To Alleviate Boarding, Consider Creating Discharge Lounge
By Dorothy Brooks
By late 2022, the ED at Northwestern Medicine Palos Hospital in Palos Heights, IL, was boarding as many as 40 patients a day while they waited for an open inpatient bed. Administrators concluded they had to do something to address the logjam. Patient care was bogged down in the ED, the leave-without-being-seen (LWBS) rate was reaching double digits, and virtually no one was happy with the situation.
To solve the problem, leaders quickly keyed in on the hospital’s discharge process. “We have many patients who go home every single day, but the process of getting them out of the hospital was extensive and could last for hours at a time,” explains Thomas Moran, MD, Palos Hospital’s vice president and chief medical officer. That tied up beds that otherwise could go to all the patients waiting for an inpatient bed in the ED. Finding a way to speed up the discharge process was crucial to helping throughput move again.
Leaders focused on the problem during a regular morning safety huddle. During the huddle, they created a plan to move patients who were ready for discharge to another space closer to the front door of the hospital. They found some free space and created what leaders call the discharge lounge. This lounge is housed within perioperative services, an area where staff already were accustomed to preparing patients to leave the hospital.
Rebecca Murphy, DNP, MBA, RN, CNOR, vice president of operations, worked with employees to find the personnel to staff the discharge lounge. “That’s what perioperative phase two nurses do all day, every day: patient education and making sure patients are understanding [everything they need] to go home,” Murphy explains.
Clinical leaders throughout the hospital were informed about how the discharge lounge would operate. Incident command was instituted to open the discharge lounge. “From that day on, this wasn’t a temporary thing. It wasn’t an emergency thing. This became our standard operating procedure,” Moran says.
The approach accelerated throughput right away. Several months into the new process, leaders note they have shortened the average discharge process from four hours to one hour. In the process, they have halved the ED’s LWBS rate. Further, patient satisfaction scores have begun to rise in both the ED and inpatient settings.
While the benefits from the discharge lounge seem to help the ED the most, Moran says administrators maintained a whole-hospital focus when implementing the approach. “Those patients who come through the ED’s front door need a place after they are done in the ED. It is up to hospital operations to make that happen,” Moran observes. “Ninety percent of all admissions come out of the ED, which is a huge amount of volume.”
Moran notes every unit now understands what the goal is in terms of throughput. That changes the overall situation for the ED. Patients who are admitted can be moved much faster from the waiting room into an inpatient bed. “This causes us to have fewer patients leave without being seen [from the ED]. The wait is what causes people to leave,” Moran says.
Ji Hun Michael Lee, DO, medical director of the Palos ED, explains his department sees roughly 60,000 patients a year in volume. “The one thing that we worry about most are people who are in our waiting room who need to be seen but can’t,” he says. However, since the creation of the discharge lounge, Lee reports the LWBS rate has declined from a high of 12% earlier this year to below 2% in June.
Lee clarifies the lounge only handles discharges from inpatient units. Patients discharged following their ED encounters usually have family members with them, expediting the discharge process in this setting.
In some cases, patients will need to await transport back to a skilled nursing facility, so they typically will experience a longer delay. However, discharges from the ED generally have not been an issue as far as throughput is concerned.
There were challenges involved with making the process stick. For example, some clinicians on the inpatient floors wanted to know why the hospital was so focused on the ED.
“We are not focused on the ED, we’re focused on patients — patients who need a bed, and patients who need to go home,” Moran says. “For those patients who are ready to go home, and they have a discharge order, we’re keeping it as simple as possible, and they’re going out the front door.”
While this message eased some concerns, it illuminated another obstacle: inpatient providers were not entirely pleased with the prospect of taking care of more patients. “Providers didn’t want to move patients to the discharge lounge because that would mean they would get new patients,” Moran explains. “Yes, after you discharge someone, you do get another patient, understanding that that is what we’re supposed to do. It isn’t extra work; it is the work that we do when we come here.”
Moran states hospital leaders have had to re-enforce this message every day.
“If we don’t have a place for the 60 to 70 patients a day coming out of the ED getting admitted, we’re doing a disservice to the community,” Moran says. “We turned [LWBS rates] from 20 to 25 patients down to sometimes zero or two patients. On a high day, there will be maybe five to seven patients.”
Murphy says it is important to refrain from focusing on all the reasons why they cannot do it. “Instead, focus on the reasons why you can, and be creative in trying to push forward,” she says. “There are a lot of reasons not to do it, but we just tried it, it was successful, and it continues to be successful.”
In fact, administrators are planning to make additional improvements to the process that will free up inpatient beds at an even faster clip. For instance, while most of the discharge process still takes place on the inpatient units before the patients are transferred to the discharge lounge, plans are in place to direct staff in the discharge lounge to handle more of those duties.
To make this aspect of the plan a reality, the hospital intends to staff the discharge lounge with patient educators five days a week. “Those educators are going to receive the patients and be able to go through instructions with the patients and their families down in the discharge lounge before they go home,” Moran says. “That’s our next evolution of this.”
Several months into the new process, leaders at Northwestern Medicine Palos Hospital report they have shortened the average discharge process from four hours to one hour, they have halved the ED’s leave-without-being-seen rate, and patient satisfaction scores have begun to rise in both the ED and inpatient settings.
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