Advertisement

Discharge Before Noon: An Urban Legend

Published:December 29, 2014DOI:https://doi.org/10.1016/j.amjmed.2014.12.011
      Like all institutions, hospitals are susceptible to beliefs that propagate and certify themselves through re-telling–to urban legends. One of these legends is that discharging more patients before noon must improve hospital kinetics.

      Evidence for the Benefit of Early Discharge

      Studies of morning hospital discharge come almost entirely from the Emergency Department and focus on the important issue of overcrowding.
      • Trzeciak S.
      • Rivers E.P.
      Emergency department overcrowding in the United States: an emerging threat to patient safety and public health.
      Kravet et al
      • Kravet S.J.
      • Levine R.B.
      • Rubin H.R.
      • Wright S.M.
      Discharging patients earlier in the day: a concept worth evaluating.
      suggested in 2007 that earlier inpatient discharge might improve Emergency Department boarding times; they piloted a physician-focused intervention that resulted in an average discharge time almost two hours earlier than before, but they did not measure the effect on crowding.
      • Kravet S.J.
      • Levine R.B.
      • Rubin H.R.
      • Wright S.M.
      Discharging patients earlier in the day: a concept worth evaluating.
      Powell et al
      • Powell E.S.
      • Khare R.K.
      • Venkatesh A.K.
      • Van Roo B.D.
      • Adams J.G.
      • Reinhardt G.
      The relationship between inpatient discharge timing and emergency department boarding.
      modeled the effect of early discharge on Emergency Department boarding in his Ontario hospital and concluded that moving peak discharge time 4 hours earlier should eliminate boarding altogether.
      • Powell E.S.
      • Khare R.K.
      • Venkatesh A.K.
      • Van Roo B.D.
      • Adams J.G.
      • Reinhardt G.
      The relationship between inpatient discharge timing and emergency department boarding.
      In Australia, Khanna et al
      • Khanna S.I.
      • Boyle J.
      • Good N.
      • Bugden S.
      • Scott M.
      Hospital level analysis to improve patient flow.
      • Khanna S.I.
      • Boyle J.
      • Good N.
      • Lind J.
      • Zeitz K.
      Time based clustering for analyzing acute hospital patient flow.
      • Khanna S.I.
      • Boyle J.
      • Good N.
      • Lind J.
      Unravelling relationships: hospital occupancy levels, discharge timing and emergency department access block.
      analyzed Australian hospital data retrospectively in a series of papers and found early discharge associated with lower Emergency Department volumes. Vermeulen et al
      • Vermeulen M.J.
      • Ray J.G.
      • Bell C.
      • et al.
      Disequilibrium between admitted and discharged hospitalized patients affects emergency department length of stay.
      showed in a retrospective analysis that fluctuation in the daily ratio of hospital discharges to admissions (particularly among medical patients) was associated with Emergency Department crowding the following day.
      But there is no study measuring Emergency Department occupancy before and after instituting early discharge, and only a single published report describing any hospital outcome after a change in discharge policy.
      • Wertheimer B.
      • Jacobs R.E.
      • Bailey M.
      • et al.
      Discharge before noon: an achievable hospital goal.
      Wertheimer et al
      • Wertheimer B.
      • Jacobs R.E.
      • Bailey M.
      • et al.
      Discharge before noon: an achievable hospital goal.
      measured the effect on Internal Medicine length of stay of a sustained, multipronged, and very successful effort that increased the percentage of prenoon medical discharges from 11% to 38%. Shorter inpatient stays, these authors argued, was a likely outcome because patients admitted early in the day would receive (as a result of early bed availability) more of the diagnostic and therapeutic benefit of that first hospital day. In fact, they did find a reduction of 9% in the ratio of observed to expected stay among all study patients after the increase in early discharge.
      The writer of this commentary, now retired, was chief of medicine in the institution studied by Wertheimer et al.
      • Wertheimer B.
      • Jacobs R.E.
      • Bailey M.
      • et al.
      Discharge before noon: an achievable hospital goal.
      During the period from which their data were gathered several other changes were made, not only efforts to increase early discharge. One initiative at the time was a substantial allocation of medical and social services to weekends. The observed decrease in length of stay (and the authors' odd finding that readmissions also decreased) may represent confounding by other institutional improvements.
      Wertheimer's
      • Wertheimer B.
      • Jacobs R.E.
      • Bailey M.
      • et al.
      Discharge before noon: an achievable hospital goal.
      study design could not distinguish between the effects of a general effort to discharge and the choice of noon as a particular goal. Unfortunately, like the Kravet, Powell, Khanna, and Vermeulen groups,
      • Kravet S.J.
      • Levine R.B.
      • Rubin H.R.
      • Wright S.M.
      Discharging patients earlier in the day: a concept worth evaluating.
      • Powell E.S.
      • Khare R.K.
      • Venkatesh A.K.
      • Van Roo B.D.
      • Adams J.G.
      • Reinhardt G.
      The relationship between inpatient discharge timing and emergency department boarding.
      • Khanna S.I.
      • Boyle J.
      • Good N.
      • Bugden S.
      • Scott M.
      Hospital level analysis to improve patient flow.
      • Khanna S.I.
      • Boyle J.
      • Good N.
      • Lind J.
      • Zeitz K.
      Time based clustering for analyzing acute hospital patient flow.
      • Khanna S.I.
      • Boyle J.
      • Good N.
      • Lind J.
      Unravelling relationships: hospital occupancy levels, discharge timing and emergency department access block.
      • Vermeulen M.J.
      • Ray J.G.
      • Bell C.
      • et al.
      Disequilibrium between admitted and discharged hospitalized patients affects emergency department length of stay.
      Wertheimer et al
      • Wertheimer B.
      • Jacobs R.E.
      • Bailey M.
      • et al.
      Discharge before noon: an achievable hospital goal.
      did not study changes in Emergency Department boarding. A decrease in prenoon boarding time might have suggested that specifically prenoon discharge caused an improvement in length of stay.
      So evidence for any benefit is, overall, remarkably weak. However, early discharge has become so generic and undisputed a good, that University HealthSystem Consortium, a respected national quality arbiter, describes 50% discharges before 11 AM as “best practice,” raising the ante on those calling merely for discharge before noon.

