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August 2016 VOL 7, NO 7
Discharge Before Noon: Possible Through Nurse-Led Initiative
A nurse-led initiative to discharge patients before noon has paid off at the Mount Sinai Hospital, New York City, according to Kathleen Edmondson-Martin, MA, RN, OCN, Clinical Nurse Manager in the hospital’s bone marrow transplant unit.
At the Oncology Nursing Society 41st Annual Congress, Ms Edmondson-Martin described the Discharge Before Noon (DBN) project, in which the treatment team makes every effort to see that oncology inpatients eligible for discharge exit the unit before noon.
DBN is an interdisciplinary initiative that promotes clinically safe and high-quality patient care. Nurses collaborate with the healthcare team to ensure that discharge needs are met. Ultimately, DBN is a means of reducing avoidable readmissions and hospital length of stay. The project first proved itself in the hematology/oncology and bone marrow transplant units and is now operating throughout the hospital.
“Overall it’s been a great success,” she said. “The DBN initiative helped to build trust and to foster a collaborative team that became part of the culture of the unit.”
DBN should be a priority for several reasons, according to Ms Edmondson-Martin. It allows patients to arrive home earlier in the day, when they have time to address “daytime-sensitive” issues, such as filling prescriptions. Problems that are not dealt with until later in the day can lead to readmissions, she pointed out.
DBN improves patient throughput, keeps patients on scheduled treatment plans, allows those waiting for oncology beds to get them sooner (reducing waiting time in the emergency department), and optimizes the patient experience, she said.
What Is Required for DBN to Work
The process requires active problem-solving in real time, structured and timely ongoing communication, continuous process improvement, and “a spirit of camaraderie,” according to Ms Edmondson-Martin.
Three questions are key for DBN to work for an individual patient: What is the plan of care today? What is the discharge date and time? Who needs to do what to make it happen?
“We have 24/7 ongoing communication that starts with the e-mail I generate after our interdisciplinary rounds every morning, and we continually update each other on the progress of discharges,” she said. “We discuss patients identified as DBN, and the nurse passes information along in the change-of-shift report.”
Also part of a successful DBN initiative are nursing and physician leadership presence and the buy-in and contribution of all team members. “Physicians and nurse practitioners had to see the value of what we were doing,” she said, noting that they had to change their habit of rounding in the morning and discharging in the afternoon.
It is also important to clearly outline the role of the clinical nurse and to have a DBN “escalation tool” that identifies what is necessary for prompt discharge, which nurse is responsible, and “who to bump it up to” if a barrier arises. A review of “near miss” cases is also part of the strategy, as this leads to improvements in the process. “We have noticed common themes for near misses, including scheduling of appointments and delays in transportation and medication deliveries, and have been able to fix those throughout our hospital,” she said.
A spirit of friendly competition also helps. At Mount Sinai, a trophy is awarded once a month to the unit with the most DBNs.
Before implementation of the DBN initiative, the baseline rate of noon discharges was 6% in 2014, which rose to 16% in 2015. After implementation, the average rate in February 2016 was 33%.
“Our DBN rate can go from 0% to 40%, based on the complexity of discharges on the unit, but it hovers around 33%,” she noted.
Avoidable readmission rates were 17.2% in 2014, dropping slightly to 16.9% in 2015. While that seems like a minor improvement, she noted, “The goal is to not have them be higher, so we are going in the right direction!”
They also saw improvement in patient satisfaction with the DBN process based on communication, pain management, discharge plan, responsiveness of hospital staff, and care transitions, as measured by Press Ganey scores. Although the scores were not perfect, she noted, “we think it’s better to be better than waiting to be perfect. Two steps forward and 1 step back is still 1 step forward...DBN is still a work in progress, and there are still things we can do to improve.”
“I think we have demonstrated that successful, sustainable improvements are possible,” Ms Edmondson-Martin commented, “and this is a win-win initiative.”
Edmondson-Martin K, Gonzales J, Butler L, et al. Discharge Before Noon: a nurse-led clinical quality initiative that improves patient experience. Presented at: Oncology Nursing Society 41st Annual Congress; April 28-May 1, 2016; San Antonio, TX.
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