The Fallacy of the Early Morning Discharge

It is not mystery that the cost of healthcare is problematic. Few providers out there have escaped some level of education regarding the need to keep the length of stay down for hospitalized patients in order to reduce costs. For prospective payment hospitals, with DRG based payments, the reduction in utilization has the specific impact of improving the reimbursement for that episode of care. That makes administrators happy.

A number of hospitals have attempted to focus on discharging patients very early of the day of discharge. The rationale is that much of the “avoidable” time associated with the admission is the time the patient is medically ready to go home, but is waiting for discharge orders or paperwork. Truly, that is sometimes the case.

Focusing on eliminating the avoidable time is reasonable. Patients who are just “hanging around” because they have not been formally discharged still need to be fed and they still need to be medicated and they still need to be assessed by nursing. All of this amounts to avoidable costs for the hospital. In some cases, the bed may be needed for other patients waiting in the Emergency Department. These delays damage the ED throughput times, cause delays for other patients in the ED and may lead to transfers and lost admissions.

The idea behind early morning discharges is that physicians generally know that certain patients will likely be discharged that particular day. Why not see those patients first and get them on their way. In some cases, the discharge times are tracked as a regular metric. Physicians may even be held accountable for this metric. In extreme cases, this may be the basis of physicians’ incentives.

Unfortunately, this thinking is often flawed. The primary fallacy is that hospitals function on an 8 a.m. – 5 p.m., Monday through Friday basis. That is simply not the case. While hospitals may not make every service available all the time, they do continue to perform evaluations, procedures and diagnostics around the clock 365 days per year. That makes clinical assessment very fluid with respect to the clock time.

To assume that a physician knows that a patient will be ready for discharge means that there is a definite endpoint to be reached. By way of example, a patient may be ready for discharge when they complete a required course of intravenous medication, when certain diagnostics are completed and the findings deemed acceptable or when the patient can accomplish a specific task like voiding after a catheter has been removed.

There really is no reason to believe that these things will only happen in the morning. Certainly these things can occur at any time and often do occur later in the day. When they do, the patient can frequently be discharged at that time rather than waiting until the next morning.

This also assumes that the physician is locked in to these endpoints or timeframes. On occasion, the plan can change quickly and physicians need to be pragmatic. If a culture report returns indicating a less virulent infection with reasonable oral treatment options, the plan may change to discharge the patient sooner, for example.

Pushing for early morning discharges may shift the focus to hitting a metric that is meaningless (time of discharge) and sabotage the one that is important (length of stay). Providers will avoid late day discharges so they can send the patient the next morning and look better with that metric. Of course this just adds time to the length of stay.

The better option to ensure that case management has worked with the patient and the family to prepare for the discharge whenever it occurs. Patients may not want to be discharged later in the day as a matter of inconvenience. The groundwork should be laid long before that moment comes to eliminate the inconveniences and that way of thinking on the part of the patient. Indeed, this is one of the primary roles of case management.

In many cases, the patient’s “discharge packet” may be easily prepared in advance. This will allow for an expedited discharge once the order is received. A good discharge packet will help the person doing the discharge planning ensure that everything is completed prior to the discharge when it is completed in advance. Unfortunately, some electronic EHR systems will not allow for anything to be done in advance and then put on hold. Whenever possible, it can streamline the process. A busy physician who must prioritize new admissions, critical care patients and discharges may push a discharge down the list if it will take the extra time to do the paperwork. Having it prepared in advance will remove that barrier.

Keeping patients and their families informed of the goals for discharge, the discharge timing and plan should be the focus. If your facility is focusing on the discharge time of day as a means to reducing the length of stay, it may be worth reconsidering.