      University HealthSystem Consortium. Commit to ACTion: best practice detail form. Discharge planning. 2007.

      Another measure of the de facto acceptance of early discharge is that in recent publications, the only hospital outcome described is success of adoption.

      Maguire P. Building a better discharge: three case studies on discharge innovation. Today's Hospitalist. July 2011. Available at: http://www.todayshospitalist.com/index.php?b=articles_read&cnt=1251#sthash.AQXFp13f.dpuf. Accessed December 8, 2014.

      McKinney M. Out by noon—a winning strategy to reduce crowding, shorten stays. Mod Healthc. April 12, 2014. Available at: http://www.modernhealthcare.com/article/20140412/MAGAZINE/304129995. Accessed December 8, 2014.

      Why Noon?

      How often and to what extent is it even necessary to “clear the Emergency Department”? Methods exist for the measurement of Emergency Department crowding on a moment-to-moment basis, but there are no published data describing how many patients need beds during the hours before noon.
      • McCarthy M.L.
      • Ding R.
      • Pines J.M.
      • Zeger S.L.
      Comparison of methods for measuring crowding and its effects on length of stay in the emergency department.
      Might “early” be better conceived as an ideal distribution of discharges among several time intervals throughout the day, and not dichotomized as “before” and “after” any single hour?
      Certainly, the definition of “early” should reflect local bed needs of each institution, at least until we learn that most institutions have the same needs.
      If, however, a single national cutoff must be chosen, to frame the task and rally support, noon would probably not be the best choice. The most recent national data indicate that Emergency Department occupancy begins to increase in the morning but does not peak until 8 PM.
      • Pitts S.R.
      • Pines J.M.
      • Handrigan M.T.
      • Kellermann A.L.
      National trends in emergency department occupancy, 2001 to 2008: effect of inpatient admissions versus emergency department practice intensity.
      So it is not before noon when Emergency Departments typically need beds for their newly admitted medical patients; it is half a day later, during the evening hours.

