Ryan D. Murphy, MD

The discharge process is a critical bottleneck for efficient patient flow through the hospital. Delayed discharges translate into delays in admissions and other patient transitions, often leading to excess costs, patient dissatisfaction, and even patient harm.^1-3 The emergency department is particularly impacted by these delays; bottlenecks there lead to overcrowding, increased overall hospital length of stay, and increased risks for bad outcomes during hospitalization.²

Academic medical centers in particular may struggle with delayed discharges. In a typical teaching hospital, a team composed of an attending physician and housestaff share responsibility for determining the discharge plan. Additionally, clinical teaching activities may affect the process and quality of discharge.^4-6

The prevalence and causes of delayed discharges vary greatly.^7-9 To improve efficiency around discharge, many hospitals have launched initiatives designed to discharge patients earlier in the day, including goal setting (“discharge by noon”), scheduling discharge appointments, and using quality-improvement methods, such as Lean Methodology (LEAN), to remove inefficiencies within discharge processes.^10-12 However, there are few data on the prevalence and effectiveness of different strategies.

The aim of this study was to survey academic hospitalist and general internal medicine physician leaders to elicit their perspectives on the factors contributing to discharge timing and the relative importance and effectiveness of early-discharge initiatives.

Study Design, Participants, and Oversight

We obtained a list of 115 university-affiliated hospitals associated with a residency program and, in most cases, a medical school from Vizient Inc. (formerly University HealthSystem Consortium), an alliance of academic medical centers and affiliated hospitals. Each member institution submits clinical data to allow for the benchmarking of outcomes to drive transparency and quality improvement.¹³ More than 95% of the nation’s academic medical centers and affiliated hospitals participate in this collaborative. Vizient works with members but does not set nor promote quality metrics, such as discharge timeliness. E-mail addresses for hospital medicine physician leaders (eg, division chief) of major academic medical centers were obtained from each institution via publicly available data (eg, the institution’s website). When an institution did not have a hospital medicine section, we identified the division chief of general internal medicine. The University of California, San Francisco Institutional Review Board approved this study.

Survey Development and Domains

We developed a 30-item survey to evaluate 5 main domains of interest: current discharge practices, degree of prioritization of early discharge on the inpatient service, barriers to timely discharge, prevalence and perceived effectiveness of implemented early-discharge initiatives, and barriers to implementation of early-discharge initiatives.

Respondents were first asked to identify their institutions’ goals for discharge time. They were then asked to compare the priority of early-discharge initiatives to other departmental quality-improvement initiatives, such as reducing 30-day readmissions, improving interpreter use, and improving patient satisfaction. Next, respondents were asked to estimate the degree to which clinical or patient factors contributed to delays in discharge. Respondents were then asked whether specific early-discharge initiatives, such as changes to rounding practices or communication interventions, were implemented at their institutions and, if so, the perceived effectiveness of these initiatives at meeting discharge targets. We piloted the questions locally with physicians and researchers prior to finalizing the survey.

Data Collection

We sent surveys via an online platform (Research Electronic Data Capture).¹⁴ Nonresponders were sent 2 e-mail reminders and then a follow-up telephone call asking them to complete the survey. Only 1 survey per academic medical center was collected. Any respondent who completed the survey within 2 weeks of receiving it was entered to win a Kindle Fire.

Data Analysis

We summarized survey responses using descriptive statistics. Analysis was completed in IBM SPSS version 22 (Armonk, NY).

Survey Respondent and Institutional Characteristics

Of the 115 institutions surveyed, we received 61 responses (response rate of 53%), with 39 (64%) respondents from divisions of hospital medicine and 22 (36%) from divisions of general internal medicine. A majority (n = 53; 87%) stated their medicine services have a combination of teaching (with residents) and nonteaching (without residents) teams. Thirty-nine (64%) reported having daily multidisciplinary rounds.

Early Discharge as a Priority

Forty-seven (77%) institutional representatives strongly agreed or agreed that early discharge was a priority, with discharge by noon being the most common target time (n = 23; 38%). Thirty (50%) respondents rated early discharge as more important than improving interpreter use for non-English-speaking patients and equally important as reducing 30-day readmissions (n = 29; 48%) and improving patient satisfaction (n = 27; 44%).

Factors Delaying Discharge

The most common factors perceived as delaying discharge were considered external to the hospital, such as postacute care bed availability or scheduled (eg, ambulance) transport delays (n = 48; 79%), followed by patient factors such as patient transport issues (n = 44; 72%). Less commonly reported were workflow issues, such as competing primary team priorities or case manager bandwidth (n = 38; 62%; Table 1).

