times since significant relationships between various COVID-19 measures and higher discharge exit times were documented.

The duration of anticoagulation bridging therapy in clinical practice may significantly exceed that observed in clinical trials.

BACKGROUND: Clinical trials involving frequent, standardized monitoring of the international normalized ratio (INR) demonstrated that a short course of low-molecular-weight-heparin (LMWH) can successfully bridge patients to oral anticoagulation. However, rigidly performed INR testing is often not feasible in the outpatient setting in actual clinical practice. The purpose of this study was to determine if the anticoagulation results of clinical trials of LMWH bridging therapy are also achieved in a single-center clinical practice setting. METHODS: We conducted a retrospective analysis of 100 patients initiating warfarin while receiving LMWH under the care of a university-based anticoagulation management service. RESULTS: Mean patient age was 56.1 +/- 16.3 years. The commonest indications for anticoagulation were venous thrombosis (57%) and atrial fibrillation (25%). Mean initial warfarin dose was 5.1 +/- 1.8 mg/day; 30% of patients received antiplatelet therapy. The mean total duration of LMWH therapy was 12.0 +/- 8.2 days, of which 9.8 +/- 8.0 days (median 7.5 days; interquartile range 4.3-13.0 days) occurred in the outpatient setting. Forty-one percent of patients received outpatient LMWH for < 7 days, 40% for 7-14 days, and 19% for > 14 days. A mean of 3.9 +/- 2.0 INRs were performed during LMWH therapy. Complications included 11 minor and 1 major bleeding episodes and 1 thrombotic event. CONCLUSIONS: The duration of LMWH bridging therapy in practice may be significantly greater than previously reported in clinical trials, and the incidence of patients requiring prolonged (>14 days) LMWH therapy is relatively high. Outpatient LMWH as employed in clinical practice safely bridges patients to oral anticoagulation. Strategies to shorten the duration of LMWH therapy are needed and are likely to improve clinical outcomes and reduce health care expenses. In prospective clinical trials low-molecular-weight-heparin (LMWH) has proven effective in transitioning patients with venous thromboembolic disease to therapeutic warfarin anticoagulation. However, it is unknown if the anticoagulation results obtained in these trials, which involved rigidly performed anticoagulation monitoring, are achieved in standard clinical practice involving patients with a variety of indications for anticoagulation. We conducted a retrospective analysis of 100 patients initiating warfarin while receiving LMWH under the management of a university-based anticoagulation management service. The mean total duration of LMWH therapy was 12.0 +/- 8.2 days, of which 9.8 +/- 8.0 days (median 7.5 days; interquartile range 4.3-13.0 days) occurred in the outpatient setting. Forty-one percent of patients received outpatient LMWH for <7 days, 40% for 7-14 days, and 19% for >14 days. We conclude that the duration of LMWH bridging therapy in practice may be significantly greater than previously reported in clinical trials, and the incidence of patients requiring prolonged (>14 days) LMWH therapy is relatively high.