Durvasula Raghu, Kayihan Arkan, Del Bene Sherri, Granich Marion, Parker Grace, Anawalt Bradley D, Staiger Thomas
Department of Medicine, University of Washington, Seattle, WA (Drs Durvasula, Staiger, and Anawalt); Transformation of Care Department, UW Medicine Health System, Seattle, WA (Mr Kayihan); Patient Care Services (Mss Del Bene and Parker), Center for Clinical Excellence (Mr Granich), University of Washington Medical Center, Seattle, WA.
Qual Manag Health Care. 2015 Jan-Mar;24(1):45-51. doi: 10.1097/QMH.0000000000000049.
In an environment where there is increased demand for hospital beds, it is important that inpatient flow from admission to treatment to discharge is optimized. Among the many drivers that impact efficient patient throughput is an effective and timely discharge process. Early morning discharge helps align inpatient capacity with clinical demand, thereby avoiding gridlock that adversely affects scheduled surgical procedures, diagnostic procedures, and therapies. At our large, academic medical center, we hypothesized that an interdisciplinary approach to scheduled discharge order entry would increase the percentage of discharges occurring before 11:00 AM and improve overall discharge time. The pilot study involved moving rate-limiting steps to earlier in the discharge process, specifically medication reconciliation to the night before discharge and "discharge to home" order entry before 9:00 AM the morning of discharge. The baseline rate of discharges before 11:00 AM was 8% and significantly increased to 11% after the intervention (P = .02). Moreover, in the subset of patients (21%) for whom early medication reconciliation and discharge to home order entry were both executed, the percentage of patient discharges occurring before 11:00 AM increased to 29.7%, with an associated average discharge time of more than 3 hours earlier. No patient harm events were associated with this pilot project. There was no significant change in length of stay, and 30-day readmission rate improved significantly from 13.8% to 10.3% (P = .002). Our study demonstrates that a multidisciplinary approach using prescribed order entry and medication reconciliation is a low cost, safe, and effective way to increase early morning discharges and improve patient flow for large hospitals with high volumes of scheduled patient admissions.
在对医院床位需求增加的环境中，优化住院患者从入院到治疗再到出院的流程非常重要。影响患者高效周转的众多因素中，有效的及时出院流程是其中之一。清晨出院有助于使住院床位容量与临床需求相匹配，从而避免出现对预定的外科手术、诊断程序和治疗产生不利影响的拥堵情况。在我们大型的学术医疗中心，我们假设采用跨学科方法进行预定出院医嘱录入，将增加上午11点前出院的比例，并改善整体出院时间。试点研究包括将限速步骤移至出院流程的更早阶段，具体而言，将用药核对提前至出院前一晚，并在出院当天上午9点前录入“出院回家”医嘱。干预前上午11点前的出院率为8%，干预后显著提高至11%（P = 0.02）。此外，在同时执行了早期用药核对和出院回家医嘱录入的患者子集（21%）中，上午11点前出院的患者比例增至29.7%，平均出院时间提前了3个多小时。该试点项目未出现与患者伤害相关的事件。住院时间没有显著变化，30天再入院率从13.8%显著改善至10.3%（P = 0.002）。我们的研究表明，采用规定的医嘱录入和用药核对的多学科方法，是一种低成本、安全且有效的方式，可增加清晨出院人数并改善大型医院大量预定患者入院情况下的患者流程。
