Background and objectives:
In September 2019, the Neonatal Intensive Care Unit (NICU) at NYU Langone Medical Center embarked on a journey to improve patient discharge. The discharge process in our NICU required optimization based on low family satisfaction scores, staff frustration and repeated failure to meet the monthly hospital goal of at least 42% of patients discharged before noon (DBN). We began an intensive quality improvement initiative to address our low DBN rate with a global aim of improving staff and family satisfaction scores related to discharge.
Methods:
We initially identified barriers related to on-time discharges through focus groups with our interdisciplinary care team, including nursing, medicine, care management, social work, nutrition, pharmacy, therapies and child life. We interviewed families of former NICU patients about their experience with discharge. We developed a data collection tool to collect information about patients going home after noon and analyzed the data using histograms and pareto charts. We held weekly debriefs with our interdisciplinary team to discuss what went well and what challenges we experienced the previous week. Interventions included: 1. Establishing a precedent to discuss a patient's anticipated discharge date and dependencies during daily rounds; 2. Adding a discharge section to the Nursing and Fellow shift handoff sheets; 3. Using Epic Secure Chat to communicate patients eligible for discharge in the next 48 hours to our interdisciplinary team on a daily basis; 4. Standardizing a communication strategy and timeline for contacting families to discuss discharge status and dependencies on a routine basis; and 5. Establishing an interdisciplinary NICU Discharge Checklist.
Results:
Pareto charts consistently identified the majority of patients discharged after 12n belong to three groups: 1. Patients completing treatment or observation; 2. Patients waiting for family to arrive and 3. Patients completing discharge teaching, screening or circumcisions the same day as discharge. The results of our data collection helped guide our interventions and PDSAs to follow. Displaying data in a control chart updated weekly increased staff awareness of our project goal and informed staff of our progress. While we were able to meet our DBN goal for many weeks after adopting our interventions, we were unable to achieve a shift in our center line. Our hospital experienced an interruption to our QI efforts when COVID-19 surged our hospital in March 2020. Recognizing continued interest in our discharge improvement efforts, we started the project again in July 2020 and continue to work towards goal.
Conclusion:
There are many unique factors that affect the timely discharge of infants in NICU. Quality improvement methodology is critical in measuring and improving discharge related processes.
