132 - Enhancing NICU Discharge Processes: A Quality Improvement Approach to Earlier Discharges by 11 am

Publication Number: 3126.132

Shruti Gupta, Yale School of Medicine, Westport, CT, United States; Vanessa Maisonave, YNHH-Greenwich Hospital, Chappaqua, NY, United States; Andrea Alicea, YNHH-Greenwich Hospital, Trumbull, CT, United States; Zara Ilahi, Yale School of Medicine, Greenwich, CT, United States; Eleanor Blythe, Yale New Haven Health System, New Haven, CT, United States

Background: Discharge from the Neonatal Intensive Care Unit (NICU) is a complex and multifaceted process, often difficult for parents to understand especially when instructions are provided on the day of discharge. Facilitating discharges before 11am can improve patient flow, enhance efficiency, and provide families with a less rushed transition. Earlier discharge may also help reduce provider workload and improve overall unit throughput.

Objective: To implement a quality improvement approach in a NICU to increase the percentage of discharges before 11 am from 9% in 2024 to 19% by September 2025, while enhancing discharge efficiency and satisfaction.

Design/Methods: We utilized a multifaceted quality improvement (QI) approach, including developing a key driver diagram (figure 1), detailed process mapping, and four-corners analysis to identify barriers and opportunities. PDSA (Plan-Do-Study-Act) cycles were implemented iteratively to test and refine interventions. A detailed Care Signature Discharge Pathway was developed as a first step followed by a step-by-step approach to improve the discharge process. Emphasis was placed on maintaining balance measures such as length of stay, readmission rates, and family satisfaction to ensure quality and safety were upheld throughout the process.

Results: The proportion of discharges occurring before 11 am increased from a mean of 9% in 2024 to a mean of 43% in 2025, representing a substantial improvement (figure 2). The moving range (mR) chart (figure 3) demonstrates a stable process with no special cause variation. This shows reduced variability, suggesting increased process consistency and progress towards the goal of discharge by 11am. The utilization of a structured Discharge Pathway increased to 97% by Sept 2025, facilitating more consistent processes. Concurrently, the mean length of stay decreased slightly (13.57 to 13.07 days), and no increase in readmission rates was observed, indicating maintained safety and quality of care. Parent satisfaction, assessed through Press Ganey surveys and follow-up phone calls, remained steady or showed slight improvement, with no negative impact on family experience. Providers and nursing team also had positive experiences and found the streamlined discharge process to be less stressful.

Conclusion(s): This QI initiative demonstrates that employing systematic improvement methods can significantly enhance discharge efficiency in the NICU. Families can discharge earlier in the day-before 11 am-without adverse effects on clinical outcomes or family satisfaction, ultimately promoting a more efficient and family-centered discharge process.

Figure 1: Key Driver Diagram.
The diagram illustrates the relationship between the global aim, SMART aim, key drivers and corresponding interventions. The global aim represents the overarching goal of improving the discharge process and the SMART aim defines the specific measurable target: to increase the percentage of patients discharged before 11am from 9% to 19% by September 2025.

Figure 2: Percentage of NICU discharges completed by 11am.
This X chart displays monthly percentages of infants discharged from the NICU by 11am. The center line (CL) represents the mean percentage of discharges before 11am (24%), the upper control limit (UCL) is set at 60% indicating the threshold for expected process variation. Progressive improvement is observed beginning in early 2025, with multiple data points approaching the UCL, indicating a positive shift towards the project goal of increasing timely discharges.

Figure 3: Moving range chart of percent of infants discharged by 11am.
The center line (CL) is set at 14% and the upper control limit (UCL) is set at 45%. There is reduced variability after initiation of the quality improvement initiative, indicating consistency in achieving discharges by 11am.