Improving Timely Discharges Through Nurse-Initiated Conditional Discharge Orders

BACKGROUND: Hospitalized patients are often medically ready for discharge before actual time of discharge. Delays are multifactorial, including medical staff workflow, knowledge, culture, and system issues. Identifying discharge criteria in a nurse-initiated conditional discharge (NICD) order facilitates a nurse-initiated discharge, creates a shared mental model for early discharge readiness, and improves workflow delays. The objective was to increase the percentage of morning discharges from 6% to 11% on the hospitalist intervention team, sustaining 11% for 6 months. METHODS: All patients admitted to a hospitalist service (intervention team) were targeted from July 2018 through March 2020. The primary outcome measure was percentage of morning discharges (6:00 am-12:00 pm). Quality improvement methodology was used to initiate bundled interventions, including NICD order use and education, written tool dissemination, and weekly e-mail reminders (PDSA1). Continued education with dissemination of an instructional module and a resident champion were established to improve resident hesitancy (PDSA2). RESULTS: Special cause variation was observed for the primary outcome after PDSA2 with a positive shift in the number of early discharges. Special cause variation was observed in the process measure after PDSA1 with 6 points above the mean. CONCLUSIONS: Through NICD orders, written tool dissemination, and a resident champion to encourage system-wide culture change, patients were discharged earlier, improving patient flow.