When physicians at ChristianaCare try to place discharge orders from inpatient status for Medicare patients who haven’t crossed a second midnight, they’re stopped by a “two-midnight alert” in the electronic health records. The alerts prompt physicians to review the discharge order and inpatient admission. They’re part of the academic health system’s electronic management of short hospital stays and its process for reviewing compliance with the two-midnight rule.

If the two-midnight alert pops up, physicians are presented with several options, said physician Anuja Mohla, senior physician advisor for utilization management and medical director of patient access and flow. “The first option is to remove the discharge order if the alert is done in error and the patient still requires inpatient hospitalization,” she explained. “The second option is to modify the discharge order to a more appropriate location,” such as hospice or another hospital or if the patient is leaving against medical advice. The third option is for patients who have improved and are being discharged early. In these cases, physicians are “hard stopped to text” to briefly explain why they’re discharging the patient before the second midnight.