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Tweet Smears Hospital's Discharge Incentive Campaign

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   August 29, 2013

A tweet decrying a Baltimore hospital's effort to speed patient discharges implied that patient safety was being put at risk. How much damage was done to the hospital's reputation remains to be seen.

Tweet from @Nurse_Rachel_

The way the tweet from @Nurse_Rachel_ made it sound, a campaign by 472-bed Sinai Hospital in Baltimore rewards nurses with $10 gift cards for kicking patients out of the hospital before they're ready for discharge.

"I'm sorry very sick patient not ready to go home, but I want to win a $10 gift card!" read one inflammatory tweet from the account of Rachel Amanda, RN, whose profile boasts, "Here to care for you. Baltimore." Another of her tweets  about the incentive program that began Monday is pictured at right.

What she tweeted was hardly the true story, which I'll explain in a moment. But the damage was already done; the tweet was rapidly retweeted. (And has since been taken down.)

@Nurse_Rachel_'s followers, including journalists and healthcare providers, piled on, appending their retweets with expletive-laced comments. "What?! That's crazy," "Grossly misguided" and "nice to see patient safety comes first," they wrote.

Naturally I was intrigued. In my decades of healthcare reporting, I've seen campaigns with original good intentions painfully backfire, with opposite consequences smearing a hospital's reputation.

When I saw @Nurse_Rachel_'s tweet, I wondered: What was Sinai Hospital thinking?

So I called Betsy Haley, Sinai's communications and social media manager, who says this was the first she'd heard about such a contest. After she checked, she was adamant that the implications in the tweets from @Nurse_Rachel_ were false.

The campaign is real, and that was a real photograph of the notice in the nurse manager's binder. But nurses are being incentivized to discharge patients from the hospital only after the physician's discharge order is signed, she says.

She read me the hospital's statement:

"What you have seen on this Twitter account is part of an internal campaign to improve patient satisfaction. Our patients have told us that the wait times between the physician's discharge orders to the actual discharge time has historically been too long. Once the patient knows he or she is being discharged, they naturally want to go home as soon as possible.

"Sinai is piloting a program to encourage its nursing staff to complete the discharge as soon as possible to better meet expectations."

The tweet from @Nurse_Rachel_, Haley adds, "was taken completely out of context. It sounds like we're trying to get people out of the hospital before they're ready," but what was communicated to staff in management meetings "was completely different. We want to raise our (nurses') awareness of this issue to try to increase our patient satisfaction, and give them a little incentive as they go. Not a big deal."

These days, with an emphasis on healthcare system efficiency and speedy throughput, it's important for hospitals that regularly have a full census to make room for new patients. That's not wrong, nor tough to understand. It's certainly not poor quality of care if the patient is ready to go home. I messaged @Nurse_Rachel_ to contact me, to get her version of this campaign. She did not.

Haley explains that the hospital was doing the right thing, responding to negative feedback from Press Ganey surveys from patients who said that after being approved for discharge, they waited too long, between 30 minutes in the best scenario, up to "several hours."

"Due to the multiple complaints, this issue has risen to the top of our priority list, and the incentive for the nursing staff is one example of how we are working to improve the process," Haley wrote me in an e-mail.

Nursing staff has a lot to do to finalize paperwork, communicate discharge instructions to the patients and family, arrange for transportation, find the patients' belongings, and continue to care for other patients, she says.

Realistically, Sinai's goal now is to get nurses to send their patient home one hour after the physician signs the discharge order. Nurses may communicate discharge instructions to the patient and/or family the day before discharge is expected, and proactively assist with coordinating and arranging for medical equipment and supplies to be in the patient's home when they'll need it. 

Games to stimulate behavior change among healthcare workers are not a new idea. For example, in Boston a few years ago, Beth Israel Deaconess Medical Center's emergency room teams launched a game of "Tag, You're It," to catch staff lapsing in their rigorous hand-washing routines. Shamed scofflaws saw their names gracing the dashboard banners of all hospital computer monitors.

So I see nothing wrong with Sinai's campaign to creatively nudge nurses to speed throughput for patients whose continued recovery depends on them sleeping in their own beds, as long as the discharge order has been signed. Keeping patients in the hospital longer than necessary can expose them to additional risk of adverse events such as infections, falls, medication errors and other mishaps.

As Dorothy said as she was transported from the land of Oz, "there's no place like home." As long as you are medically well enough to go there.


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