Abstract
When patient demand exceeds hospital capacity in certain scenarios, such as natural disasters, terrorist attacks, or staffing shortages, the rapid discharge of patients identified through reverse triage methodologies can create surge capacity. The evaluation of this concept has been documented in numerous resources and studies, but current tools tend to be extensive and siloed, which may make them difficult to use during emergencies. To prepare the largest municipal healthcare system in the United States for situations requiring rapid patient discharge, NYC Health + Hospitals/Central Office Emergency Management sought to develop a short, synthesized, and user-friendly plan. After consulting experts and reviewing existing peer-reviewed articles, gray literature, and internal facility documents, the team created a 7-page rapid action checklist that synthesizes important content. The Risk-based, Abbreviated, Patient Identification Discharge (RAPID) tool was successfully used during a resident labor action in May 2023, illustrating that its utility may extend beyond the system in which it was used. Future work should be done to validate and improve upon this tool.
Introduction
I
As a result, New York City Health + Hospitals (NYC H+H)/Central Office Emergency Management sought to develop a short and customizable plan for all of New York City’s public hospitals to use in the face of risks related to a mismatch between provider supply and patient demand. With 11 hospitals, 5 skilled nursing facilities, and over 70 patient care sites throughout communities and schools, NYC H+H is the largest municipal healthcare system in the United States.1,2 NYC H+H plays a critical role in caring for the residents of New York City’s 5 boroughs, including uninsured patients. Previously, NYC H+H facilities were affected by crises like Hurricane Sandy in 2012, which flooded hospitals, disrupted services, and forced the evacuation of several medical facilities, including Bellevue Hospital and Coney Island Hospital, within the NYC H+H system. 3 In response to such major crises, load-balancing across the NYC H+H system became crucial to ensure that patients could be distributed to functioning facilities to maintain continuity of care, minimize strain on any single hospital, and optimize resource utilization across the system. Consequently, the success of New York City’s response efforts to any surge in patient demand or decline in capacity is dependent upon the resilience of NYC H+H as a safety net system.
The objective of this effort to develop a rapid discharge plan was to first ensure that all facilities had some form of practical guidance on rapid discharge procedures in general, and second to encourage all facilities to follow similar protocols to maximize synergy and overlap during large-scale, citywide rapid discharge efforts. As a result, we developed a 7-page response action checklist called the Risk-based, Abbreviated, Patient Identification Discharge (RAPID) tool (available in Supplemental Materials, www.liebertpub.com/doi/suppl/10.1089/hs.2024.0096). The tool was distributed to all NYC H+H acute care sites in January 2023 and subsequently tested in a real-world scenario during the response to a resident physician strike at NYC H+H/Elmhurst in May 2023.
Methods
In creating a rapid discharge plan for use across NYC H+H acute care sites, we followed an iterative and stepwise approach by first looking to existing tools within the published peer-reviewed and gray literature. We assessed current facility-specific documents within our healthcare system and incorporated expert consultation and tool refinement from diverse clinical and operational healthcare backgrounds. Finalized tools were ultimately deployed in a real-world incident requiring rapid patient discharge.
Literature Search
We conducted a scoping review of the published literature to identify existing rapid discharge tools used for acute care hospitals. We searched PubMed and Google Scholar using combinations of the keywords “rapid patient discharge,” “reverse triage,” and “surge discharge,” and reviewed English-language literature published over the last 20 years for topical relevance. We likewise searched for relevant gray literature published on hospital or organizational websites, such as rapid discharge tools, using Google searches. Finally, we contacted several disaster medicine experts to request materials on this topic from their own experiences or recommendations from the literature.
Facility-Specific Documents
In parallel to the literature search, we surveyed emergency management leadership from within NYC H+H acute and postacute care facilities to obtain all existing rapid discharge materials. Nine facility-specific sets of rapid discharge materials were identified and reviewed to identify structures, operational considerations, procedural steps, and patient-related considerations for incorporation into the final product.
