Transcript Safer Hospital Discharges - Society of Hospital Medicine

Teaching Safer Hospital
Discharges
Curriculum Overview
1
Introduction
• This slide set gives you (the educator) a
brief description of:
– Discharge literature (a detailed
discussion of the literature is one of the
attached tools)
– The different Housestaff Education Tools
in the “Teaching Safer Hospital
Discharges” tool kit
– Bibliography
2
What happens to patients when they
are discharged?
• One in five general medicine patients
experiences an adverse event (resulting
from medical management) within two
weeks of hospital discharge 1
– 66% of these events are adverse drug
events, 17% are related to procedures
– 33% of these events lead to disability
– Two-thirds of these events are
preventable or ameliorable
3
What happens to patients when they
are discharged?
• Many patients (41%) are discharged with
test results still pending, and physicians
are often (61%) unaware of test results
that may change management returning
after discharge 3
• Adverse events occur more frequently in
teaching hospitals than in large community
or small hospitals 4
4
Why are discharges unsafe?
• 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
• No longer does one practitioner typically take responsibility
for the discharge 5
• Communication breakdown between multiple providers and
between providers and patients 5, 6, 7
• Less than half of patients discharged from academic general
medicine know their diagnoses, treatment plan or side effects
of prescribed medications 8, 9
5
How to prevent unsafe discharges
• At the oversight level:
– Payment policies to explicitly recognize the
work associated with discharge 5
– JCAHO mandates 5
• At the organizational level:
– Technology (e.g. computerized sign-outs) 10
– Improve the work environment (e.g. work hour
limitations, location of medical charts) 10
– Change academic culture (e.g. encourage blame-free
error reporting) 10
– Scheduling discharges to improve patient flow 11
– Standardized method for patient handoffs 12
– Medication reconciliation, Discharge planning, Home
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Care 13-16
How to prevent unsafe discharges
• New approaches to Housestaff Education:
– Based on principles of adult learning and self-directed
learning 12,17
– Recognize high-risk nature of discharge process
– Prospectively identify system issues and implement
strategies to ameliorate them
– 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) 18-20
– Train housestaff to be more effective communicators
and patient educators 12, 21-24
7
Housestaff Education Tools
8
Tool#1: Power Point presentation
• Goals:
– Raise awareness (of complexity and high-risk nature
of discharge process)
– Help identify areas for systems and individual
improvement
• Didactic presentation of epidemiology of unsafe
discharges and strategies to improve safety
• Typical venue – noon conference
• Time required – 45 minutes
• STRONGLY recommend: Post-presentation 15 minute
discussion of LOCAL challenges and personal changes
residents will make in their individual practice (after
hearing this presentation). If possible, Case
management, Social work & Nursing should be present
9
Tool#2: “Medication Errors at Time of Discharge A Team Learning Exercise”
• Goals: At the end of this session, participants should be
able to:
– Recognize discharge situations that carry increased
risk for adverse outcomes related to medications.
– Propose strategies to reduce the incidence of
discharge-related adverse medication outcomes.
• Team learning exercise that includes a readiness
assessment tool and an application exercise.
• Typical venue – Lecture setting with attendees divided
into groups of 5-8.
• Time required – 50 minutes contact. 2-3 hours prep
time
• TIPS: The moderator’s guides are fairly specific in their
recommendations. The exercise is intended to engage
learners actively.
10
Tool#3: Teaching Accountability at Transitions
• Series of learning activities surrounding…
– The “bounce back” policy – Is this good for the
doctors or the patients?
– What happens to patients after they go home?
– Why do patients “fail” at home?
– Why do readmissions occur and what can we do to
prevent them?
11
Tool#4: Discharge Summary Format Pocket Card
• Goals: Provide a clear and comprehensive format for
dictating discharge summaries that can be carried in
one’s pocket for easy reference.
• Highlights of the Pocket Card
 Section I: designed to match content required for rehab or
nursing home referral forms
 Section II: guidance for a succinct and organized summary
 Special populations are listed to provide reminders for
documentation of JCAHO measures and other patient care goals
 Documentation of key information about anticoagulation
emphasized
 May be used as a teaching tool for house staff
• Typical users: any MD or midlevel provider responsible
for preparing discharge summaries
• The card is easily updated as new core measures are
developed
12
Tool#5: Discharge ‘Time-Out’
• Goals
– to focus the inpatient team on the importance of care transitions
– to practice the skills necessary for effective transfer of care
• Brief description: Analogous to “Preoperative Time Out” used by surgical
teams at the start of a case. The inpatient team meets briefly for a
“Discharge Time Out” at the time of patient discharge and reviews the
evolution of the working diagnoses, learning from the clinical events of
the case. The exercise occurs prior to the formulation of the discharge
paperwork and discharge summary and provides a synthesis of the case
which improves the quality of the discharge handoff.
