Patient Safety Tip of the Week
April 28, 2009 Ticket Home and Other Tools to Facilitate Discharge
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.
References:
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)
http://www.nursingtimes.net/5000511.article
http://www.patientsafetysolutions.com
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