The association between discharge before noon and length of stay in medical and surgical patients

Rajkomar, Alvin; Valencia, Victoria; Novelero, Maria; Mourad, Michelle; Auerbach, Andrew D.

doi:10.1002/jhm.2529

Cited by 33 publications

(34 citation statements)

References 3 publications

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“…4 These findings contrast with Rajkomar et al, who reported that DCBN was associated with a longer LOS in adult patients. 6 The contrasting findings could be due to differences in pediatric versus adult patients. Additionally, the population Rajkomar et al studied was predominantly surgical patients, whose discharges may differ from medical patients' in many aspects.…”

Section: Discussionmentioning

confidence: 99%

The Association of Discharge Before Noon and Length of Stay in Hospitalized Pediatric Patients

James

Steiner

Holmes

et al. 2019

Journal of Hospital Medicine

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M any hospitals and emergency departments (EDs) face challenges posed by overcrowding and hospital throughput. Slow ED throughput has been associated with worse patient outcomes. 1 One strategy increasingly employed to improve hospital throughput is to increase the rate of inpatient discharges earlier in the day, which is often defined as discharges before noon (DCBNs). The hypothesis behind DCBN is that earlier hospital discharges will allow for earlier ED admissions and thus mitigate ED overcrowding while optimizing inpatient hospital flow. Previous quality improvement efforts to increase the percentage of DCBNs have been successfully implemented. For example, Wertheimer et al. implemented a process for earlier discharges and reported a 27-percentage point (11% to 38%) increase in DCBN on general medicine units. 2 In a recent survey among leaders in hospital medicine programs, a majority reported early discharge as an important institutional goal. 3 Studies of the effectiveness of DCBN initiatives on improv-ing throughput and shortening length of stay (LOS) in adult patients have had mixed results. Computer modeling has supported the idea that earlier inpatient discharges would shorten ED patient boarding time. 4 Wertheimer et al. performed a retrospective analysis of a DCBN intervention on two inpatient medicine units and reported an association between slightly shorter observed versus expected inpatient LOS 2 and earlier arrival time of inpatient admissions from the ED. 5 In contrast, Rajkomar et al. conducted a retrospective analysis of the association of DCBN and LOS in a predominantly surgical services population and reported a longer LOS for DCBN patients when controlling for patient characteristics and comorbidities. 6 These mixed findings have led some authors to question the value of DCBN initiatives and created concern for the potential of prolonged patient hospitalizations as a result of institutional DCBN goals. 7 The impact of DCBN in pediatric patients is much less studied. A question of interest for hospitals is if DCBN is a good indicator of shorter LOS, or is DCBN an arbitrary indicator, as morning discharges might just be the result of a delayed discharge of a patient ready for discharge the prior afternoon/ evening. Our study objectives were: (1) to determine whether DCBN is associated with a shorter LOS in a pediatric population at an academic medical center, and (2) to examine separately this association in medical and surgical patients given the different provider workflow and patient clinical characteristics in those groups. BACKGROUND AND OBJECTIVES:To optimize patient throughput, many hospitals set targets for discharging patients before noon (DCBN). However, it is not clear whether DCBN is an appropriate measure for an efficient discharge. This study aims to determine whether DCBN is associated with shorter length of stay (LOS) in pediatric patients and whether that relationship is different between surgical and medical discharges.

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Section: Discussionmentioning

confidence: 99%

The Association of Discharge Before Noon and Length of Stay in Hospitalized Pediatric Patients

James

Steiner

Holmes

et al. 2019

Journal of Hospital Medicine

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“…The use of a single, fixed discharge time target such as “discharge by noon” or “X% of discharges by 11:00A.M.” is becoming increasingly prevalent. Rajkomar, et al 7 recently reported a retrospective single institution review of discharge by noon, in which improvement in that metric was actually shown to be associated with increased acute care LOS. The authors concluded that focusing solely on a single metric alone was an insufficient approach.…”

Section: Discussionmentioning

confidence: 99%

“…4, 5 LOS also lacks the granularity to capture nuances of inpatient hospital admission patient flow which have implications for patient outcomes and staff work burden. 5, 6, 7 For example, a delay in discharge time from 11:00 a.m. to 7:00 p.m. does not cause an appreciable increase in the LOS. However, by decreasing bed availability, delays of this nature increase post-anesthesia care unit (PACU) and emergency department (ED) boarding times.…”

Section: Introductionmentioning

confidence: 99%

“…This initiative focused on newer metrics of throughput, such as specific time of discharge and discharge by noon. 7, 31, 32 Here we discuss how the vascular surgery division at our academic medical center utilized a systematic approach to identify barriers to efficient patient throughput and successfully implemented a patient flow intervention.…”

Section: Introductionmentioning

confidence: 99%

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Systematic identification and management of barriers to vascular surgery patient discharge time of day

Sharma

Wong

Arnaoutakis

et al. 2017

Journal of Vascular Surgery

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Objectives Length of stay fails to completely capture the clinical and economic effects of patient progression through the phases of inpatient care, such as admission, room placement, procedures, and discharge. Delayed hospital throughput has been linked to increased time spent in the emergency department and post-anesthesia care unit, delayed time to treatment, increased inhospital mortality, decreased patient satisfaction, and lost hospital revenue. We identified barriers to vascular surgery inpatient care progression and instituted defined measures to positively impact standardized metrics. Methods The study was divided into three periods: pre-intervention, “wash-in”, and post-intervention. During the pre-intervention phase, barriers to patient flow were quantified by an interdisciplinary team. Suboptimal provider communication emerged as the key barrier. An enhanced communication intervention consisting of face-to-face and mobile application-based education on key patient flow metrics, explicit discussion of individual patient barriers to progression at rounds and interdisciplinary huddles, and communication of projected discharge and potential barriers via e-mail was developed with input from all stakeholders. Following a four-week wash-in implementation phase, data collection was repeated. Results The pre- and post-intervention patient cohorts accounted for 244.3 and 238.1 inpatient days, respectively. Both groups had similar baseline demographic, clinical characteristics, and procedures performed during hospitalization. The post-intervention group was discharged 78 minutes earlier (14:00:32 versus 15:18:37, P=0.03) with a trend toward increased discharge by noon (94% versus 88%, P=0.09). Readmission rates did not differ (P=0.44). Conclusions Implementation of a focused, interdisciplinary, frontline provider-driven, enhanced communication program can be feasibly incorporated into existing specialty surgical workflow. The program resulted in improved timeliness of discharge and projected cost savings, without increasing readmission rates.

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“…For example, pre-noon discharges and provider-scheduled follow-up appointments may lead to unintended negative consequences and futility. 1,2 In contrast, weekend discharges, which were often viewed to be unsafe, may reduce lengths of stay without compromising care even in high-risk patients. 3 Having obfuscated the line between good and bad, we can now turn our attention to the ugly.…”

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confidence: 99%

Postdischarge Emergency Department Visits: Good, Bad, or Ugly?

Banerjee

Greysen

2018

Journal of Hospital Medicine

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The association between discharge before noon and length of stay in medical and surgical patients

Cited by 33 publications

References 3 publications

The Association of Discharge Before Noon and Length of Stay in Hospitalized Pediatric Patients

The Association of Discharge Before Noon and Length of Stay in Hospitalized Pediatric Patients

Systematic identification and management of barriers to vascular surgery patient discharge time of day

Postdischarge Emergency Department Visits: Good, Bad, or Ugly?

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