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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5537_Библиотеки_им_академика_М_И_Перельмана.pdf
are transferred from one provider to another within hospital walls and at the
time of discharge. Work hour restrictions for house staff and the increased
use of hospitalists may be contributing to this trend. In fact, in one teaching
institution, residents alone had 300 signouts per month and 4,000 handoffs
occurred per day among all providers.
2
In response to this, the Joint
Commission has implemented several National Patient Safety Goals relating to handoffs, medication reconciliation at transition points, and discharge
communication to better standardize care.
3
While all transitions of care and
handoffs are problematic, the process of discharging a patient from an acute
setting to home or another care facility can lead to a host of problems,
including medication errors, patient dissatisfaction, increased healthcare
costs, patient confusion and misunderstanding, and readmission.
The discharge process requires the careful coordination of a multidisciplinary team to optimally arrange the needed resources for patients. As
patients transition from the hospital to the next level of care, medications
are altered, follow-up testing and procedures may be needed, and additional follow-up care involving appointments and therapy is often
required. This process takes adequate preparation and coordination to
ensure success, and when poorly executed, frequently results in errors.
For example, one in five patients experience an adverse event upon discharge, the most common of which is an adverse drug events.
5
With system improvements, as many as two-thirds of these adverse events could
be avoided or mitigated.
5
Additionally, over 40% of patients have test
results return after they leave the acute setting, with as many as 9% of
these returned tests considered actionable.
7
Perhaps more concerning is
that outpatient physicians are unaware of these tests 62% of the time.
7
Physician communication between the inpatient provider and outpatient
provider is poor, occurring only 3 to 20% of the time.
8
Similarly, discharge summaries are only available at first follow-up 12 to 24% of the
time.
8
Moreover, patients with an error in their work-up post-discharge are
6.2 times more likely to be readmitted in the following three months.
6
The
fact that almost 20% of Medicare recipients are readmitted within 30 days
of hospital discharge suggests that focusing on the discharge transition
may be high yield.
4
104
J. Goldenberg, R. Jervis and K. Cunningham
This chapter will review the components needed to transition a patient
from the hospital to home, first reviewing the required key features and
secondly discussing those interventions considered optional given the
intensive resources needed for implementation.
Required Components of the Discharge Process
The ideal discharge process should be a team approach using the combined efforts of physicians, nurses, pharmacists and social workers. The
team should pay extra attention to the psychosocial aspects of the patient’s
care, the acuity of disease, and any barriers to care. The discharge process
starts at the time of admission and should include thoughtful planning and
teaching on a daily basis until discharge is carried out.
The discharge transition is complex and has many critical components, as listed in Table 1. The discharge process should always include a
careful review of home medications and hospital medications and the generation of a discharge medication list. Follow-up arrangements should be
made ideally within seven to 14 days after discharge.
9
Patients given
scheduled appointments are more likely to show up for their appointments
than patients asked to call to arrange follow-up.
10
Patients with high risk
diagnoses (i.e. congestive heart failure) or those patients taking medications that require close monitoring (i.e. warfarin) should be seen in less
than one week.
9
Anticipatory guidance in the form of directions to patients, caregivers
and providers on which symptoms and signs may occur post-discharge and
how to respond should be clearly outlined. Instructions to the patient and
next provider should detail any needed tests, studies, or referrals.
6
Any
pending labs at the time of discharge should be explicitly indicated.
6
Patients should receive both clear verbal and written instructions. Written
material should be at a 6th grade reading level and should be reinforced by
the multidisciplinary team.
11
These instructions should be tailored to the
patient’s or care giver’s cognitive level and native language. The technique
of teach-back should be employed whenever possible.
12
To perform teach-
back, the teacher asks the learner to repeat back the information they have
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Transitions of Care: The Hospital Discharge
106
J. Goldenberg, R. Jervis and K. Cunningham
Table 1. Key Components of the Discharge Transition
Key Components Details/Comments
Medication • Reconcile home and hospital medications to compile one
Management
11
accurate list of discharge medications.
• Clearly identify new medications, changed medications
and stopped medications; add indications and
explanation for changes whenever possible.
• Use a pharmacist when available to assist with process.
Follow-up
9
• Schedule within 7–14 days.