Initiatives to Improve Discharge

The most commonly implemented initiatives perceived as effective at improving discharge times were the preemptive identification of early discharges to plan discharge paperwork (n = 34; 56%), communication with patients about anticipated discharge time on the day prior to discharge (n = 29; 48%), and the implementation of additional rounds between physician teams and case managers specifically around discharge planning (n = 28; 46%). Initiatives not commonly implemented included regular audit of and feedback on discharge times to providers and teams (n = 21; 34%), the use of a discharge readiness checklist (n = 26; 43%), incentives such as bonuses or penalties (n = 37; 61%), the use of a whiteboard to indicate discharge times (n = 23; 38%), and dedicated quality-improvement approaches such as LEAN (n = 37; 61%; Table 2).

Our study suggests early discharge for medicine patients is a priority among academic institutions. Hospitalist and general internal medicine physician leaders in our study generally attributed delayed discharges to external factors, particularly unavailability of postacute care facilities and transportation delays. Having issues with finding postacute care placements is consistent with previous findings by Selker et al.¹⁵ and Carey et al.⁸ This is despite the 20-year difference between Selker et al.’s study and the current study, reflecting a continued opportunity for improvement, including stronger partnerships with local and regional postacute care facilities to expedite care transition and stronger discharge-planning efforts early in the admission process. Efforts in postacute care placement may be particularly important for Medicaid-insured and uninsured patients.

Our responders, hospitalist and internal medicine physician leaders, did not perceive the additional responsibilities of teaching and supervising trainees to be factors that significantly delayed patient discharge. This is in contrast to previous studies, which attributed delays in discharge to prolonged clinical decision-making related to teaching and supervision.^4-6,8 This discrepancy may be due to the fact that we only surveyed single physician leaders at each institution and not residents. Our finding warrants further investigation to understand the degree to which resident skills may impact discharge planning and processes.

Institutions represented in our study have attempted a variety of initiatives promoting earlier discharge, with varying levels of perceived success. Initiatives perceived to be the most effective by hospital leaders centered on 2 main areas: (1) changing individual provider practice and (2) anticipatory discharge preparation. Interestingly, this is in discordance with the main factors labeled as causing delays in discharges, such as obtaining postacute care beds, busy case managers, and competing demands on primary teams. We hypothesize this may be because such changes require organization- or system-level changes and are perceived as more arduous than changes at the individual level. In addition, changes to individual provider behavior may be more cost- and time-effective than more systemic initiatives.

Our findings are consistent with the work published by Wertheimer and colleagues,¹¹ who show that additional afternoon interdisciplinary rounds can help identify patients who may be discharged before noon the next day. In their study, identifying such patients in advance improved the overall early-discharge rate the following day.

Our findings should be interpreted in light of several limitations. Our survey only considers the perspectives of hospitalist and general internal medicine physician leaders at academic medical centers that are part of the Vizient Inc. collaborative. They do not represent all academic or community-based medical centers. Although the perceived effectiveness of some initiatives was high, we did not collect empirical data to support these claims or to determine which initiative had the greatest relative impact on discharge timeliness. Lastly, we did not obtain resident, nursing, or case manager perspectives on discharge practices. Given their roles as frontline providers, we may have missed these alternative perspectives.

Our study shows there is a strong interest in increasing early discharges in an effort to improve hospital throughput and patient flow.

Acknowledgments

The authors thank all participants who completed the survey and Danielle Carrier at Vizient Inc. (formally University HealthSystem Consortium) for her assistance in obtaining data.

Disclosures

Hemali Patel, Margaret Fang, Michelle Mourad, Adrienne Green, Ryan Murphy, and James Harrison report no conflicts of interest. At the time the research was conducted, Robert Wachter reported that he is a member of the Lucian Leape Institute at the National Patient Safety Foundation (no compensation except travel expenses); recently chaired an advisory board to England’s National Health Service (NHS) reviewing the NHS’s digital health strategy (no compensation except travel expenses); has a contract with UCSF from the Agency for Healthcare Research and Quality to edit a patient-safety website; receives compensation from John Wiley & Sons for writing a blog; receives royalties from Lippincott Williams & Wilkins and McGraw-Hill Education for writing and/or editing several books; receives stock options for serving on the board of Acuity Medical Management Systems; receives a yearly stipend for serving on the board of The Doctors Company; serves on the scientific advisory boards for amino.com, PatientSafe Solutions Inc., Twine, and EarlySense (for which he receives stock options); has a small royalty stake in CareWeb, a hospital communication tool developed at UCSF; and holds the Marc and Lynne Benioff Endowed Chair in Hospital Medicine and the Holly Smith Distinguished Professorship in Science and Medicine at UCSF.

