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How do you do it?

FGHburg FGHburg (New) New

does anyone have any ideas or techniques to incentivize nurses to get their discharges ready and out so new patients may be admitted and diversion can be avoided?

thank you in advance for your responses!

Hire more staff so that the pt-nurse ratio is smaller, then maybe nurses can get things done faster.

Hire more staff so that the pt-nurse ratio is smaller, then maybe nurses can get things done faster.

Ha! easier said than done.:monkeydance:

Staffing and faster aren't necessarily the issues when some nurses may be intentionally delaying discharges so "the next shift can take care of them." We are looking for ideas to avoid this situation and encourage the nursing staff to discharge as soon as patients are ready. It's so hard to realize that discharges cut our financial losses while making room for admissions which generate revenues that could be put back into us (the staff) when we're already working so hard on the floors...

:lol2: OP did ask for ideas!!

Staffing and faster aren't necessarily the issues when some nurses may be intentionally delaying discharges so "the next shift can take care of them." We are looking for ideas to avoid this situation and encourage the nursing staff to discharge as soon as patients are ready. It's so hard to realize that discharges cut our financial losses while making room for admissions which generate revenues that could be put back into us (the staff) when we're already working so hard on the floors...

If a pt has d/c orders in the morning there should be absolutely no reason to delay discharge until the next shift, especially if the discharge is expected by the staff. If nothing else is working you may have to go to disciplinary action.

Tweety, BSN, RN

Has 28 years experience. Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

Stop bugging and harrassing me to get my patient out. It will get done when it gets done to the absolute best of my ability. I realize "staff nurses don't understand the raminifactions of diversion" quote from our VP of Patient Care Services, but asking me every five minutes and bugging me to death about it isn't going to get them out faster. And each time I have to stop and explain what is taking to long only adds to it.

And just because I discharge someone doesn't mean I'm available right then and there to immediately accept another patient. I have other patients.

I promise that as a professional I don't dilly dally and obstruct admissions and transfers because I'm lazy and am playing games.

Don't get me started. Sorry. Very sore point with me.

Tweety, I would agree with your points, except the OP specified that the nurses are leaving the d/c's for the next shift. Not cool.

Tweety, BSN, RN

Has 28 years experience. Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

Tweety, I would agree with your points, except the OP specified that the nurses are leaving the d/c's for the next shift. Not cool.

Sorry, I answered before reading the thread and I realize I was totally unsympathetic and offered no suggestions.

I would look at the process. A discharge order comes through.......then what? What are the nurses doing? Are they eating bon bons and reading magazines? Are they trying to get home to kids and lifes outside of work? Like where I work are employees getting "counseled" about incidental overtime after their shift is supposed to end. Are they overworked and tired and deliberately sabatoging the discharge because it's so close to change of shift that they couldn't face another admission and keep their sanity? Are they lazy? Can case management help? Are there other issues that are holding it up?

Hold a staff meeting and ask "why when patients are ready to be discharged does it take so long, and why are some of you asking the next shift to discharge". Go directly to the source and confront.

Our hospital has a "never go on diversion, no matter what it takes" policy and they merely crack the whip like slave drivers. I think more often than not they really don't know what's going on in the units and make judgements like "nurses don't understand the financies is what keeps their jobs, they need to work harder and not be so lazy because it's in their best interest....nurses deliberately slow up discharges and admissions because they don't want to work, I don't understand what's taking so long........"

Dispite the financial raminifacations of diversion, one also has to look at staff nurse satisfaction and retention.

I'm not being fair and am not the one to ask. So I'll bail on this one. Sorry.

does anyone have any ideas or techniques to incentivize nurses to get their discharges ready and out so new patients may be admitted and diversion can be avoided?

thank you in advance for your responses!

are you thinking of morning discharges? i work the evening shift and try to get as much discharge paperwork and teaching out of the way to help the morning nurse expedite things.

what i mean is, have certain discharge tasks distributed thruout the shifts on the day before anticipated discharge, so that by the time the morning of discharge comes, much of it is done.

Lenap

Has 16 years experience. Specializes in Infusion, Oncology, Home Care, Med/Surg.

