Ahead of the Curve and Beating the Clock: Discharge Before Noon

Rehabilitation medicine, perhaps more than any other area of care, is profoundly dependent on the integration of multidisciplinary teams. Could the interdisciplinary coordination evident in treatment be harnessed and taken one step further, to improve discharge time? NYU Langone’s medical center-wide initiative focusing on discharge before noon (DBN) was taken very much to heart at Rusk and best evidenced by the efforts of Arthur Jimenez, MD, in Rusk’s orthopaedic rehab unit at 17th Street, in the Hospital for Joint Diseases.

DBN is widely accepted to reduce time and resource expenditures, easing gridlock by allowing efficient patient flow between units and opening up beds for additional admissions. Though hospitals aim, on average, for a DBN rate between 30% and 40%, Dr. Jimenez set a goal of 75% for his unit, back in early 2012. From there, he systematically investigated, uncovered, and addressed the origins of discharge delays in order to meet—and, as it turns out, outdo—his ambitious goal.

Meeting with members from every discipline revealed opportunities for saving time. Though physicians made early-morning rounds, many wrote discharge orders between 11am and 12pm. In some cases this delay was caused by the wait time for morning blood test results; discussions with lab technicians and specimen transporters explaining the need for quicker results improved turnaround times significantly. Physicians also began to initiate medication reconciliation on the evening prior to discharge.

Nurses, driven by their responsibility for patient comfort, were primarily delayed by matters relating to the transition back into a home environment. Concerned that patients leaving mid-morning might not be able to prepare a meal at home, nurses would hold patients slightly longer so they would be served lunch. This discovery led to the rollout of a simple solution: brown-bag lunches for patients to take home.

More complex was the need to supply certain patients with durable medical equipment (DME) to aid at-home recovery. Delivery, tracking, and payment for DME constituted a timeconsuming challenge. In response, nurses shifted delivery from 11am on the day of discharge to the night before or early in the morning. This led to a second benefit: validating patient insurance ahead of discharge, enabling the team to address any payment obstacles relating to DME or hospital charges.

Patient transportation proved to be another important factor. Social workers responsible for coordinating transfers to a second facility made arrangements well ahead of time, and the care team communicated clear and firm plans with family members responsible for transporting patients home. The team conveyed that an on-time pickup is needed for on-time care of the next incoming patient—affirming for the family Rusk’s loyalty to its patient population and giving them an opportunity to pay the goodwill forward.

One of the most critical components spanned all the disciplines: motivation. To maintain momentum, Dr. Jimenez would access his unit’s quality and performance dashboard to print the prior day’s DBN rate and post it in staff areas and nursing stations. Just a simple, visual reminder kept the team focused and enthusiastic.

In the end, Dr. Jimenez’s stated goal was far surpassed: logistical changes, effective communication and the cooperation of a dedicated team led to a DBN rate of 82.2% by the time summer 2012 arrived.

While a number of causes for delayed discharge were identified, there were none that couldn’t be addressed with the significant support and commitment of the Rusk physicians, staff, and patients. Thus proving the theory that a Rusk multidisciplinary team adds up to much more than the sum of its parts—in clinical care and beyond.

Previous Article Next Article
Back to Main Menu