(Clockwise from top left): Jeanne Elgie-Watson, Manager, Dr. Eric Degen, CV Hospitalist, Diana Mourao, Pharmacist, CV Surgery, Nancy Braich, Charge Nurse, 4B, participating in daily discharge rounds, where the team identifies patients leaving within 48 hours to make sure they are ready to go.
(Photo: UHN)
The longer a patient spends in a hospital, the more chance they have to experience a fall, medication incident, delirium or acquire an infection they wouldn't have otherwise.
That's why hospitals need to discharge people as soon as they are ready to go – getting them to the right place at the right time.
One unit at the Peter Munk Cardiac Centre (PMCC) has done just that.
"We're not doing this to create more bed space," says, Jeanne Elgie-Watson, Nurse Manager on 4A/B at PMCC. "In our effort to become a high-reliability organization, we need to look at reducing length of stay as a fundamental part of improving patient safety."
By the numbers:*
Average length of stay down to
6.1 days from a baseline of
7.3 days
100 per cent of appropriate patients are referred to cardiac rehab, up from
13 per cent
90 per cent of patients are aware of their discharge plan, up from
21 per cent
46 per cent of patients are discharged by 11 a.m., up from
7 per cent
*All numbers refer to 4A/B cardiovascular surgery patients.
Most healthcare practitioners will tell you that's easier said than done. Jeanne will tell you that cardiovascular surgery patients on her unit heading home with or without support are leaving, on average, just over a full day earlier than they were three months ago.
That's a 16 per cent reduction in length of stay, down to 6.1 days from 7.3 in just three months.
"We achieved this reduction by bringing both units together into one team and smoothing out the barriers to timely discharge," says Jeanne. "The work started with help from the Lean Process Improvement team in our Rapid Improvement Event and it's continued every day since in our huddles."
While the team has made numerous minor changes to the discharge process, much of the improvement has come from three major changes:
- Ensuring test results are ready in time to discharge the patient
- Continuous communication of an up-to-date discharge plan to the patient and their family
- Daily huddles implemented by the clinical team to discuss process problems and discharge rounds so as to identify patients who will be ready for discharge within 48 hours
Test Results
"We need to look at results from morning blood tests and echocardiograms before discharging anyone," says Jeanne. "The night shift team now draws blood by 6 a.m. for patients we're planning to discharge that day. By starting the process earlier, we get the results back in time to make the decision.
"At 60 days after the event, we found delayed echocardiogram test results partly contributed to us missing our 11 a.m. discharge target. Fortunately, the echo team has been very engaged in attending our meetings to understand our issues.
"Through a collaborative approach, they provide early morning spots for tests, they are working to provide test results sooner and that helps us meet our 11 a.m. target."
Communicating the discharge plan
After surgery, most patients need family support to safely transition back home. The team communicates the estimated discharge date (EDD) to the family two days in advance, giving them some time to make arrangements for transportation and home care. Modified white boards in patient rooms also now include a space for the EDD.
"Even two days notice doesn't always give family enough time to make arrangements," says Jeanne. "We're now working on identifying the discharge date earlier. What makes this particularly challenging is that we know it is common for patients to experience complications three or four days after surgery, which can delay the discharge."
Daily huddles
The engine driving all these improvements are the team's daily huddles, where they addresses any problems they are facing, and the discharge rounds. At 1:30 p.m. every day, the entire team gathers for 15 minutes to identify any patients who will be ready for discharge in the next 48 hours, and discuss their individual needs or outstanding tests.
"Knowing who will be going home in two days helps all the contributing team members organize their discharge preparations," says Jeanne. "Everyone attends the rounds: the physician, nursing staff, nurse practitioners, physiotherapists, occupational therapists, pharmacists, social workers, the patient coordinator and management."
Jeanne asks that team members show up on time, with a good understanding of their patients' overall condition. The two charge nurses update patients' EDD on the electronic white board in the moment so it's visible to everyone.
The unit's target length of stay is six days. When they beat it, they celebrate as a team. When they meet it, they record it as a success on their performance board. When a patient is discharged on day seven or later, they find out why.
Often a delayed discharge is because the patient required more medical care, but if the delay was due to a problem with the discharge process the team is reluctant to simplify, they dig into the root cause and address it.
"Everyone knows our goal, and we work together to achieve it," says Helen Zhang, a Nurse Practitioner at PMCC. "It's great. Before we didn't have a clear goal. If a patient was supposed to go home by 11 a.m. on a particular day and it didn't happen that was okay.
"Now whenever a patient is ready to go home by day six after surgery, we cheer."
If you're interested in learning more about the Lean methodology Jeanne and her team used to decrease length of stay, the Lean Process Improvement department can provide you with a toolkit to help you assess your current process, improve it, standardize it and sustain it.
