While you are all busy out there developing your discharge planning checklists that we talked about in our Patient Safety Tips of the Week for April 7, 2009 “Project RED” and April 14, 2009 “More on Rehospitalization After Discharge”, we’ve come across another good checklist tool to facilitate hospital discharge. Last week’s Nursing Times had an article on the “Ticket Home” project (Webber-Maybank et al 2009).
Ticket Home is another checklist-like tool that facilitates communication among many disciplines, somewhat akin to the “Ticket to Ride” tool we’ve described previously for inhospital transports. It is a laminated card that is placed at the patient bedside, easily visible, with sections for multidisciplinary input (eg. PT, OT instructions), information about whether the patient requires transportation home, whether their medication reconciliation has been done and followup appointments scheduled, and a section for planned date of discharge. The latter, of course, is estimated early in the admission and has to be updated regularly. The Webber-Maybank study, done at an orthopedic hospital, was associated with about a 20% sustained reduction in length of stay.
The concept is actually a throwback to the 1990’s, when “clinical pathways” were the rage. Many of us spent hours and hours in the ‘90’s developing clinical pathways for clinical problems most commonly seen in our facilities. We later concluded that they were successful primarily because of the standardized order sets we attached to them and the other things we implemented to facilitate them (such as nurse case manager programs). However, one of the good things about clinical pathways was that we usually also gave a modified copy of the pathway to the patient. That helped both the patient and the family better understand what to expect during the hospital stay and anticipate what goals need to be met to move on. We found that these often brought out the competitive spirit in our patients. They strove to meet those goals or be ahead of them. As early as the day of admission (or pre-admission for elective surgery cases), we would show the patient when and to where we anticipated they’d be discharged. Of course, Ticket Home is doing the same thing. Using that anticipated date of discharge is also very helpful for the patient’s family or other caregivers. They can plan their availability around that anticipated date.
The Ticket Home concept works well for discharges after certain types of admission. You can all readily see its potential for many orthopedic admissions. It is obviously much more difficult to anticipate the date of discharge for many medical admissions. But that should not dissuade you from adopting the Ticket Home concept because you will continuously be updating the anticipated discharge date.
The Ticket Home project had two very desirable offshoots as well – weekend discharges increased and the number of patients being discharged prior to 12 noon increased.
We often see hospitals with lots of discharges happening in late afternoon. We say “That’s great! Must mean your doctors are doing a second set of rounds and getting patients discharged a day early?”. (Laughter ensues). Wrong…they should have been discharged this morning. Now they are being discharged later in the day, often around the time of nursing change of shift or physician signout, and when staffing levels may be lower. Those are factors that may contribute to fumbled handoffs at discharge. And now your housekeeping staff may also be increasingly taxed to turn around that patient room. And then there is the cascade effect where admissions from the emergency department or transfers from the ICU’s are delayed because of bed inavailability on the floors, creating bottlenecks throughout the system.
So enter another ‘90’s tool-gone-by-the-wayside “the discharge lounge”. The discharge lounge takes its origin from the hotel industry. You all know the rules – the hotel checkout time is 11 AM or 12 noon. That’s how they maximize use of their rooms. But they add amenities to help you. If you are attending a conference, for example, and won’t be leaving until later in the day, the hotel usually provides concierge service to at least check your luggage and provide a comfortable place to wait.
So the discharge lounge concept is the same. Patients who are awaiting transportation home can be formally discharged and then wait in a designated area that is appropriately staffed and provides amenities. The area should be quiet and provide privacy and be convenient to the person who will be providing transportation to the patient. The chairs should be comfortable and there must be ready availability and easy access to bathrooms. Provision of beverages and light snacks is typical. There need to be activities for the patients (eg. TV, computer access, magazines, etc.). When you eventually have your own “Louise” virtual nurse discharge advocate that we noted in our Project RED columns, your patients could play those interactions over and over as many times as they want while waiting in the discharge lounge, too. Your brochure should include a phone number for the family or caregiver to call though your hospital operator should also be able to connect them to the discharge lounge (maintaining all HIPAA requirements as if the patient were an inpatient).
Staffing of a discharge lounge is variable, both by facility size and type and in some cases by state regulations. This is a great place to utilize your hospital volunteers. They can provide most of the necessary services. Since many of the patients may have difficulty ambulating, you must have some staff who are trained and competent in helping patients ambulate or moving them in wheelchairs. Many discharge lounges will help the patient get their medications by faxing copies of the discharge prescriptions to the pharmacy the patient requests. In those that have an inhouse outpatient pharmacy, those prescriptions may be filled while the patient waits in the discharge lounge. Some discharge lounges help patients schedule followup appointments. However, if you are a Project RED believer you will have already done all that before the patient leaves the floor! Whether you need an RN or not depends on your circumstances. Certainly, larger hospitals that will expect multiple patients waiting in the discharge lounge will want to have RN staffing or at least ready availability of RN’s. This is also where specific state requirements may mandate RN coverage. However, remember that these are patients who are already formally discharged from the hospital. They are usually expected to be able to manage things like their medications themselves at home. But not all are capable of that and that is where an RN may be helpful in the discharge lounge. Either way, you must anticipate that a patient in the discharge lounge is likely to have some medication needs while waiting so you must either ensure they have brought their own medications or ensure that they were provided before the patient was discharged.
The discharge lounge must be desirable in terms of location and aesthetics and staffing so that physicians and nurses feel comfortable in doing morning discharges. Your biggest sales challenge is usually not to the patient and family but rather to your physicians and nurses. But remember – the two biggest factors in patient/family satisfaction with a hospitalization are (1) what happens on entering the hospital and (2) what happens on leaving the hospital. You clearly want to make a good impression on both the patient and their family when they are going home. And a good discharge lounge program may also improve satisfaction on the front end by relieving ED bottlenecks. Discharge lounges aren’t for everyone but you should do a cost-effectiveness analysis and see whether they make sense for your organization.
Webber-Maybank, M., Luton, H. Making effective use of predicted discharge dates to reduce the length of stay in hospital. Nursing Times 2009; 105: 15 (early online publication)