Turning over the Beds – How Optimizing Pre-Discharge Patient Teaching Reduced Discharge Delays in the Inpatient Hospital at Dana-Farber Cancer Institute and Brigham and Women's Hospital

Abstract

<h3>Introduction</h3> With rapidly increasing demand at academic medical centers, inpatient resource allocation is a critical focus. Patients receiving autologous stem cell transplant (ASCT) often face complicated discharges, requiring lengthy day of discharge teaching sessions from nurses and dietitians that may cause delays in discharge time. We queried if streamlining the complex discharge process by scheduling teaching appointments in advance would reduce unnecessary delays in discharge. <h3>Methods</h3> An interdisciplinary committee reviewed existing workflows with relevant stakeholders. Process improvement methodologies, including value-stream mapping, were utilized to reduce variation and delays. New teaching workflows ("discharge pilot") were implemented using a model line approach to iteratively test operations on 1 inpatient pod and were later rolled out on 4 (of 10) pods. After IRB review, patients were allocated to receive the discharge pilot based upon admission to one of these pods. Discharge time was compiled to assess impact. <h3>Discharge teaching before</h3> Typically, discharge teaching was completed on the day of discharge as clinicians waited for caregivers to arrive, contributing to delays; teaching took 2 hours. Information given in teach sessions varied greatly between clinicians. Beyond poor utilization of staff, patients and caregivers reported they could not retain critical information as they were prepared for discharge. <h3>Discharge Teaching Workflow Redesign</h3> Teach content delivery was standardized using templated guidelines for home and medication preparation. A provider checklist (Fig 1) was created specifying when to complete discharge readiness tasks. Specialized posters were hung in patient rooms for provider documentation and to engage patients and caregivers on their care journey (Fig 2). Nurses distributed caregiver requirements prior to the teaching appointment and caregivers were notified of required attendance. Teaching appointments were scheduled 2-3 days prior to discharge. <h3>Resulting change in discharge timing</h3> Between Jan. – Sep. 2019, 58.8% of patients receiving pilot (advance) discharge teachings (n = 68) discharged before 2pm (range 10:27a – 7:01p). During this same time, only 39.7% of patients receiving no discharge intervention (n = 68) discharged before 2pm (range 11:29a – 11:30p) (p = 0.0257) (Fig 3). <h3>Conclusion</h3> Scheduling discharge teaching for patients and their caregivers in advance increased discharges from the hospital before 2pm, significant for operational improvement. This optimized staff resource utilization and allowed for more efficient bed turnover. Other factors like central line removal and transfusion timing should be examined. We are now examining satisfaction and anxiety during discharge when advance teaching is performed. Further research should assess precaution adherence for this intervention.