Reducing Discharge Boarding Time from the Pediatric Inpatient Unit - A Quality Improvement Project in Progress

Purpose/Objectives: Prolonged discharge boarding time (DBT) is recognized worldwide as a major concern in hospitals and has negative ramifications for patients, staff, and health care institutions. With a national DBT benchmark of 2h, studies have shown estimated cost savings of $5.9 million that directly apply to families and hospitals, as well as improvement in patient satisfaction scores.
This Quality Improvement (QI) project focuses on improving the DBT at Brookdale Hospital’s pediatric inpatient unit by increasing the percentage of patients being discharged (DC) within 2h of being medically ready for discharge by 25% from baseline in 6 months using facility-tailored interventions (goal of 47.2%). The balancing measure is 30-day readmission rate for the same or related cause.

Design/Methods: A needs assessment was completed in which DBTs were collected along with perceived barriers faced to discharge patients in a timely way. Meetings were held with key stakeholders (nurses, social workers, transportation managers) to discuss the project, assess barriers and determine possible interventions (Figure 1). Plan-Do-Study-Act methodology was implemented. Cycle 1 focused on obtaining social clearances 24h prior to discharge or by Friday (if weekend discharges were anticipated), Cycle 2 focused on the preparation of discharge summaries at least 12h prior to discharge, and Cycle 3 focused on parental notification of possible discharge at least 12h prior to discharge. Data collection began in November 2020. Data was collected biweekly via chart audits and analyzed with run charts. Once special cause variation was noted, a control chart (p-chart) was used for analysis.

Results: Baseline DBT average was 5.04h, and only 22.2% of patients were discharged within 2h. Main barriers encountered were obtaining social worker clearance (average 10.5h), parental readiness (average 1.5h), transportation arrangements (average 3.5h), discharge summary (average 1.4h), pending consults (average 2h), medication reconciliation (average 1.1h), nursing delays (average 1h), and appointment scheduling (average 6.25h). The project’s population consisted of 283 discharged patients from 11/18/20 – 06/15/21. For our outcome, special cause variation was seen associated with parental notification of potential discharges (PDSA #3), resulting in a center-line shift from 28% to 55% (Figure 2). Average DBT decreased to 1.94h by 6/15/21, and 65.2% of patients were discharged within 2h.

Conclusion/Discussion: Facility-tailored DBT interventions based on initial needs assessment and early involvement of key stakeholders is crucial to the proper implementation of this project. Interventions were successful in decreasing DBT, we appreciated special cause variation by the 3rd PDSA cycle, and our goal was surpassed by the 6th month of the project. Future cycles will target appointment scheduling and introduction of a discharge checklist. Reducing DBT is associated with reduction in length of stay, improvement of quality of care, reduction in cost of care, increases in access to available hospital resources and improvement of overall patient satisfaction.