February 2003 • Volume 27 No. 2

Hi-tech ID wristbands boost safety, efficiency

New policy details procedure for missing patients

New Cellular Therapeutics Lab boosts SHC's bone marrow transplant capacity

Emergency Medicine faculty promotes specialty halfway around the globe

Revised policies mean cell phones, laptops can be used in some areas

Physicians can take simple steps to improve patient safety







Time for an earlier discharge


For as long as I have worked at Stanford Hospital, I have not been aware of a set discharge time for patients. Insurance companies don't mandate a specific discharge time (because per-diem contracts don't reimburse the hospital for the patient's final day), and I believe this has contributed to the notion that there is no set time by which patients should be picked up on the day of discharge. In practice, the bulk of our discharges occur in the afternoon or evening.

It has become apparent, however, that this situation must change. The hospital recently analyzed our average discharge times and the impact they have on our operations. This analysis reveals that our later discharge times have contributed to a midday bed crunch caused in part by the high patient volumes we have experienced in recent months. We have particularly encountered problems finding beds for patients admitted out of the operating rooms and the emergency room. Consequently, patients in the emergency room or recovery room sometimes find themselves waiting for a bed to be emptied and cleaned for them. This not only frustrates patients, but has occasionally resulted in emergency room closures and operating room delays.

Over the past year we have had about 12 percent of our discharges before 11 a.m., 48 percent of discharges between 11 a.m. and 3 p.m., 35 percent between 3 and 8 p.m., and 5 percent between 8 p.m. and midnight. These data are available by unit and seem to be fairly consistent across services, although the surgical units have a somewhat greater percentage of patients discharged earlier in the day.

What factors have contributed to late discharges? First, we as an institution have not set an expectation for patients and their families that they will need to arrange for transportation home early on the day of discharge. If physicians are, like myself, unaware of a particular discharge time, then naturally we don't let patients know they must have family or friends pick them up early.

Institutional factors are also at work. Because we are an academic medical center, often the decision to discharge a patient is not made until attending (teaching) rounds occur, and this inevitably results in a later discharge than necessary. Also, discharge orders usually are not written until after rounds are completed, often by residents who are overwhelmed with multiple orders to write. Many times there are also clinical needs holding up a discharge, such as catheters to pull, patients to mobilize or tests to complete.

If we made an effort to discharge patients earlier, we could improve operations at Stanford Hospital in several ways. First, we could get patients placed in rooms more quickly and efficiently. This would not only mean greater patient satisfaction but would increase our bed capacity without physically adding beds. That, in turn, would help improve the hospital's financial performance.

Given these benefits, the hospital is launching an initiative to set our discharge time at or before 11 a.m. What can we do to help bring about this change? First, we need to make discharge decisions earlier in the day. This may require some process changes, such as conducting our attending rounds earlier.

Next, physicians need to plan ahead the night or the day before discharge. We should complete paperwork early, including prescriptions. We must also plan ahead for special discharge needs, such as home IV therapy or placement in a skilled nursing facility. We will also need to change some clinical practices, such as removing Foley catheters and surgical drains earlier on the day of discharge. Decisions for discharge should be made the night before whenever possible.

Finally, we need to help set expectations with patients and their families by informing them of the 11 a.m. discharge time and telling them in advance, if possible, when they will likely be discharged. The hospital staff will play an important role in reinforcing this message when communicating with patients and families.

The administrator championing the early discharge initiative is Elizabeth Polek, LCSW, director of Social Work and Case Management.

Questions or comments regarding this matter can be directed to Polek at Elizabeth.Polek@medcenter.stanford.edu or to Larry Shuer at lshuer@stanford.edu or give me a call at 723-5371.