Goals-to-Discharge Patient Checklist

Abstract

Fast-track or enhanced recovery after surgery (ERAS) pathways are evidence-based perioperative guides that promote stress reduction and earlier return to function following surgery. They emphasize preoperative counseling, nutrition optimization, analgesia standardization, fluid and electrolyte balance, minimally invasive approaches, and early ambulation. Although ERAS pathways were implemented in 2016 on a 43-bed postoperative colorectal medical–surgical unit, inpatient stays remained beyond the projected two-day length of stay (LOS). A quality improvement team was formed and an eight-week pilot project was initiated in 2018. The project included the implementation of a laminated bedside goals-to-discharge checklist in the immediate postoperative period.

Fast-track or enhanced recovery after surgery (ERAS) pathways are evidence-based, multimodal perioperative guides that focus on stress reduction and an earlier return to function following surgery (Patel et al., 2014). First introduced in 1997 by Henrik Kehlet, the ERAS approach was generated to improve surgical outcomes by decreasing length of stay (LOS) and complications, leading to early recovery and reduction of economic burdens (Kehlet, 1997; Taurchini et al., 2018). The pathways emphasize preoperative counseling, nutrition optimization, analgesia standardization, fluid and electrolyte balance, minimally invasive approaches, and early ambulation (Ljungqvist et al., 2017).

Within Memorial Sloan Kettering Cancer Center in New York, New York, the ERAS pathways for patients with colorectal cancer include the minimally invasive colon resection pathway (two-day LOS) and the open colon resection pathway (four-day LOS). Patients choosing the two-day pathway undergo minimally invasive surgery (MIS), such as a laparoscopic or robotic procedure, which may require creation of an ostomy. The four-day pathway includes patients who undergo an open procedure involving a large incision made by a scalpel; these patients may also require formation of an ostomy. However, simply establishing ERAS pathways may not be adequate to achieve sustainable improvement in the overall quality of patient care, including the discharge process (Taurchini et al., 2018).

Although ERAS pathways had been implemented since 2016 on the 43-bed postoperative colorectal medical–surgical unit, inpatient stays often exceeded the projected LOS. Delays in discharge translated into delayed access to care for patients awaiting admission. Because of inadequate patient preparation, delayed discharges led to inadequate numbers of inpatient beds and surgery cancellations. Unit discharge delays also resulted in adverse hospital bed turnover times and excessive LOS. A frontline oncology nurse practitioner proposed that patients might benefit from a step-by-step guide of milestones needed for individualized discharge planning. Early implementation of a goals-to-discharge checklist was envisioned to foster patient engagement, optimize time of discharge, and reduce LOS.

Goals-to-Discharge Checklist

A goals-to-discharge checklist was developed after reviewing the literature regarding discharge criteria following colorectal surgery and the value of checklists. Clinical face validity was granted by the colorectal service surgical chief and colorectal surgery team before initiating a pilot project to assess the value of a checklist and discharge metrics for designated ERAS patients. The initial checklist was a laminated 12-by-18–inch poster placed at the patient’s bedside (see Figure 1). Patients were instructed to note real-time progress on each discharge milestone with magnetic dry erase markers. Occasionally, family caregivers, nurses, and/or the surgical team offered input.

FIGURE 1.

INITIAL CONTENT OF GOALS-TO-DISCHARGE CHECKLIST

The pilot project took place at Memorial Sloan Kettering Cancer Center from August to September 2018. Discharge times and LOS of colorectal ERAS patients before and after the implementation of the goals-to-discharge checklist were evaluated. The preimplementation baseline data included 60 colorectal ERAS patients from August to September 2017. A waiver of consent was obtained from the hospital’s institutional review board because the program was determined to be without human study and deemed a quality improvement project. A convenience sample of 60 men and women undergoing oncology surgery on the colorectal medical–surgical unit was identified (see Table 1). Patients were given the checklist on postoperative day 0 (day of surgery) or on postoperative day 1 and were provided education and instruction on how to use the checklist and record progress in real time. Once completed, the patient reviewed the checklist with a staff nurse; this was followed by notification to the surgical team’s advanced practice provider (APP) that discharge criteria were met.

TABLE 1.

SAMPLE PATIENT DEMOGRAPHICS: PRE- AND POSTIMPLEMENTATION OF THE ENHANCED RECOVERY AFTER SURGERY CHECKLIST (N = 60)

CHARACTERISTIC	PREIMPLEMENTATION	POSTIMPLEMENTATION
	RANGE	RANGE
Average age (years)	60–69	50–59
CHARACTERISTIC	n	n
Gender
Female	28	27
Male	32	33
Treatment
Patients undergoing MIS without an ostomy	36	38
Patients undergoing MIS with an ostomy	12	20
Patients undergoing an open procedure	12	2

MIS–minimally invasive surgery

Note. MIS includes either robotic or laparoscopically performed surgery; an open procedure is defined as a procedure in which an incision is made using a scalpel.

Data Analysis

Two discharge metrics were analyzed in this pilot project: time of discharge and LOS. Statistical tests were performed via IBM SPSS Statistics, version 23.0, and were used to record and analyze all data collected throughout the project. Frequency tables analyzed the data collected and included the following patient information: age, gender, and type of colorectal surgery (MIS versus open). A comparison between the pre- and postimplementation groups was analyzed using mean and the frequency of each identified data element. The average discharge time during the pilot was compared to the baseline average discharge time. However, the baseline data did not include the individualized discharge times; therefore, only the average time of discharge could be assessed and compared. To identify any statistical difference associated with LOS between the pre- and postimplementation groups, mean scores and an independent t test were used. In addition, an independent t test was used to evaluate any difference between type of colorectal surgery and LOS when comparing the pre- and postimplementation groups. A p value of < 0.05 was used to determine statistical significance of findings.