      Early Discharge and Measurable Hospital Outcomes

      Measuring Emergency Department occupancy would certainly illuminate the proposed mechanism of benefit, but the effect of early discharge on a range of other hospital outcomes must also be considered. These outcomes could be measured among all patients before and after a successful discharge intervention (bias lower) or else compared between patients discharged early and late using risk adjustment or propensity scoring (power greater).
      Hospital length of stay is an outcome widely believed to improve with early discharge, but this may not be so. For one thing, doctors and nurses often prioritize hospital rules and goals or work “creatively” with them. When this activity is admired, it is called “systems-based practice,” and when disapproved of, it is called “using work-arounds.” Under pressure to discharge before noon, caregivers might well be tempted to hold a patient over for next-morning departure if preparations have not been completed by noon. The practice would reduce or even reverse any gains in length of stay.
      Even if there were grass-roots and full-throated support for prioritizing prenoon discharge, would other floor duties be postponed as a result, slowing progress toward the future discharge of other patients? Morning in a hospital is, after all, temporal real estate of the greatest value.
      A second important outcome is patient satisfaction, a marker of financial consequence to hospitals for both reimbursement and market share. It is not obvious what effect early discharge might have.
      A third is nursing and support staff satisfaction, which affects morale and recruitment. In academic hospitals, early discharges occur during teaching rounds, often pulling house officers away to deal with last-minute obstructions to departure. If teaching is perceived as a casualty of early discharge, resident and attending satisfaction might decline; on the other hand, starting the day with a smaller patient census might satisfy residents.
      An easily measured outcome is readmission rate. Does early discharge really decrease readmissions, as Wertheimer found? Perhaps the aggressive social service effort required for early discharge also results in better planning for home care. Or perhaps patients discharged prenoon are not readmitted because they choose to go to a different hospital-one less ready to bounce them out.
      Increasingly front loaded, costs are unlikely to change with early discharge, but in a very busy hospital, the opportunity cost of beds that are occupied too long may represent a cost that is hidden but large.
      • Bayley M.D.
      • Schwartz J.S.
      • Shofer F.S.
      • et al.
      The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission.
      Finally, early discharge may affect the rate of hospital complications, actual or detected.

      Conclusions

      Prenoon discharge is rapidly becoming a universal goal, without much evidence that the required effort produces benefit in any hospital outcome. It may be too late to explore differences among institutions, to study variations in the definition of “early” discharge, or to question this urban legend.

      References

        • Trzeciak S.
        • Rivers E.P.
        Emergency department overcrowding in the United States: an emerging threat to patient safety and public health.
        Emerg Med J. 2003; 20: 402-405
        • Kravet S.J.
        • Levine R.B.
        • Rubin H.R.
        • Wright S.M.
        Discharging patients earlier in the day: a concept worth evaluating.
        Health Care Manag (Frederick). 2007; 26: 142-146
        • Powell E.S.
        • Khare R.K.
        • Venkatesh A.K.
        • Van Roo B.D.
        • Adams J.G.
        • Reinhardt G.
        The relationship between inpatient discharge timing and emergency department boarding.
        J Emerg Med. 2012; 42: 186-196
        • Khanna S.I.
        • Boyle J.
        • Good N.
        • Bugden S.
        • Scott M.
        Hospital level analysis to improve patient flow.
        Stud Health Technol Inform. 2013; 188: 65-71
        • Khanna S.I.
        • Boyle J.
        • Good N.
        • Lind J.
        • Zeitz K.
        Time based clustering for analyzing acute hospital patient flow.
        Conf Proc IEEE Eng Med Biol Soc. 2012; 2012: 5903-5906
        • Khanna S.I.
        • Boyle J.
        • Good N.
        • Lind J.
        Unravelling relationships: hospital occupancy levels, discharge timing and emergency department access block.
        Emerg Med Australas. 2012; 24: 510-517
        • Vermeulen M.J.
        • Ray J.G.
        • Bell C.
        • et al.
        Disequilibrium between admitted and discharged hospitalized patients affects emergency department length of stay.
        Ann Emerg Med. 2009; 54: 794-804
        • Wertheimer B.
        • Jacobs R.E.
        • Bailey M.
        • et al.
        Discharge before noon: an achievable hospital goal.
        J Hosp Med. 2014; 9: 210-214
      1. University HealthSystem Consortium. Commit to ACTion: best practice detail form. Discharge planning. 2007.

      2. Maguire P. Building a better discharge: three case studies on discharge innovation. Today's Hospitalist. July 2011. Available at: http://www.todayshospitalist.com/index.php?b=articles_read&cnt=1251#sthash.AQXFp13f.dpuf. Accessed December 8, 2014.

      3. McKinney M. Out by noon—a winning strategy to reduce crowding, shorten stays. Mod Healthc. April 12, 2014. Available at: http://www.modernhealthcare.com/article/20140412/MAGAZINE/304129995. Accessed December 8, 2014.

        • McCarthy M.L.
        • Ding R.
        • Pines J.M.
        • Zeger S.L.
        Comparison of methods for measuring crowding and its effects on length of stay in the emergency department.
        Acad Emerg Med. 2011; 18: 1269-1277
        • Pitts S.R.
        • Pines J.M.
        • Handrigan M.T.
        • Kellermann A.L.
        National trends in emergency department occupancy, 2001 to 2008: effect of inpatient admissions versus emergency department practice intensity.
        Ann Emerg Med. 2012; 60: 679-686
        • Bayley M.D.
        • Schwartz J.S.
        • Shofer F.S.
        • et al.
        The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission.
        Ann Emerg Med. 2005; 45: 110-117