Hospital's discharge process was improved
Hospital's discharge process was improved
Here's how it was done
When hospital leaders decide to participate in Project BOOST (Better Outcomes for Older adults through Safe Transitions), they should prioritize their goals, first selecting some key discharge processes they'd like to improve and then focus resources and attention on those.
For instance, the University of New Mexico Hospital in Albuquerque, NM, chose a handful of areas on which to focus attention.
"There probably are 30 things we could have done to try and improve our discharge process, but we chose five," says Percy Pentecost, MD, assistant professor of medicine at the University of New Mexico Hospital.
The hospital worked to improve these areas:
1. Create better discharge paperwork.
"We felt we needed better, more user-friendly discharge paperwork for our patients when they leave the hospital," Pentecost says.
"We wanted something that would help them understand what happened in the hospital, why they were there, and what the next steps would be to improve their health," he explains.
For example, the patient's discharge education should include details about warning signs regarding their particular illness and when to seek medical attention.
Also, discharge paperwork should communicate in clear terms what has happened in the hospital, leaving no ambiguity or uncertainty for the next care provider, Pentecost says.
The hospital's traditional discharge paperwork was too busy, and it sometimes could be more trouble than help when patients showed it to their primary care providers (PCPs), he adds.
"If the story is not communicated accurately, then it can lead to misconceptions," he explains. "If sparse data are included in the discharge paperwork and the patient doesn't have the same story in his or her head that we providers have in our heads, then they'll fill in the gaps inaccurately for their PCPs."
When discharge paperwork is filled out accurately and completely, and when it's explained clearly to patients, then it's less likely there will be problems, Pentecost adds.
However, the hospital's discharge paperwork, prior to Project BOOST, had evolved with various pieces patched onto it and so a fresh start was needed, he says.
One important change was to add a simple discharge checklist to the process for nurses to follow during patients' discharges.
So far, the process to change the paperwork has been slowed by the hospital's plans to change its computer system, Pentecost says.
"That's a challenge that we didn't really anticipate the magnitude of a year ago, because things were supposed to happen quickly," he says. "We don't want to overhaul our paper system and then have to overhaul it again as an electronic format."
The optimal solution will be to create a new electronic version of the discharge forms that will be used when the hospital makes its transition to the new electronic system. This would save providers' time and steps, Pentecost notes.
2. Improve medication reconciliation.
The hospital's standard process has been for nurses to confirm that medication reconciliation has taken place and that patients have an updated list of their medicines, Pentecost says.
"What's happened in the ensuing months since we started using the nurse discharge checklist is we found our medication reconciliation process did not turn out an accurate list of home medications," Pentecost explains. "A lot of that has to do with glitches in the computer system, and so we've recently instituted a new process for medication reconciliation."
For instance, the medication list often doesn't reflect all of the discharge medicines added to the patient's prescription list and may list old and inaccurate prescriptions, he says.
The new system puts more responsibility on the provider rather than relying so heavily on technology, he says.
"We've been having the health unit coordinators print the discharge medicine list and make sure it all looks fine," Pentecost says.
Once physicians or other providers manually verify the medication list, a nurse practitioner or physician's assistant, who is providing medication reconciliation, will change the computerized list to reflect all changes made in the patient's medications at discharge.
"This is an example where in some ways the technology is adding complexity and has made it more work for us," Pentecost says.
3. Call patients within 72 hours after discharge.
"We plan to call patients 24 to 72 hours after their discharge," Pentecost says. "We haven't implemented this change yet, because we need to identify what our manpower needs will be to make these calls."
Post-discharge phone calls may be handled by nurse case managers, Pentecost says.
The issues with implementing this change include taking time away from the nurse case managers' other duties and finding extra funding to hire more nurse case managers, he says.
"Then we have to find people to take the job, receive training, and then get up to speed," he adds.
The chief benefit would be to identify problems and safety issues soon after patients return home.
"For those of us in internal medicine, I think most people would agree that we get more challenging patients because they are older, have more comorbidities, and oftentimes there are safety issues at home," Pentecost says.
4. Give patients a number to call after discharge.
"We wanted to identify a way for patients to call their providers after they were discharged," Pentecost says. "So, we've been successful in doing that, and it basically wasn't a high-tech solution."
Hospital leaders decided the most important thing would be consistency, so they decided to identify the floor from which the patient was discharged as the contact number, he says.
"If you went to the UNM hospital and were discharged and called the operator to speak with your doctor, the operator wouldn't be able to help you for complicated reasons," Pentecost says. "So, we identified several dead-ends for patients when they call back with problems, and so we decided to be consistent and have them call the floor from which they were discharged."
After taking the call, the health unit coordinator would contact the attending physician or whoever else might be able to help, he adds.
For instance, if a patient left his dentures in the room, the unit coordinator would contact the charge nurse to see if the nurse could locate them, Pentecost says.
If there's a medical issue or question, the unit coordinator would contact the physician on duty on that floor, and the physician would be the point person to handle the patient's concerns, he adds.
"If they can't figure out what else to do then they can always call the provider who discharged them," Pentecost says. "And if it was last week, and I discharged the patient but am no longer on service, then whoever replaced me will get the call."
The whole idea is to avoid having someone answer a patient's call and say, "No, that person's not here, so you'll have to go to the emergency room," Pentecost says. "The vast majority of call backs are easily resolved."
Since the call-back system was implemented, it has worked very well, he notes.
"We have not had the volume of calls we used to, and patients aren't showing up unexpectedly," he says. "Whether that's because we're doing a better job of our discharges or because of the discharge checklist or because we are just sort of more globally aware of the details, it's working."
5. Make certain hospital providers can contact PCPs.
Hospital providers need to have a way to contact patients' primary care physicians at discharge, Pentecost says.
"We want to make sure they're aware that their patients have been in the hospital and what the problems were and what the plan is," he explains. "We're still trying to work out this issue, because our patient population is inconsistent in their relationship with PCPs."
Hospital providers often have no one to contact because the patient doesn't have a regular primary care provider, he adds.
"We have a very good community health network that adopts the majority of our patients who come in without primary care providers," Pentecost says. "Our university system itself is so saturated, we can't absorb any more patients because we're short on doctors within the UNMH system."
So, the first choice for patients without a PCP is to refer them to a sister network, he says.
"It can take six to eight weeks before they can see a PCP for the first time, and so we have, independent of Project BOOST, started a discharge clinic where we will see patients and follow up with them," Pentecost says.
This clinic, which is funded by the university hospital for patients who have no other safety nets, will provide care until the patient is able to meet with a primary care provider in the sister network, he adds.
"We started that just prior to becoming involved with BOOST," he says.
"Really, I think the discharge clinic and getting involved in Project BOOST has helped us see where we don't do a good job of discharging patients, raising this as an issue," Pentecost says.
When hospital leaders decide to participate in Project BOOST (Better Outcomes for Older adults through Safe Transitions), they should prioritize their goals, first selecting some key discharge processes they'd like to improve and then focus resources and attention on those.Subscribe Now for Access
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