Effective Clinical Practice
LETTER TO THE EDITOR
The recent article, "Caregiver Perceptions of the Reasons for Delayed Hospital Discharge" (1) highlights dysfunctional communication between medical and nursing staff as a reason for differing perceptions of the causes for delayed hospital discharge at an academic medical center. The introduction to the piece highlights the financial implications of delayed discharge to the facility.
The question propounded does not address delayed discharge adequately. The authors have confounded hospital discharge with discharge to other hospital units of greater or lesser nursing care involvement. Is the problem with discharge to another unit a billing problem or the rendering of appropriate care? Further, is the problem with hospital discharge that of dismissal from the business office or with having someone take the patient from the hospital itself? Each may have differing causes yet contribute to the same misperception measured by the authors. Notwithstanding, the financial implications may not be serious if the hospital day is defined from midnight as opposed to noon.
It has been a longstanding risk-management practice to record the date and time on progress notes and orders as well as to record the date and time when orders are removed for action--for example, if the medical team discharges a patient at 9 am but does not turn in the order until rounds are completed at 11 am, and ward personnel are then asked to transpose all orders, is it unreasonable that some discharges occur after noon? Or that the business office completes the financial discharge later? If this is in place at the authors' facility, delays in discharge may be pinpointed as to medical, nursing, or business staff, allowing appropriate intervention, and correction of caregiver perceptions. This may also support a change in defining the hospital day. The communication between medical and nursing staff may not be dysfunctional.
Kenneth Alonso, MD
Morehouse School of Medicine
1. Minichiello TM, Auerbach AD, Wachter RM. Caregiver perceptions of the reasons for delayed hospital discharge. Eff Clin Pract. 2001;4:250-5.
THE AUTHORS RESPOND
We appreciate Dr. Alonso's interest in our study. We agree that the relevance of saving a few hours in the hospital by more timely discharge may have financial impact only if the hospital day is defined by noon vs. midnight. However, patients may benefit from more expeditious discharge regardless of this distinction. Discharge earlier in the day may improve patient care by allowing ancillary care providers (such as infusion therapy or visiting nurses) or family members more time to set up home care arrangements during working hours. Patients discharged later in the day, although not staying past midnight and not incurring an additional day in the hospital, may not be able to deal with discharge needs until the first business day following discharge.
Workflow related to order writing is indeed another possible contributor to delayed discharge. We feel that how caregivers perceive the process--even if notes are submitted, dated, and timed appropriately by physicians--is equally important. In addition, orders alone may not capture the timing of communication between caregivers, many of which are not associated with a written order. A complete analysis of the problem would involve evaluation of the work flow process, as Dr. Alonso suggested, so that individual hospitals can determine points in the workday where communication between inpatient care providers can be systematized according to local needs.
Tracy Minichiello, MD
Andrew D. Auerbach MD, MPH
Robert M. Wachter, MD
University of California, San Francisco
San Francisco, Calif