• Typical Venue: During or after work rounds on the anticipated day of
discharge, as a hallway discussion or at the white board.
• Time: 5-15 minutes, or lengthened for formal teaching rounds.
• Tips: Develop and adopt a systematic approach to the Time Out review.
Two such examples are provided in the outline. Solicit input from all
members of the team, not just the involved housestaff.
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Other Tools
•
Ideal Discharge checklist - Society of Hospital
Medicine - Quality Improvement Tools 25
http://www.hospitalmedicine.org/AM/Template.cfm?Sec
tion=Quality_Improvement_Tools&Template=/CM/Cont
entDisplay.cfm&ContentID=8363
•
“Getting Ready to Go Home” – simple checklist for
patients and families to help think about discharge
issues 26
http://www.hospitalmedicine.org/AM/Template.cfm?Sec
tion=Search_Advanced_Search&section=Supplements
&template=/CM/ContentDisplay.cfm&ContentFileID=14
47
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Bibliography
Epidemiology of unsafe discharges:.
1.
The Incidence and Severity of Adverse Events Affecting Patients
after Discharge from the Hospital. Forster AJ. Ann Intern Med.
2003;138:161-167
2.
Medical errors related to discontinuity of care from an inpatient to
an outpatient setting. Moore C. JGIM. Aug 2003, 18(8):646-51
3.
Patient Safety Concerns Arising from Test Results That Return
after Hospital Discharge. Roy CL. Ann Intern Med. 2005;143:121128.
4.
The Canadian Adverse Events Study: the incidence of adverse
events among hospital patients in Canada. Baker GR. CMAJ.MAY
25, 2004; 70 (11)
Why are discharges unsafe?
5.
Lost in Transition: Challenges and Opportunities for Improving the
Quality of Transitional Care. Coleman EA. Ann Intern Med.
2004;140:533
6.
Low health literacy called a major problem. Vastag B. JAMA. May
12 2004;291(18):2181-82
7.
Resident recognition of low literacy as a risk factor in hospital
readmission. Powell CK. JGIM 20(11):1042-4, 2005 Nov.
8.
Patients’ Understanding of Their Treatment Plans and diagnosis
at discharge. Makaryus AN. Mayo Clin Proc. August
15
2005;80(8):991-994
Bibliography
Why are discharges unsafe?(continued):
9.
Post-hospitalization concerns of medical-surgical patients. Boyle
K. Applied Nursing Research. 5(3):122-6, 1992 Aug
How to prevent unsafe discharges:
10. Residents’ Suggestions for Reducing Errors in Teaching
Hospitals. Volpp KGM, NEJM. Feb 27, 2003.348;9.851-855
11. http://www.ihi.org/IHI/Topics/Flow/PatientFlow/Changes/Schedulet
heDischarge.htm
12. Lost in Translation: Challenges and Opportunities in Physician-toPhysician Communication During Patient Handoffs. Darrell J.
Solet, Acad Med. 2005; 80:1094–1099
13. Role of pharmacist counseling in preventing adverse drug events
after hospitalization. Schnipper JL. Arch Int Med. 166(5):565-71,
2006 Mar 13.
14. Comprehensive Discharge Planning With Postdischarge Support
for Older Patients With Congestive Heart Failure. Phillips CO.
JAMA, March 17, 2004.Vol 291, No. 11:1358
15. Discharge planning from hospital to home. Shepperd, S. The
Cochrane Library Volume (3), 2006
16. Home Care. Levine SA. JAMA, Sept 3, 2003—Vol 290, No.
9:1203
16
Bibliography
Housestaff education (also see 10 and 12):
17. Reforming internal medicine residency training. Holmboe, Eric S. J
Gen Intern Med. 20(12):1165-72, 2005 Dec
18. When should learning about hospitalized patients end? Wright S
M. Academic Medicine. 75(4):380-3, 2000 Apr
19. 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
20. Effects of a Postdischarge Clinic on Housestaff Satisfaction and
Utilization of Hospital Services. Diem SJ. JGIM. Vol 11(3), March
1996, pp 179-181
21. A patient-centered model of care for hospital discharge. Anthony
MK. Clinical Nursing Research. 13(2):117-36, 2004 May.
22. Patient education before discharge from the hospital. Romang L.
Southern Medical Journal. 79(8):998-1001, 1986 Aug
23. Health Literacy- a manual for clinicians. Weiss BD. American
Medical Association. 2006. http://www.amaassn.org/ama/pub/category/8115.html
24. 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=Qualit
y_Improvement_Tools&Template=/CM/ContentDisplay.cfm&Conte
ntID=8363
26. http://www.hospitalmedicine.org/AM/Template.cfm?Section=Searc
h_Advanced_Search&section=Supplements&template=/CM/Cont
entDisplay.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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