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Targeting tomorrow’s discharges today

Aim for what is possible, not what's typical

September 2020

AS CORONAVIRUS swept through the Northeast this spring, an early draft of this article focused on how decreasing length of stay could effectively boost bed capacity in anticipation of dire shortages. Then, as now, despite elective procedures being cancelled and dramatic reductions in volume for usual care, many regions were stretched to—or beyond—their limits by an overwhelming influx of sick patients.

The combination of cancelled high-revenue surgical cases, outsized costs for covid care, and the drop in non- covid-related ambulatory, ED and hospital volumes has financially crippled U.S. health care. While estimates vary, a report from the American Hospital Association issued in June projected 2020 losses for hospitals and health systems of $323 billion.

Efforts to enhance revenue by safely bringing back volume continue. In the meantime, it has become all the more crucial to manage utilization appropriately. While specific strategies may vary for each facility, a general goal of more timely discharges will trim costs for pharmacy, nursing and ancillary staff. And given the nature of hospitals’ bundled fee structure, appropriate discharges may convert non-reimbursable in-house imaging studies and procedures to separately billable outpatient services. That could help transform costs into revenue.

If a patient is stable in your medical judgment, don’t wait hours for a consultant to come and validate your own expertise.

Here are five tips that can improve length of stay by reducing avoidable delays. They emphasize communication and better stewardship to enhance bed capacity.

Ask “Why not today?”
When you’re identifying barriers to discharge, make sure those are as specific as possible, then commit yourself to resolving them. Does your patient truly need to stay for an MRI that can’t be done until tomorrow? Can you wean the patient from oxygen or advance the restricted diet (or safely maintain it for the near term)? Is there a reason any of these can’t be done in another care setting outside the hospital?

Many hospitals hold morning interdisciplinary rounds. During rounds, it’s easy to make disposition decisions that may unnecessarily commit the patient to “one more day.” What happened to the rest of today? A snapshot encounter at 8 a.m. may not reliably predict how the patient will look and feel by mid-afternoon. Rather than closing the door on discharge prematurely, leave open the possibility that over the course of the day the pa- tient may improve and be well enough to leave.

Recognize trends toward improvement/wellness
We often keep patients an extra day for extended monitoring and additional testing or consults. Why? Sometimes, it’s out of a sense of duty (first do no harm), or it’s inexperience, fear or lack of confidence. But we don’t need 95% clinical certainty. If a patient with UTI, fever and leukocytosis has responded well to our IV antibiotic of choice, that’s likely the appropriate regimen. We can convert the patient to an oral medication of the same class instead of waiting for pristine labs, vitals and confirmatory cultures.

Similarly, the dehydrated patient with resolving symptoms and labs who’s tolerating a liquid diet is very likely to recover—even without continued hospital-level care. Use your clinical judgment and common sense, and always give patients strong anticipatory guidance about what symptoms to watch for that would indicate a need to return.

Accelerate communication with consultants
We often hear, “Let’s see what consultant A has to say” or “They can go as long as they are cleared by consultant B.” We need to change this passive stance and be proactive about what a consultant needs to tell us and why.

If a patient is stable in your medical judgment, don’t wait hours for a consultant to come and validate your own expertise. Send a secure text, pick up the phone or otherwise escalate the case by saying, “Ms. Smith looks good. I’m sending her home with ABC, contact me with concerns.” By the same token, actively reach out if you need directives to progress care. By doing so, you jump-start the care plan and shrink delays. You may even avert a formal consult for a specialist who is stretched too thin.

Top-of-license care, with warm handovers
Many SNFs or home care providers have untapped capabilities. Having them provide IV meds, wound care and palliative services can lighten your load and allow acute care hospitals to prioritize care for the sickest patients.

In my first job out of residency, I found myself doing a task that a senior provider observed and then advised: “If it doesn’t require the letters MD after your name, ask whether someone else can do it.”

In this spirit, ask yourself and the care team whether a patient absolutely needs to be in the hospital or if appropriate care could be done elsewhere. With the right advance notice, equipment, expectations and communication, hospitalists can provide warm handovers to primary care physicians and nursing facility medical directors. That should address their concerns and promote safe transitional care plans.

It is critically important to reimagine timelines and ways around constraints. By challenging the traditional mentality of discharge readiness and operations, we can redefine what is possible and help further the recovery of our health systems.

John Krisa, MDJohn Krisa, MD, is a former regional medical director for a national hospitalist group. He currently serves as a physician advisor for St. Peter’s Health Partners, a large integrated health system in the Capital District of New York. You can contact him at johnkrisa@hotmail.com

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January 2021 3:35 pm

I am family member awaiting d/c loved one from 20+ day Covid pneumonia…..it has been put off and put off several times. As a retired RN, I know how much is involved in this decision. but most lay folk do not – please keep family in loop.

Juliet B. Ugarte Hopkins, MD, CHCQM, Linked In
Juliet B. Ugarte Hopkins, MD, CHCQM, Linked In
September 2020 1:13 pm

Excellent points. More providers need to step away from the culture of making discharge decisions at morning rounds. There’s a whole day to solve barriers and for the patient to clinically improve!

Darlyn Victor, MD, Linked In
Darlyn Victor, MD, Linked In
September 2020 1:14 pm

I agree 100%! Discharge planning should start as early as on the day of hospitalization.

Jonathan Hart, MD MBA, Linked In
Jonathan Hart, MD MBA, Linked In
September 2020 1:53 pm

Agreed, Dr. Victor! I’ll go one better, though, and say that in a world of Value-based Care, the discharge planning started before the admission, when the provider, pop health team, and CM team identify medical, social, and behavioral risks, addressing them in a plan of care. If the admission is unplanned, it merely leads to a modification of the patient’s existing plan that considers and addresses that patient’s individual challenges.

Darlyn Victor, MD, Linked In
Darlyn Victor, MD, Linked In
September 2020 1:54 pm

Excellent point, Dr. Hart! Culture change is probably one of the biggest barriers to any health system. How do we achieve the value-based care experience you just described? Cross-silo (horizontal) leadership!

Tricia ScheunemN
Tricia ScheunemN
October 2020 7:07 pm

These points are well known to any hospitalist. Primary care teams continuously address discharge planning. I am not sure exactly where the daily attempt to discharge and find lower levels of care for seamless integration doesn’t happen. Yet it is still a daily topic if discussion, begging one to ask whether the data is actually reviewed and if there are actually true barriers to discharge.