Clinical trial NCT05370638: Discharge in the AM
Official title: Discharge in the AM: A Randomized Controlled Trial of Physician Rounding Styles to Improve Hospital Throughput and Length of Stay
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Hospitalism
Flow or Discharge
Keywords: hospitalist
patient flow
early discharge
discharge before noon
inpatient
Lead sponsor: University of Colorado, Denver
Sponsor class: OTHER
Collaborators: name: Denver Health and Hospital Authority
name: Johns Hopkins University
First posted: 2022-05-11
Enrollment: 61
Sex: ALL
Standard ages: CHILD
ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief summary: As hospitals around the country continue to work to manage a high patient census, provider prioritization of discharges is one low cost mechanism to help improve patient throughput and patient length of stay. The investigators conducted a prospective randomized study to understand if this commonly utilized approach to expedite care results in earlier discharges and lower hospital lengths of stay while also understanding the impact on other patient care (such as test and consult order times on other patients that the physician is caring for).

Detailed description: Hospitals around the country face bottlenecks and capacity issues. When hospitals are successful at managing high capacity this allows for increased access for patients who need this higher level of care and expertise.

Unfortunately, hospital discharges frequently occur in the afternoon or evening hours and can adversely affect patient flow throughout the hospital which, in turn, can result in delays in care, medication errors, increased mortality, longer lengths of stay, higher costs, lower patient satisfaction, and decreased access to care at these facilities. While some of the delays in discharges result, appropriately, from the caring of other patients and conducting the necessary tasks and assessments for acutely ill patients, previous work also identified that providers may be able to prioritize their work in a different way in order to facilitate this throughput. The investigators aim to conduct a randomized controlled trial of physician rounding style at three institutions in order to: (1) determine if prioritizing discharging patients first will result in earlier discharges and decreased lengths of stay, (2) determine if prioritizing discharges first will cause other care delays or affect patient experience and, (3) determine factors that contribute to physician ability to prioritizing discharges first. The study is a prospective, multi-center, cluster randomized trial designed to test the effects of rounding on discharging patients first compared to usual practice and will utilize an effectiveness-implementation hybrid approach. The investigators will recruit hospitalist attending physicians from three hospitals in the US to be randomized to one of two rounding styles: (1) prioritize discharges first and (2) usual practice. The main outcome measure will be discharge order time. Secondary outcomes will be length of stay and lab/diagnostic test order time. Additionally, the investigators will study how team composition (teaching, non-teaching, teams with advanced practice providers), team census (i.e. the number of patients a provider is caring for), and number of admissions affect the ability for providers to prioritize discharges first.

Through qualitative methods the investigators will also gain an understanding from physicians as to why or why not they were able to prioritize discharges first. This study will add to the evidence to either support or negate the practice of prioritizing discharges. There have been no randomized studies to date that have addressed these issues. Additionally, the investigators aim to understand how team composition and census affect discharge times. Institutions across the country will be able to utilize these findings to help refine current rounding models. The investigators believe these findings will be pivotal for clinicians to be more willing to change their practice style. The investigators also believe this study will aid in the understanding of what factors may function as facilitators and barriers of earlier discharges.

Eligibility criteria: Inclusion Criteria:

Physicians:

-Hospital Medicine attending-level physicians who consented to participate and patients

Patients:

* At least 18 years of age
* Admitted to a Medicine service and assigned by standard practice to a general medical hospitalist team including a provider who agreed to participate in the study

Exclusion Criteria:

-Patients assigned, by standard practice, to a general medical hospitalist team and on the team of providers who chose not to participate in the study

Primary outcomes:
measure: Physician discharge order time
timeFrame: From the midnight of the day the patient was discharged until time the patient had a discharge order placed, assessed up to 6 months from the start of the study.
Secondary outcomes:
measure: Patient discharge time
timeFrame: From the midnight of the day the patient was discharged until the time the patient was discharged from the hospital, assessed up to 6 months from the start of the study.
measure: Patient length of stay
timeFrame: From the time that the patient was admitted to hospital until time the patient had a discharge order placed, assessed up to 6 months from the start of the study.
measure: Average time of day of orders for imaging, consults, or procedures were entered by participating physicians into the electronic health record
timeFrame: From the midnight of the day each day to the time of day each patient had an order placed for imaging, consults, or procedures, assessed up to 6 months from the start of the study.
Other outcomes:
Locations:
city: Aurora
country: United States
facility: University of Colorado
state: Colorado
Study officials:
affiliation: University of Colorado School of Medicine
name: Marisha Burden, MD
role: PRINCIPAL_INVESTIGATOR
References: