Paperless Discharge in the Emergency Department

Abstract

Purpose: The purpose of this project is to implement a paperless discharge process for lower acuity patients in the ED will a decrease in the number of minutes in the overall LOS in the ED and decrease in the number of minutes from disposition to depart in the ED. A decrease in overall LOS will decrease ED overcrowding by decreasing patient wait time to be seen by provider in the ED. Methods: PLAN: Project Design: A non-research pilot quality improvement project was implemented to consistently use the electronic medical record paperless discharge system, already in place, to discharge lower acuity patients from the ED. Both overall LOS in minutes from door to discharge as well as disposition to discharge time were the outcome measures utilized for this project. IRB approval was obtained. SETTING: ED of a community-based hospital that sees patients across their lifespan. This ED sees approximately 4500 patients monthly offering emergency services to patients of all ages. PARTICIPANTS: Eligible participants included adult patients aged 18 years and older who presented to the ED with an Emergency Severity Index (ESI) acuity level of 3, 4, or 5. Inclusion criteria required that patients be established users of the MyOchsner patient portal, demonstrate proficiency in its use, and express willingness to participate in a paperless discharge process. Additionally, all participants were required to be English-speaking. DO: Pre-Implementation- ED staff education Educational sessions for ED staff were conducted over a two-week period preceding the implementation of the study. These sessions were offered at various times and on different days to enhance accessibility and promote broad staff participation. In total, 48 hours were dedicated to training ED personnel on the procedures, objectives, and workflow associated with the project, particularly the introduction of the electronic discharge process. Staff were provided with standardized scripting to guide conversations with patients who expressed interest in electronic discharge. This scripting was intentionally general in nature, with the project lead available to address any detailed or patient-specific inquiries. Obtaining separate patient consent for participation was not required, as consent for care, including participation in quality improvement initiatives, was covered under the general consent signed by patients upon presentation to the ED. Implementation: The intervention group consisted of English-speaking adult patients, aged 18 years or older, who presented to the ED with an acuity level of 3, 4, or 5. Eligible participants demonstrated proficiency with the MyOchsner patient portal and expressed willingness to engage in the paperless discharge process. A total of 39 patients met these inclusion criteria and were subsequently assigned to the intervention group (n = 39), which utilized the paperless discharge protocol. A total of 230 patients were included in the control group, all of whom underwent the standard discharge process (c = 230). These individuals were English-speaking and presented with acuity levels of 3, 4, or 5. They exhibited similar chief complaints and presented during the same operational hours as those in the intervention group. All control group patients were evaluated, treated, and discharged by alternate healthcare providers within the ED. Recruitment Intervention group- Chart reviews were conducted at the time of patient check-in to the ED to identify individuals who met the established inclusion criteria. Eligible patients were subsequently invited to participate in the project and, if they consented, were provided with information regarding the study and instructions on how to access their discharge materials electronically. In addition, retrospective chart reviews were performed at the conclusion of each shift to document relevant data for subsequent analysis. These activities were conducted over a cumulative total of 300 hours, corresponding to 25 12-hour shifts. Control group- At the end of each shift, a retrospective chart review was conducted for a duration of one hour to identify adult, English-speaking patients who presented with chief complaints analogous to those of the intervention group and during equivalent operational hours. The review was limited to patients managed by providers not involved in the intervention and did not consider the patients’ level of proficiency with the MyOchsner patient portal. These activities were conducted over a cumulative total of 25 hours, corresponding to 25 12-hour shifts. Advertising Material Patient education- Laminated informational flyers will be strategically placed in triage and designated patient care areas within the ED to inform patients about the availability of the paperless discharge option. Patients who meet eligibility criteria for the study will also receive a printed handout containing detailed information and step-by-step instructions on how to access their electronic discharge materials through the MyOchsner patient portal following discharge. Data Collection Data for both the control and intervention groups were systematically collected and recorded in an encrypted Excel spreadsheet. For each participant in the control group, data included patient acuity, overall LOS, and time from disposition to discharge (measured in minutes), along with de-identified demographic information. Additionally, aggregate data on the number of control group patients were documented without individual identifiers, preserving only the overall LOS and disposition-to-discharge times. All data was securely stored on-site in an encrypted, password-protected Excel file accessible exclusively to the project lead. RESULTS: Results were analyzed using descriptive statistics. Figure 1 presents a comparative analysis, in minutes, of the average overall LOS and disposition-todeparture times between patients who underwent paperless discharge and those who experienced the traditional discharge process. Implementation of the paperless discharge protocol was associated with a reduction in average overall LOS by 47 minutes and a decrease in average disposition-to-departure time by 9 minutes. The implementation of the intervention resulted in a reduction of the average overall LOS by 47 minutes, decreasing from 234 minutes to 187 minutes. Additionally, the average time from disposition to physical departure was reduced by 9 minutes, from 46 minutes to 37 minutes. IMPLICATIONS FOR PRACTICE: Discharge delays contribute to ED overcrowding, which in turn can worsen patient outcomes. The AIM for this project was met. The average LOS was reduced by 20% and the disposition to depart time was reduced by 19.6% in the control group. These findings indicate that implementing a paperless discharge process within the ED may enhance patient throughput by reducing delays associated with traditional discharge procedures. These procedures often involve time-consuming administrative tasks such as documenting patient-specific discharge instructions, printing instructional materials, and generating hardcopy prescriptions. The implementation of paperless discharge in this project demonstrated a reduction in both overall LOS and disposition-to-discharge time. By streamlining the discharge process through electronic means, valuable time is returned to healthcare providers, potentially allowing for increased attention to other patients, expedited patient turnover, and more rapid access to critical follow-up information. These improvements may contribute to decreased wait times and enhanced patient flow within the ED.