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Rounding first on discharging patients does not lead to earlier discharge times or shorter length of stay
Question clinique
Does rounding first on patients with anticipated discharges result in earlier discharge and shorter length of stay?
L’Essentiel
Although considered a strategy to improve throughput, prioritizing rounding on discharging patients first thing in the morning did not result in earlier discharge times and did not reduce hospital LOS. Despite asking the intervention group to place a discharge order as early as possible, the average order placement time for both groups occurred in the afternoon. This may reflect other inefficiencies in the 3 hospitals in which this study took place. 1b
Référence
Plan de l'etude: Randomized controlled trial (nonblinded)
Financement: Government
Cadre: Inpatient (ward only)
Sommaire
These investigators tested whether prioritizing rounding on discharging patients led to earlier discharge times and shorter lengths of stay (LOS). Hospitalist physicians across 3 hospitals were randomized, using concealed allocation, to use 1 of 2 rounding styles: (1) prioritizing rounding on patients who were discharging that day (n = 30), and (2) usual rounding practice (n = 31). Physicians in the intervention group were asked to enter a discharge order as early as possible. Both groups rounded on patients across 4 to 5 hospital units and the mean starting morning census was similar (11.5 patients). In the primary intention-to-treat analysis of almost 4500 discharged patients, there were no significant differences detected in time of placement of discharge order (13:03 in the intervention group vs 13:11 in the usual care group), time of actual patient discharge from the hospital (15:22 vs 15:21), or LOS (75 hours vs 78 hours). In a per-protocol analysis, the time of placement of discharge order shifted 37 minutes earlier (12:34 vs 13:11; P = .001), but there was no difference in actual discharge time or LOS. Prioritizing rounding on discharging patients did not result in time delays in placement of other orders such as procedures, consults, and imaging. However, physician surveys revealed possible disadvantages of prioritizing rounding on discharging patients, specifically a perceived increase in work and travel between patients, and potential harm when prioritizing rounding on discharging patients over sick patients.
Reviewer
Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL
Commentaires
Impact assessment
Excellent
Discharge
Discharge is complex. Most patients being discharged have some idea by the night prior. Even if the doctor enters an order there are other limitations like nursing rounds. Removal of IV’s discharge instructions. Physio etc. Rides need to be available too. the order is only a small piece.
Rounding
Makes sense
Rounding
Makes sense
incomplete information
I was disappointed with the information provided. No strategies were identified. Was it at the discretion of the physicians or team? The conclusion stated could potentially cause teams to abandon a strategy that does have potential to help patient flow given appropriate physician buy-in and involvement
Focus on discharging patients
Interesting study. Not too surprised by the results though. To me, I would have engaged the nursing staff to be participants since their typical daily work flow probablywouldn't change as a result of a physicians writing an earlier discharge order. Concerns expressed by the physicians e.g. risk in not seeing sicker patients earlier of course is simply conjecture likely without any evidence to support this notion.