How to be successful at early discharges

A hospitalist offers tips on planning and working ahead.

Somebody once said that more than half the battle is won with good preparation. This certainly applies to early discharges, which are very important to most hospitals and many patients. Hospitalists are at the forefront of all early-discharge efforts. Since I am a hospitalist myself, this is something that I deal with daily. I have come up with some strategies to make myself more efficient in my practice, and I think other hospitalists might benefit from these strategies too.

Things to do at admission

Photo courtesy of Dr Piracha
Photo courtesy of Dr. Piracha

The foundation of any discharge can be laid as early as the day of admission. Many times, even then, the hospitalist has a rough idea about some aspects of a successful discharge. One of the most common examples of this is the discharge destination. Depending upon the physical abilities of the patient and the circumstances of the case, one can estimate whether the patient will be able to go back home or will require placement in a facility for rehabilitation or continued medical care. If the latter is the case, case management consultation should be sought immediately. Also, physical and occupational therapy consultations should be obtained right up front because often these recommendations form the basis for insurance approval. This allows the hospitalist the time to focus on the patient's medical issues while case management is simultaneously approaching the patient's insurance.

Things to do the day before discharge

As much attention as possible should be paid to the day before anticipated discharge. This is where most successful early discharges are planned and executed. The hospitalist should review all of the patient's pertinent labs and imaging results. A lot of times, this alone is enough to plan for discharge the next day. However, in certain cases, the morning labs on the day of discharge need to be satisfactory for the patient to be successfully sent home. In these circumstances, the hospitalist must make sure to order those labs the night before, so they are done and results are available the next morning. Also, the hospitalist must communicate with any consultants on the case the night before to make sure that they clear the patient to be discharged from their perspective. Often, consultants are tied up on the morning of discharge, so this conversation must happen the night before.

I cannot tell you how many early discharges fail because of a lack of transportation on the day of discharge. Most times, patients depend on a relative or a loved one to come pick them up from the hospital. If the hospitalist waits to inform the patient about his discharge until the actual day it's happening, his ride may not be available until after 5 p.m., when most people get off work. Transportation issues must be worked out with the patient the day before discharge if an early discharge is to be successful.

Things to do the day of discharge

The first thing to do on the day of discharge is to look over all the morning labs and imaging results to make sure they are satisfactory. Next, the hospitalist must talk to the patient's nurse to inquire about any important overnight events that could have a bearing on discharge, such as a rapid response or deterioration in the patient's condition. Next, if a placement is planned, the hospitalist should communicate with the case manager to make sure insurance approval has been obtained. By this time, the hospitalist should have already obtained clearance from the consultants on the case and the patient's transportation should have been adequately arranged. Often, hospitalists have 15 to 20 patients on their list to see every day, so they must take the time to see their possible discharges first. The hospitalist must sit down with each patient to carefully give them a brief synopsis of their hospitalization and go over discharge instructions, discharge prescriptions, and follow-up appointments. Most electronic medical records allow the hospitalist to electronically prescribe medications, but the hospitalist must make sure that any prescriptions are transmitted to the patient's preferred pharmacy.

These are just some of the general tactics that I have used in my practice to successfully achieve the goal of early discharges. Of course, every patient is unique and one size does not fit all. But if hospitalists focus on some of the key points I have mentioned, in most cases they should come out ahead.