Increasing patient discharge by 50 percent from neonatal intensive care unit (NICU) and neonatal ward before 11am improves the efficiency of health officials, according to a study.

About 38 percent of patients at the unit and 20 percent at the ward were discharged before 11am.

The study was conducted for four months last year.

Sending patients home before 11am is one of the 50 key performance indicators in the annual performance agreement of Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) to measure the success of the organisation.

Presenting the study findings, a nurse with the Gyaltsuen Jetsun Pema NICU at the national referral hospital, Sonam Chophel, said that a multidisciplinary quality improvement team was formed to carry out the study after learning that patients were discharged mostly in the afternoons from the two units.

He presented the findings at the third international conference on medical and health sciences in Thimphu last week.

The team included neonatologists, pediatricians, resident doctors, in-charges from NICU and neonatal ward and volunteer nurses from the two units. The study was set in a 16-bed NICU and 24-bed neonatal ward of JDWNRH in Thimphu.

The nurse said that the study found that there is wide variation in the definition of discharge time among the staff.

He said that discharge time is defined as the time when all the discharge-related documents that include discharge slip, laboratory or other investigation reports, high-risk follow-up sheet, and medicines are handed over to patient party with proper instructions, and patients are ready to leave the ward. “Late discharge leads to delay in treatment of newly admitted patients.”

Sonam Chophel said baseline assessment included reviewing of daily activities and causes of delayed discharge were documented using root cause analysis. “The data were collected daily and reviewed weekly.”

Long consultant round, disorganised medical charts, delay of laboratory reports and face sheet, unplanned patient discharge, shortage of staff, multitasking during emergencies in NICU and late rounds by doctors caused delay in patient discharge.

He said interventions were developed based on the baseline assessment and were implemented consistently.  The change was monitored and reviewed periodically.

The interventions included multiple system changes such as developing medical chart standard and organising it with standardised divider; implementing discharge plan checklist to identify and plan early discharge criteria and preparation checklist to prepare discharge early and to complete all the procedures and necessary documentation before the day of the discharge.

Sonam Chophel said additional intervention includes residents or interns completing the pre-round at the wards latest by 8:30am, asking to deploy a paediatrician to start consultant rounds latest by 9:30am and complete by 10:20am while the neonatologist does the NICU round in parallel. “The vital signs monitoring timing was changed from 10am to noon for nurses.”

He said a laboratory report tracking system with ‘due report folder’ and ‘designated status seals’ in the units were developed to ensure timely report collection.

It was found that the baseline of patients discharged before 11am before the introduction of the interventions was 38.46 percent in NICU and 20 percent in the neonatal ward, which increased to 84.1 percent and 65.4 percent when the interventions were implemented.

“Towards the end of 11th month, the percentage reached 100 percent in NICU and 89 percent in neonatal ward,” Sonam Chophel said. “It has also improved teamwork, work efficiency and brought in numbers of positive changed in the units.”

He said discharging patients early benefitted the patient and the parents by being able to go home early and incurred no extra cost for staying an extra night in Thimphu for those who live in other dzongkhags. “For the hospital, it improved the key performance indicators, improved patient satisfaction, can accommodate more patients and reduce the costs.”

Dechen Tshomo