Day of Discharge Planning Utilizing the n-by-T Strategy

Abstract

Background: Hospital discharges are a complex process that can directly impact a patient’s length of stay and decrease the quality of care that the patients receive. An ineffective discharge process increases the number of unplanned readmissions, which are costly to hospitals and affect patients negatively. Local Problem: The medical providers on the General Surgery Unit at a Maryland hospital recognized the need for a discharge process that would increase the number of before-noon discharges. The unit experienced many late-day discharges which would contribute to increased night shift admissions. The unit also experienced higher than average readmission rates when compared to the rest of the organization. Interventions: The purpose of this Doctor of Nursing Practice project was to implement and evaluate the n-by-T strategy into the discharge process for the medical patients on a 30-bed general surgery unit starting October 1, 2018. The quality improvement project involved utilizing a discharge checklist with the n-by-T strategy during morning rounds to safely schedule a number of patients (n) for same day discharge by a goal time (T). The medical director set a daily goal of two patients discharged by noon. Pre-implementation data was collected from September 1-30, 2018. Post-implementation data was collected from October 1, 2018 through November 30, 2018. Data collection included the use of the discharge checklist Monday through Friday during discharge rounds, the average time of discharges, the average length of the discharge process, and the unit’s 7-day and 30-day readmission rates. Results: Pre-implementation data collected in September 2018 showed an average time of discharge of 15:30, the average speed of the discharge process was 2.80 hours, the 7-day readmission rate for the unit was 7.27%, and the 30-day readmission rate for the unit was 21.82%. The average discharge time post-implementation was 15:26 and the average discharge process time was 2.99 hours. The 7-day readmission was 2.22% and 4.91% for October 2018 and November 2018, respectively. The 30-day readmission rate was 6.22% and 10.27% for October 2018 and November 2018, respectively. The discharge checklist was completed 38 out of 45 days, with an 84% completion rate Conclusions: There was no statistically significant change in the average discharge time or the average length of the discharge process. The readmission rates showed statistically significant improvement in 7-day and 30-day rates post-implementation. Post-implementation provider feedback was positive from the providers for placing an emphasis on prioritizing patients for earlier same-day discharges. The process of this quality improvement project was successful, though sustainability at the project site was dependent on a re-evaluation of the discharge checklist due to the time burden associated with it. Future projects are recommended to assess other methods, besides an independent discharge checklist, in assessing patient readiness for before-noon same-day discharges. Future projects also include implementation on other inpatient units within the organization or to outpatient settings, such as subacute rehabilitation facilities.