• High risk diagnoses and medications will require
follow-up in less than 7 days.
Pending Data; • Alert patient and next provider about needed follow-up
Follow-up Tests tests, procedures, and pending data and provide.
and Procedures
6
anticipatory guidance based on results.
Patient Education
12
• Provide clear and simple verbal and written instructions
to patient and caregiver.
• Tailor to patient’s literacy level and native language
whenever possible.
• Employ techniques of teach-back to verify understanding.
Emergency Contact • Provide patients with instructions about who to call with
Information questions and which scenarios require medical attention.
Verbal Communication • Verbally hand over care at the time of discharge.
to Next Provider
13
Discharge Letter or • Complete on the day of discharge and forward to the next
Summary
8
provider before first follow-up visit.
• Include:
Problem that led to hospitalization.
Discharge diagnosis.
Condition at discharge.
Key findings and test results.
Brief problem-based hospital course.
Recommendations and contact information of
subspecialty consultants.
Comprehensive and reconciled discharge medication
list.
Follow-up appointments with names, dates and times
and contact information.
Pending lab work and tests.
Contact information for hospitalist.
just learned to confirm understanding.12The patient’s paperwork at discharge should be clear, simple, legible, and contain:
• Details about the reason for hospital admission
• Discharge diagnosis
• Relevant tests and procedures
• Discharge medications
• Follow-up appointments
• Anticipatory guidance
• Red flags
• Emergency contact information
Any transportation needs and other home services (i.e. physical therapy,
nursing services) should be carefully considered and arranged. A standard
verbal communication in the form of a phone call should be considered
mandatory to the receiving provider to highlight any special discharge
needs or instructions.
13
Discharge summaries are an important target for improving the discharge process, as they are frequently difficult to read, tardy, and lacking
in important information regarding the hospitalization. For example, most
physicians (between 66% and 88%) do not receive a copy of the discharge
summary in time for the patient’s follow up appointment.
8
A quarter of
physicians never receive a discharge summary at all.
8
These discharge
summaries are often lacking the primary diagnosis (17.5%), a list of discharge medications (21%) and pending test results (65%).
8
Most importantly, a discharge summary must be timely, as a thorough
discharge summary is of little value if the patient has contact with a healthcare setting before the discharge summary is made available. Ideally,
discharge summaries should be completed the day that the patient is discharged. Handing the discharge summary to the patient may facilitate the
transfer of the discharge summary to the outpatient physician, but this
should be done in addition to a more formal transfer of information with
the receiving physician. An electronic facsimile or other delivery service to
the accepting physician is usually preferred and the mode of delivery
should be confirmed during a verbal exchange.
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Transitions of Care: The Hospital Discharge
The required components of a discharge summary are listed in
Table 1. A structured template rather than a free form narrative is the best
strategy to produce discharge summaries in an accurate and efficient
manner.
14
In one study, structured discharge summaries were shorter (302
versus 619 words) and were rated as having more clinically relevant
information.
14
Electronic summaries should be used when available to
increase efficiency and decrease the delay imposed by transcription
services.
15
Optional Components of the Discharge Process
While every discharge should contain the above key components, additional interventions can be useful and should be considered for high risk
patients (i.e. multiple co-morbidities, elderly, congestive heart failure).
Optional components of the discharge process are listed in Table 2. These
interventions often require increased staffing and organizational support.
One such intervention includes follow-up phone calls to patients. These
phone calls can help inpatient providers collect information on the discharge process and more importantly serve as a venue to field patient questions, clarify medication changes, and understand patient compliance.
16
108
J. Goldenberg, R. Jervis and K. Cunningham
Table 2. Optional Components of the Discharge Transition
Optional Components Details/Comments
Follow-up Phone Calls
16
• Can assist in:
Fielding patient questions
Resolving medication discrepancies
Identifying medication side effects
Ensuring compliance with therapy and follow-up
Home Visits with an • Initial in hospital visit made by transitional worker
Enhanced Discharge followed by continued home visits and telephone
Process
17–20
contact for extended period of time post-discharge.
• Emphasis on early response to status changes that
could precipitate readmission.
• Has been shown to lower health care costs, improve
patient satisfaction and reduce hospital readmission.