Stop bugging and harrassing me to get my patient out. It will get done when it gets done to the absolute best of my ability. I realize "staff nurses don't understand the raminifactions of diversion" quote from our VP of Patient Care Services, but asking me every five minutes and bugging me to death about it isn't going to get them out faster. And each time I have to stop and explain what is taking to long only adds to it.

And just because I discharge someone doesn't mean I'm available right then and there to immediately accept another patient. I have other patients.

:yeah: Agree with Tweety

I left Med/Surg floor and one of the reasons was I had enough of having to discharge 3-5 pts and immediately accept just as many post-op!

But for advice to speed up discharges:

1. Have all docs write their discharges in advance along with all prescriptions.

2. Have the docs tell their patients approximate length of stay post up, so they are not surprised in a morning by discharge and start making up new pains and SOB so they can get more work up to stay longer.

3. All homecare teachings should be started at least 1 day prior to discharge, so you can ask pt for a return demonstration (and not to spend next 2 hrs teaching them)

4. Have family notified to be ready for pt's pick up by specific hr. Or at least ask when they can make it, so you can prioritize discharges.

5. Have a wheelchair ready by pt's door. Usually a task that can be done by night shift, as there will be plenty of wheelchairs around the hospital.

6. Have all the extra supply for homecare ready in advance.

I can't think of anything else, but hope these help :wink2:

Maybe you could designate one nurse to do all discharges. A lot of places (skilled nursing and long-term care) have an admissions nurse, who does all the admits and then gives report to the nurse assigned to that pt. Why couldn't Med-Surg do that, too?

Problem: 1 nurse can do only so much, even if Admits and DC's are all she does.

You have to be realistic. I really think you need to look at the whole process in your hospital. We all know that the place has to be profitable, we know the economics of it. What we have trouble with is being able to work like automatons, at faster and faster paces, while worried about other patients or needing to pee, BM, take a sip of H2O or a morsel of food, or change our menstrual pad. The pace is killing in so many places, in other words. Just make sure that YOU understand that, even though A&D's are necessary to economic health, you don't forget that there are other factors in Nursing and in running a hospital.

Maybe your suits need to spend a couple of shifts, full shifts, with the staff nurses. Then, maybe they could come up with some cures. It needs to be a team effort.

If nurses are truly dragging their feet, find out why and fix that.

I work in a mother baby unit. Candy bars have worked for the first nurse to have her patient discharged and out the door. Also a good incentive is to have the nurse be given the "privelege" of having 1/2 hour - 1 hour of no new admits post pt discharge to enable her to complete charting and caring for her other patients. This may work on some units...Especially if the nurses are truly holding up their discharges just so that they don't have to take any new patients.

What can you do to streamline the paperwork? (computerwork?) Discharging isn't quite as painful as admitting. And usually discharging means an admit is soon to follow. It seems I always have an admit at 1830, and then I can count on staying at least an hour + after my shift doing the paperwork.

The admit procedure is so repetitive! I understand the importance of assessing a patient, but why spend so much time gathering a pt history when the doctor has already included the patient's medical history in the chart? Having to ask the patient the same questions he/she was asked 20 minutes earlier by the doctor is aggravating for me and the patient - and it makes us look like none of us are on the same page. And entering in pt meds? Very time consuming when the patient is on at least 20 meds. And guess what - the doctor has already written out a list of pt's meds in the chart - another duplication.

The point to my rambling is maybe they're holding up discharges because the admit procedure is so time consuming and cumbersome - and they don't want to stay for the 13th & 14th hour. Can you do something to streamline the paperwork?

In addition, having a designated admit/discharge nurse is a good idea too.

Medic/Nurse, BSN, RN

Specializes in Flight, ER, Transport, ICU/Critical Care.

I'll agree with TazziRN on this one - more nurses equal faster throughput.

My DISCHARGED PATIENTS go to the bottom of my "nurse priority" scale, pretty fast - if I'm already running at warp speed.

One trick was using "Admission Nurses" this did shorten the process of new to bed.

