Transcript Safer Hospital Discharges - Society of Hospital Medicine

Safer Hospital Discharges
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Questions
• What adverse events happen to patients when
they are discharged?
• Why are discharges unsafe?
• How to prevent unsafe discharges.
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ACGME Competencies
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Patient Care
Medical Knowledge
Professionalism
Interpersonal and Communication skills
Practice-based learning and improvement
Systems-based practice
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• Case 1:
– In July: 71 man discharged from Boston hospital to Manchester, New Hampshire.
Started on Digoxin for new atrial fibrillation
– Discharge summary: “…f.u with PCP in 1-2 weeks particularly for dig level
check..”. No follow-up appointment made
– October : PA visit. No mention of Digoxin
– December : MD visit. Digoxin noted. No level checked
– January : Readmitted. Per H&P, “… on several heart meds prescribed in
Boston. A friend will bring in meds… “
• Case 2:
– In February: 79 man discharged on Insulin (new). PCP f.u appointment 1 week
later
– Day after discharge: “…Wife called and is frantic that pt. is home.....never
took insulin before….”.
– March readmission for mouth pain: “…spouse apparently continued to give
insulin with lower bs…”.CXRay concerning for mesothelioma. No mention of
w.u on discharge summary.
– March readmission for fatigue/ leukocytosis. Hilar mass. Discharged to get PET
scan as outpatient - not done.
– April : died
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What happens to patients when they
are discharged?
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What happens to patients when they
are discharged?
• Forster & Bates - Prospective cohort study 1
• Objective: to describe the incidence,
severity, preventability, and “ameliorability” of
adverse events affecting patients after discharge
• Tertiary care academic hospital
• 400 medicine patients discharged home
• At 3 weeks - Medical record review and
Telephone call (structured interview by internist)
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What happens to patients when they
are discharged?
• Incidence: One in five patients
experienced an adverse event (resulting
from medical management)
• Nature: Two-thirds of these events are adverse
drug events, 17% are related to procedures
• Severity: A third of these events lead to
disability
• Preventability: Two-thirds of these events are
preventable or ameliorable
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What happens to patients when they
are discharged?
• Types of discharge errors: 2
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42% of patients had medication continuity errors
12 % had work-up errors
8% test follow-up errors
Patients with work-up errors were more likely to be
rehospitalized
DC Plan.doc
• Pending test results:3
– Many patients (41%) are discharged with test results still
pending.
– Many of these results (10%) can change management
– Physicians are often (61%) unaware of test results returning
after discharge that may change management
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What happens to patients when they
are discharged?
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Adverse events occur more frequently in teaching hospitals (10%) than in
large community (6%) or small hospitals (5%) 4
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For 45% of these Adverse events, the service most responsible for the
delivery of care was medicine 4
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Medicine residents chart audit (unpublished):
11 residents reviewed an average of 9.2 charts each (Discharge summaries
and follow-up to 90 days). Every single resident found areas for
improvement in both their own practice and systems of care.
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Discharge medication list does not highlight changes or tell the patient in ‘plain
language’ what to stop taking.
Inappropriate discharge medications ( e.g. discharge included sedation meds from
endoscopy)
“..On almost all discharge summaries reviewed, the condition on d/c was vague and indescript)..”
Failure to identify outstanding issues e.g Dilantin titration… digoxin level not
checked..”
Failure to identify specific provider to follow up on outstanding issues (e.g.
pathology, labs…)
No mention of advance directives or social issues that would affect healthcare
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Summary
• Adverse events resulting from medical
(mis)management at discharge are:
– Common in our patients
– Often involve Medications and Tests
– Dangerous and result in significant morbidity and
increased healthcare utilization
– Preventable
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Process mapping of Hospital Discharge
Jack B. et al. Reengineering the hospital
discharge. Boston Medical Center
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Process mapping of Hospital Discharge
Jack B. et al. Reengineering the hospital
discharge. Boston Medical Center
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Process mapping of Hospital Discharge
Jack B. et al. Reengineering the hospital
discharge. Boston Medical Center
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Why are discharges unsafe?
• Complex process involving multiple disciplines
• Unsafe discharges are an under recognized yet
significant issue that has received
almost no attention in health care 5
• Discharges can be urgent and unplanned 5
• Time constraints 5
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Why are discharges unsafe?
• Communication breakdown between multiple providers 5
• No longer does one practitioner typically take responsibility
for the discharge and follow-up 5
• Discharging practitioner may be unfamiliar with the
capacity to provide care of settings to which they send
patients 5
• Lack of a universal electronic health information system 5
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Why are discharges unsafe?