Another optional intervention is a comprehensive discharge process
followed by home visits and telephone contact with the help of a transitional care provider. This approach allows for early identification of problems with medications and symptom control and allows for active
participation with patients and families.
17–20
The Care Transitions
Intervention is a program that uses a “transition coach” to guide patients
from the hospital to home.
20
The program starts when the patient is still
inpatient and the “transition coach” follows the patient out into community with both home visits and phone calls. The goals of the intervention
include patient (and caregiver) understanding of medications, a self
directed and compiled personal health record, scheduled and made follow-up appointments, and an understanding of “red flags” and how to
respond. These four pillars are emphasized in the hospital, at home visits
and by telephone.
20
The authors of this study found that patients in the
intervention group had lower 30 and 90 day rehospitalization rates as
compared with the control group and lower rehospitalization rates for
same condition that precipitated index hospitalization at 90 and 180
days.
20
Another example of success was noted in the Reengineered
Discharge Study, known as Project Red. Their intervention uses a nurse
“discharge advocate” who assists patients in arranging follow-up, confirmation of medication reconciliation, and assists with providing discharge
information to the next provider.
19
A pharmacist is responsible for a post-
discharge follow-up call at two to four days.
19
The authors found a 30%
lower rate of hospital utilization in the intervention group as compared
with usual care.
19
These two interventions along with a few other similar
approaches have demonstrated reduced hospital readmission rates,
decreased health care costs, and increased patient satisfaction.
18–20
Conclusions
The transition from hospital to home is a complex and time-intensive
multidisciplinary process. Hospitalists are key players in improving the
way this transition occurs. Hospitalists can lead efforts to improve and
standardize the transition. Every discharge should contain the discussed
109
Transitions of Care: The Hospital Discharge
key features, highlights of which include medication reconciliation,
follow-up arrangements, and communication with the receiving provider.
When staffing allows, organizations should consider a more comprehensive interventions that may include follow-up phone calls, transitional
workers, and home visits.
References
1. Horwitz LI, Moin T, Krumholz HM, et al. (2008) Consequences of inad-
equate sign-out for patient care. Arch Intern Med 168(16): 1755–1760.
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online]. September 2006. Available at: http://webmm.ahrq.gov/case.
aspx?caseID=134. Accessed Sept 2010.
3. National Patient Safety Goals. Joint Commission on Accreditation of
Healthcare Organizations. Available at: http://www.jointcommission.
org/PatientSafety/NationalPatientSafetyGoals. Accessed Sept 2010.
4. Jencks SF, Williams MV, Coleman EA. (2009) Rehospitalizations
among patients in the medicare fee-for-service program. New Eng J
Med 360(14): 1418–1428.
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severity of adverse events affecting patients after discharge from the
hospital. Ann Intern Med 138: 161–167.
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physicians. JAMA 297: 831–841.
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10. Lowenthal G. (2006) The best way to improve emergency department
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Section=QI_Clinical_Tools&Template=/CM/ContentDisplay.cfm&
ContentID=10303. Accessed Sept 2010.
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14. van Walraven C, Duke SM, Weinberg AL, Wells PS. (1998)
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Health Informatics for Hospitalists
Anuj K. Dalal* and Kendall Rogers
†
Key Pearls
• Health information technology (HIT) can dramatically improve health-
care quality and safety when effectively designed and implemented.
• As a function of the electronic health record (EHR), computerized
physician order entry (CPOE) with clinical decision support (CDS)
reduces errors and improves the delivery of evidenced-based medical
care.
• The importance of EHR functionality to improve patient safety and
quality of care often competes with the need for efficient system
design for pharmacy, central supply and administrative services.
• Hospitalists should understand the benefits and risks to patient safety
offered by the EHR at their institution.
• Hospitalists are uniquely qualified to drive EHR design and imple-
mentation to improve patient safety and quality of care.
Introduction
Practicing hospitalists have first-hand experience with the benefits, pitfalls,
and challenges of health information technology (HIT). Most clinicians
agree that current technology often does not meet patient’s and provider’s
113
11
Chapter
*Birgham and Women’s Hospital, Boston, MA, USA.
†
University of New Mexico School of Medicine, Albuquerque, NM, USA.