Holiday Special 2024: No Place Like Home (23 mins)

As the holidays approach, I'm revisiting the subject of what matters most to patients. This episode discusses the discharge process, length of stay, and outcome metrics that can serve as a compass for other quality measures.
Key Points:
-Universal needs
-Critical questions
-What if?

Transcript

In nursing school, one of my instructors taught us the principal of Discharge Barrier Rounds, where the charge nurse, primary nurse, and case manager rounded on the unit to discuss what was keeping each patient from safely discharging home. We talked about any case management barriers such as durable medical equipment needs and transportation, or whether their antibiotics could be completed under home health care, and whether nursing had reported the patient’s constipation to the surgeon so that orders could be written to prevent an ileus. I quickly realized that this concept was completely in-line with what most patients really want. The number one question every clinician hears a thousand times a day is, “When can I go home?”

Since my nursing school days, I have learned more about this process. Now I understand that Case Managers and Clinical Documentation Integrity (CDI) specialists review a variety of metrics based on CMS data on the expected length of stay by diagnosis code.[1] One of my favorites among those metrics is the Length of Stay Index (LOSI), which is similar to the mortality index in that it compares actual length of stay (LOS) measured in days and compared to the national average LOS for that diagnosis. A LOSI score less than 1 indicates a shorter than average length of stay, and a score greater than 1 means the patient is staying in the hospital longer than expected. The national average LOS is listed with the Diagnosis Related Group (DRG) codes published by CMS and the hospital typically uses this data already for case management and documentation integrity workflows—because an increased length of stay can be an indicator of things like increased cost, increased risk of hospital-acquired conditions, barriers found in the social determinants of health assessment, a difficult discharge placement, or a mismatch between the documented diagnosis and the patient’s actual condition (the patient is in septic shock but the diagnosis is for cholecystitis without complications, for example). 

The fee system is complex, but sometimes a patient might stay four days, but CMS only pays for three of those days because that is the national average and anything above is considered a wasteful use of resources. Since an extended LOS is associated with increased cost, it is better to know about discharge barriers early in the encounter rather than later.[2]

So why isn’t this talked about more? Sometimes it seems like we relegate this topic to a single field -- case management -- and then wash our hands of it. But really, I see three important perspectives on patient discharge: The patient, the healthcare providers, and administration.

The first perspective to consider is the patient. This is probably the most motivated participant in discharge planning. Every patient asks every day when they will be ready to go home. I had homeless patients who were living on the street asks me when they could go home, because they wanted their freedom back. I saw people eager to return to an impoverished home so that they could sleep at night and not be awakened every two hours. Literally, no one wants to stay in the hospital.

Okay, so there are two types of patients that I can think of that liked being there: Prisoners from the jail were happy because they had their own room and it was calm and quiet compared to jail, and drug-seekers were happy for a couple days if opioids were prescribed. So I can say that staying in a hospital is slightly better than being in jail. That pretty well sums up the issue, right?

So patients are motivated to do whatever it takes to get out of the hospital, but they are also the least informed members of the team. They have no idea what the average length for their condition might be. They ask every day when they can go home because no one is telling them.

The second perspective is the healthcare providers -- the physicians, nurses, and everyone else on the team of direct patient care providers. This perspective is interesting, because knowledge of how long it should take for a condition to be treated is higher, but real-time awareness of where the patient is in that timeframe is rather low. It’s easy to lose track of post-op days, and we are slow to notice problems and delays in care. We are busy with the tasks of the day, and if we don’t do discharge barrier rounds, we are poorly focused on the things that are keeping the patient in the facility.

So awareness is low, but what about motivation for this group? Sadly, motivation is low. Hospitalists will push for discharge (sometimes to a fault), but everyone else is more likely to be in a state of apathy. I was asked on multiple occasions by the nurse handing off a patient to me that I make sure that I “kept” that patient for then tomorrow. I was told that they were an easy patient who hardly needed any nursing care, and they wanted that patient to fill a slot on their assignment list so their day would be easy. If the patient doesn’t need nursing care, they probably should be going home, right?

Besides apathy, why does this phenomenon even happen? Because the day of discharge is grueling for staff. All the appts for follow-up need to be made, all the medical equipment and medication reconciliation and summaries need to be prepared -- it’s a ton of work. Sometimes, the appts cannot even be made, or oxygen cannot be delivered, because the home provider does not have weekend or holiday hours. So the patient is ready to go, the paperwork is done, but some facemask for their bipap machine cannot be delivered until Monday, or the feedings cannot be delivered for another 24 hrs. This is key to remember, because when we look at solutions in a moment, we are going to look at whether the day of discharge needs to be so chaotic.

Regardless, awareness of discharge needs can be low among healthcare providers, and motivation can be low if the provider is burned out or feeling some level of apathy. It’s human nature to want easier work sometimes, and it is probably worthwhile to admit that this problem exists from the start.

The third perspective is administration. There are pockets of administration that will look at metrics affected by length of stay, but the actual involvement in the details is not typically very high. In my experience, I would say it is viewed as an accountability exercise, putting pressure on the case management and hospitalist teams, but without significant involvement in the details. The times when I have heard of administration getting into the details, they were wildly successful and found significant barriers that were relatively simple to fix. But I would say that the connection between discharge barriers and cost or quality metrics has not really sunk in at the boardroom level.

