Background: Delayed discharges create a bottleneck for patient flow through hospitals. Prolonged stays increase mortality and medical complications. Later afternoon discharges in particular can limit the completion of day jobs for new admissions, as staff and services available are limited at these times. This thus unnecessarily extends the length of stay and restricts patient care. Optimising the timelines of discharges would therefore benefit patients and staff as well as hospitals and affiliated services.The outcome measure for this quality improvement project (QIP) was the percentage of patients in the general paediatrics ward at Evelina London Children’s Hospital, who are discharged before 5 pm and the accompanying aim was to increase this percentage by 20% over a period of 5 months. At baseline on the general paediatrics ward, more than 50% of discharges occurred after 5 pm.Method: The first intervention was to encourage utilisation of the EPIC discharge milestones to target communication between the nursing and medical teams over 2.5 weeks. We formally presented the baseline data and plans for the first PDSA and supplemented this with posters as reference points. The process measure was the number of completed milestones per discharged patient.The second intervention was to add a pharmacist to the medical team’s midday huddle which aimed to target communication between the pharmacy and medical teams over 4 weeks. The process measures were a record of the pharmacist’s daily attendance at midday huddle and the time-of-day of pharmacy discharge completion extracted from EPIC.The third implementation was to encourage the completion of medication reconciliations during the morning ward round over 3 weeks. This was proposed to allow pharmacists adequate time to prioritise and complete the to-take-out medications (TTO) after joint discussions between the pharmacy and medical teams at midday huddle. The process measure was the time of day of pharmacy discharge completion and a star chart which recorded the adherence to this intervention. Results: The outcome measure increased from baseline by 10.22%, decreased by 7.51% and increased by 13.8% after PDSA cycles 1, 2 and 3 respectively.During PDSA 1, the average number of milestones completed increased from 2 to 3.During PDSA 2, a pharmacist attended 87% of huddles. The spread of “time-of-day of pharmacy TTO completion” shifted to create two peaks corresponding with the times of morning and afternoon huddle. This contrasts with baseline data, where this was completed most frequently in the late afternoon, with outliers at 20:00 and 01:00.During PDSA 3, TTOs were completed on the ward round on 13 out of 21 days. The “time-of-day of pharmacy TTO completion” was most frequently during the times of morning ward round and midday huddle. (figure)Conclusion: This study suggests that improved utilisation of discharge checklists, prompt completion of medication reconciliations, and increased collaboration between pharmacists and doctors can improve patient flow. Adoption of these strategies in other working environments could yield similar positive outcomes. Although the target percentage increase was not sustained in this QIP, this is likely a reflection of the multifactorial nature of discharge delays.
