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Brigham and Women's Hospital Nursing Innovation Units Reduce LOS for Orthopedic Surgical Patients via Discharge Bundle

Rationale / Objectives

The Brigham and Women's Hospital Innovation Units were identified in September 2011. One of the innovation units’ areas of focus was improved discharge of the patient.

Project/Program Description & Major Achievements

Innovation Units were established in 2011 at Brigham and Women's Hospital. One of the innovation units’ areas of focus was discharge of the patient. A discharge “bundle” packages together certain tasks associated with discharging a patient to make it more likely that he or she will successfully recover upon leaving the hospital, whether the patient is going home or to another facility. Following implementation, 70 percent of orthopedic surgery patients now go home within two days, up from 40 percent prior to their work.

Lessons Learned

The discharge phone call component of the bundle helped the staff validate that the work they had undertaken was making a positive difference in the lives of patients and staff. It also helps validate the staff’s multidisciplinary approach to caring for the elective total joint replacement patient population. At first, staff needed to be convinced that discharging patients within two days was the right thing to do for the patient. One of the challenges with the project was making sure calls could be kept short enough so that they did not interfere with staff nurses’ other daily tasks. Through an evolving process, they have found that nurses are able to have meaningful discharge phone calls in an average of six minutes.

People / Organizations Involved

Further Description

Founded in 1994 by Brigham and Women's Hospital and Massachusetts General Hospital, Partners HealthCare includes community and specialty hospitals, a managed care organization, a physician network, community health centers, home care and other health-related entities. The Innovation Units were established in 2011 at Brigham and Women's Hospital. One of the innovation units’ areas of focus was discharge of the patient. A discharge “bundle” packages together certain tasks associated with discharging a patient to make it more likely that he or she will successfully recover upon leaving the hospital, whether the patient is going home or to another facility. Six units were selected to test, pilot, and implement the discharge bundle, as well as unit-specific ideas that support care transitions. One of these, specifically around the proper discharge of a patient, was piloted on 16 A/B, the orthopedic surgery unit. On this unit, nurses have instituted a discharge bundle that involves four main elements:

  • Discharge phone calls: Following up with the patient on the phone once he or she has returned home.
  • Warm handoffs: If a patient is being transferred to a nursing or rehabilitation facility, connecting with staff at the facility prior to the patient’s transfer to make sure all pertinent information has been communicated.
  • High-risk medication discussion: Making sure patients and family members understand what their medications are, how to take them, and why they are important before and after discharge.
  • Validation of a follow-up appointment: Scheduling orthopedic surgery patients for a follow-up appointment when they book their surgery so they can plan for it ahead of time.

 

Nurses crafted a standard set of questions to guide discussions with patients during the summer of 2012. This set was based off of some trial runs of the discharge call to specific types of patients, such as those who have had total hip or knee replacements. They found that patients often had similar questions, and eventually staff knew ahead of time what answers to have and what specific questions to touch on such as 'How are you feeling today? How is your pain being managed?'. They also check on other items from the discharge bundle, such as how they are doing with their high-risk medications (usually anticoagulants for orthopedic surgery patients) and where they will be seeing their doctors for their follow-up appointment.

Major Achievements

Partners HealthCare is also the recipient of many industry awards and recognition. These awards range from being recognized as a top place to work to as an innovative user of information technology. With respect to the discharge bundle work at Brigham and Women's Hospital, staff are now moving the discharge bundle into the mainstream across all practice areas. Their goal is that every nurse will call one patient once a week, which would equal about 30 patients per week, and they discharge about 36 per week.

Metric Result Detail
Discharge within 2 days increased by 40% one-year post implementation

Supporting Evidence: