PM2035: P.R.E.P. for Discharge: A Discharge Prioritization Initiative

Purpose/Objectives: At Johns Hopkins All Children's Hospital, we have seen a significant increase in the number of patients declined for admission throughout the COVID-19 pandemic due to increased pressure on the healthcare system. Between March and September 2021, our institution declined admission of over 237 patients due to staffing shortages or bed capacity issues. The goal of this initiative is to utilize the P.R.E.P for discharge bundle (Figure 2) to prioritize discharge order entry by 10 AM on clinically eligible patients to facilitate safe discharges by noon. Our objective is to increase the percentage of discharge orders placed by 10 AM on the pediatric hospital medicine service from 9.4% (3-month rolling average) to 20%, and increase the percentage of discharges by noon on the pediatric hospital medicine service from 9.8% (3-month rolling average) to 20% in 6 weeks.

Design/Methods: Scope: This project was initiated at Johns Hopkins All Children's Hospital within the pediatric hospital medicine service, comprised of two University of South Florida pediatric residency teams, one Johns Hopkins All Children's Hospital pediatric residency team, and one attending-only overflow team. Patients who were discharged home or transferred to another healthcare facility from the pediatric hospital medicine service were included. Patients transferred to another unit or service were excluded. Outcome Measures: Percentage of patients discharged by noon from the pediatric hospital medicine service. Process measures: Percentage of patients with discharge orders placed by noon on the pediatric hospital medicine service. Balancing measures: (1) 7-day readmission rate from the pediatric hospital medicine service, (2) Monitoring of incident reports and grievances related to the PREP bundle or early discharges. Initial interventions by date: 8/16/21 – email to hospitalists to prioritize early discharges; 8/23/21 – resident education; 9/1/21 – official PREP bundle start date; 9/15/21 – formal PREP bundle education with hospitalists.

Results: Our team initially met our goal of increasing the percentage of discharged by noon to 20% in under 6 weeks (Figure 1). We then experienced a decline in DCBN orders and were no longer at goal. Barriers were identified via resident and nursing feedback. Barriers included resident workload, transportation limitations in otherwise ready patients, lab delays, and pharmacy delays. We responded with these additional interventions by date: 10/20/21 – monthly prize for resident with most DCBN orders; 11/1/21 – activity center area and cafeteria/ride share vouchers for patients awaiting transportation; 4/1/22 – official discharge planning guide. With these interventions, we again met our goal of 20% of discharge orders placed by noon.

Conclusion/Discussion: By increasing the percentage of patients discharged from the pediatric hospital medicine service by noon, we hope to shift up average discharge times, increasing the number of beds available for transfers and new admissions, and thereby decreasing the number of patients declined.