The discharge process is a critical bottleneck for efficient patient flow through the hospital. Delayed discharges translate into delays in admissions and other patient transitions, often leading to excess costs, patient dissatisfaction, and even patient harm.^1-3 The emergency department is particularly impacted by these delays; bottlenecks there lead to overcrowding, increased overall hospital length of stay, and increased risks for bad outcomes during hospitalization.²

Academic medical centers in particular may struggle with delayed discharges. In a typical teaching hospital, a team composed of an attending physician and housestaff share responsibility for determining the discharge plan. Additionally, clinical teaching activities may affect the process and quality of discharge.^4-6

The prevalence and causes of delayed discharges vary greatly.^7-9 To improve efficiency around discharge, many hospitals have launched initiatives designed to discharge patients earlier in the day, including goal setting (“discharge by noon”), scheduling discharge appointments, and using quality-improvement methods, such as Lean Methodology (LEAN), to remove inefficiencies within discharge processes.^10-12 However, there are few data on the prevalence and effectiveness of different strategies.

The aim of this study was to survey academic hospitalist and general internal medicine physician leaders to elicit their perspectives on the factors contributing to discharge timing and the relative importance and effectiveness of early-discharge initiatives.

Study Design, Participants, and Oversight

We obtained a list of 115 university-affiliated hospitals associated with a residency program and, in most cases, a medical school from Vizient Inc. (formerly University HealthSystem Consortium), an alliance of academic medical centers and affiliated hospitals. Each member institution submits clinical data to allow for the benchmarking of outcomes to drive transparency and quality improvement.¹³ More than 95% of the nation’s academic medical centers and affiliated hospitals participate in this collaborative. Vizient works with members but does not set nor promote quality metrics, such as discharge timeliness. E-mail addresses for hospital medicine physician leaders (eg, division chief) of major academic medical centers were obtained from each institution via publicly available data (eg, the institution’s website). When an institution did not have a hospital medicine section, we identified the division chief of general internal medicine. The University of California, San Francisco Institutional Review Board approved this study.

Survey Development and Domains

We developed a 30-item survey to evaluate 5 main domains of interest: current discharge practices, degree of prioritization of early discharge on the inpatient service, barriers to timely discharge, prevalence and perceived effectiveness of implemented early-discharge initiatives, and barriers to implementation of early-discharge initiatives.

Respondents were first asked to identify their institutions’ goals for discharge time. They were then asked to compare the priority of early-discharge initiatives to other departmental quality-improvement initiatives, such as reducing 30-day readmissions, improving interpreter use, and improving patient satisfaction. Next, respondents were asked to estimate the degree to which clinical or patient factors contributed to delays in discharge. Respondents were then asked whether specific early-discharge initiatives, such as changes to rounding practices or communication interventions, were implemented at their institutions and, if so, the perceived effectiveness of these initiatives at meeting discharge targets. We piloted the questions locally with physicians and researchers prior to finalizing the survey.

Data Collection

We sent surveys via an online platform (Research Electronic Data Capture).¹⁴ Nonresponders were sent 2 e-mail reminders and then a follow-up telephone call asking them to complete the survey. Only 1 survey per academic medical center was collected. Any respondent who completed the survey within 2 weeks of receiving it was entered to win a Kindle Fire.

Data Analysis

We summarized survey responses using descriptive statistics. Analysis was completed in IBM SPSS version 22 (Armonk, NY).

Survey Respondent and Institutional Characteristics

Of the 115 institutions surveyed, we received 61 responses (response rate of 53%), with 39 (64%) respondents from divisions of hospital medicine and 22 (36%) from divisions of general internal medicine. A majority (n = 53; 87%) stated their medicine services have a combination of teaching (with residents) and nonteaching (without residents) teams. Thirty-nine (64%) reported having daily multidisciplinary rounds.

Early Discharge as a Priority

Forty-seven (77%) institutional representatives strongly agreed or agreed that early discharge was a priority, with discharge by noon being the most common target time (n = 23; 38%). Thirty (50%) respondents rated early discharge as more important than improving interpreter use for non-English-speaking patients and equally important as reducing 30-day readmissions (n = 29; 48%) and improving patient satisfaction (n = 27; 44%).

Factors Delaying Discharge

The most common factors perceived as delaying discharge were considered external to the hospital, such as postacute care bed availability or scheduled (eg, ambulance) transport delays (n = 48; 79%), followed by patient factors such as patient transport issues (n = 44; 72%). Less commonly reported were workflow issues, such as competing primary team priorities or case manager bandwidth (n = 38; 62%; Table 1).

