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Patient Bettye King is being transported for discharge by William Sawyer./ Photo by Dana Johnson

VUH to improve patient discharge

BY: PAUL GOVERN

12/19/2003 - VUMC faculty and staff are launching a patient discharge initiative to reduce midday patient access problems at Vanderbilt University Hospital.

As recommended by the project team, the Clinical Enterprise Group (academic department chairs and senior administrators) endorsed two new requirements.

• Doctors enter “anticipate discharge” orders at least 24 hours ahead of discharge.

• Doctors enter discharge orders before 9 a.m. on the day of discharge.

“These two process improvements have been talked about awhile but never before endorsed as a way to do business across the entire hospital,” said project leader Dr. Allen B. Kaiser, professor and vice chair of Medicine.

Beginning in mid-December, department chairs have begun to receive periodic electronic reports on faculty and house staff adherence to the new requirements. Nurse managers will receive similar reports, along with data on room turnaround (time from discharge order to patient departure).

The patient discharge initiative is among 10 VUMC strategic initiatives that emerged from a clinical leadership retreat hosted this summer by Dr. Harry R. Jacobson, vice chancellor for Health Affairs. Kaiser said that academic department chairs and senior administrators helped to increase the priority for the discharge initiative and have supported its implementation across the organization.

A midday VUH bottleneck is routine, with discharges sometimes so backed up that new patients must be diverted to other facilities. At 10 a.m. on a recent Wednesday, there were as usual several patients in the ED waiting for admission to the hospital. “We’ve had five discharge orders written so far this morning — there ought to be 30,” Kaiser said.

He said writing of discharge orders before 9 a.m. will be a major change for faculty and house staff. As morning rounds get underway, doctors have always tended to visit the sickest patients first, so that for the less sick patient who is ready to go home, writing of discharge orders is typically delayed until later in the day. “It’s natural and very understandable for doctors to start the day attending to the sickest patients,” Kaiser said. “Switching to round first on the least sick patients is a gigantic culture change. It will take constant reminding about the importance of timely patient departure to support optimum hospital access.”

Kaiser recommends that teams start morning rounds with the question, Who is ready to go home today? and end rounds with the question, Who is likely to go home tomorrow?

Doctors have been prevented from writing discharge orders the day before discharge because reimbursement for the patient’s stay gets shut off by the insurance company the day the order is written. To solve this problem, the project team worked with the Informatics Center to develop an anticipate discharge screen in WizOrder. (Note to users: to get to the screen, type “discharge” or “anticipate.”) The screen includes a prescription writer: rather than giving a handwritten prescription to the patient, the doctor pulls up the current medication orders and clicks to print discharge prescriptions that can be faxed to the patient’s pharmacy.

A day’s advance notice of expected discharge will be a big help to staff, patients and families, said Wendy S. Leutgens, assistant hospital director for clinical services access. Though discharge planning begins at the time of admission to VUH, much of the work of discharge must wait until the patient is nearly ready to leave: nurses must instruct patients in self-care; predischarge tests and treatments may be needed; nurses may need to instruct family members and coordinate care at other facilities. When patients aren’t informed of discharge ahead of time, they have more trouble arranging rides home, and lack of transportation is in fact the chief cause of late departure.

Leutgens said plaques will be mounted on every hospital room door frame to inform patients of the VUH 10 a.m. discharge time. Also, new software is being evaluated to automate room turnaround dispatch and monitoring processes.

“There was a time when it took six to eight hours to turn around one of our rooms,” Leutgens said. “As the new process, electronic tools and reports become available, we’re expecting an average turnaround time of one hour or less.”

The following initiatives were launched at a July 2003 retreat hosted by Dr. Harry R. Jacobson, vice chancellor for Health Affairs:

• Manage discharge times

• Increase ED patient throughput

• Improve the accuracy of diagnosis coding through improved documentation

• Reduce unwanted variability of treatment and testing

• Curb unnecessary use of clinical resources by supplying practice groups with their own utilization data

• Boost case mix and plan for best use of new hospital capacity that will be created by the Children’s Hospital move

• Optimize inpatient capacity by evening out volume and flexing staffing

• Improve OR patient throughput

• Enhance outpatient productivity by improving access, reducing appointment cancellations and balancing clinic workload

• Deploy more intensive faculty coverage for acute admissions

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