Improving Medicine-Telemetry Discharge Process Improving Medicine-Telemetry Discharge Process

Practice Problem: In Maryland, the most recent coronavirus disease (COVID-19) surge caused a significant increase in hospitalization and urgent demand for critical care beds. The identified delays in discharging patients from the emergency department to inpatient units resulted in more extended hospital stays, higher complication rates, and morbidity, which also impacted the health care organization's finances. PICOT: The PICOT question that guided this project was in a medicine-telemetry unit (P), does the implementation of an enhanced electronic discharge planning tool (I) compared to the current discharge planning tool (C) affect timely discharge (O) during an eight-week time period (T)?. Evidence: The synthesis of ten articles consisting of eight primary research and two systematic reviews resulted in eight eligible studies that support implementing an evidence-based project to increase timely discharge and bed availability. Intervention : The use of an enhanced electronic discharge planning tool was implemented for eight weeks in a medicine-telemetry unit on discharges to home as the intervention. Outcome: The result shows a 25% improvement in discharge process time. Although the 50% goal was not achieved, the findings suggest that enhancing the discharge planning tool positively impacts the time spent printing the after-visit summary sheet and the discharge process. Conclusion: The enhanced electronic discharge planning tool provided structure to the current discharge planning tool by eliminating the manual work surrounding the process. This project helped leaders improve patient and employee satisfaction and contributed to the organization's financial success.


Improving Medicine-Telemetry Discharge Process
Health care organizations are challenged to excel at capacity management. In Maryland, the most recent coronavirus disease  surge caused a significant increase in hospitalization and the need for critical care beds. Leaders were tasked to formulate a plan that would ensure safe and efficient patient flow to respond to the community's urgent needs.
A hospital with a solid throughput process positively impacts patient satisfaction, employee satisfaction, and the organization's financial success (Lyons et al., 2019). The purpose of this paper is to outline and describe a theoretical framework and change theory; synthesize the themes of recommended practice; identify the setting and stakeholders; implement and evaluate the plan; understand the impact of the project; and disseminate the planned change surrounding improving patient flow in the medicine-telemetry unit, particularly the discharge process.

Significance of the Practice Problem
For many years, the organization's fragmented patient flow process has been causing inefficiencies contributing to delayed discharges (Mangum et al., 2021). A delay in discharging patients in an inpatient unit can limit the hospital's ability to accommodate patients needing inpatient beds. The extra bed days patients spend in the hospital account for approximately 30.7% of the total cost, resulting in surgical case cancellations and treatment delays (Rojas-Garcia et al., 2017). Barriers to timely discharge include laboratory test delays, patients' reluctance to be discharged, transport delays, and skilled nursing facility acceptance delays (Ibrahim et al., 2022). Hospital discharge delays negatively impact the quality of care, patient safety, and experience (Bai et al., 2019). According to Laam et al. (2021), discharge delays from the emergency department (ED) to inpatient units result in more extended hospital stays, higher complication rates, and morbidity Delayed discharge is a global problem contributing to higher hospital costs (Rojas-Garcia et al., 2017). In the United States, the average cost of an inpatient day in a nonprofit hospital is 2,738 dollars (Michas, 2022) and 2,998 dollars in the State of Maryland (Kaiser Family Foundation [KFF], n.d.). In Canada, the UK, Israel, and Switzerland, discharge delays impact mortality, medical complications, depression and anxiety, and impaired activities of daily living.
At the project site, patients in the ED wait approximately 480 minutes to transfer to a medicine-telemetry unit. On the other hand, patients ready to be discharged from the medicinetelemetry unit wait for about 122 minutes from when a discharge order was written until the patient is discharged home. Two main factors contributing to these delays and efficient patient flow are the cumbersome printing of after-visit summaries (AVS) and inconsistencies in nurses' timely documentation of actual discharge time (K. Meade, personal communication, April 4, 2022). To be specific, once a discharge order is placed, nurses spend a lot of time sending secure chat messages to providers to confirm if AVS can be printed, and providers' responses are not always prompt. The timing of break time, hospital transport delay, and late arrival of patients' rides are some minor improvement opportunities identified as well (K. Meade, personal communication, April 4, 2022).