Initiatives to Improve Discharge

The most commonly implemented initiatives perceived as effective at improving discharge times were the preemptive identification of early discharges to plan discharge paperwork (n = 34; 56%), communication with patients about anticipated discharge time on the day prior to discharge (n = 29; 48%), and the implementation of additional rounds between physician teams and case managers specifically around discharge planning (n = 28; 46%). Initiatives not commonly implemented included regular audit of and feedback on discharge times to providers and teams (n = 21; 34%), the use of a discharge readiness checklist (n = 26; 43%), incentives such as bonuses or penalties (n = 37; 61%), the use of a whiteboard to indicate discharge times (n = 23; 38%), and dedicated quality-improvement approaches such as LEAN (n = 37; 61%; Table 2).

Our study suggests early discharge for medicine patients is a priority among academic institutions. Hospitalist and general internal medicine physician leaders in our study generally attributed delayed discharges to external factors, particularly unavailability of postacute care facilities and transportation delays. Having issues with finding postacute care placements is consistent with previous findings by Selker et al.¹⁵ and Carey et al.⁸ This is despite the 20-year difference between Selker et al.’s study and the current study, reflecting a continued opportunity for improvement, including stronger partnerships with local and regional postacute care facilities to expedite care transition and stronger discharge-planning efforts early in the admission process. Efforts in postacute care placement may be particularly important for Medicaid-insured and uninsured patients.

Our responders, hospitalist and internal medicine physician leaders, did not perceive the additional responsibilities of teaching and supervising trainees to be factors that significantly delayed patient discharge. This is in contrast to previous studies, which attributed delays in discharge to prolonged clinical decision-making related to teaching and supervision.^4-6,8 This discrepancy may be due to the fact that we only surveyed single physician leaders at each institution and not residents. Our finding warrants further investigation to understand the degree to which resident skills may impact discharge planning and processes.

Institutions represented in our study have attempted a variety of initiatives promoting earlier discharge, with varying levels of perceived success. Initiatives perceived to be the most effective by hospital leaders centered on 2 main areas: (1) changing individual provider practice and (2) anticipatory discharge preparation. Interestingly, this is in discordance with the main factors labeled as causing delays in discharges, such as obtaining postacute care beds, busy case managers, and competing demands on primary teams. We hypothesize this may be because such changes require organization- or system-level changes and are perceived as more arduous than changes at the individual level. In addition, changes to individual provider behavior may be more cost- and time-effective than more systemic initiatives.

Our findings are consistent with the work published by Wertheimer and colleagues,¹¹ who show that additional afternoon interdisciplinary rounds can help identify patients who may be discharged before noon the next day. In their study, identifying such patients in advance improved the overall early-discharge rate the following day.

Our findings should be interpreted in light of several limitations. Our survey only considers the perspectives of hospitalist and general internal medicine physician leaders at academic medical centers that are part of the Vizient Inc. collaborative. They do not represent all academic or community-based medical centers. Although the perceived effectiveness of some initiatives was high, we did not collect empirical data to support these claims or to determine which initiative had the greatest relative impact on discharge timeliness. Lastly, we did not obtain resident, nursing, or case manager perspectives on discharge practices. Given their roles as frontline providers, we may have missed these alternative perspectives.

Our study shows there is a strong interest in increasing early discharges in an effort to improve hospital throughput and patient flow.

Acknowledgments

The authors thank all participants who completed the survey and Danielle Carrier at Vizient Inc. (formally University HealthSystem Consortium) for her assistance in obtaining data.

Disclosures

Hemali Patel, Margaret Fang, Michelle Mourad, Adrienne Green, Ryan Murphy, and James Harrison report no conflicts of interest. At the time the research was conducted, Robert Wachter reported that he is a member of the Lucian Leape Institute at the National Patient Safety Foundation (no compensation except travel expenses); recently chaired an advisory board to England’s National Health Service (NHS) reviewing the NHS’s digital health strategy (no compensation except travel expenses); has a contract with UCSF from the Agency for Healthcare Research and Quality to edit a patient-safety website; receives compensation from John Wiley & Sons for writing a blog; receives royalties from Lippincott Williams & Wilkins and McGraw-Hill Education for writing and/or editing several books; receives stock options for serving on the board of Acuity Medical Management Systems; receives a yearly stipend for serving on the board of The Doctors Company; serves on the scientific advisory boards for amino.com, PatientSafe Solutions Inc., Twine, and EarlySense (for which he receives stock options); has a small royalty stake in CareWeb, a hospital communication tool developed at UCSF; and holds the Marc and Lynne Benioff Endowed Chair in Hospital Medicine and the Holly Smith Distinguished Professorship in Science and Medicine at UCSF.