Results

Discharge Time

Discharge time was defined as the window of time between when the order was written by the provider and the actual time stamp of discharge as recorded in the electronic health record (EHR). The average discharge time did not reveal any difference between the two groups. The average discharge time for the postimplementation group was 2 hours and 24 minutes, and the preimplementation group average discharge time was 2 hours and 25 minutes. However, 40% of patients left before noon, compared to only 10% prior to implementation. This finding was considered advantageous by hospital administrators because higher bed turnover rates equated to improved patient access, fewer surgery cancellations, and/or less overflow in the urgent care center and postanesthesia care unit.

Length of Stay

LOS was measured in a subgroup of 56 patients because four patients were excluded from the postimplementation group. These four patients included two patients who were considered outliers related to the presence of multiple complications, such as anastomotic leaks. These two patients had discharges greater than seven days. Two other patients had open procedures and were removed from the analysis because of the small sample size. In the postimplementation group, 56 participants scored a mean LOS of 2.66 days (see Table 2).

TABLE 2.

LENGTH OF STAY: PRE- AND POSTIMPLEMENTATION (N = 56)

CHARACTERISTIC	2017	2018
	X̅	X̅
Length of stay (days)	3.13	2.66
Length of stay for MIS without an ostomy (days)	2.62	2.39
Length of stay for MIS with an ostomy (days)	3.89	3.21

MIS–minimally invasive surgery

Note. 2017 and 2018 data were collected in August and September.

Note. For average length of stay, p = 0.028; for MIS without an ostomy, p = 0.262; for MIS with an ostomy, p = 0.031.

No outliers were removed from the preimplementation group; however, 12 open procedures were excluded to determine the mean LOS. The mean LOS was 3.13 days for the remaining 48 participants. This was a statistically significant change in LOS (p < 0.05). Comparison between the pre- and postimplementation MIS without an ostomy group showed no statistically significant difference (p > 0.05). For patients who underwent MIS with an ostomy, a statistically significant difference was found (p < 0.05). Of note, an operational finding after the implementation of the goals-to-discharge checklist revealed that 45% of patients were discharged on or before the projected ERAS discharge date, compared to 28% in the preimplementation group. This finding supports the value of a checklist in promoting early discharge.

The goals-to-discharge checklist received positive feedback from patients, oncology staff nurses, surgeons, APPs, and hospital administrators. With continuous input and improvement, the draft checklist was reviewed by several hospital committees before integration into the EHR in February 2020. One noteworthy contribution was from the Patient and Caregiver Education Department, which provided key revisions to ensure a fifth-grade reading level. After this adaptation, the colorectal physician surgical team approved the checklist and it was forwarded to the Health Informatics Department for integration into the patient portal and linked to the EHR (see Figure 2).

FIGURE 2.

GOALS-TO-CHECKLIST UPDATED CONTENT

Discussion

Adherence to the ERAS pathway results in quicker bed turnover, decreased LOS, and a positive impact on hospital revenue. ERAS pathways have shown net savings for health systems. The estimated return on investment for every $1 invested in ERAS was $3.80 (Thanh et al., 2016). An estimated 1,900 colorectal cases are performed each year at the current institution, and the cost to the patient is about $24,000 per day prior to insurance coverage following MIS colorectal surgery. With a shortened LOS, the patient’s financial burden is decreased. In addition, quicker bed turnover is achieved with the improvement of discharge prior to noon. Without surgical cancellations, patient access is maintained with associated hospital revenue.

The checklist encourages patients to remain involved in the discharge process and to voice concerns and needs prior to discharge. Patients who report that they feel engaged in the discharge process feel empowered as partners with the care team (Hardiman et al., 2016). The checklist serves as a visual cue for the patient, nurse, and surgical team to remember to address all discharge teaching needs, including education regarding care of an ostomy. With discharge teaching occurring earlier in the postoperative stay, patients are more prepared for discharge when medically cleared.

Implications for Nursing

Checklists are an established means to improve quality of care and patient safety. Integrating a discharge checklist with ERAS pathways can offer a practical intervention to promote safe and timely transitions to outpatient care (Prince et al., 2019). In a report titled The Future of Nursing: Leading Change, Advancing Health (Institute of Medicine, 2011), a promising field of evidence links high-quality nursing care to patient safety. Frontline nurses play a crucial role in the safe facilitation of patients’ transition from hospital to home.

This report also recommends that nurses work collaboratively with physicians, other healthcare professionals, and patients in redesigning care. This includes identifying problems and initiating quality improvement projects with patients as proactive partners. Future performance improvement efforts can characterize the level of patient satisfaction and documentation in the EHR or patient portal during hospitalization.

Limitations

Although the project had statistical and clinically significant results, there were several limitations. The project was implemented among a small English-speaking sample of patients with colorectal cancer, which limits its generalizability to other practice areas. In addition, there have been recent changes on the unit, including other discharge initiatives and new ERAS pathway order sets, which could have influenced the results. An identified barrier was the lack of access to individualized discharge times for the preimplementation group. This limited the extent of data analysis and testing for a statistically significant change.

Conclusion

Although ERAS pathways imply fast-track surgery, the key surgical goal is quality rather than speed of recovery. A goals-to-discharge checklist adds value as a patient-centered and evidence-based tool. Oncology nurses can consider integrating intentional patient participation to optimize time of discharge and LOS. Checklists are valuable tools that can promote patient self-management, education, and early discharge with or without an EHR.

AT A GLANCE.

• ERAS pathways are evidence-based guides and need to include a component of patient participation for self-management.

• Checklists are valuable tools that can ensure a structured approach to patient education and early discharge with or without an electronic health record.

• Quality improvement projects can be developed, evaluated, and adopted to optimize patient participation and organizational metrics.

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