PICOT Question
In a medicine-telemetry unit (P), does the implementation of an enhanced electronic discharge planning tool (I) compared to the current discharge planning tool (C) affect timely discharge (O) during an eight-week time period (T)?

Population
The population is focused on adult patients admitted to the medicine-telemetry unit that were discharged home.

Intervention
The intervention that will be applied in this project is the implementation of an enhanced electronic discharge planning tool called the discharge navigator that will guide stakeholders to have an efficient workflow. In this intervention, nurses will be expected to complete the discharge planning tool tasks, including completing the medication and patient belongings list, completing the stroke scale, resolving patient education and care plan, administering influenza vaccine if needed, discussing the patient portal, and obtaining preferred pharmacy location.
Timely documentation of actual discharge time will also be required. In addition, providers will be educated to place the discharge order in an electronic health record (EHR) when the patient is entirely ready to be discharged. To streamline this process, when a discharge order is signed, the charge nurse and nurse assigned to the patient will receive an automatic notification that AVS is ready to be printed.

Comparison
The comparison has a discharge planning tool that does not have the functionality needed to expedite discharges. It was identified that nurses spend a lot of time sending secure chat messages to providers to confirm if AVS can be printed, and providers' responses are not always prompt (K. Meade, personal communication, April 4, 2022). The other issue identified was inconsistencies in nurses' timely documentation of actual discharge time, affecting the admission nurse's ability to see available beds for incoming patients (K. Meade, personal communication, April 4, 2022).

Outcome
The desired outcome of this project is to determine if implementing an enhanced electronic discharge planning tool can reduce discharge process time by 50%. The discharge process time is the difference between the time the provider wrote the order and the actual timestamp of discharge noted by the nurse as recorded in EHR. The enhanced electronic discharge planning tool will provide structure to the current discharge planning tool by eliminating the manual work surrounding the process.

Timing
It is anticipated that project will take eight (8) weeks from start to finish.

Evidence-Based Practice Framework & Change Theory
The Johns Hopkins Nursing Evidence-Based Practice (JHEBP) framework is commonly used in healthcare practice. Inquiry, practice, and learning are this model's three relevant interrelated components that guide a nurse in ensuring the latest best practices are incorporated into patient care (Dang & Dearholt, 2018). This framework encompasses a conscious effort to identify a problem, practice components of nursing based on standards established by the professional nursing organization, and have a learning culture necessary to build practice expertise. According to Speroni et al. (2020), healthcare providers must apply evidence to improve, achieve, and sustain change that impacts patient and work environment-related outcomes. Therefore, JHEBP can be highly effective in identifying and implementing the EBP to improve the discharge process.
Implementing an EBP that will prevent hospital discharge delays is a process of change that is important but challenging for health care leaders when members prefer to retain the status quo (Kuo & Chen, 2019). Kotter proposed the change model designed to improve the organization's ability to increase its chances of successfully institutionalizing change (Najjar & Ascione, 2020). This change model encompasses eight interrelated steps: establish a sense of urgency; create a powerful guiding coalition; create a strategic vision; communicate the vision; empower others to act on the vision; plan for and create short-term wins; consolidate improvements and institute change (Haas et al., 2020). The key stakeholders' grassroots participation, including the front-line staff and executive leadership team, was emphasized in this model as critical in promoting and implementing change (Najjar & Ascione, 2020). With this simple approach, this model is a valuable guide for approaching the planned practice change in the medicine-telemetry unit.

