Optimisation of Inpatient Discharge for TTSH Main Ward

Year Submitted: 2025
Published Date: 19 December 2025

Tags: Inpatient Care, Quality Improvement, Workflow Redesign, Care Continuum, Care Process ＆ Redesign

About this Content

Aims

To promote timely discharge (before 4pm) in Inpatient to free up beds for ED patients.

COLLECTIVE GOALS
1. Timely Discharge (Actualised)
30% before 12pm and
80% before 4pm (days cumulative)
Note: To allieviate ED bed wait situation, 40-50 acute beds need to be targeted for before 12pm discharge at TTSH main wards, about 28% of total days discharge (avg: 175 daily discharges)

2. Better Communications (facilitate discharge planning)
Care team needs EDD and Discharge Order at D-1
NOKs need Discharge date, expected activities

3. Minimal Wait
Discharge activities to begin promptly upon agreed discharge time or when NOK arrives (whichever occurs later)

Background

Reason for Action
A general trend has been observed of TTSH Main Wards Inpatient Discharge moving away from 11am, towards afternoon discharge, adding to the bed distress situation and surge in Emergency Pharmacy (EP) after hours workload. In addition, feedback was received of the discharge experience being less optimal.

Initial State (Jan 2019 - Jul 2022)
Increasing trend of discharge moving towards after 4pm, creating workload stress downstream at Emergency Pharmacy and not freeing up beds for admission.

Methods

Study on patients discharging to home was conducted between 26 Jul - 19 Sep 2022 (pre and post Epic) to identify possible contributing factors for discharge delays.

Amongst other findings, 2 key observations were found:
1. Care Team requires an indication to prepare patients and NOK towards discharge i.e. AHP to plan rehab and CGT and Nurses to prepare family for patients return to home
2. Processes are interdependent esp on discharge day. Discharge Order needs to be received 2hours before discharge for Pharmacists to conduct bedside counselling in time for discharge

Future state workflow co-designed by Doctors, Inpatient Nursing, Pharmacy, Allied Health and Kaizen Office between 28 Sep - 21 Oct 2022 for all patients in TTSH main ward was rolled out on 1 Nov 2022. The new workflow placed emphasis on the following to enable timely discharge:
1. Estimated Discharge Date (EDD) to drive communications and discharge activities
2. Submission of Discharge Orders and documents at D-1 to drive 11am discharge
3. Submission of Discharge Orders and documents by 3pm for timely same-day discharge

Results

Initial State (1 Jun 2022 - 30 Sep 2022)
Before 12pm - 9.8%
Before 4pm - 52.2% (days cumulative)

In the final iteration of using ALOS to project EDD
Avg Discharge Distribution (Actualised Discharge, 16 Oct 2023 - 4 Nov 2023) - Incl Discharge Chair
Before 12pm 14%
Before 4pm 62%
(Initial Improvement and plateaued)

As at Nov 2023, while overall office-hour discharges has increased (reducing the pressure at after-hours Emergency Pharmacy), the office-hour discharges is still not strong enough to alleviate the bed wait situation at ED.

With the adoption of ALOS for EDD on 16 Oct 2023, EDD will definitely hit the target of 80%. However, EDD is just an input to cue the entire care team to work towards discharge. Early discharge before 12pm still require stratified identification of patients for early discharge and close coordination between doctors and pharmacists (doctors to confirmed discharge order & prescription and pharmacists rush to conduct bedside counselling. This is evidently seen in the CPIP project whereby a Teams chat is created to form the tag team for reminders.

Conclusion

A Care Team model was planned to be introduced in TTSH. With that, early discharge would be driven through this Care Team model and this project was retired.

Lessons Learnt

For dynamic situations, process alone sometimes might not work.
For long term success, a care team that constantly communicate and monitor the situation might give the outcome a better chance.

Keywords

Inpatient Discharge

Innovators' Details

Connect with this contributor!

Hui Pin Lim - hui.pin.lim@nhghealth.com.sg ↗ (opens in new tab)

Project Attachment

Inpatient-Discharge-Project-20240311.pdf ↗ (opens in new tab)