The discharge process is a critical bottleneck for efficient patient flow through the hospital. Delayed discharges translate into delays in admissions and other patient transitions, often leading to excess costs, patient dissatisfaction, and even patient harm.^1-3 The emergency department is particularly impacted by these delays; bottlenecks there lead to overcrowding, increased overall hospital length of stay, and increased risks for bad outcomes during hospitalization.²

Academic medical centers in particular may struggle with delayed discharges. In a typical teaching hospital, a team composed of an attending physician and housestaff share responsibility for determining the discharge plan. Additionally, clinical teaching activities may affect the process and quality of discharge.^4-6

The prevalence and causes of delayed discharges vary greatly.^7-9 To improve efficiency around discharge, many hospitals have launched initiatives designed to discharge patients earlier in the day, including goal setting (“discharge by noon”), scheduling discharge appointments, and using quality-improvement methods, such as Lean Methodology (LEAN), to remove inefficiencies within discharge processes.^10-12 However, there are few data on the prevalence and effectiveness of different strategies.

The aim of this study was to survey academic hospitalist and general internal medicine physician leaders to elicit their perspectives on the factors contributing to discharge timing and the relative importance and effectiveness of early-discharge initiatives.

Study Design, Participants, and Oversight

We obtained a list of 115 university-affiliated hospitals associated with a residency program and, in most cases, a medical school from Vizient Inc. (formerly University HealthSystem Consortium), an alliance of academic medical centers and affiliated hospitals. Each member institution submits clinical data to allow for the benchmarking of outcomes to drive transparency and quality improvement.¹³ More than 95% of the nation’s academic medical centers and affiliated hospitals participate in this collaborative. Vizient works with members but does not set nor promote quality metrics, such as discharge timeliness. E-mail addresses for hospital medicine physician leaders (eg, division chief) of major academic medical centers were obtained from each institution via publicly available data (eg, the institution’s website). When an institution did not have a hospital medicine section, we identified the division chief of general internal medicine. The University of California, San Francisco Institutional Review Board approved this study.

Survey Development and Domains

We developed a 30-item survey to evaluate 5 main domains of interest: current discharge practices, degree of prioritization of early discharge on the inpatient service, barriers to timely discharge, prevalence and perceived effectiveness of implemented early-discharge initiatives, and barriers to implementation of early-discharge initiatives.

Respondents were first asked to identify their institutions’ goals for discharge time. They were then asked to compare the priority of early-discharge initiatives to other departmental quality-improvement initiatives, such as reducing 30-day readmissions, improving interpreter use, and improving patient satisfaction. Next, respondents were asked to estimate the degree to which clinical or patient factors contributed to delays in discharge. Respondents were then asked whether specific early-discharge initiatives, such as changes to rounding practices or communication interventions, were implemented at their institutions and, if so, the perceived effectiveness of these initiatives at meeting discharge targets. We piloted the questions locally with physicians and researchers prior to finalizing the survey.

Data Collection

We sent surveys via an online platform (Research Electronic Data Capture).¹⁴ Nonresponders were sent 2 e-mail reminders and then a follow-up telephone call asking them to complete the survey. Only 1 survey per academic medical center was collected. Any respondent who completed the survey within 2 weeks of receiving it was entered to win a Kindle Fire.

Data Analysis

We summarized survey responses using descriptive statistics. Analysis was completed in IBM SPSS version 22 (Armonk, NY).

Survey Respondent and Institutional Characteristics

Of the 115 institutions surveyed, we received 61 responses (response rate of 53%), with 39 (64%) respondents from divisions of hospital medicine and 22 (36%) from divisions of general internal medicine. A majority (n = 53; 87%) stated their medicine services have a combination of teaching (with residents) and nonteaching (without residents) teams. Thirty-nine (64%) reported having daily multidisciplinary rounds.

Early Discharge as a Priority

Forty-seven (77%) institutional representatives strongly agreed or agreed that early discharge was a priority, with discharge by noon being the most common target time (n = 23; 38%). Thirty (50%) respondents rated early discharge as more important than improving interpreter use for non-English-speaking patients and equally important as reducing 30-day readmissions (n = 29; 48%) and improving patient satisfaction (n = 27; 44%).

Factors Delaying Discharge

The most common factors perceived as delaying discharge were considered external to the hospital, such as postacute care bed availability or scheduled (eg, ambulance) transport delays (n = 48; 79%), followed by patient factors such as patient transport issues (n = 44; 72%). Less commonly reported were workflow issues, such as competing primary team priorities or case manager bandwidth (n = 38; 62%; Table 1).