Expert Consultation
Leveraging both the literature and facility-specific materials, we then developed a preliminary draft of the rapid discharge plan and tested it in exploratory feedback sessions with internal subject matter experts representing the fields of emergency management, clinical operations, transitional care/discharge planning, hospitalist medicine, and emergency medicine.
Real-World Implementation
After expert review and simulation piloting and refinement, we tested the finalized RAPID tool at NYC H+H during a limited-notice real-world incident that required the rapid discharge of patients to lessen hospital inpatient service demand in preparation for a labor strike. Use of the tool was observed to identify strengths and weakness, operational considerations, and recommendations for adjunct processes instituted to mitigate risks of rapid discharges.
Results
Findings From Existing Resources
The literature review revealed approximately 40 papers related to reverse triage and rapid discharge. Kelen et al conducted seminal work in this area, beginning with their 2006 gathering of 39 expert panelists to develop a hospital disposition classification system that was categorized according to the risk of consequential medical events—defined by consensus as “unexpected death, irreversible impairment, or reduction in function within 72 h of hospital discharge for which an in-hospital critical intervention would be initiated to stabilise or ameliorate the medical disorder or disorders.” 4 They then used this system to identify and rank a set of “critical interventions” based on the risk of withdrawing or withholding them because a patient was discharged. 5 Additional work included a 2009 study that identified 44% of patients were eligible for rapid discharge across 3 hospitals when applying their criteria, 1 a 2017 study 6 that estimated bed capacity could be increased by nearly 50% using reverse triage in a pediatric hospital, and a 2018 article 7 describing a web-based simulation to show how reverse triage could increase bed capacity. 1 The approaches and findings from these studies directly informed the patient categorizations and risk descriptions incorporated in the Reverse Triage Guide of our RAPID tool (Supplemental Material, Appendix C), which aims to modify Kelen et al’s 28 critical interventions 4 into a usable table.
Several tools were also identified in the gray literature. Published in 2013, the NYC Department of Health Patient Surge in Disasters: A Hospital Toolkit for Expanding Resources in Emergencies – Rapid Discharge Tool is a 76-page document consisting of numerous appendices. 8 This tool was associated with a 2013 study showing that up to 21.4% of beds in New York City could be made available across 55 hospitals when rapid discharge was implemented. 9 Several key concepts recommended within this tool include the use of rosters for the bed management committee and a unit-based rapid patient discharge team with specified individuals. Similarly, the Michigan Immediate Bed Availability Decompression Strategy Guidelines and Toolkit 10 is a 49-page document that serves as another extensive guide for facilities to follow, and its guidelines for identifying patients for discharge were integrated into our Reverse Triage Guide. Other relevant documents included the HICs 260 – Patient evacuation/transfer tracking form 11 and the Administration for Strategic Preparedness and Response’s Technical Resources, Assistance Center and Information Exchange (TRACIE) Surge Discharge plan 12 that categorizes patients as easy, intermediate, or difficult to discharge. For this background review, we did not evaluate the large body of literature focused specifically on patient evacuation.
In addition to elements identified from the peer-reviewed and gray literature, tools obtained from emergency preparedness coordinators across NYC H+H facilities included procedural steps, transfer form templates, evacuation summary sheets, and patient tracking documents. While some of the plans collected from emergency preparedness coordinators were long, others that were more concise and rapidly deployable were adapted and incorporated into the appendices of our final rapid discharge product. 13
The NYC H+H Rapid Patient Discharge Tool
The final product was a 7-page rapid action checklist—the Risk-based, Abbreviated, Patient Identification Discharge (RAPID) tool (see Supplemental Materials). This short, user-friendly document synthesizes, simplifies, and condenses content from the referenced sources. The document consists of 2 pages to describe the activation and steps of the rapid discharge plan, followed by 5 pages of appendices. The appendices include rosters for the bed management committee and unit-based rapid patient discharge team, a reverse triage guide for selecting patients, a rapid patient discharge and transfer form, an evacuation summary sheet to track patient movements, and a list of references used to create the tool. The rosters will enable hospitals to predetermine what staff members will be involved in the decisionmaking process for each unit and the hospital at large, while the reverse triage guide will aid providers in making individual patient decisions about who can or cannot stay in the hospital. The rapid discharge and evacuation forms are intended for patient tracking to ensure that all actions are documented and all patients are accounted for. Finally, the list of references was included for users to look at the sources that influenced the creation of the tool. The synthesized and standardized 7-page plan was distributed internally to the clinical and emergency management leadership of all NYC H+H facilities to use and adapt as needed.
