IOWA CITY — Although the University of Iowa Hospitals and Clinics has an institutional goal of discharging inpatients by 11 a.m., the average discharge time actually is three hours later at 2:06 p.m. — with the 11 a.m. metric achieved just 10 to 15 percent of the time, according to an internal audit.
In response to the audit — flagged as “red” or “high” for its opportunities to improve efficiency, revenue, and patient satisfaction — UIHC management is considering a range of discharge-improvement steps, from creating a new “discharge lounge” for patients awaiting transportation to increasing staffing.
The university also is looking to improve patient planning, contract with a medical transportation vendor, and re-evaluate its targets. According to the audit, presented to the Board of Regents last week, the 11 a.m. discharge aim has been an organization goal — although management is assessing whether it’s “achievable and whether this should be a unit/service specific goal.”
UIHC is not alone in its discharge difficulties, according to Patrice Sayre, chief audit executive for the Board of Regents. According to the audit, “throughput challenges resulting from the increasing demand for acute patient care is a nationwide industry challenge that requires constant process re-evaluation and rework.”
But discharge woes are both affected by and exacerbating other UIHC issues — like rising census numbers and stretched resources — creating a Catch-22.
“The number of patients admitted to UIHC has been increasing over the past five years, resulting in an increase in wait times in the emergency department as patients wait for inpatient beds to become available,” according to the audit.
UIHC CEO Suresh Gunasekaran — also at last week’s regents meeting — reported the average length of stay in the emergency room has escalated from just over four hours in 2015 to nearly 6 hours in 2019. The average midnight census of ER patients awaiting beds congruently grew from 21 in 2014 to 31 this year, according to Gunasekaran’s report.
And the campus’ wider average inpatient census has jumped from 509 in 2015 to 580 in 2019.
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In assessing UIHC discharge woes, auditors identified major culprits — including caregiver transportation for patients needing a ride and discharge orders not being entered promptly.
Those delays, according to the audit, relate to the multipronged process involved in patient discharge and the need for various patient care groups to be “uniformly focused on the discharge of a patient to ensure that all tasks are completed in time to allow for discharge by 11 a.m.”
Provider availability — or lack thereof — also can postpone a patient’s discharge. Resident teams, for example, can be delayed by the competing teaching responsibilities and other administrative duties of their attending faculty.
Surgery teams, despite making rounds earlier, often are less available during the day to make medical decisions. And “hospitalist teams” that cover patient cases teaching teams can’t manage a greater number of cases, “often resulting in less efficient processes.”
The audit found resident-teaching teams average the greatest difference between discharge order and when a patient is actually discharged — nearly three hours.
To address transportation-related barriers to patient discharge, auditors suggested creating a “discharge lounge” and more consistently including patient transportation plans “as part of upfront care team discussions.”
UIHC managers said they’re developing the lounge “as an area where patients can await arrival of transportation once discharged,” freeing up beds earlier for patients waiting to be admitted.
They also committed to consistently writing expected discharge dates and times on patient room whiteboards, and incorporating “discharge before 11 a.m.” language into patient dialogue — while also evaluating whether the 11 a.m. metric “is achievable” or should be a unit-specific goal.
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In that auditors found UIHC does not have any contracts with medical transportation companies, “resulting in varying levels of service available to the hospital when these services are required to discharge a patient,” they suggested the hospital pursue more formal arrangements.
UIHC management reported plans to issue a call for proposals from companies interested in becoming a preferred medical transportation provider
“Participating vendors would be asked to charge standard rates in exchange for being included on a preferred vendor listing,” according to the audit.
In assessing trends in delayed discharges, auditors found weekends are worse — with fewer resources and staff resulting in about 35 percent fewer discharges on a Saturday or Sunday than an average weekday.
“Significantly fewer discharges occur over the weekend because patients requiring specialized testing or services prior to discharge may need to wait until staff return on Monday to perform those tasks,” according to the audit, which recommended weekend availability of things like phlebotomy, echo tests, and specialty labs, procedures, and social workers.
UIHC managers vowed to consider changes in weekend coverage for some services. And they reported adding a “child abuse social worker position” in January in response to audit findings of more Department of Human Services-related issues in pediatric inpatient units.
The UI Steady Family Children’s Hospital currently has just one social worker per inpatient floor.
“Pediatric patients often require specialized social services support throughout their stay rather than only at the discharge process,” according to the audit. “When social workers are occupied by these pediatric-specific tasks, nurses often pick up the discharge processes typically assigned to social workers, such as finding facilities, arranging medical transportation, and working with insurance companies.”
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