BACKGROUND Late afternoon hospital discharges are thought to contribute to admission bottlenecks, overcrowding, and increased length of stay (LOS). In January 2012, the discharge before noon (DBN) percentage on 2 medical units was 7%, below the organizational goal of 30%. OBJECTIVE To sustainably achieve a DBN rate of 30% and to evaluate the effect of this intervention on observed‐to‐expected (O/E) LOS and 30‐day readmission rate. DESIGN Pre‐/post‐intervention retrospective analysis. SETTING Two acute care inpatient medical units in an urban, academic medical center. PATIENTS All inpatients discharged from the units. INTERVENTION All staff helped create a checklist of daily responsibilities at a DBN kickoff event. We initiated afternoon interdisciplinary rounds to identify next‐day DBNs and created a website for enhanced communication. We provided daily feedback on the DBN percentage, rewards for success, and real‐time opportunities for case review. MEASUREMENTS Calendar month DBN percentage, O/E LOS, and 30‐day readmission rate. RESULTS The DBN percentage increased from 11% in the 8‐month baseline period to an average of 38% over the 13‐month intervention (P = 0.0002). The average discharge time moved 1 hour and 31 minutes earlier in the day. The O/E LOS declined from 1.06 to 0.96 (P = 0.0001), and the 30‐day readmission rate declined from 14.3% to 13.1% (P = 0.1902). CONCLUSIONS Our study demonstrates that increased DBN is an achievable and sustainable goal for hospitals. Future work will allow for better understanding of the full effects of such an intervention on patient outcomes and hospital metrics. Journal of Hospital Medicine 2014;9:210–214. © 2014 Society of Hospital Medicine

Increasing the DBN rate correlates with admissions arriving earlier in the day and reductions in high-frequency peaks of ED admissions. Statistically significant improvements in DBN rates are sustainable.

Reactivation of Mycobacterium tuberculosis can occur in patients with latent tuberculosis (TB) with risk factors including chronic disease (i.e., malignancy). We herein describe the case of an immigrant from Hong Kong with lung cancer and no known TB disease who presents with reactivation of TB in the setting of chemotherapy and radiation therapy.

Hepatitis B reactivation can occur with cytotoxic chemotherapy in patients with hepatitis B and cancer. Reactivation can occur in a patient with chronic hepatitis, an inactive carrier, or one with resolved hepatitis. Clinical presentation may range from subclinical elevation of liver enzymes to fatal fulminant hepatic failure. Mammalian target of rapamycin inhibitors, which include everolimus, are a new generation of targeted agents that are currently approved for many cancers (since March 2009) including advanced hormone receptor positive, human epidermal growth factor receptor 2-negative breast cancer, in conjunction with exemestane (as of July 2012). We are therefore still learning the various adverse events that occur with this new class of agents. Here, we present an unfortunate case of fatal hepatitis B reactivation in a woman with metastatic breast cancer treated with everolimus and exemestane. We have detailed the controversies around hepatitis B screening prior to immunosuppressive therapy. Clinicians and patients should be aware of this rare but fatal complication prior to everolimus use, and a detailed history, screening for hepatitis B and prophylactic antiviral treatment should be considered.

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