Evidence Search Strategy
It is vital to obtain answers that underpin evidence-based recommendations, decisions, or practices using an effective and unbiased search strategy (Gallagher & Melnyk, 2019). In this paper, the sources of evidence were obtained from four databases. These include Science Direct, PubMed, CINAHL Complete, and Cochrane. The keywords searched were standard discharge process, inpatient discharge process, standard inpatient discharge process, early discharge, lean discharge process, fragmented discharge process, hospital throughput, inpatient throughput, patient flow, efficient patient flow, and efficient discharge. MeSH heading searched were patient discharge and efficiency. The filters were set to English and published dates of 2012 to 2022. The total cumulative article to be screened yielded to 367 (Table 1).

Inclusion Criteria
To meet the inclusion criteria, articles had to be published between (a) February 14, 2012, andFebruary 14, 2022, (b) containing information specific to the inpatient unit, (c) focus on adult patients, and (d) studies conducted in a hospital setting.

Exclusion Criteria
Exclusion criteria for reviewed articles included (a) surgical inpatient unit and (b) adult patients who were not discharged home.

Evidence Search Results
A total of 367 studies identified by searching four databases (Science Direct, PubMed, CINAHL Complete, and Cochrane) were screened. Of these, 157 duplicates were removed. Of the remaining 210 studies, titles and abstracts were assessed for eligibility and 200 were consequently removed according to pre-set criteria. A total of 158 were irrelevant to questions, 27 were wrong interventions, and 15 were editorial. Of the remaining, ten abstract full-text articles were retrieved and assessed for eligibility ( Table 2). The ten remaining articles consisted of eight primary research evidence and two systematic reviews. Primary research evidence consisted of four Level III qualitative studies, two Level V quality improvement, one retrospective randomized cohort Level III, and one retrospective Level III (Appendix A). Systematic reviews consisted of one Level I systematic review and metanalysis and one Level II retrospective quasi-experimental. Eight out of ten eligible studies have supporting evidence to improve the evidence-based project.

Themes with Practice Recommendations
A literature review is essential in the identification and synthesis of themes that support practice recommendations. The synthesis of the studies about improving the discharge process includes eight primary research with four themes. The articles had a few overlapping themes, but the main focus was consistent. The main ideas in Table 3 were organized into four themes: (1) increased early discharges, (2) decreased readmission rates, (3) cost reduction or savings, and (4) decreased length of stay (LOS).

Decreased Readmission Rates
It is noted that readmission rates significantly decreased using multidisciplinary care pathways and discharge planning tools (Kurcharczuk et al., 2022;Duvarsula et al., 2015;Patel & Dickerson, 2018;Patel et al., 2019;Sullivan et al., 2018). The subsequent reduction in readmission rates from using the discharge planning tool was 29% (Kurcharczuk et al., 2022)

Decreased Length of Stay
Decreased LOS was a benefit realized when a multidisciplinary care pathway or discharge readiness tool was created and implemented (Ibrahim et al., 2022;Lovett et al., 2021;Patel et al., 2019). Implementing the discharge readiness tool achieved an average of .26 days decrease in LOS (Lovett, 2021).

Similarities, Differences, and Controversies
Most of the literature proved that having a standard discharge planning tool can improve timely discharge, but some controversies have been identified up to date. A discharge planning tool called the discharge navigator is a user-friendly tool embedded in an electronic health record (EHR). It enables the population of the table into an electronic note within seconds and allows users to quickly move within elements using the tab key (Kucharczuk et al., 2022). This tool allows healthcare providers to see and complete tasks that must be performed to discharge a patient successfully. Examples in the nursing section include printing AVS, completing medication and patient belongings lists, completing stroke scale, resolving patient education and care plan, administering influenza vaccine if needed, discussing patient portal, and obtaining preferred pharmacy location. The study of Kucharczuk et al. (2022), showed that timely discharges before noon increased by 76.2%, but specific discharge order sets should be shifted to the evening before discharge. Similarly, the study by Patel et al. (2019) showed that discharge before noon increased by 11.6% with the implementation of afternoon huddles and physician continuity. Meanwhile, the study by Lovett et al. (2021) proposed a discharge readiness tool with a specific rounding model that is effective in timely discharge and team satisfaction. It is also important to note that a significant cost reduction amount of $1,294,228 was achieved using the discharge planning tool (Kurcharczuk et al., 2022).