Real-World Implementation
At NYC H+H/Elmhurst, preparations began on May 2, 2023, due to intelligence that a potential house staff labor action could be on the horizon. In addition to increasing staffing during this time, steps were taken to reduce the number of patients in the hospital. 14 The RAPID tool was identified as an important resource to assist with this plan. Prior to notification of the action, there had been some initial orientation to the RAPID tool during the nursing strike that occurred at Mount Sinai Hospital on January 9 to 10, 2023. 15 Hospital leaders were convened to learn about their assigned roles and responsibilities in case of an influx of patients at NYC H+H/Elmhurst due to the nursing strike at Mount Sinai.
Between May 2 and 16, 2023, the same leadership assigned to the rapid discharge roles prior to the nursing strike were convened. The workflow was repeatedly reviewed up until the day before the expected strike action would occur, with the expectation that the plan would be executed the next day. This final leadership meeting emphasized that the rapid discharge plan would be executed daily, starting May 17, 2023, until the end of the strike. Patients would be discharged during interdisciplinary rounds in accordance with the Reverse Triage Guide from the RAPID tool.
On the morning of May 22, over 170 resident physicians in internal medicine, psychiatry, and pediatrics officially went on strike at NYC H+H/Elmhurst. The action lasted until May 25. The workflow from the RAPID tool was executed successfully as planned between May 17 and 27, to quickly discharge 311 patients. The average number of patients discharged per day was 28, with the highest number (44) on May 18, and the lowest number (9) on May 21. While the strike action was concluded on May 25, the rapid discharge of patients continued through May 27 to provide operational flexibility during the demobilization stage of the strike response. This continued use of the tool allowed for a smoother return to normal operations in the hospital after May 27.
Discussion
The success of the RAPID tool at NYC H+H, the country’s largest municipal healthcare system that cares for an underinsured population, suggests that it can be used in other facilities regardless of their complexity. Given the success of the rapid discharge protocol in moving healthy patients out and opening up bed space within the hospital, NYC H+H hospital administrators are considering ways to implement aspects of the rapid discharge protocol into standard operations. By circumventing roadblocks in the discharge process at NYC H+H/Elmhurst, the rapid discharge plan inspired leadership to identify specific obstacles in the routine discharge process over the coming months. It is important to emphasize that the utility of such a full procedure will decrease as the risk tolerance decreases, so these routine changes will focus on barriers that delay release for patients who were already eligible for discharge. 16
To complement this broader plan, several protocols were put in place. All patients who were flagged for rapid discharge by the interdisciplinary rounds team would receive emails from the social worker and social work director to connect them with community liaison workers, to ensure they arrange their follow-up appointments. Those rapid discharge patients in need of urgent outpatient studies would have them ordered by their provider, who would email their name and medical record number to our associate executive director of clinical operations with the required date for the study, while rapid discharge patients needing expedited medications would prompt the interdisciplinary rounds care manager to contact the pharmacy assistant director for urgent fulfillment.
These steps are particularly important for patients in low-income housing or experiencing homelessness, for whom special considerations are needed to ensure they are discharged to a safe setting. For resource-limited populations, such as the unhoused, patients needing home health services, or those transitioning to nursing homes, care coordination is critical to prevent adverse outcomes. Discharging unhoused patients requires a comprehensive approach, including partnering with shelters, transitional housing programs, or medical respite care facilities where patients can continue recovery in a safe environment. It is crucial to engage social workers early in the discharge planning process to address both medical and social needs, ensuring that patients are not simply released back onto the streets, which could lead to deteriorating health. For patients discharged to home but requiring additional support like wound care, physical therapy, or intravenous antibiotics, ensuring early access to such home health services is vital. The challenge for lower socioeconomic patients may include inadequate insurance coverage or logistical barriers such as lack of transportation. Discharge planners must work closely with community-based organizations, public assistance programs, and insurance providers to arrange for these services.
