Discharge lounges done right

Studies show how to make these waiting spaces useful, even in a pandemic.

Discharge lounges have been used for decades at busy hospitals to alleviate overcrowding, offering a comfortable waiting area for patients who are ready for discharge but await transportation home and freeing up inpatient beds for those newly admitted or boarding in the ED.

“If a patient is ready to go home at 10 a.m. but their family can't pick them up until 6 p.m., it may make sense to have them wait in a designated lounge area rather than take up an inpatient bed,” said Brian Franklin, MBA, a medical student at the University of Michigan in Ann Arbor and lead author of a study on discharge lounges published in the June 2020 Annals of Emergency Medicine.

Image by Getty Images
Image by Getty Images

However, discharge lounges are not the solution to every hospital's overcrowding problem. Key determinants of their value include the number of patients likely to use them, the causes of bed shortages, and staff buy-in. Experts experienced with lounges offered their insight on these issues, optimal implementation practices, and pandemic-related modifications.

Research causes, set goals

Because discharge lounges aren't right for every facility, figuring out the root causes of a hospital's overcrowding or boarding is a necessary first step.

For example, if patients are waiting for medications to take home with them, having medications delivered to the lounge could be a solution, according to the Annals of Emergency Medicine study. However, hospitals should examine other variables, such as whether they are synchronizing discharge-related activities to avoid delays (for example, ordering patient transport from the ED when room cleaning starts, as opposed to when a room is ready).

They also need to make sure there will be a regular stream of patients using the lounge. “You need a large enough population of patients in that category to make discharge lounges cost-effective,” said Mr. Franklin.

Hospitals must also overcome common barriers to implementation, which may include reluctance among needed participants, such as nurses, based on concerns about issues such as patient supervision.

“Our nurses were key to ensuring that implementation was a success,” said Regine Thigpen, RN, executive director of nursing acute care for 633-bed Wellstar Kennestone Hospital in Marietta, Ga. “There was a learning curve when the facility first opened, but our nurses quickly adapted to providing the same level of care to patients in our discharge lounge.”

Since opening its discharge lounge in 2017, the hospital has saved an average of 200 bed-hours per month in time that discharged patients spent in the lounge rather than occupying a bed, she reported.

Involvement of nurses in the design and implementation of lounges is key to realizing their potential, according to research. One study published in the July/September 2020 Journal of Nursing Care Quality, for example, found that use of the discharge lounge at a large academic center increased significantly after the hospital implemented several interventions based on feedback from the nursing staff.

At OSF-Saint Francis Medical Center, a 649-bed hospital in Peoria, Ill., staff embarked on a months-long study of best practices across the country before relaunching its discharge lounge, said Mary C. Fisher, RN, MS, MSN, director of clinical operations. Their research aimed to improve upon their previous efforts, which had resulted in the discharge lounge being underused.

They found that successful programs tend to share a few common characteristics, such as staffing the lounge with registered nurses and working closely with clinicians on the floors to fit the discharge lounge into existing workflows.

“We now have three registered nurses and a medical history specialist in our lounge to assist with paperwork,” said Ms. Fisher. “We send out a nurse to help with admissions and discharges when nurses on the floors get busy—something that has helped immensely with turning over beds.”

Another critical piece of building trust with nurses is clear communication about patient eligibility criteria and the level of support available in the discharge lounge, according to the Annals of Emergency Medicine findings. Most discharge lounges accept patients who are ambulatory, being discharged to home, and free from serious behavioral issues. Still, nurses may be reluctant to send some patients who fit the criteria due to safety concerns, such as how patients will be moved to the lounge.

The system works best when nurses view the lounge as a “continuum of care and support to the bedside nurse,” as opposed to an added burden, according to findings in the Journal of Nursing Care Quality study. Educational efforts, such as brochures and in-service training, can help clarify the goals of the lounge and address any fears or misconceptions about the level of service provided.

Even when clinicians are on board with the concept and clear about eligibility criteria, more proactive efforts may be necessary to ensure that the lounge is actually used, noted Ms. Fisher.

“Getting people in the mindset of moving patients out of their rooms, that was the biggest challenge for us,” she said. “Now, if we see a patient is ready for discharge, we ask what the holdup is. . . . We've had to be very persistent to make it successful.”

At Brigham and Women's Hospital, a 793-bed teaching hospital in Boston, the discharge staff takes steps to make moving to the lounge as easy and convenient as possible for staff and patients, said Samantha Andreasen, MSN, RN, interim nurse director.

“On busy days we dedicate a member of our transport team to moving patients from the floors to the discharge lounge,” she said. “We also send out periodic reminders to staff about the discharge lounge and what it offers, so that it stays in their minds.”

Wellstar Kennestone uses a deployment strategy to encourage use of the discharge lounge, said Ms. Thigpen. During busy times, a nurse from the lounge is deployed to the floor to assist with paperwork, such as going over discharge instructions with patients.

“Once the [floor] nurses saw that we could actually lessen their workload and help discharge patients sooner, they bought in to the concept quickly,” she said. In addition, use of the discharge lounge is discussed on rounds the day prior to discharge so that the patient is well-informed about the discharge process and ready to go there the next morning.

Making it work for patients

When implemented effectively, discharge lounges can make clinician workflow more efficient and enhance the patient experience, noted Ms. Thigpen. Discharge lounge staff can take care of tasks such as making follow-up appointments, reviewing discharge instructions, ordering prescription refills, and helping patients log into patient portals.

“Instead of [patients] waiting in their rooms to go over discharge instructions, we provide a comfortable and safe area where they can relax, watch television, and have snacks until their ride arrives,” she said. “We want the lounge to be a place where patients get what they need and want before leaving the hospital, rather than just another required stop.”

Discharge lounges can also reduce the time and cost burden on families picking up patients at hospitals in busy metropolitan areas. At Brigham and Women's, for example, the discharge lounge is located centrally in the main lobby and staff bring patients out to family members parked in the nearby valet area.

“Families appreciate that they do not have to pay to park, find their way up to the patient's room, and maneuver through elevators to get back to their car,” said Ms. Andreasen. “We have also given out parking vouchers when patients need to come back for a follow-up visit.”

The location of the lounge can also be a determinant in how much it gets used, noted Ms. Fisher. At OSF-Saint Francis, the lounge is situated next to the short-stay or observation unit, which has led to almost all of those patients being discharged through the lounge, she said.

How long patients spend in lounges can vary from a few minutes to five or six hours. Volume fluctuates along with demand for inpatient beds, ranging, on average, from a few patients to 10 or more per day, the experts said.

Restrictions related to COVID-19 have forced discharge lounges to make some modifications, such as individualizing food and snack options, eliminating magazines and other shared reading materials, and allowing more time for cleaning between patients.

At OSF-Saint Francis, for example, the lounge expanded into a nearby meeting room to allow for social distancing, while Brigham and Women's limited capacity of their lounge to three patients at a time. Wellstar Kennestone opened a separate, isolated lounge area for discharged patients recovering from COVID-19.

No matter the precise specifics of a hospital's discharge lounge, however, keeping it running efficiently depends on integrating it into the hospital workflow and providing a positive patient experience, said Ms. Thigpen. For the hospital's staff, the discharge lounge is now an important part of the planning that starts at admission, she said, while patients have come to enjoy the services provided.

“The discharge lounge was a huge and positive change in our process,” she said. “Our regular patients immediately noticed the difference and quickly came to appreciate services such as scheduling a follow-up appointment and filling prescriptions. The discharge lounge is a big win for our patients. It's less they have to worry about.”