Identifying Barriers for Early Discharge in a Children’s Hospital

From the 2021 HVPAA National Conference

Logan Breehl (Akron Children’s Hospital), Marshall LeLand, Allison Marko, Elizabeth Gegorski, Spencer Gasser, Prabi Rajbhandari

Background

Hospitals routinely face challenges with patient flow and throughput. Discharges typically happen in the afternoon, which creates a mismatch between demands and bed availability in the morning. Early discharges, defined as discharge before noon, allow for increased bed turnover, bed availability and reduces overcrowding in the emergency department (ED). Depending on the internal discharge process, barriers to early discharge vary between institutions. Discharging a patient is not a single event but a process. Each institution requires an internal assessment to identify discharge barriers to develop an effective discharge planning system.

Objective

The primary objective of this study was to identify barriers for early discharge for admitted patients in our institution within the pediatric hospital medicine service. The secondary objective of this study was to focus on the identified barriers and form a multidisciplinary quality improvement (QI) team to improve the early discharge process.

Methods

We developed an online survey to understand the barriers to early discharge. A 12-question online survey was created, and face validated by a small group of nursing, resident, and hospitalist attendings. The survey was divided into four domains that addressed factors related to early discharge, (1) barriers in the identification of early discharge patients, (2) communication barriers, (3) computerized discharge process (system) barriers, and (4) patient and physician (human) barriers. The survey was voluntary, open for 4 weeks (2/3/21- 3/3/221) and was distributed via hospital email addresses. Descriptive statistics were used to summarize survey responses.

Results

Of 116 eligible respondents, 98 responded to the survey (59%), with residents and nurses being the primary respondents (36% and 21% respectively) (Figure 1 ). Seventy-four percent responded that they could identify early discharge patients “always or frequently.” Sixty-six percent responded that communication is inadequate, with the majority reporting that the gap lies between residents and attendings (34%) and between the medical team and ancillary staff (33%). Discharge orders not being ready (including discharge instructions and prescriptions) was identified as the top reason for discharge delays followed by care-coordination with other sub-specialties, case management issues, and social work issues following subsequently in the order (Figure 2). The leading patient factor hindering early discharges was reported as patient or family not being medically ready for discharge. Residents ranked rounding late with attendings as the number one physician-related hindrance to early discharges.

Conclusions

We identified several barriers encountered in our hospital for early discharge including, poor communication, time delay in preparation of discharge orders and instructions, and poor care coordination with other subspecialties. We are currently targeting these barriers as a driver to improve our QI project.

Clinical Implications

Timely hospital discharge reduces overcrowding in ED and transfers from other departments like intensive care units and elective admissions. It can improve hospital bed capacity and can increase patient satisfaction. Identifying barriers early on equips us with the potential challenges that our project may face and helps us design our interventions to implement in our QI study successfully.