IT’S BECOME THE GO-TO TACTIC in many hospitals to try to speed up throughput: having hospitalists prioritize early discharges to clear out beds. Morning discharge rates have even become a common item in hospitalist bonus plans.
But does rounding on discharges first actually improve throughput? Previous studies—all observational—have delivered mixed responses to that question. Some research finds that targeting early discharges may increase length of stay by disincentivizing doctors to do discharges later in the day.
For a more definitive answer, Marisha Burden, MD, division head of hospital medicine at the University of Colorado Anschutz Medical Campus in Aurora, Colo., helped devise the first randomized controlled trial to look at prioritizing rounding first on patients expected to be discharged. (The controls were hospitalists using their usual rounding practice.) The goal was to see if that rounding strategy reduced length of stay.
“What do we need to work on and test next to actually drive better outcomes?”
Marisha Burden, MD
University of Colorado Anschutz Medical Campus
But as published in the April issue of the Journal of Hospital Medicine, Dr. Burden and her team found no significant difference between the two study arms in terms of length of stay. Throughput, in other words, stayed the same.
“It’s easy to get caught up in trying to do something even if it’s non-evidence-based,” Dr. Burden says. “Based on this randomized controlled trial, this tactic doesn’t work.”
Moreover, based on the qualitative comments from hospitalists enrolled in the trial, rounding first may actually cause harm and inefficiencies. “So we have to ask ourselves: What do we need to work on and test next to actually drive better outcomes that benefit patients and the workforce?”
Neither Dr. Burden nor her research colleague Angela Keniston, PhD, MSPH, director of data and analytics for the hospital medicine division at the University of Colorado Anschutz, were surprised that no randomized controlled trials had yet tested the effectiveness of early discharges. That’s because such trials on operational practices come with a lot of challenges.
The study was carried out across three academic centers during six months in 2021. Thirty hospitalists were assigned to prioritizing rounding first on patients with anticipated discharges, while 29 rounded in their usual style. Before the study began, fewer than 4% of physicians in either group said their most commonly used rounding style was discharges first.
Going into the study, based on their own experience and their previous research around discharges, Dr. Burden and her colleagues expected a 50% nonadherence rate among doctors assigned to prioritize discharges first.
“Think holistically about what the downstream effects of an intervention may be.”
Angela Keniston, PhD, MSPH
University of Colorado Anschutz Medical Campus
“As a frontline clinician, you have to weigh a lot of things you need to get done,” she points out. “While we may intend to get patients out the door as quickly as possible, that’s not always practical or feasible. Sometimes, sick patients require our attention first or we have other priorities such as calling consultants or ordering more urgent tests.”
Sure enough, in the arm assigned to rounding on discharging patients first, physicians actually started their rounds seeing patients they expected to discharge only 48.5% of the time. Fortunately, each physician in the study filled out a brief survey after each shift.
“We needed that daily survey so we could understand under what conditions physicians abandoned their assigned strategy of rounding on discharging patients first and why,” Dr. Keniston says.
The comments doctors left in their daily surveys are a gold mine of insights into both the discharge barriers that hospitalists run into and the setbacks that prioritizing early discharges can potentially cause.
One doctor commented that the rounding team abandoned early discharges to visit sicker patients first; doing otherwise “could have been seriously harmful.” Other physicians noted that discharges were delayed for a host of reasons: consultants hadn’t signed off, lab results weren’t ready or families didn’t agree with the discharge plan.
Doctors also had these objections to prioritizing discharges: “tons of extra travel time,” and “It feels really inefficient to round on discharging patients in far satellite units during high-capacity times when our service is full.”
“In hospital operations, think holistically about what the downstream effects of an intervention may be,” Dr. Keniston points out. It was clear, for instance, that doing discharges first sometimes caused physicians to have to circle back to those same patients later in the day.
Dr. Burden points out that hospitalists are acutely aware when their hospitals are full. Multiple reminders via e-mail or text blasts that “The hospital is at X capacity, please prioritize discharges” are unlikely to lead to earlier discharges.
“Those communication strategies tend to be disruptive,” she says. “When you’re already working hard, it’s not a value add.”
Work designs and team structure
The study’s message, Dr. Burden notes, “is not per se to not prioritize discharging patients.” In fact, that rounding strategy may on some days be an appropriate strategy. Instead, the take-home message is to tailor the day based upon actual priorities.
“Think about your day as a whole and what you need to do first to take the best care of your patients,” Dr. Burden says. “Prioritizing discharges on some days may make the most sense while seeing the sickest patients first makes the most sense on others.” Focusing on a specific time to target discharges to is a misguided strategy, she thinks. Instead, she wants to design—and test—different strategies that support clinicians in real time.
“What is the optimal work design and workload?” she asks. “What’s the best team structure that drives the best outcomes?” Having—or not having—a stable team of nurses is yet another variable. “We have to figure out the best way to build all these key components into daily operations to support our teams.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
Published in the May/June 2023 issue of Today’s Hospitalist