ABSTRACT
IMPORTANCE: Early discharge of patients has become standard work in acute care settings to reduce inpatient length of stay (LOS), improve patient flow, and reduce boarding in the emergency department (ED). OBJECTIVE: Retrospective analysis of outcomes from a discharge by 11 am program at an academic medical center from January 1, 2020, to June 30, 2022. The analysis addresses the effects of a discharge by 11 am goal on time from discharge order release to patient discharge, ED boarding, LOS, and observed-to-expected LOS. DESIGN, SETTING, AND PARTICIPANTS: Patient-level electronic health record data included discharge order entry time, discharge time, LOS, and diagnosis-related group geometric LOS (GMLOS). Additional unit-level data for ED boarding volumes and hours were included. Analyses were conducted at the hospital and unit levels where indicated. RESULTS: Patients with a discharge order by 9 am have longer mean hours from order to discharge than patients without a discharge order by 9 am (9.04 vs 2.48 hours, P < .001) ED boarding total (R2 = 46.2%, P ≤ .001), percentage (R2 = 50.4%, P ≤ .001), median minutes (R2 = 24.6%, P = .005), and total minutes (R2 = 40.8%, P ≤ .001) all increased as discharge by 11 am performance improved. The mean LOS is longer for the discharge by 11 am group than the non-discharge by 11 am group -1.67; 95% CI, -2.03 to -1.28, P < .001). Discharge by 11 am patients had a LOS/GMLOS ratio 21.9% higher than the non-discharge by 11 am cohort (difference -0.31; 95% CI, -0.36 to -0.26, P < .001). CONCLUSIONS: Discharge order entry and release by 9 am and patient physically discharged by 11 am initiatives demonstrate a statistical increase in time from discharge order to discharge time, ED boarding, LOS, and observed-to-expected LOS.
ABSTRACT
To develop and implement a protocol to increase patient mobility in three adult ICUs using an interdisciplinary approach and existing resources. DESIGN: The Iowa Model of Evidence-Based Practice was used for synthesis of literature and intervention planning. A retrospective pre- and post-intervention data collection design was used to compare outcomes of interest. SETTING: Three adult ICUs (64 total beds) in an urban, academic hospital. Physician, nursing, respiratory therapy, physical therapy, and occupational therapy representatives participated in planning and development. All adult ICU patients were included. INTERVENTIONS: Development and implementation of an inclusive early mobility protocol in three adult ICUs. Focus on interdisciplinary collaboration to restructure workflow, focusing on optimization and coordination of standard tasks. Multimodal education occurred in an interdisciplinary setting and on-site champions facilitated implementation. MEASUREMENTS AND MAIN RESULTS: Time from admission to ambulation, overall frequency of ambulation, and frequency of ambulation by age group were assessed across three time periods: no awareness (Time 1), awareness without protocol (Time 2), and protocolization (Time 3). Decrease in hours from admission to ambulation were seen in the cardiovascular ICU (62.3 vs 56.1; p = 0.10) and surgical ICU (64.9 vs 58.6; p = 0.022). Significant increase demonstrated in the proportion of patients who ambulated while in the ICU (24.6% vs 33.0%; p < 0.001). All age groups had increase in frequency of ambulation. The largest gains in patients over 65 years old (T1 = 19.7%, T2 = 26.6%, T3 = 30.9%; p < 0.001). No change found in ICU length of stay, hospital length of stay, or ventilator days. CONCLUSIONS: This single-center evidenced-based practice project demonstrated increased mobility for ICU patients without addition of staff resources following implementation of an early mobility protocol using an interdisciplinary approach. Successful implementation led to creation of mobility protocol toolkit for use across all ICUs in the broader health system.
