The "hard, relentless, never-ending" work of focusing on discharge: a qualitative study of managers' perspectives

PURPOSE

Interventions to hasten patient discharge continue to proliferate despite evidence that they may be achieving diminishing returns. To better understand what such interventions can be expected to accomplish, the authors aim to critically examine their underlying program theory.

DESIGN/METHODOLOGY/APPROACH

Within a broader study on patient flow, spanning 10 jurisdictions across Western Canada, the authors conducted in-depth interviews with 300 senior, middle and frontline managers; 174 discussed discharge initiatives. Using thematic analysis informed by a Realistic Evaluation lens, the authors identified the mechanisms by which discharge activities were believed to produce their impacts and the strategies and context factors necessary to trigger the intended mechanisms.

FINDINGS

Managers' accounts suggested a common program theory that applied to a wide variety of discharge initiatives. The chief mechanism was inculcation of a sharp focus on discharge; reinforcing mechanisms included development of shared understanding and a sense of accountability. Participants reported that these mechanisms were difficult to produce and sustain, requiring continual active management and repeated (re)introduction of interventions. This reflected a context in which providers, already overwhelmed with competing demands, were unlikely to be able (or perhaps even willing) to sustain a focus on this particular aspect of care.

ORIGINALITY/VALUE

The finding that "discharge focus" emerged as the core mechanism of discharge interventions helps to explain why such initiatives may be achieving limited benefit. There is a need for interventions that promote timely discharge without relying on this highly problematic mechanism.

Improving Patient Flow: Analysis of an Initiative to Improve Early Discharge

BACKGROUND

Discharge delays adversely affect hospital bed availability and thus patient flow.

OBJECTIVE

We aimed to increase the percentage of early discharges (EDCs; before 11 am). We hypothesized that obtaining at least 25% EDCs would decrease emergency department (ED) and postanesthesia care unit (PACU) hospital bed wait times.

DESIGN

This study used a pre/postintervention retrospective analysis.

SETTING

All acute care units in a quaternary care academic children's hospital were included in this study.

PATIENTS

The patient sample included all discharges from the acute care units and all hospital admissions from the ED and PACU from January 1, 2014, to December 31, 2016.

INTERVENTION

A multidisciplinary team identified EDC barriers, including poor identification of EDC candidates, accountability issues, and lack of team incentives. A total of three successive interventions were implemented using Plan-Do-Check-Act (PDCA) cycles over 10 months between 2015 and 2016 addressing these barriers. Interventions included EDC identification and communication, early rounding on EDCs, and modest incentives.

MEASUREMENTS

Calendar month EDC percentage, ED (from time bed requested to the time patient left ED) and PACU (from time patient ready to leave to time patient left PACU) wait times were measured.

RESULTS

EDCs increased from an average 8.8% before the start of interventions (May 2015) to 15.8% after interventions (February 2016). Using an interrupted time series, both the jump and the slope increase were significant (3.9%, P = .02 and 0.48%, P < .01, respectively). Wait times decreased from a median of 221 to 133 minutes (P < .001) for ED and from 56 to 36 minutes per patient (P = .002) for PACU.

CONCLUSION

A multimodal intervention was associated with more EDCs and decreased PACU and ED bed wait times.

A Comprehensive Risk Score to Predict Prolonged Hospital Length of Stay After Heart Transplantation

BACKGROUND

Prolonged hospital length of stay (PLOS) after heart transplantation increases cost and morbidity. To better inform care, we developed a risk score to identify patients at risk for PLOS after heart transplantation.

METHODS

We queried the United Network for Organ Sharing Scientific Registry of Transplant Recipients database for adult patients who underwent isolated heart transplantation from 2003 to 2012. The population was randomly divided into a derivation cohort (80%) and a validation cohort (20%). The outcome of interest was PLOS, defined as a posttransplant hospital length of stay of more than 30 days. Associated univariables (p < 0.20) in the derivation cohort were included in a multivariable model, and a risk index was derived from the adjusted odds ratios of significant covariates.

RESULTS

During the study period, 16,723 patients underwent heart transplantation with an average PLOS of 19 ± 21 days, and 2,020 orthotopic heart transplant recipients (12%) had PLOS. Baseline characteristics were similar between the derivation and validation cohorts. Twenty-four recipient and nine donor variables, cold ischemic time, and center volume were tested as univariables. Seventeen covariates significantly affected PLOS and comprised the prolonged hospitalization after heart transplant risk score, which was stratified into three risk groups. The risk model was subsequently validated, and predicted rates of PLOS correlated well with observed rates (R = 0.79). Rates of PLOS in the validation cohort were 8.3%, 11%, and 22% for low, moderate, and high risk groups, respectively.

CONCLUSIONS

The risk of PLOS after heart transplantation can be determined at the time of transplant. The prolonged hospitalization after heart transplant score may lead to individualized postoperative management strategies to reduce duration of hospitalization for patients at high risk.