Dear Editor,
The discharge procedure is one of the most prominent aspects of patient satisfaction and hospital service quality (1, 2). Lengthy patient discharge procedures, as negative factors in hospital management, productivity, and bed turnover, can slow down the admission of new patients by increasing patient wait times for vacant beds, especially in the emergency ward; it can also disable the emergency department from accepting new patients. These consequences increase the hospital's costs, cause other issues, and adversely affect other clinical services (3).
The discharge procedure poses a significant administrative issue for hospitals, and, therefore, all hospital activities are defined, developed, and executed based on the improvement in the implementation of the given procedure (3). On the other hand, the discharge procedure in pediatric hospitals is crucial since children cannot often be left alone in the hospital. Parents who reside in adjacent villages or towns have to stay at the hospital in order to provide their children with care (2).
A study conducted in Tehran, Iran, revealed that the average time required for patients to complete the discharge procedure was 246.96 ± 3.25 minutes (4). In the given descriptive and cross-sectional study, an eclectic method [stopwatch method, observations, file reviews, focus group discussion (FGD), and brainstorming] was adopted to examine the factors causing the delay in the discharge process at the pediatric teaching hospital.
Four bullet points represent the factors significantly impacting the length of time a patient has to wait before s/he could leave the hospital. These factors include the time required to obtain a discharge order, the legibility of orders, the time the staff need to write and control a patient file summary, and, in some units, the time spent before a file is sent to another ward.
The discharge order is typically issued after morning rounds because the hospital has an educational mission; however, reviewing files and writing a summary after morning rounds seem to delay the discharge. In some instances, this process is prolonged due to a lack of workers or staff who lack the required knowledge and training to operate hospital information systems.
A study by Patel et al. found numerous barriers to hospital discharge, such as delays in diagnostic testing and counseling, as well as poor communication between members of the care team or between patients and service providers (5). Unaka et al. identified the failure in communication and inadequate training as the barriers to timely patient discharge (6). Zoucha et al., on the other hand, documented several factors as the most decisive factors causing the delay in the discharge process; these factors included issues related to discharge time, shortage of medical staff, lack of a monitoring and evaluation system, lack of practical training, as well as staff's waiting for the arrival of physician in the ward and requesting ancillary services such as counseling (7).
Writing the file summary by the residents before the start of the medical students' training classes, releasing a resident from the morning program on a rotating basis to write the patient file summary, shortening the time of file summary writing stage, increasing the number of nurses in charge of file control's meticulousness in order for minimizing the number of returned issues, and a timely transfer of the patient's records are some of the solutions offered to improve the discharge period.
In general, various efforts can be taken to shorten the discharge process. Setting an excellent timeline for section performance evaluation and implementing continuous training programs for supervisors and nurses to improve their skills to use new information technologies can be quite beneficial. Additionally, frequent monitoring of the supervisor to rectify the drugs returned from the unit, together with rotating secretaries in the sections by a checklist to collect the patients' documentation, are operational means of minimizing the discharge procedure. As Finn et al. argue, the discharge process has been improved in many ways thanks to the assignment of supporting staff to time-consuming tasks such as completion of discharge paperwork, prescription scheduling, arrangement of the follow-up appointments, cooperation with other nurses and doctors to discharge the patients, and responding to discharged patients’ questions (8).
In sum, it is recommended that the following procedures be followed to improve the quality of the discharge process and gain patient satisfaction: writing file summaries before the morning round ends; timely collecting files from the ward; hiring a circular secretary to collect patients' files from different wards; maintaining records and tracking them using a standard checklist; training nurses; and monitoring them constantly.
References
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1.
El-Eid GR, Kaddoum R, Tamim H, Hitti EA. Improving hospital discharge time: a successful implementation of Six Sigma methodology. Medicine (Baltimore). 2015;94(12). e633. [PubMed ID: 25816029]. [PubMed Central ID: PMC4554014]. https://doi.org/10.1097/MD.0000000000000633.
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2.
Henwood M. Effective partnership working: a case study of hospital discharge. Health Soc Care Community. 2006;14(5):400-7. [PubMed ID: 16918832]. https://doi.org/10.1111/j.1365-2524.2006.00651.x.
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3.
Dukkers van Emden DM, Ros WJ, Berns MP. Transition of care: an evaluation of the role of the discharge liaison nurse in The Netherlands. J Adv Nurs. 1999;30(5):1186-94. [PubMed ID: 10564418]. https://doi.org/10.1046/j.1365-2648.1999.01190.x.
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4.
Fazel Asl N, Ghaffari F, Nasiripour AA. [Determining Factors on Hospital Discharge Process Via Data-Mining Method Administered at Shahid Modares Hospital, Tehran]. Payavard Salamat. 2018;11(5):509-17. Persian.
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5.
Patel H, Yirdaw E, Yu A, Slater L, Perica K, Pierce RG, et al. Improving Early Discharge Using a Team-Based Structure for Discharge Multidisciplinary Rounds. Prof Case Manag. 2019;24(2):83-9. [PubMed ID: 30688821]. https://doi.org/10.1097/NCM.0000000000000318.
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6.
Unaka N, Statile A, Jerardi K, Dahale D, Morris J, Liberio B, et al. Improving the Readability of Pediatric Hospital Medicine Discharge Instructions. J Hosp Med. 2017;12(7):551-7. [PubMed ID: 28699944]. https://doi.org/10.12788/jhm.2770.
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7.
Zoucha J, Hull M, Keniston A, Mastalerz K, Quinn R, Tsai A, et al. Barriers to Early Hospital Discharge: A Cross-Sectional Study at Five Academic Hospitals. J Hosp Med. 2018;13(12):816-22. [PubMed ID: 30496327]. https://doi.org/10.12788/jhm.3074.
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8.
Finn KM, Heffner R, Chang Y, Bazari H, Hunt D, Pickell K, et al. Improving the discharge process by embedding a discharge facilitator in a resident team. J Hosp Med. 2011;6(9):494-500. [PubMed ID: 22042739]. https://doi.org/10.1002/jhm.924.