Practice Recommendations
The success of a structured EBP relies on the appropriate identification of a PICOT and an extensive literature search. After thoroughly reviewing the literature and synthesizing evidence, the DNP student found strong evidence supporting implementing an enhanced discharge planning tool to increase timely discharge and bed availability. It is recommended that the discharge planning tool available in the current electronic health record be utilized properly and consistently. Additional significant benefits such as efficiency, decreased LOS, and cost savings will also be achieved upon implementing this EBP project.

Setting, Stakeholders, and Systems Change
This DNP project will reduce discharge delays in a nonprofit community hospital in Maryland. The population of interest is adult medical-telemetry unit patients. The health care organization's mission is to provide medical care and service of the highest quality to each patient and educate the next generation of clinicians, leading to health, healing, and hope for the community. Its vision is to develop a model system for delivering evidence-based patientcentered care. The organization's vision phrase is to every patient, every time, we will provide the care we would want for our own loved ones. Its values are intended to create and sustain a culture of service excellence.
The organizational need was established as part of the Lean Management System initiative, which revealed an opportunity to improve communication between the registered nurse and patient regarding the discharge process. The medicine-telemetry unit takes an average of 122 minutes to discharge a patient from when the discharge order is written. It also shared that most discharges occur after 11:00 a.m. (K. Meade, personal communication, April 4, 2022). As a result, the ED is boarding medicine-telemetry patients, and the nurses in the medicine-telemetry unit are staying over the required shift.
Understanding that reducing patient discharge delay is a high priority, the patient and family member, Performance and Innovation (PI) representative, unit nurse manager, physician champion, case manager, utilization review manager, pharmacy manager, EPIC representative, nurse educator, and transportation manager are the identified stakeholders who will participate in this project. The PI representative will guide the discussion on critical steps to improve discharge delays. At the same time, the rest of the team will establish the specific goals and action steps necessary to meet the desired outcome. Permission to implement the project has been obtained from the Director of the Medicine-Telemetry Unit at the project hospital. It is predicted that the level of system change with this project is both micro and meso.
The micro-level will pertain to the changes that will occur at the individual nurse level regarding process education, and meso change will reflect the change within the organization to improve compliance with the use of the discharge planning tool.
A strengths, weakness, opportunities, and threats (SWOT) analysis (Appendix E) will guide and direct the team to design the action plan and project activities. The strengths of this organization include highly competent health care providers, a collaborative interdisciplinary team, established daily Lean Management System rounds, a supportive leadership team, and increase patient and family participation. On the other hand, lack of policy on the discharge planning process, limited education on the appropriate discharge process, unclear delineation of responsibilities, shortage of employed nurses, and inconsistent expected date of discharge information are the noticeable weaknesses that need to be addressed. The present opportunities are reduced wait time for patient transportation, reduced boarding time in the ED, improved communication regarding the care plan, and fewer calls to physicians to follow up on AVS. On the contrary, the interdisciplinary team's openness to change and nurses' views of redundant extra work are identified threats.

Implementation Plan with Timeline and Budget
The overall goal of this EBP project is to implement an enhanced electronic discharge planning tool in a medicine-telemetry unit that will improve the average time of discharge to 50% from when the discharge order was written to when the patient left the facility by June 27, 2022.
The first objective that guides this project's implementation and evaluation is to promptly identify patients requiring discharge. The second is to understand the barriers contributing to discharge delays. The third is to facilitate discharge planning by collaborating with the stakeholders.
Kotter's change model was used to define the tasks that guide the implementation and evaluation of this project which includes8/2 establishing a sense of urgency; creating a powerful guiding coalition; forming and communicating a strategic vision; empowering others to act on the vision; generating short term wins; sustaining acceleration, and instituting change (Haas et al., 2020). It was also used to determine how the objectives would be met.

