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Before 11 a.m. discharge: These units know what time it is

Toronto, May 6, 2015

By Emily Holton

Barb Hooper and Arleen Guerrero hold a sign with a patient’s estimated date of discharge
Case manager Barb Hooper and Arleen Guerrero, registered nurse, plan a patient’s discharge in Hematology-Oncology. Beside every bed in Hematology-Oncology is a laminated sign with the patient’s estimated date of discharge and a note reminding them to arrange a ride home. (Photo by Katie Cooper)

Since the hospital renewed its focus on “before 11 a.m. discharge” (or B.E.D. if you’re in the know) in 2014, several units and programs have found new ways to get patients ready to go home sooner. The results have been remarkable.

The impact of an earlier discharge – by just a few hours – is surprisingly great. Emergency Department volumes peak around 1 p.m., so having a few more free beds on the wards after lunch can prevent major bottlenecks for ED patients waiting to be admitted.

The Hematology-Oncology Unit has improved its B.E.D. by more than 10 per cent in just a few months. Case manager Barb Hooper attributes that success to physicians and staff championing the right recipe of tools and initiatives, including one to make sure patients have a ride home arranged ahead of time.

An audit of late discharges showed Hooper that rides home were a big issue and that patients and families needed help planning ahead. Hooper introduced a laminated sign to be posted beside every bed in the unit, with the patient’s estimated date of discharge and a reminder to arrange a pickup for 10:30 a.m. that day.

“Now, we can identify and address barriers and concerns about going home ahead of time,” said Hooper. “We’re having fewer conversations on the day of discharge.”

The General Surgery, Gastrointestinal and Plastics Units have tackled the same issue. The units’ physicians start the conversation with patients about their date of discharge and ride home, and staff reinforce those messages for patients throughout their stay. Up to 75 per cent of patients in General Surgery are now discharged before 11 a.m.

  Different areas of the hospital have different targets. The hospital’s overall goal is to make sure that as many as discharges as possible happen before 11 a.m.

Both Hooper and Joanne Bennett, the clinical leader-manager for General Surgery, Gastrointestinal and Plastics, say that weekly performance data from the hospital’s Decision Support team has helped inspire their teams. Hematology-Oncology posts its progress over time on a graph in the report room, and the team reviews the numbers at huddles and at inter-disciplinary rounds. In General Surgery, B.E.D. data is a weekly agenda item at all staff and surgeons’ meetings.

“We take pride in our B.E.D. performance,” said Bennett. “No one wants a late discharge on their watch!”

The Cardiovascular Unit has boosted its B.E.D. performance from 19 per cent in the fall to about 50 per cent. They began with a brainstorming session, when the multidisciplinary team listed the unit’s barriers to B.E.D. Some solutions were simple, such as making sure the patients’ discharge papers were in their charts the night before. Some required more investigation and evaluation, such as a new approach to the medication schedules that patients take home with them.

Cardiovascular surgery nurse practitioner Marnee Wilson re-evaluated her own practice, and how her decisions can affect a patient’s discharge time. Every day, Wilson reviews her patients’ estimated dates of discharge.

“I go down the list and think, what do I have to do before we can get this person home,” said Wilson. “Have I completed the discharge summary, what tests do I need to order, does this patient need a physio assessment or education around medications before they can leave? I can make sure those visits are arranged ahead of time.”

About St. Michael's Hospital

St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in 27 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael's Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.