• ‘Health (Il)Literacy’: Nearly half of adults have trouble understanding
simple health information (procedure consent, prescriptions, oral
instructions) 6
• Less than half of patients discharged from academic general medicine
know their diagnoses, treatment plan or side effects of prescribed
medications 7
• Post-hospitalization patients typically identified multiple concerns
including understanding their progress, activity, insurance, medications,
and pain control 8
• 98 IM residents and students randomized to Case A (clues to suggest
low literacy was a potential factor in readmission ) or Case B (no clues) 9
– 25% in Group A and 4% in Group B recognized possibility of low
literacy
– Most then recommended ‘patient education’; Only 16% suggested
strategies for low-literate patients
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• Case 1:
– In July: 71 man discharged from Boston hospital to Manchester, New Hampshire.
Started on Digoxin for new atrial fibrillation
– Discharge summary: “…f.u with PCP in 1-2 weeks particularly for dig level
check..”. No follow-up appointment made
– October : PA visit. No mention of Digoxin
– December : MD visit. Digoxin noted. No level checked
– January : Readmitted. Per H&P, “… on several heart meds prescribed in
Boston. A friend will bring in meds… “
• Case 2:
– In February: 79 man discharged on Insulin (new). PCP f.u appointment 1 week
later
– Day after discharge: “…Wife called and is frantic that pt. is home.....never
took insulin before….”.
– March readmission for mouth pain: “…spouse apparently continued to give
insulin with lower bs…”.CXRay concerning for mesothelioma. No mention of
w.u on discharge summary.
– March readmission for fatigue/ leukocytosis. Hilar mass. Discharged to get PET
scan as outpatient - not done.
– April : died
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Summary
• Discharges are unsafe for a number of reasons:
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complex process
time constraints
low priority
poor planning
lack of ‘ownership’,
poor communication
not ‘patient=centered’
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How to prevent unsafe discharges
• At the oversight level:
– Payment policies to explicitly recognize
the work associated with discharge 5
– JCAHO mandates 5
– Change academic culture
(e.g.
encourage blame-free error reporting) 10
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How to prevent unsafe discharges
• At the organizational level:
– Scheduling discharges to improve patient flow 11
– Standardized method for patient handoffs 12
– Technology (e.g. computerized sign-outs, text
pagers, email..) 10
– Improve the work environment (e.g. work hour
limitations, location of medical charts) 10
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How to prevent unsafe discharges
– Medication reconciliation at discharge 13
– Comprehensive discharge planning 14, 15
– Post-discharge support (e.g. Pharmacist call,
home care..) in specific conditions may be
helpful 13,14,16
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How to prevent unsafe discharges
• Housestaff:
– Recognize high-risk nature of discharge process
– Formal housestaff training in team management 10, 17
– Enhance personal accountability e.g. Provide
housestaff with post-discharge follow-up information
(e.g. follow-up forms, home visits or post-discharge
clinics) 18, 19, 20
– Actively involve patients early in the discharge process
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How to prevent unsafe discharges
• Communicate and educate patients more effectively 12, 22,
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– YOU CAN’T TELL HEALTH ILLITERACY BY
LOOKING! ‘Red flags”:
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elderly
low income
unemployed
minority
did not finish high school
immigrant
born in US but English second language
noncompliance
can’t name meds
“forgot my glasses…will read later”
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How to prevent unsafe discharges
– Six Steps for oral communication:
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Slow down
Plain language
Pictures
Limited information
Repeat
Teach-back
Shame free environment
– Provide oral and written information 24
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Summary
• Oversight, Organizational and Individual
strategies are needed to make discharges safer
• Prospectively identify System challenges and
implement strategies to ameliorate them
• Prospectively identify Individual challenges and
implement strategies to ameliorate them
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Some practical tools
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Ideal Discharge checklist: Society of Hospital
Medicine - Quality Improvement Tools: 25
http://www.hospitalmedicine.org/AM/Template.cfm
?Section=Quality_Improvement_Tools&Template=/
CM/ContentDisplay.cfm&ContentID=8363
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“Getting Ready to Go Home” – simple checklist for
patients and families at admission to help think
about discharge issues 26
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Conclusion
• Adverse events (AE’s) after discharge are common, serious and
preventable
• Medication and test errors are common AE’s
• Systems issues – especially poor communication (with other
providers and patients) and failure to monitor patients and
medications post-discharge are important causes of AE’s
• Organizational and personal initiatives can reduce AE’s
• Consider using “Getting Ready to Go Home” checklist at
admission and “Ideal Discharge Checklist’ at discharge
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ACGME Competencies
•
•
•
•
•
•
Patient Care
Medical Knowledge
Professionalism
Interpersonal and Communication skills
Practice-based learning and improvement
Systems-based practice
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Bibliography
Epidemiology of unsafe discharges:.