Create a Sense of Urgency
The project manager communicated the current number of minutes spent from when the discharge order was written to the actual patient out-the-door time with corresponding delay reasons or barriers. Immediately after the identified issues were shared, approval was obtained to start the EBP project.

Build a Guiding Coalition
The grassroots participation of the stakeholders, including the front-line staff and the leadership team, is essential in promoting and implementing the necessary change (Najjar & Ascione, 2020). A meeting with the stakeholders to introduce EBP was scheduled to build a guiding coalition. A project plan and committee membership needs were discussed in the meeting.

Form a Strategic Vision
The goals and metrics for success aligned with a strategic vision were created. Action plans were set, and the stakeholders' inputs were incorporated.

Enlist a Volunteer Army
Tasks were assigned to stakeholders where clarity of roles and responsibilities was crucial. After the stakeholders designed the enhanced discharge planning tool, approval was obtained and communicated to the EPIC representative to be incorporated into EHR. Education and training were scheduled.

Enable Action by Removing Barriers
To continuously support stakeholders, bi-weekly meetings were scheduled. The identified barriers and possible solutions were discussed.

Generate and Celebrate Short Term Win
The project's progress was tracked, and small successes or wins were celebrated to show appreciation for the hard work and dedication of the stakeholders.

Sustain Acceleration
The approved enhanced electronic discharge planning tool was used in discharging patients to home. Data was gathered, recorded, and reported. At the evaluation, issues were promptly addressed.

Institute Change
The EBP practice change was fully implemented and consistently evaluated. The project manager and unit manager collected data bi-weekly and provided reports to the stakeholders.
The project manager oversaw the project from conception to completion. In addition to identifying key stakeholders and implementing action steps, the project manager also determined the logistics. It was identified that a minimum amount was needed to cover the direct expense (see Figure 1).

Results
The electronic medical record collected four weeks of pre-implementation or baseline and eight weeks of post-implementation data. It contains the number of discharges per day, discharge order placed to AVS print time, and discharge order placed to discharge time (discharge process time). The 30 days and 60 days post-implementation data were compared with the baseline data. The EPIC staff pulled reports stored and protected in the EPIC system.
Data were reviewed and analyzed by the project manager and unit manager. It was ensured that the data collected was HIPAA compliant. Permission to use the data collected from the electronic medical record was obtained from the facility.
A total of 101 baseline discharge data were collected from May 29, 2022 to June 26, 2022. The baseline data showed that the printing of AVS from the time the discharge orders were placed took an average of 54 minutes, and the discharge process time took an average of 122 minutes.
The first 30 days of project implementation occurred from June 27, 2022 to July 24, 2022. A total of 95 discharge data were collected. The printing of AVS sheets from the time the discharge orders were placed took an average of 36 minutes, and the discharge process time took an average of 108 minutes.
The last 30 days of project implementation occurred from July 25, 2022 until August 20, 2022. A total of 88 discharge data were collected. The printing of AVS sheets from the time the discharge orders were placed took an average of 38 minutes, and the discharge process time took an average of 92 minutes.
The 30 days post-implementation data showed a 12% improvement in the discharge process time but was short by 3% to meet the goal of 15%. Similarly, 60 days postimplementation data shows a 25% improvement in discharge process time, but the goal of 50% was not achieved (Appendix D & H). Although the 50% goal was not achieved, the result of the two-tailed paired samples t-test was significant based on an alpha value of .05, t(283) = -10.36, p < .001. This finding suggests that enhancing the discharge planning tool positively impacts reducing the time spent printing AVS and the discharge process.
According to Page (2014), a clinically meaningful change pertains to a beneficial and significant change when considering the cost of implementing a strategy, making the wrong decision, and the possibility of individual response to the treatment and harmful side effects. In this project, the clinically meaningful criteria achieved was that patients were safely discharged 25% earlier using an enhanced electronic discharge planning tool.
Moreover, approximately $2,841.00 was saved for improving the discharge process by 14 minutes in the 30 days of implementation multiplied by 95 discharges. An additional $5,516.00 was saved for reducing discharge delays by 30 minutes in the 60 days of implementation for 88 discharges. In total, an average of $8,357.00 in revenue was accounted for during the two months of project implementation. The amount was calculated by multiplying discharge process improvement in minutes and $2.08, which is the benchmark inpatient cost ( Figure 1).

