Hospitals around the country face bottlenecks and capacity issues. When hospitals are successful at managing high capacity this allows for increased access for patients who need this higher level of care and expertise. Unfortunately, hospital discharges frequently occur in the afternoon or evening hours and can adversely affect patient flow throughout the hospital which, in turn, can result in delays in care, medication errors, increased mortality, longer lengths of stay, higher costs, lower patient satisfaction, and decreased access to care at these facilities. While some of the delays in discharges result, appropriately, from the caring of other patients and conducting the necessary tasks and assessments for acutely ill patients, our previous work also identified that providers may be able to prioritize their work in a different way in order to facilitate this throughput.
We aim to conduct a randomized controlled trial of physician rounding style at three institutions in order to: (1) determine if prioritizing discharging patients first will result in earlier discharges and decreased lengths of stay, (2) determine if prioritizing discharges first will cause other care delays or affect patient experience and, (3) determine factors that contribute to physician ability to prioritizing discharges first. The proposed study is a prospective, multi-center, cluster randomized trial designed to test the effects of rounding on discharging patients first compared to usual practice and will utilize an effectiveness-implementation hybrid approach. We will recruit hospitalist attending physicians from three hospitals in the US to be randomized to one of two rounding styles: (1) prioritize discharges first and (2) usual practice. The main outcome measure will be discharge order time. Secondary outcomes will be length of stay, lab/diagnostic test order time, and patient experience as measured through the HCAHPS survey. Additionally, we will study how team composition (teaching, non-teaching, teams with advanced practice providers), team census (i.e. the number of patients a provider is caring for), and number of admissions affect the ability for providers to prioritize discharges first. Through qualitative methods we will also gain an understanding from physicians as to why or why not they were able to prioritize discharges first. This study will add to the evidence to either support or negate the practice of prioritizing discharges. There have been no randomized studies to date that have addressed these issues. Additionally, we aim to understand how team composition and census affect discharge times. Institutions across the country will be able to utilize these findings to help refine current rounding models. We believe these findings will be pivotal for clinicians to be more willing to change their practice style. We also believe this study will aid in the understanding of what factors may function as facilitators and barriers of earlier discharges.
As hospitals around the country continue to work to manage a high patient census, provider prioritization of discharges is one low cost mechanism to help improve patient throughput and patient length of stay. If the results of this prospective randomized study supports this premise, this approach may be more widely adopted.