1.
2.
3.
4.
The Incidence and Severity of Adverse Events Affecting Patients after
Discharge from the Hospital. Forster AJ. Ann Intern Med. 2003;138:161-167
Medical errors related to discontinuity of care from an inpatient to an
outpatient setting. Moore C. JGIM. Aug 2003, 18(8):646-51
Patient Safety Concerns Arising from Test Results That Return after
Hospital Discharge. Roy CL. Ann Intern Med. 2005;143:121-128.
The Canadian Adverse Events Study: the incidence of adverse events
among hospital patients in Canada. Baker GR. CMAJ.MAY 2004;70 (11)
Why are discharges unsafe?
5.
6.
7.
Lost in Transition: Challenges and Opportunities for Improving the
Quality of Transitional Care. Coleman EA. Ann Intern Med. 2004;140:533
Low health literacy called a major problem. Vastag B. JAMA. May 12
2004;291(18):2181-82
Patients’ Understanding of Their Treatment Plans and diagnosis at
discharge. Makaryus AN. Mayo Clin Proc. August 2005;80(8):991-994
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Bibliography
Why are discharges unsafe?(continued):
8.
9.
Post-hospitalization concerns of medical-surgical patients. Boyle K. Applied Nursing
Research. 5(3):122-6, 1992 Aug
Resident recognition of low literacy as a risk factor in hospital readmission. Powell
CK. JGIM 20(11):1042-4, 2005 Nov.
How to prevent unsafe discharges:
10.
11.
12.
13.
14.
15.
16.
Residents’ Suggestions for Reducing Errors in Teaching Hospitals. Volpp KGM,
NEJM. Feb 27, 2003.348;9.851-855
http://www.ihi.org/IHI/Topics/Flow/PatientFlow/Changes/ScheduletheDischarg
e.htm
Lost in Translation: Challenges and Opportunities in Physician-to-Physician
Communication During Patient Handoffs. Darrell J. Solet, Acad Med. 2005;
80:1094–1099
Role of pharmacist counseling in preventing adverse drug events after
hospitalization. Schnipper JL. Arch Int Med. 166(5):565-71, 2006 Mar 13.
Comprehensive Discharge Planning With Postdischarge Support for Older Patients
With Congestive Heart Failure. Phillips CO. JAMA, March 17, 2004.Vol 291, No.
11:1358
Discharge planning from hospital to home. Shepperd, S. The Cochrane Library
Volume (3), 2006
Home Care. Levine SA. JAMA, Sept 3, 2003—Vol 290, No. 9:1203
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Bibliography
Housestaff education (also see 10 and 12):
17.
18.
19.
20.
21.
22.
23.
24.
Reforming internal medicine residency training. Holmboe, Eric S. J Gen
Intern Med. 20(12):1165-72, 2005 Dec
When should learning about hospitalized patients end? Wright S M.
Academic Medicine. 75(4):380-3, 2000 Apr
Hospital to home: Improving internal medicine residents' understanding of
the needs of older persons after a hospital stay. Matter CA. Acad Med.
78(8):793-7, 2003 Aug
Effects of a Postdischarge Clinic on Housestaff Satisfaction and Utilization
of Hospital Services. Diem SJ. JGIM. Vol 11(3), March 1996, pp 179-181
A patient-centered model of care for hospital discharge. Anthony MK.
Clinical Nursing Research. 13(2):117-36, 2004 May.
Patient education before discharge from the hospital. Romang L. Southern
Medical Journal. 79(8):998-1001, 1986 Aug
Health Literacy- a manual for clinicians. Weiss BD. American Medical
Association. 2006. http://www.amaassn.org/ama/pub/category/8115.html
Written and verbal information versus verbal information only for patients
being discharged from acute hospital settings to home. Johnson, A. The
Cochrane Library. Volume (3), 2006
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Bibliography
Other Tools:
25. http://www.hospitalmedicine.org/AM/Template.cfm?Section
=Quality_Improvement_Tools&Template=/CM/ContentDis
play.cfm&ContentID=8363
26. http://www.hospitalmedicine.org/AM/Template.cfm?Section
=Search_Advanced_Search&section=Supplements&template
=/CM/ContentDisplay.cfm&ContentFileID=1447
Recommended readings:
•
Hospital discharge: Basaviah P, Williams MV. Hospital
Medicine 2nd ed. 2005. Chapter 5:31-36. Lippincott Williams &
Wilkins
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