7 Steps to Implementing Same-Day Discharge

Previously Published in OR Manager April Issue


As hospitals ramp up outpatient Total Joint Arthroscopy (TJA), Senior Vice President Gerald E. Biala, MSN, RN, CNOR, CSSM, of Sullivan Healthcare Consulting shares with OR Manager how his team devised a 7-step strategy for safely discharging TJA patients on the same day of surgery.

Pilot Testing: St Luke’s Health System in Boise, Idaho

A key metric is whether or not patients are returning to the hospital or the emergency department following surgery. So far, SHC has had no such occurrences at St. Luke’s Health System.

“We pulled a lot from the ambulatory surgery center (ASC) world and tailored this to the hospital setting. Everything from surgeon preferences to logistical support processes needs to be taken into consideration. Key steps are identifying patients who will do well in a same-day discharge (SDD) program and working with surgeons to support processes that align with the program,” says Gerald E. Biala, MSN, RN, CNOR.

SHC’s Approach to Shifting Procedures to SDD

Our approach was to establish a steering committee of providers across the continuum to make the final recommendations in the design of the program; this includes the surgical staff, therapy staff, and case managers. Administrators will also need to coordinate with their information technology (IT) staff to support changes to orders and medical record documentation and finance to understand the impact of charging and reimbursements.

Patients were also asked to enlist a coach — a caregiver, family member, or friend — to accompany them on their journey. The coach must be 18 years of age or older and have a current driver’s license. Pre admission and TJA navigators ensure that the coach is capable of helping the patient walk.

7 Steps to Implementing SDD

  1. Patient Selection. Patients comfortable with SDD who satisfy clinical criteria such as comorbidities, age, and body mass index are good candidates.

  2. Surgical Scheduling. TJA should be the first, second, or even third case of the day, with the aim to complete the surgery.

  3. Anesthesia Protocols & Procedures. The anesthesia care team works closely with surgeons on selecting medications to be given pre-, intra-, and postoperatively, using multimodal protocols to manage pain (especially breakthrough pain), nausea, and vomiting postpartum.

  4. Pre admission preparation and education. The pre admission staff work closely with clinics and TJA navigators to ensure patient readiness for surgery. Patients attend a preoperative class to learn about their surgery as well as home care and safety.

  5. Preoperative Preparation on the Day of Surgery. Preoperative staff must reinforce the patient’s expectations for SDD, including the role of the patient’s coach.

  6. Postoperative Recovery & Preparations for Discharge. Some hospitals may not have the space to allow for patient safety assessments to support SDD. In these situations, there needs to be close planning and coordination with hospital bed management for transfer to a patient care unit before discharge.

  7. Post Discharge Patient Care. Planning for patients’ care at home can include coordinating nursing care and home therapy, as well as follow-up calls to the patient from the hospital staff and/or surgeons office or clinic. We shouldn’t forget the obligation to follow patients in the post-discharge phase.

As value-driven healthcare becomes more prevalent and the demand for SDD becomes increasingly incentivized, surgeons and anesthesiologists must work together in each phase of care. A team-based approach is critical to increasing surgery case volumes in a COVID-19 era (and likely beyond).

To learn more about our perioperative and/or ASC services and how SHC can shift appropriate cases to outpatient and achieve SDD, contact us today.

Gerry Biala

Gerry Biala, RN, MS, CNOR, CSSM is Senior Vice President of Sullivan Healthcare Consulting. Gerry has extensive experience managing the operations of surgical/anesthesia services in diverse hospital and ambulatory surgery environments, with an additional expertise in sterile processing and supply management. He has expertise in optimizing the performance of all elements of surgical services and is highly skilled in facilitating and consolidating multiple departments and physician objectives into a unified plan to achieve desired results. He recently co-authored The Healthcare Executive’s Guide to Navigating the Surgical Suite, a book directed at perioperative services healthcare leaders.

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