An Iterative Quality Improvement Process Improves Pediatric Ward Discharge Efficiency

Abstract

Discharge of hospitalized pediatric patients may be delayed for various "nonmedical" reasons. Such delays impact hospital flow and contribute to hospital crowding. We aimed to improve discharge efficiency for our hospitalized pediatric patients by using an iterative quality improvement (QI) process. METHODS: Opportunities for improved efficiency were identified using value stream mapping, root cause, and benefit-effort analyses. QI interventions were focused on altered physician workflow, standardized discharge checklists, and physician workshops by using multiple plan-do-study-act cycles. The primary outcome of percentage of discharges before noon, process measure of percentage of discharges with orders before 10 AM, and balancing measures of readmission rate, emergency department revisit rate, and parent experience survey scores were analyzed by using statistical process control. The secondary outcome of mean length of stay was analyzed using t tests and linear regression. RESULTS: Implementation of our interventions was associated with special cause variation, with an upward shift in mean percentage of discharges before noon from 13.2% to 18.5%. Mean percentage of patients with discharge orders before 10 AM also increased from 13.6% to 23.6% and met rules for special cause. No change was detected in a control group. Adjusted mean length of stay index, 30-day readmissions, and parent experience survey scores remained unchanged. Special cause variation indicated a decreased 48-hour emergency department revisit rate associated with our interventions. CONCLUSIONS: An iterative QI process improved discharge efficiency without negatively affecting subsequent hospital use or parent experience. With this study, we support investment of resources into improving pediatric discharge efficiency through value stream mapping and rapid cycle QI.

Short stay unit led by pediatric hospital medicine advanced practice providers

“…Despite targeted quality improvement (QI) projects to promote early discharges on the pediatric hospital medicine (PHM) service, systems drivers continued to influence length of stay (LOS) at our institution. Similar patterns have been reported at other large children's hospitals, where despite iterative QI cycles facilitating early discharge, 75%–80% of discharges still occurred in the afternoons 10,11 …”

“…Overall, the median (IQR) LOS was 18h (10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22) in the SSU and 20h (16)(17)(18)(19)(20)(21)(22)(23)(24)(25) and cost reduction of $593 (95% CI: $348-$839). Discharge timing was similar to the main analysis.…”

“…Similar patterns have been reported at other large children's hospitals, where despite iterative QI cycles facilitating early discharge, 75%-80% of discharges still occurred in the afternoons. 10,11 The concept of observation units or short stay units (SSUs) as a strategy to optimize healthcare utilization is well established in adult medicine, but evidence is conflicting in pediatric care. 12,13 The majority of pediatric SSUs are outpatient-based and/or attached to the ED and are designed to prevent hospital admissions.…”

Use of Lean Healthcare to Improve Hospital Throughput and Reduce LOS

“…1 , 2 The discharge of hospitalized pediatric patients may be delayed for various “nonmedical” reasons; such delays impact hospital flow and contribute to hospital crowding. 3 Data also suggest that inpatient discharge delays affect hospital throughput and contribute to emergency department (ED) crowding. 4 These delays have also resulted in an unnecessarily increased inpatient length of stay (LOS), diminished hospital revenue, and negative impacts on patient safety and experience.…”

The Effectiveness of a Multidisciplinary Electronic Discharge Readiness Tool: Prospective, Single-Center, Pre-Post Study (Preprint)

“…Typical workflows rely on processes implemented outside of the electronic health record (EHR), such as meetings, paging, and telephone calls, which are inadequate for efficient discharge communication and frequently interrupt patient care [25,26]. Health information technology solutions most often described in the literature include passive communication tools, such as electronic patient journey boards, hospital capacity dashboards, asynchronous electronic reports, and discharge checklists [4,[27][28][29][30][31][32][33][34], or health information technology tools that reside outside of the EHR [35,36]. Even commonly used tools within the EHR, such as messaging or conditional discharge orders, do not provide real time, integrated communications despite being a function of an EHR [37,38].…”