Proactive follow-up and regular communication between the healthcare team and home healthcare providers are also essential. Patients being discharged to nursing homes or rehabilitation facilities must have a smooth transfer process. Lower socioeconomic status patients may face challenges in securing beds in higher-quality facilities, which could impact their recovery. Discharge teams should advocate for timely placement in appropriate settings by navigating Medicaid coverage, identifying nearby facilities, and ensuring the patients’ complex medical needs are met. Additionally, access to medications, postdischarge supplies, and food security are essential considerations for socioeconomic-disadvantaged patients. Programs that assist with medication adherence, such as low-cost or free pharmacies, and transportation services for follow-up visits, can be critical components of a safe discharge plan. For lower socioeconomic status patients, successful and safe rapid discharge is achieved through proactive coordination among social services, community programs, and healthcare providers to mitigate the social determinants of health that could compromise postdischarge recovery.
Rapid patient discharge, when appropriately managed, can improve hospital efficiency and patient satisfaction. It can also facilitate timely intensive care unit (ICU) downgrades, where stabilized ICU patients can be transferred to lower-acuity beds to open up ICU beds for new critically ill patients, or to reduce emergency department dwell time by moving patients from arrival into opened beds as needed. However, it must be balanced with safety considerations to avoid adverse outcomes. Markers of unsafe discharge include readmission rates, short-term mortality, and access to timely follow-up care. A high rate of readmissions within 30 days of discharge is a key indicator of unsafe or premature discharge. It suggests that patients may have been discharged before their condition was fully stabilized or without adequate support for postdischarge care. Increased short-term mortality within 30 days postdischarge is another critical marker of unsafe discharge, indicating that patients may have been discharged in a medically vulnerable state or without adequate monitoring. Ensuring patients have timely access to follow-up care, including primary care providers or specialists, is essential for safe discharge. Lack of access can lead to missed opportunities for early detection of complications, poor medication adherence, and overall deterioration of the patient’s condition postdischarge. Rapid discharge protocols should incorporate a thorough assessment of patient stability, ensure access to necessary resources and follow-up care, and involve careful monitoring to minimize risks of readmission or short-term mortality.
One related challenge with the rapid discharge approach is ensuring that patient outcomes, such as readmission rates and adverse events, are tracked. By tracking the medical record numbers of all patients who are discharged via a discharge protocol, facilities can monitor admissions and outcomes over the ensuing days to ensure continued support is provided to those patients. While rapid discharge may be a necessary step at facilities in crisis to free up bed space, further research should be conducted on outcomes after rapid patient discharge to verify that these patients are not adversely impacted by this procedure. Additionally, follow-up work can be done to reevaluate the breakdown of patients by category as described in the RAPID tool, both retroactively for events like the May 2023 labor actions, and proactively for subsequent utilization of this rapid discharge plan.
Conclusion
The rapid discharge of relatively healthy patients is a critical strategy for managing hospital operations and patient care when patient demand exceeds provider supply. By consulting the published literature, reviewing existing rapid discharge protocols, and consulting with experts from relevant disciplines, the authors sought to develop a short and usable rapid discharge plan for the nation’s largest municipal health system. The RAPID tool was effectively used during a provider strike in May 2023 and could prove effective in future emergency scenarios. Further work should be done to refine the product, particularly in improving the clinical criteria and algorithms to be followed for determining which patients are eligible for rapid discharge, with the goal of aiding clinical decisionmaking. Additional efforts could also prove valuable for accelerating the discharge of patients in a safe manner under ideal conditions, potentially improving patient satisfaction by reducing discharge wait times while improving bed availability.
Footnotes
Acknowledgments
We are grateful for the assistance of Dr. Jonathan Meldrum, Dr. Ian Fagan, Mr. Jory Guttsman, and Mr. Bill Fasbender in developing the RAPID Appendix.
References
Supplementary Material
Please find the following supplemental material available below.
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