Discharge in the AM

Discharge in the AM: A Randomized Controlled Trial of Physician Rounding Styles to Improve Hospital Throughput and Length of Stay

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. The investigators conducted a prospective randomized study to understand if this commonly utilized approach to expedite care results in earlier discharges and lower hospital lengths of stay while also understanding the impact on other patient care (such as test and consult order times on other patients that the physician is caring for).

Study Overview

• Status: Completed
• Conditions: Hospitalism; Flow or Discharge
• Intervention / Treatment: Other: Rounding on discharging patients first

Detailed Description

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, previous work also identified that providers may be able to prioritize their work in a different way in order to facilitate this throughput. The investigators 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 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. The investigators 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 and lab/diagnostic test order time. Additionally, the investigators 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 the investigators 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, the investigators 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. The investigators believe these findings will be pivotal for clinicians to be more willing to change their practice style. The investigators also believe this study will aid in the understanding of what factors may function as facilitators and barriers of earlier discharges.

• Study Type: Interventional
• Enrollment (Actual): 61
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Colorado
    • Aurora, Colorado, United States, 80045
      • University of Colorado

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

Inclusion Criteria:

Physicians:

-Hospital Medicine attending-level physicians who consented to participate and patients

Patients:

• At least 18 years of age
• Admitted to a Medicine service and assigned by standard practice to a general medical hospitalist team including a provider who agreed to participate in the study

Exclusion Criteria:

-Patients assigned, by standard practice, to a general medical hospitalist team and on the team of providers who chose not to participate in the study

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: rounding on discharging patients first; Rounding on discharging patients meant that the attending physician and accompanying team (i.e. if they were working with advanced practice providers or learners) would prioritize seeing any patients that were going to discharge that day.	Other: Rounding on discharging patients first; Rounding on discharging patients meant that the attending physician and accompanying team (i.e. if they were working with advanced practice providers or learners) would prioritize seeing any patients that were going to discharge that day. The attending could break protocol if needed for patient care purposes and this was tracked each day.
No Intervention: usual practice; Usual practice was categorized as: seeing discharging patients first, sickest patients, decompensating patients, new patients (i.e. patients admitted to their team overnight), or based on geography.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Physician discharge order time	Physician discharge order time entered into the electronic health record	From the midnight of the day the patient was discharged until time the patient had a discharge order placed, assessed up to 6 months from the start of the study.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Patient discharge time	The time the patient left their hospital bed/actually discharged from care in the hospital	From the midnight of the day the patient was discharged until the time the patient was discharged from the hospital, assessed up to 6 months from the start of the study.
Patient length of stay	The total length of stay in hours	From the time that the patient was admitted to hospital until time the patient had a discharge order placed, assessed up to 6 months from the start of the study.
Average time of day of orders for imaging, consults, or procedures were entered by participating physicians into the electronic health record	average time of day over the course of each patient's hospitalization that orders for imaging, consults, or procedures were entered by participating physicians	From the midnight of the day each day to the time of day each patient had an order placed for imaging, consults, or procedures, assessed up to 6 months from the start of the study.

Collaborators and Investigators

• Sponsor: University of Colorado, Denver
• Collaborators: Johns Hopkins University; Denver Health and Hospital Authority
• Investigators: Principal Investigator: Marisha Burden, MD, University of Colorado School of Medicine

Study record dates

Study Major Dates

• Study Start (Actual): February 9, 2021
• Primary Completion (Actual): July 31, 2021
• Study Completion (Actual): July 31, 2021

Study Registration Dates

• First Submitted: April 25, 2022
• First Submitted That Met QC Criteria: May 6, 2022
• First Posted (Actual): May 11, 2022

Study Record Updates

• Last Update Posted (Actual): May 11, 2022
• Last Update Submitted That Met QC Criteria: May 6, 2022
• Last Verified: May 1, 2022

More Information

Terms related to this study

• Keywords: inpatient; early discharge; hospitalist; patient flow; discharge before noon
• Other Study ID Numbers: 19-1607

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No