Where: Yale-New Haven Hospital, 1,571-bed academic/community hospital in New Haven, Conn.
The issue: Discharging more patients by 11 a.m.
By 2009, Yale-New Haven Hospital had tried a number of strategies to deal with bed shortages, according to ACP Member Kusum S. Mathews, MD, MPH. “Should we have the medicine teams admit the patients and have them board in the emergency room...or do we allow the ED to just hold on to them and continue management? Then they tried other things, like giving us incentives—coffee cards—to try to get our patients out the door,” said Dr. Mathews, who was a resident there at the time and has since become an assistant professor of medicine at Mount Sinai Hospital in New York City.
Finally, as part of a hospital-wide, multidisciplinary Safe Patient Flow initiative, the barriers to faster discharge were investigated. “The nurses highlighted issues: ‘The doctors keep changing their minds.’ Or ‘We don't know when the doctors are rounding that they've decided to discharge this patient...All of a sudden we're scrambling trying to get them out the door,’” Dr. Mathews said.
Concluding that such gaps in communication could be responsible for many discharge delays, the hospital team decided to try out the red/yellow/green (RYG) discharge tool, a concept that has been tested in other hospitals here and overseas, as a possible solution.
How it works
The RYG tool required an inpatient's physician (housestaff or hospitalist) to assess whether the patient was very likely (green), possibly likely (yellow), or unlikely (red) to be discharged the next day. In the initial implementation of the tool, the choice of red/yellow/green was a forced field that a physician had to complete every time she made changes to the patient's signout. (The tool was later moved to the progress note to better fit housestaff's practice patterns.) Nurses on the night shift would begin discharge paperwork for all patients with a green or yellow status, and 7 a.m. huddles would specifically target green patients.
At first, Dr. Mathews had her doubts about the effectiveness of the RYG tool. “I was sure that it wasn't working, because in the microcosm of the service I was managing, I was frustrated by the lack of accuracy [in color assignments],” she said.
But when she looked at the data on the tool, it turned out to be making a difference. Before RYG, only 11.1% of patients were discharged by 11 a.m., compared to 18.3% soon after implementation, a number that eventually rose to 24% by 2011. Patients with an RYG designation were also discharged earlier than those without one (2:07 p.m. vs. 2:40 p.m.), according to results published in The Joint Commission Journal on Quality and Patient Safety in June.
“When you look at the aggregate, you can see that we were moving the needle. In the scheme of an entire hospital, where there are 1,500 beds, having earlier discharge even by an hour actually can alleviate some of the congestion in an emergency room, in a [post-anesthesia care unit],” Dr. Mathews said.
The new system affected communication about discharge not only between doctors and nurses but other hospital staff as well. “The cleaning staff looks at the list of greens for the next day and plans their shift,” said Dr. Mathews.
Challenges and next steps
Red and green are pretty clear designations, but the uncertainty of a yellow rating posed some issues. Especially once the RYG tool moved to the progress note, physicians often chose a designation early in the day, when they were naturally more uncertain about the patient's trajectory, and so would often pick yellow.
“Without even knowing it, the interns were triggering the nurses to put in paperwork,” said Dr. Mathews. Then the nurses would be frustrated when the yellow patients weren't discharged the next day and they had to redo paperwork. This complaint came up during follow-up focus groups about the new system, and a solution was developed.
A transitional care round was added in the afternoon to improve accuracy of the discharge prediction. “After social work, care coordination, and transportation issues have been addressed, one of the team members updates the RYG tool for each patient before the nighttime shift comes in,” said Dr. Mathews. Discharge paperwork for green patients was then prioritized over yellows.
The tool hit another bump when the hospital changed its electronic health records (EHRs) system. “Each system has its own set of quirks, and Epic does not have forced field entry, which I thought was going to spell the death of the RYG tool,” said Dr. Mathews. She was surprised to find that physicians continued to choose a color even when they weren't forced to.
“The adherence rates actually stayed pretty steady,” she said. “Physicians had already integrated RYG into their workflow and understood the value of communicating this with the nurses in a way that was almost automated. They were already thinking, ‘When is this patient able to go?’ from day 1.”