Initiatives to Improve Discharge

The most commonly implemented initiatives perceived as effective at improving discharge times were the preemptive identification of early discharges to plan discharge paperwork (n = 34; 56%), communication with patients about anticipated discharge time on the day prior to discharge (n = 29; 48%), and the implementation of additional rounds between physician teams and case managers specifically around discharge planning (n = 28; 46%). Initiatives not commonly implemented included regular audit of and feedback on discharge times to providers and teams (n = 21; 34%), the use of a discharge readiness checklist (n = 26; 43%), incentives such as bonuses or penalties (n = 37; 61%), the use of a whiteboard to indicate discharge times (n = 23; 38%), and dedicated quality-improvement approaches such as LEAN (n = 37; 61%; Table 2).

Our study suggests early discharge for medicine patients is a priority among academic institutions. Hospitalist and general internal medicine physician leaders in our study generally attributed delayed discharges to external factors, particularly unavailability of postacute care facilities and transportation delays. Having issues with finding postacute care placements is consistent with previous findings by Selker et al.¹⁵ and Carey et al.⁸ This is despite the 20-year difference between Selker et al.’s study and the current study, reflecting a continued opportunity for improvement, including stronger partnerships with local and regional postacute care facilities to expedite care transition and stronger discharge-planning efforts early in the admission process. Efforts in postacute care placement may be particularly important for Medicaid-insured and uninsured patients.

Our responders, hospitalist and internal medicine physician leaders, did not perceive the additional responsibilities of teaching and supervising trainees to be factors that significantly delayed patient discharge. This is in contrast to previous studies, which attributed delays in discharge to prolonged clinical decision-making related to teaching and supervision.^4-6,8 This discrepancy may be due to the fact that we only surveyed single physician leaders at each institution and not residents. Our finding warrants further investigation to understand the degree to which resident skills may impact discharge planning and processes.

Institutions represented in our study have attempted a variety of initiatives promoting earlier discharge, with varying levels of perceived success. Initiatives perceived to be the most effective by hospital leaders centered on 2 main areas: (1) changing individual provider practice and (2) anticipatory discharge preparation. Interestingly, this is in discordance with the main factors labeled as causing delays in discharges, such as obtaining postacute care beds, busy case managers, and competing demands on primary teams. We hypothesize this may be because such changes require organization- or system-level changes and are perceived as more arduous than changes at the individual level. In addition, changes to individual provider behavior may be more cost- and time-effective than more systemic initiatives.

Our findings are consistent with the work published by Wertheimer and colleagues,¹¹ who show that additional afternoon interdisciplinary rounds can help identify patients who may be discharged before noon the next day. In their study, identifying such patients in advance improved the overall early-discharge rate the following day.

Our findings should be interpreted in light of several limitations. Our survey only considers the perspectives of hospitalist and general internal medicine physician leaders at academic medical centers that are part of the Vizient Inc. collaborative. They do not represent all academic or community-based medical centers. Although the perceived effectiveness of some initiatives was high, we did not collect empirical data to support these claims or to determine which initiative had the greatest relative impact on discharge timeliness. Lastly, we did not obtain resident, nursing, or case manager perspectives on discharge practices. Given their roles as frontline providers, we may have missed these alternative perspectives.

Our study shows there is a strong interest in increasing early discharges in an effort to improve hospital throughput and patient flow.

Acknowledgments

The authors thank all participants who completed the survey and Danielle Carrier at Vizient Inc. (formally University HealthSystem Consortium) for her assistance in obtaining data.

Disclosures

Hemali Patel, Margaret Fang, Michelle Mourad, Adrienne Green, Ryan Murphy, and James Harrison report no conflicts of interest. At the time the research was conducted, Robert Wachter reported that he is a member of the Lucian Leape Institute at the National Patient Safety Foundation (no compensation except travel expenses); recently chaired an advisory board to England’s National Health Service (NHS) reviewing the NHS’s digital health strategy (no compensation except travel expenses); has a contract with UCSF from the Agency for Healthcare Research and Quality to edit a patient-safety website; receives compensation from John Wiley & Sons for writing a blog; receives royalties from Lippincott Williams & Wilkins and McGraw-Hill Education for writing and/or editing several books; receives stock options for serving on the board of Acuity Medical Management Systems; receives a yearly stipend for serving on the board of The Doctors Company; serves on the scientific advisory boards for amino.com, PatientSafe Solutions Inc., Twine, and EarlySense (for which he receives stock options); has a small royalty stake in CareWeb, a hospital communication tool developed at UCSF; and holds the Marc and Lynne Benioff Endowed Chair in Hospital Medicine and the Holly Smith Distinguished Professorship in Science and Medicine at UCSF.

