Improving Discharge Efficiency in Medically Complex Pediatric Patients.

BACKGROUND AND OBJECTIVE: Children with medical complexity have unique needs when facilitating transitions from hospital to home. Defining readiness for discharge is challenging, and preparation requires coordination of family, education, equipment, and medications. Our multidisciplinary team aimed to increase the percentage of medically complex hospital medicine patients discharged within 2 hours of meeting medical discharge goals from 50% to 80%. METHODS: We used quality improvement methods to identify key drivers and inform interventions. Medical discharge goals were defined on admission for each patient. Interventions included implementation of a complex care inpatient team with electronic admission order set, weekly care coordination rounds, needs assessment tool, and medication pathway. The primary measure, percentage of patients discharged within 2 hours of meeting medical discharge goals, was followed on a run chart. The secondary measures, pre- and post-intervention length of stay and 30-day readmission rate, were compared by using Wilcoxon rank-sum and χ(2) tests, respectively. RESULTS: The percentage of medically complex patients discharged within 2 hours of meeting medical discharge goals improved from 50% to 88% over 17 months and sustained for 6 months. In preintervention-postintervention comparison, median length of stay did not change (3.1 days [interquartile range, 1.8-7.0] vs 2.9 days [interquartile range, 1.7-6.1]; P = .67) and 30-day readmission rate was not impacted (30.7% vs 26.4%; P = .51). CONCLUSIONS: Efficient discharge for medically complex patients requires support of a multidisciplinary team to proactively address discharge needs, ensuring patients are ready for discharge when medical goals are met.

Using quality improvement to optimise paediatric discharge efficiency.

BACKGROUND: Bed capacity management is a critical issue facing hospital administrators, and inefficient discharges impact patient flow throughout the hospital. National recommendations include a focus on providing care that is timely and efficient, but a lack of standardised discharge criteria at our institution contributed to unpredictable discharge timing and lengthy delays. Our objective was to increase the percentage of Hospital Medicine patients discharged within 2 h of meeting criteria from 42% to 80%. METHODS: A multidisciplinary team collaborated to develop medically appropriate discharge criteria for 11 common inpatient diagnoses. Discharge criteria were embedded into electronic medical record (EMR) order sets at admission and could be modified throughout a patient's stay. Nurses placed an EMR time-stamp to signal when patients met all discharge goals. Strategies to improve discharge timeliness emphasised completion of discharge tasks prior to meeting criteria. Interventions focused on buy-in from key team members, pharmacy process redesign, subspecialty consult timeliness and feedback to frontline staff. A P statistical process control chart assessed the impact of interventions over time. Length of stay (LOS) and readmission rates before and after implementation of process measures were compared using the Wilcoxon rank-sum test. RESULTS: The percentage of patients discharged within 2 h significantly improved from 42% to 80% within 18 months. Patients studied had a decrease in median overall LOS (from 1.56 to 1.44 days; p=0.01), without an increase in readmission rates (4.60% to 4.21%; p=0.24). The 12-month rolling average census for the study units increased from 36.4 to 42.9, representing an 18% increase in occupancy. CONCLUSIONS: Through standardising discharge goals and implementation of high-reliability interventions, we reduced LOS without increasing readmission rates.