Improving Timely Discharges Through Nurse-Initiated Conditional Discharge Orders.

BACKGROUND: Hospitalized patients are often medically ready for discharge before actual time of discharge. Delays are multifactorial, including medical staff workflow, knowledge, culture, and system issues. Identifying discharge criteria in a nurse-initiated conditional discharge (NICD) order facilitates a nurse-initiated discharge, creates a shared mental model for early discharge readiness, and improves workflow delays. The objective was to increase the percentage of morning discharges from 6% to 11% on the hospitalist intervention team, sustaining 11% for 6 months. METHODS: All patients admitted to a hospitalist service (intervention team) were targeted from July 2018 through March 2020. The primary outcome measure was percentage of morning discharges (6:00 am-12:00 pm). Quality improvement methodology was used to initiate bundled interventions, including NICD order use and education, written tool dissemination, and weekly e-mail reminders (PDSA1). Continued education with dissemination of an instructional module and a resident champion were established to improve resident hesitancy (PDSA2). RESULTS: Special cause variation was observed for the primary outcome after PDSA2 with a positive shift in the number of early discharges. Special cause variation was observed in the process measure after PDSA1 with 6 points above the mean. CONCLUSIONS: Through NICD orders, written tool dissemination, and a resident champion to encourage system-wide culture change, patients were discharged earlier, improving patient flow.

Making sense of nonsense: experiences of mild cognitive impairment.

Alzheimer's disease (AD) is a stigmatised condition popularly assumed to be a death sentence for diagnosed individuals. Consequently, people with AD are often deemed incapable (and perhaps unworthy) of contributing to the social discourse surrounding their illness experience. Data from qualitative interviews with 18 people diagnosed with the potential precursor of AD known as mild cognitive impairment (MCI) are examined. Using grounded theory methods, analysis revealed overarching themes of uncertainty concerning definitions of memory loss, MCI, and AD as well as distinctions between normal ageing and dementia. While this confusion over the terminology and prognosis mirrors the lack of scientific consensus about nosology and appropriate treatment regimens, such ambiguity creates social and psychological tensions for diagnosed individuals. Arguably, participants' unequivocal fear of and subsequent desire to differentiate their experiences from Alzheimer's, however, stems from the exclusively negative social constructions of AD. Drawing from Goffman, these findings demonstrate the psychosocial impact of 'framing contests' and how 'courtesy stigma' can apply not only to associated persons but also associated conditions, such as MCI to AD. Given the underlying nosological creep - or medicalisation - of the recent diagnostic guidelines proposing two new pre-dementia stages, understanding the illness narratives of MCI is critical.