Where: Massachusetts General Hospital (MGH), a 907-bed urban teaching hospital in Boston.
The issue: Making discharge safer and reducing workload for housestaff.
“Everyone kept wondering, ‘What could we offload off the housestaff's plates?’” said Kathleen Finn, MD, FACP, associate program director of the internal medicine residency at MGH. Dr. Finn and her colleagues weren't looking to steal residents' food; they were concerned that trainees had too much work to fit into their shortened work hours and that not all of these tasks required a physician's knowledge and skills.
The program leaders were also interested in providing the best discharges possible for their patients. “All the papers keep coming out showing that discharge is a dangerous time for patients. … It's the time when all the balls in the air can fall down,” said Dr. Finn.
A few years before, a nurse practitioner (NP) had been assigned to one academic team. “She was trying to help with the discharge process, but we weren't entirely clear what the benefits were,” Dr. Finn said. This time, the group decided to more definitively assess the effects of having an NP work with residents on discharge.
How it works
An NP was randomly assigned to one of the service's five resident teams in November 2008. For the next five months, she attended daily resident work rounds and interdisciplinary discharge rounds and collaborated with the residents to identify patients being discharged in the next few days. She then composed the discharge summaries (which were edited by residents), met with patients to answer questions, provided her business card for post-discharge questions, and scheduled follow-up appointments, in addition to performing medication reconciliation and faxing prescriptions and discharge summaries.
“We were hoping overall that the discharge process would be safer and better for patients, there'd be more discharge summaries available for primary care doctors, there'd be more follow-up appointments, the patients would be better satisfied, and the nurses would be better satisfied. We were hoping in the long run that would be reflected in reduced readmissions and ED visits or even a shortened length of stay,” said Dr. Finn.
To assess whether their goals were met, statistics for the resident team with the NP were compared to those of a similar team on another floor.
On several fronts, the project was a success. In results published in the November/December 2011 Journal of Hospital Medicine, Dr. Finn and co-authors reported that patients on the NP team were significantly more likely than controls to have their discharges completed promptly (67% vs. 47% within 24 hours) and follow-up appointments scheduled (62% vs. 36%). They were also more satisfied with the discharge process (97% vs. 76%).
The new system also had satisfying results for residents. On average, they signed out 46 minutes earlier every day. “[This finding] told us that we were offloading a lot of busywork from the housestaff,” said Dr. Finn.
However, the intervention didn't improve some of the other markers that the researchers measured.
“It didn't seem to affect length of stay or emergency department visits and readmission rates, which was unfortunate because that's probably where the cost savings would come from to hire another NP,” Dr. Finn said.
The program hired several more NPs to help with discharge, despite the additional cost. “The NP was so helpful with the discharge process, even if the financial components didn't come through, [and] even though we didn't seem to reduce readmissions,” said Dr. Finn.
The new NP discharge coordinators have also gained an additional task: helping with morning discharges. “That frees up the housestaff to be at attending rounds and work rounds and focusing on the current patients,” Dr. Finn said. “We're one of those hospitals at 100% occupancy. We need the pre-noon discharges to keep the flow.”
“There were growing pains,” according to Dr. Finn. “Early on, when the first NP started, there were junior residents who had the belief that they should be doing everything and that they didn't need the extra help and only they can do it correctly,” she said. “Over the five years that that attitude has completely gone 180 degrees. Now when the NP went on maternity leave, I started getting emails saying, ‘Where's the NP?’”