I think a Discharge SWAT team may be needed!? :eek:

A trick I did see work at times -

When ED saturation occurs - - rather that divert - - the entire hospital goes into Decompression Mode. Supervisors, case managers and the like all get involved. A "team" approach - does work at times (Everyone - from dietary to housekeeping to staffing to facilities has ONE goal). D/C'ed patients are sent out, ICU beds are made available if possible, MS admits are taken up without delay and with hold orders if necessary. Anyway, the point is this - no the nurse who is still an admission behind with 7 - 9 other patients is NOT asked to drop everything!

Also, this is not used to excess - it only occurs when it occurs.

Also, there are obvious limitations - # beds, # staff etc.

Good Luck - as we are all aware - DIVERSION is a difficult issue.

RNinSoCal

Has 13 years experience. Specializes in Home health, Med/Surg.

At my current facility we have a "Home by noon" policy. The doctors can write DC orders in the evening or early am and we send them home as close to noon as possible which opens the floor for PACU transfers and ER admits. Discharges are very streamlined here with MDs writing most of the instructions. It is hard to delay a discharge when it is a hospital wide policy AND the MDs are on board with it.

Stop bugging and harrassing me to get my patient out. It will get done when it gets done to the absolute best of my ability.

And just because I discharge someone doesn't mean I'm available right then and there to immediately accept another patient. I have other patients.

I once saw the Med-Surg director announce that any nurses who were "sitting" on discharges would get written up. At the time, we were discharging patients as fast as we could. All I could think of was ... wow, no wonder they were short of RN's. Needless to say, I won't be working there when I graduate.

At the second hospital I worked at ... I didn't see that kind of pressure at all. While they did try to discharge patients by noon ... management didn't ride the RN's about it. And, if the RN's couldn't take more admits they'd say so ... and that was the end of it.

:typing

Tweety, BSN, RN

Has 28 years experience. Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

I once saw the Med-Surg director announce that any nurses who were "sitting" on discharges would get written up. At the time, we were discharging patients as fast as we could. All I could think of was ... wow, no wonder they were short of RN's. Needless to say, I won't be working there when I graduate.

:typing

I think that's what bugs me the most is the suit's presumption and judgement that we're "sitting" on discharged and deliberately dragging them out. I'm sure that happens otherwise there wouldn't be that stereotype.

While I might not understand the ramifications of ER diversion (but I'm smart enough to know that each ambulance that drives by our busy and unsafe ER is lost revenue) they truly don't have a clue what I'm doing either.

My apologizies to the original poster for highjacking the thread.

I think that's what bugs me the most is the suit's presumption and judgement that we're "sitting" on discharged and deliberately dragging them out.

Well ... I'm sure it can look like that's happening but, it's often not the case. If you call the family at noon and nobody's home because they are at work or ... they can't come pick up the patient right away because they're at work ... there's not much you can do about it. What are you supposed to do, dump the patient in the parking lot?

:typing

Tweety, BSN, RN

Has 28 years experience. Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

Well ... I'm sure it can look like that's happening but, it's often not the case. If you call the family at noon and nobody's home because they are at work or ... they can't come pick up the patient right away because they're at work ... there's not much you can do about it. What are you supposed to do, dump the patient in the parking lot?

:typing

Our VP of patient care services (not a nurse) said we need to dump them off at the coffee shop or cafeteria and make them wait. I wasn't at that meeting, but the room apparently got very quiet and stunned at this "solution". I'm glad I wasn't there to ask "are you going to help him to the bathroom and clean him up, and bring him pain medicine?". Sheesh.

Most of my discharges aren't easy, and there's a lot to do and we are getting much better with case managers at planning ahead. But still the time of order and the time at the door sometimes involves issues outside of my control.

Again, I apologize to the OP.

gr8greens

Specializes in cardiac, med-surg, some critical care.

We have two admit/ dc nurses for the whole house at the present time. It works out very well....when they are on. They're only part-time, and the days they're not here really stink! I work a 32 bed, very busy tele unit....high turnover every day. We'll be asked to take report from the cath lab or ER even before the bed is empty! Paperwork is just unbeleivable.

More staff would help but we all know how that goes.

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