In our busy academic teaching hospital, we are often at admission capacity and thus a health system goal is to discharge all routine post-operative admissions before noon on their day of anticipated discharge. Our objective in this quality improvement audit was to identify barriers to timely discharge of post-operative gynecology patients.

Between May and November 2017, patients admitted to a medical-surgical floor after gynecologic surgery were randomly selected for an audit of discharge process flow. Discharge date, unit, surgical procedure, discharge criteria, time of actual discharge, and reason(s) for discharge delay were noted on a standardized form by the patient’s care team and collated in an Excel spreadsheet. Descriptive analyses were used to characterize this sample, identify the proportion of patients who met the goal of discharge before noon, and identify common barriers to timely discharge using SPSS.

Data were recorded for 38 gynecologic post-operative discharges between May and November 2017. Table 1 describes surgical details and admission unit for the total sample and stratified by time of discharge. Of note, one patient underwent both laparoscopic and vaginal procedures. The majority of patients underwent hysterectomy. Of the 38 surgical patients included in this study, 17 (45%) failed to be discharged before noon. Given the small sample size, there were no statistically significant differences between those discharges who met the goal (prior to noon) versus those who experienced a delayed discharge. Common reasons for delayed discharge are presented in Table 2. No reason was provided for 3 of these 17 patients (19%). The most frequent reasons for delayed discharge were not meeting milestones for discharge (not yet ambulating, not tolerating oral intake, inadequate pain control) and voiding issues (elevated post-void residual requiring repeat voiding trial or catheter teaching).

Almost half of our post-operative gynecology cases audited failed to meet our health system’s timely discharge goal. While we were not powered to detect statistically significant differences, patients undergoing laparotomy were most likely to experience a delayed discharge, while those undergoing vaginal surgery were most likely to meet the goal of discharge before noon. We have instituted two practice changes in the hopes of improving our rates of timely discharge: 
1)	To minimize delays due to voiding issues, we have instituted a standard 6 am retrograde fill voiding trial for our post-operative patients in whom voiding trial is indicated. 
2)	To minimize laboratory and pharmacy delays, patients for whom discharge is anticipated that day now are seen by laboratory and pharmacy services preferentially prior to those patients who are not anticipated to be discharged that day. 
3)	Patients undergoing minimally invasive surgery are counseled pre-operatively that our goal is for them to leave the hospital before 10am on POD#1, and are advised to arrange for transportation prior to the day of discharge.

Timely discharge is of the utmost importance, especially at a time when our hospital is at full capacity with bed shortages. Effective discharge planning is a process that starts pre-operatively. Patient counseling and involvement both pre- and post-operatively and interdisciplinary care are needed to achieve higher rates of timely discharge. Partnering with pharmacy to decrease medication wait times and with phlebotomy to prioritize day of discharge blood draws may ameliorate these delays. A follow-up audit will assess the impact of these interventions.