So what would that really look like? What if the entire hospital was devoted to getting patients home in a stable condition? How does that even happen? What if we didn’t just round on patients asking about discharge barriers, or report off a list of performance numbers each quarter? What if we started acting like the entire goal of the patient’s stay was to get healthy enough to leave?

I think it would help if the discharge summary paperwork was treated like a living document and was started upon admission. For example, when a consult signs-off with a note to see the patient for follow-up in two weeks, that appointment could be made and stored in the discharge documentation for future use -- there is no need to wait until the day of discharge to call for those appt requests. My unit decided to try this, and as the night shift charge nurse I reviewed all the patients that the dayshift charge nurse said was “getting close” to discharge. She spoke with case management during the day and combined that information with her nurse’s reports, and then in the evening I worked on writing summaries of care, preparing discharge education packets and making sure all the quality measures were current, and printing the papers for medication reconciliation. We still did not have an efficient way of making appointments in advance, but I can confirm that our bed availability for new patients turned around overnight -- literally.

I wondered later what it would have been like if our patient census had a report for expected length of stay compared to current number of days. Some hospitals pull this type of data into their Electronic Medical Record (EMR) where physicians and nurses can anticipate discharge needs and collaborate with the interdisciplinary team. However, most hospitals do not routinely communicate this information to clinical staff. 

This is unfortunate, because a review of the LOSI for each patient could help hospitals prepare discharge paperwork in advance, like we did on my unit, as well as identify patients with additional needs when the LOSI is higher than expected. I would love to see this metric integrated in the electronic census itself, where the EMR could pull the LOSI automatically: Patient names turn green when they are within 48 hours of expected discharge, or their name could turn blue when they are overdue for discharge. Those patients who are over the expected timeframe could be reviewed by the care team to solve barriers and help the patient get the care that they need in a timely manner. 

And if we wanted to be really revolutionary, we could tell the patient on the day they are admitted how many days it ought to take for them to get better assuming there are no complications. Then explain those potential complications and what the patient can do to help prevent them. Most of the time, our open heart bypass patients were the only ones in the ICU who were given an expected length of stay with prescribed daily progress toward that goal. If they were not extubated and sitting up for breakfast the next morning, there was some intense review of that case by everyone involved. Compared to other patients who were not aware of the expected recovery time, the open heart patients would eagerly participate in incentive spirometry, physical and occupational therapy, compliance with a heart healthy diet, attentive to patient education, and they were prepared to discuss pain management because they knew the goal was to be up and walking as soon as possible. 

We already discussed that every patient wants to go home with the rare exception of prisoners. What if we made the hospital visit less like a prison term? We have mandatory patient consent for procedures, but when do we really obtain consent for the hospital visit? We hold them there and threaten demerits on their insurance for being non-compliant if they say they want to leave AMA (against medical advice), but we are not really communicating what they can expect in return. They are brought into this restricted environment, and no one can tell them when they will be allowed to leave. To me, that is kind of an abuse of power. I don’t think it’s necessarily intentional, but it’s there just the same. If we shared the expected LOS with patients when they admitted, and told them what they need to do to get home, I think it would revolutionize all of these metrics on utilization and performance.

We’ve discussed a living discharge document that would help alleviate the discharge workload on healthcare providers. We’ve talked about how helpful it would be to have the LOS Index available for everyone on the team via the patient census in the EMR. And I shared a revolutionary idea of telling the patient what the national average LOS is for their condition, with tips on how they can participate in their care and achieve the best results.

But why would a hospital invest time in changing these entrenched workflows? Because regardless of my dream solutions, excess LOS is going to be on the administrative radar this year more than any other, because it inadvertently impacts staffing – when nurses are caring for a patient who could have gone home the day before, that nurse is unable to take a new admission. That new admission then sits in the Emergency Department, which keeps the new emergency from having a place to go. Suddenly, we are treating patients in the waiting room, people are leaving without being seen, patients are discharging from the ED (which is not ideal) because their entire stay was spent waiting for a bed upstairs -- it’s pure chaos. So I recommend integrating the LOSI into the daily administrative review. Print the whole hospital census and look for stragglers to ensure that patients receive timely care and clinicians receive support for solving unique problems like feeding deliveries and bipap masks and appointment availability. I believe this is an action item that would be appropriate for the Quality Department to champion since a successful discharge affects so many quality indicators as well.

The world of QI is replete with some amazing tools that were created by inquiring minds who were just trying to make their work easier with better results. There is a simple beauty in finding a tool that fits the problem, and the CMS case management tool of a LOS index seems like a natural fit for expansion. Perhaps it will be helpful to you; or perhaps you have an idea that would be helpful to me. The important thing is to keep sharing those ideas with each other.

[1] The Centers for Medicare & Medicaid Services (CMS). (n.d.). DRG Relative Weights. Retrieved August 24, 2022, from https://www.cms.gov/Medicare/Medicaid/Medicare-fee-for-service-payment/acuteinpatientpps.acute-inpatient-files-for-download-items/CMS022597.
[2] Krell, R; Girotti, M; Dimick, J. (2014). Externded Length of Stay After Surgery: Complications, Inefficient Practice, or Sick Patients? Jama Surg, 149(8). 15-820. Doi:10.1001/jama-surg.2014.629.