Filling in The Gaps: 5 Ways Sacred Heart Hospital Streamlined Discharges
1. Create a discharge process deployment guide. At Sacred Heart, physicians and nurses abide by a discharge process guide that Ms. Peiffer jokes "is kind of our Bible." The guide includes a multitude of chapters that range from definitions of standardized roles, forms and discharge instructions for specific patient populations. Ms. Peiffer says the upfront planning and creating of the guide may seem onerous to hospitals that haven't established one yet, but the benefits of such a guide far outweigh those apprehensions.
"I created this discharge process guide, and our nurses use it frequently to double check discharge instructions for patients being discharged to their home or a skilled nursing home," she says. "It's been incredibly useful for us, and it's also available on our intranet."
Ms. Peiffer adds the discharge process deployment guide is a work in progress that "keeps getting a little bit better."
2. Establish projected discharge dates. Every discharge process needs to start somewhere, and that starting point should be establishing projected discharge dates, Ms. Peiffer said. Projected discharge dates should be well-established upon every patient's admission so that his or her care process is streamlined and executed in a timely manner. Projected discharge dates will vary procedure-to-procedure and will also be based on each patient's severity of condition. For instance, a patient scheduled to undergo a revision of a hip or knee revision (depending on any complications) has a projected discharge date of 3-7 days, Ms. Peiffer says.
A comprehensive list of DRGs and associated geometric mean length of stay has been formulated by the Centers for Medicare and Medicaid. Hospitals can use this information to establish projected discharge dates for patients. At Sacred Heart Hospital, nurses took it one step further during a pilot project and wrote every patient's projected discharge date on a white board in his or her room.
"We started piloting this in November in our orthopedic and surgical units. We write [these projected dates] on the white boards so patients and families know what date they can go home," Ms. Peiffer says. "This way, the caregivers also know exactly how to plan for the patient's care in that time period and get all the prep work done before discharge. Physicians can write their orders the day before the discharge, and the unit coordinator can begin making appointments and enter orders, such as for diet and activity, into discharge instructions for patients to prepare for next-day discharge."
The most obvious downfall of not projecting a discharge date is an unorganized discharge, which can lead to a disgruntled and unhappy patient. However, Ms. Peiffer also noted projected discharge dates are exactly that — projected. Physicians and care givers may change those dates if necessary and alert patients in a timely matter.
3. Weave patient education throughout the patient's stay. After the projected discharge date has been established, physicians, nurses and other caregivers must formulate a patient education program that is ongoing and easily understood by patients. Ms. Peiffer says nurses on Sacred Heart's pilot units start education on patients' first full day and weave that education throughout their stay.
The nurses rely on a set of tools to ensure patient education is effective and meaningful, Ms. Peiffer says. Those tools include a module comprised of specific information on a particular procedure and patient self-management, such as wound care and diet. Nurses also utilize the "teach back" method to ensure patients fully understand how to take care of themselves once they are discharged. This method calls on patients to repeat back what has just been explained by the physician or nurse. Published research has shown that this method can reduce the incidence of unnecessary hospital readmissions.
Patient education can extend beyond nurse caregivers as well. A new pilot project at Sacred Heart that recently got off the ground is similar to the nurses' patient education system but instead involves the hospital's on-site pharmacists. Ms. Peiffer said the hospital is still working through the initial stages of the pilot, but for now the pharmacists visit pre-determined "high risk" patients before their discharge to double check for home medication checklist accuracy and patient understanding. The meetings are designed to prevent medication errors.
4. Maintain ongoing communication of care with staff members. The discharge process occurs while clinicians are caring for other patients, which makes the continuum of care that much more complex, Ms. Peiffer says. In order to sustain a smooth continuum of care for every patient, Sacred Heart caregivers hold interdisciplinary meetings to ensure providers are on the same page about every patient in their unit. The meetings so far have successfully helped reduce delays in care and maintain smooth transitions in between hand-offs and during discharges.
"These interdisciplinary meetings are a chance to give a clinical snapshot of each patient's condition, such as vital signs and abnormal lab results," Ms. Peiffer says. "These meetings are short and to the point. For our hospital specifically, it helped to have a charge nurse facilitate to ensure it is a meaningful meeting with key things that are routinely shared."
5. Evaluate the entire process of care to ensure a safe and positive discharge process. The aforementioned strategies are all smaller pieces of a larger picture to ensure safe and positive patient care, and in order to truly achieve optimum results hospitals must make time to take a step back and evaluate the entire care process, Ms. Peiffer says. For her part, Ms. Peiffer once followed a nurse for six hours to evaluate her workload and behaviors. This allowed her to look for steps that can be cut out or gaps that can be filled to make the care process smoother.
"I am constantly looking for ways to streamline care processes for nurses. So if I find, for example, nurses are running into the kitchen to fill water pitchers for medication every day at noon, we'll want to take steps [to smooth that out]," she says. "If you just focus on the discharge process alone, you might not see staff members are taking more steps than needed in the overall care process."
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