At Stony Brook University Hospital, there was a much lower rate of early discharge from resident-led medical teaching services versus nonteaching services, which negatively affected the hospital's overall rate of early discharge, said Nirvani Goolsarran, MD, FACP. “It has to do with workflow and rounding style. . . . That was the root cause, and we thoroughly analyzed it and decided that our workflow needs to be changed,” she said.
The workflow had entailed trainees prerounding at 7 a.m. and receiving new admissions. Discharges wouldn't happen until after they finished rounds in the afternoon, Dr. Goolsarran said. As associate program director of the internal medicine residency program, she led a multidisciplinary intervention to restructure rounds to allow for more early discharges.
How it works
The intervention had three main components. The first was education, since early discharge was not initially a priority for residents, said Dr. Goolsarran, who is also an associate professor of clinical medicine and associate vice chair for quality, patient safety, and compliance. “We said, ‘From now on, we are going to focus on moving patients out of the hospital early’” and explained the benefits, such as reducing ED overcrowding and improving patient flow, she said.
Second, the teaching services implemented new rounds, in which the residents round with their attending, often around 4 p.m. after regular rounds are completed, and plan for next-day discharges, Dr. Goolsarran said. These “walk rounds” took an average of 20 to 30 minutes and were key for proactively arranging for early discharge, she said.
The third and final piece of the intervention was a multidisciplinary discharge huddle. “As soon as walk rounds is completed, we walk straight to a conference room that has all of our case workers and social workers . . . and tell them, ‘This is our list. We believe these patients can be ready for tomorrow. Can we prioritize for early discharge?’” said Dr. Goolsarran. “They then [do] a lot of work behind the scenes to get those patients out the following day.”
In 2017, before the intervention, 12% of the teaching service's discharge orders were before 11 a.m., and that rose significantly to 29% after the intervention, with no change in readmissions, according to results published online in December 2019 by the Journal of General Internal Medicine.
Sixteen of 29 (55%) residents agreed that the early-discharge initiative helped them understand the importance of prioritizing patients for early discharge. However, 20 of 36 (55%) residents reported that the intervention compromised their learning during teaching rounds. “I wish we'd done more follow-up because . . . let's say they're entering clinical practice. How does this initiative benefit them then? That's the true value of teaching because now they're expected to have this metric across many institutions,” Dr. Goolsarran said.
Length of stay did significantly increase under the intervention (by 1.47 days), but because it also increased on the nonteaching teams, which were not subjected to the intervention, “I don't know that we could say it was attributable to the intervention,” she said.
Overall, the biggest challenge was balancing clinical education with institutional requirements, such as early discharge. “I think that's so tough to do, and I think many programs struggle with this. . . . To overcome this challenge, I think educators have to understand the importance of the quality metrics and the difference it makes in patient care and patient flow,” she said. Another challenge was getting buy-in from residents, who have less of an understanding of quality metrics than attendings, said Dr. Goolsarran.
The team used several resident champions to engage their peers. “I think that's a key success for this initiative. . . . They were reminding them to do the huddles, they were checking in, and they were physically present,” said Dr. Goolsarran. She added that program director support is also important “because that's the key to converting this to an educational initiative and not just an institutional metric.”
The early-discharge initiative has now become the standard for the hospital's medical teaching services. “Going on its third year, our current teaching discharge rate mirrors, if not better than, our nonteaching discharge rate,” she said. “It has become the culture. Now when I start rounding, they are expected to start with the early discharges, and we as the attendings don't have to ask anymore.”
Dr. Goolsarran also developed a direct-observation tool that measures residents' education and counseling to the patient during the discharge process. “We routinely start rounds by choosing a discharge patient to educate. This helps us to ensure that the discharge process is an educational part of rounding,” she said. “Because of the feedback, I wanted to make sure that education, or at least that perception of education, is not further compromised.”