Clinical Question: Is high-flow oxygen noninferior to noninvasive ventilation (NIV) in preventing postextubation respiratory failure and reintubation?

Background: Studies that suggest NIV usage following extubation reduces the risk of postextubation respiratory failure have led to an increase in use of this practice. Compared with NIV, high-flow, conditioned oxygen therapy has many advantages and fewer adverse effects, suggesting it might be a useful alternative.

Study design: Randomized clinical trial.

Setting: Three ICUs in Spain.

Rates of most secondary outcomes, including infection, mortality, and hospital length of stay (LOS) were similar between the two groups. ICU LOS was significantly less in the high-flow oxygen group (3d vs. 4d; 95% CI, –6.8 to –0.8).

Additionally, every patient tolerated high-flow oxygen therapy, while 40% of patients in the NIV arm required withdrawal of therapy for at least 6 hours due to adverse effects (P less than .001).

Bottom line: High-flow oxygen immediately following extubation may be a useful alternative to NIV in preventing postextubation respiratory failure.

Citation: Hernández G, Vaquero C, González P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: a randomized clinical trial. JAMA. 2016;315(13):1354-61.

Dr. Murphy is a clinical instructor at the University of Utah School of Medicine and an academic hospitalist at the University of Utah Hospital.

Clinical Question: Is high-flow oxygen noninferior to noninvasive ventilation (NIV) in preventing postextubation respiratory failure and reintubation?

Background: Studies that suggest NIV usage following extubation reduces the risk of postextubation respiratory failure have led to an increase in use of this practice. Compared with NIV, high-flow, conditioned oxygen therapy has many advantages and fewer adverse effects, suggesting it might be a useful alternative.

Study design: Randomized clinical trial.

Setting: Three ICUs in Spain.

Rates of most secondary outcomes, including infection, mortality, and hospital length of stay (LOS) were similar between the two groups. ICU LOS was significantly less in the high-flow oxygen group (3d vs. 4d; 95% CI, –6.8 to –0.8).

Additionally, every patient tolerated high-flow oxygen therapy, while 40% of patients in the NIV arm required withdrawal of therapy for at least 6 hours due to adverse effects (P less than .001).

Bottom line: High-flow oxygen immediately following extubation may be a useful alternative to NIV in preventing postextubation respiratory failure.

Citation: Hernández G, Vaquero C, González P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: a randomized clinical trial. JAMA. 2016;315(13):1354-61.

Dr. Murphy is a clinical instructor at the University of Utah School of Medicine and an academic hospitalist at the University of Utah Hospital.

Clinical Question: Is high-flow oxygen noninferior to noninvasive ventilation (NIV) in preventing postextubation respiratory failure and reintubation?

Background: Studies that suggest NIV usage following extubation reduces the risk of postextubation respiratory failure have led to an increase in use of this practice. Compared with NIV, high-flow, conditioned oxygen therapy has many advantages and fewer adverse effects, suggesting it might be a useful alternative.

Study design: Randomized clinical trial.

Setting: Three ICUs in Spain.

Rates of most secondary outcomes, including infection, mortality, and hospital length of stay (LOS) were similar between the two groups. ICU LOS was significantly less in the high-flow oxygen group (3d vs. 4d; 95% CI, –6.8 to –0.8).

Additionally, every patient tolerated high-flow oxygen therapy, while 40% of patients in the NIV arm required withdrawal of therapy for at least 6 hours due to adverse effects (P less than .001).

Bottom line: High-flow oxygen immediately following extubation may be a useful alternative to NIV in preventing postextubation respiratory failure.

Citation: Hernández G, Vaquero C, González P, et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: a randomized clinical trial. JAMA. 2016;315(13):1354-61.

Dr. Murphy is a clinical instructor at the University of Utah School of Medicine and an academic hospitalist at the University of Utah Hospital.

Clinical question: What is a safe target hemoglobin level for patients requiring red blood cell transfusion, and how long can red blood cells be stored prior to transfusion?

Background: The AABB, formerly the American Association of Blood Banks, notes several new, large, rigorous studies on transfusion thresholds were published since their last guideline in 2012. Additionally, there are concerns from initial studies of increased morbidity and mortality with transfusions of red blood cells stored for longer periods of time.

Study design: Systematic review and meta-analysis.

Setting: Summary findings from the AABB clinical transfusion medicine committee.

Synopsis: Thirty-one randomized clinical trials (RCTs) evaluating blood transfusion thresholds were reviewed and analyzed, including 12,587 patients across various clinical scenarios. The authors recommend a restrictive threshold of 7 g/dL for most hospitalized adult patients in the appropriate clinical context. For patients undergoing orthopedic or cardiac surgery, or with cardiovascular disease, a threshold of 8 g/dL is recommended, as it was the threshold used in studies of these patients (though such patients may actually tolerate a lower value).