Impact
Three primary impacts identified upon completing the implementation include efficiency, minimal reduction in LOS, and cost savings. The staff in the practice setting appreciated the improvement made to the enhanced discharge planning tool. Holding the nurses and providers equally accountable for completing the tasks listed in Appendix G has contributed to staff satisfaction. It streamlined communication and eliminated the unnecessary manual steps between the nurses and providers in confirming if the AVS can be printed. The clinical significance achieved by implementing this practice change was the assurance and confidence to safely discharge patients in a shorter period, corresponding to a minimal reduction in LOS.
Reducing delays in discharging patients also gave the practice setting the ability to admit patients from the ED at a faster pace and provided the opportunity to manage patients' needs promptly. The amount saved in two months of implementing this project is also significant for the facility, as any cost-saving initiatives were captured.
This EBP project positively impacted the discharge process in the practice setting.
However, implementing the enhanced electronic discharge planning tool for patients discharged to home on weekdays is a limitation of this project. More information is needed to further improve the discharge process, including capturing the factors contributing to the delays in discharging patients after the AVS is printed.
As the project continues beyond the implementation stage, the future implications of including this EBP practice change in the discharge policy should be considered. For sustainability, the practice-setting unit manager will continue using the enhanced electronic discharge planning tool and coordinate the implementation with other inpatient unit nurse managers. The ongoing evaluation of the project's effectiveness will continue to be monitored by pulling the unit discharge process time monthly report. The results will be shared with stakeholders as a basis to create specific action plans if needed. Data on the length of time medicine-telemetry patients wait in the ED should also be monitored to capture the additional benefit of implementing this DNP project.

Dissemination
Dissemination of the practicum project findings includes providing a local and national presentation within the facility and within the professional community. Locally, the project findings were shared with leaders of the subject setting in a face-to-face meeting using a PowerPoint presentation. Paper copies of the presentation were also provided. Results were also shared with the stakeholders and members of the subject unit utilizing a PowerPoint presentation held via Microsoft Teams during the monthly staff meeting. The information presented includes the practice problem and its significance, intervention, sample, setting, data collection, results, and impact. In both venues, all attendees were given the opportunity to ask questions and share feedback.
In addition, a poster presentation will be provided to scholarly disseminate the project to peers and the School of Nursing faculty. The project will also be published in the Scholarship and Open Access Repository at the University of St. Augustine for Health Sciences.

Conclusion
This DNP project contributed to the success of hospital capacity management and patient flow in the medicine-telemetry unit, particularly in the discharge process. The aim was achieved using the Johns Hopkins Nursing Evidence-Based Practice (JHEBP) framework that effectively helped identify the EBP to improve discharge process time. After thoroughly reviewing the literature and synthesizing evidence, the DNP student implemented the EBP supporting an enhanced discharge planning tool that increased timely discharge and bed availability. Additional significant benefits such as efficiency, decreased LOS, and cost savings were also achieved upon implementation of this EBP project. This enhanced tool provided structure to the current discharge planning tool by eliminating the manual work surrounding the process. Kotter's change model, designed to improve the organization's ability to increase its chances of successfully institutionalizing change, was used to implement this project. Identified stakeholders were informed and involved throughout the process. This EBP project helped leaders improve patient and employee satisfaction and achieve the organization's financial success.  This evidence-based project is designed to improve discharge process in a medicine-telemetry unit of a community hospital. The use of enhanced electronic discharge planning tool will be implemented in all adult patients in medicine-telemetry for patients with home disposition. The length of time spent in discharging patients when this tool was used will be measured.