No recommendations were made for patients with acute coronary syndrome, hematological or oncological disorders, severe thrombocytopenia, or chronic transfusion-dependent anemia given limited data.

To determine a safe period of time for blood storage prior to transfusion, 13 RCTs were reviewed and analyzed. The authors recommend that patients requiring transfusion receive red blood cell units at any period within the standard issue period (less than 42 days), rather than limit transfusion to fresh units (less than 10 days).

Bottom line: A restrictive red blood cell transfusion threshold of 7-8 g/dL is safe in most clinical settings, and there is no advantage to using fresh units as opposed to those stored for the standard period.

Citation: Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB. JAMA. 2016;316(19):2025-35.

Dr. Murphy is a clinical instructor at the University of Utah School of Medicine and an academic hospitalist at the University of Utah Hospital.

Clinical question: What is a safe target hemoglobin level for patients requiring red blood cell transfusion, and how long can red blood cells be stored prior to transfusion?

Background: The AABB, formerly the American Association of Blood Banks, notes several new, large, rigorous studies on transfusion thresholds were published since their last guideline in 2012. Additionally, there are concerns from initial studies of increased morbidity and mortality with transfusions of red blood cells stored for longer periods of time.

Study design: Systematic review and meta-analysis.

Setting: Summary findings from the AABB clinical transfusion medicine committee.

Synopsis: Thirty-one randomized clinical trials (RCTs) evaluating blood transfusion thresholds were reviewed and analyzed, including 12,587 patients across various clinical scenarios. The authors recommend a restrictive threshold of 7 g/dL for most hospitalized adult patients in the appropriate clinical context. For patients undergoing orthopedic or cardiac surgery, or with cardiovascular disease, a threshold of 8 g/dL is recommended, as it was the threshold used in studies of these patients (though such patients may actually tolerate a lower value).

No recommendations were made for patients with acute coronary syndrome, hematological or oncological disorders, severe thrombocytopenia, or chronic transfusion-dependent anemia given limited data.

To determine a safe period of time for blood storage prior to transfusion, 13 RCTs were reviewed and analyzed. The authors recommend that patients requiring transfusion receive red blood cell units at any period within the standard issue period (less than 42 days), rather than limit transfusion to fresh units (less than 10 days).

Bottom line: A restrictive red blood cell transfusion threshold of 7-8 g/dL is safe in most clinical settings, and there is no advantage to using fresh units as opposed to those stored for the standard period.

Citation: Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB. JAMA. 2016;316(19):2025-35.

Dr. Murphy is a clinical instructor at the University of Utah School of Medicine and an academic hospitalist at the University of Utah Hospital.

Clinical question: What is a safe target hemoglobin level for patients requiring red blood cell transfusion, and how long can red blood cells be stored prior to transfusion?

Background: The AABB, formerly the American Association of Blood Banks, notes several new, large, rigorous studies on transfusion thresholds were published since their last guideline in 2012. Additionally, there are concerns from initial studies of increased morbidity and mortality with transfusions of red blood cells stored for longer periods of time.

Study design: Systematic review and meta-analysis.

Setting: Summary findings from the AABB clinical transfusion medicine committee.

Synopsis: Thirty-one randomized clinical trials (RCTs) evaluating blood transfusion thresholds were reviewed and analyzed, including 12,587 patients across various clinical scenarios. The authors recommend a restrictive threshold of 7 g/dL for most hospitalized adult patients in the appropriate clinical context. For patients undergoing orthopedic or cardiac surgery, or with cardiovascular disease, a threshold of 8 g/dL is recommended, as it was the threshold used in studies of these patients (though such patients may actually tolerate a lower value).

No recommendations were made for patients with acute coronary syndrome, hematological or oncological disorders, severe thrombocytopenia, or chronic transfusion-dependent anemia given limited data.

To determine a safe period of time for blood storage prior to transfusion, 13 RCTs were reviewed and analyzed. The authors recommend that patients requiring transfusion receive red blood cell units at any period within the standard issue period (less than 42 days), rather than limit transfusion to fresh units (less than 10 days).

Bottom line: A restrictive red blood cell transfusion threshold of 7-8 g/dL is safe in most clinical settings, and there is no advantage to using fresh units as opposed to those stored for the standard period.

Citation: Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB. JAMA. 2016;316(19):2025-35.

Dr. Murphy is a clinical instructor at the University of Utah School of Medicine and an academic hospitalist at the University of Utah Hospital.