Improve DP outcomes with limited resources

Optimize EMR use

What hospitalists and others involved in the discharge process truly want to do is reduce patients' risk at discharge while implementing quality improvement (QI) initiatives with limited resources.

"There is national attention on readmission and the quality of work we do to identify patients at risk, and we're doing everything we can to reduce that risk," says Aroop Pal, MD, assistant professor and hospitalist at Kansas University Medical College (KUMC) of the University of Kansas in Kansas City, KS. Pal also is the program director of Transitions of Care Services.

"What we're trying to accomplish in a world of limited resources is finding potential interventions that can help with those [QI] projects," Pal says. "We're identifying who is at highest risk and seeing what can be done to reduce the risk."

Whenever an organization starts a new QI project, it's a good strategy to target a unit for an intervention. So KUMC decided to screen all patients to identify those who were at high risk of readmission after discharge.

Although KUMC has become involved with Project BOOST, the goal was to screen all patients and not just older patients, Pal notes.

"From a practical standpoint, we felt all patients deserved to be screened," he adds. "We're an academic, tertiary care center with a very sick population, and we have a high case mix index and high risk for readmission."

The hospital's overall readmission rate is one out of five people within 30 days, he says.

"We felt like we had an opportunity to improve our process," Pal says. "And we implemented tools that Project BOOST provided."

Here's how the hospital implemented the QI project:

• It set goals and a philosophy. KUMC approached the discharge QI project with the philosophy that the hospital discharge and transition-to-care process encompasses everything that's done in the hospital from the first time a provider encounters a patient, Pal explains.

"We need to prepare the patient for the next step and give providers the information they need," he says. "So, we took the opportunity to re-examine how we do things and see if there are opportunities to improve the process."

• It optimized electronic medical record use. One process improvement involved using electronic medical records, which were a relatively new intervention in patient care in the hospital, Pal notes.

"We're trying to optimize the use of electronic medical records and use electronic records for discharges, including using computerized physician order entry at discharge," he says.

The QI process included re-examining the current workload and identifying better opportunities for coordinating care, Pal says.

"We've made some strides," he adds. "But the challenges and reality are that if [an efficient] workflow isn't in place before an EMR is introduced, then it's more difficult to implement it."

• It provided electronic notifications. The EMR provides electronic notification of expected discharge dates.

"That's a new field within our system that we're using to encourage providers to update regularly as information is known," Pal says. "We use the system to let nurses know the physician orders are complete."

This is more effective than the previous process, because before, there wasn't a way for nurses to be certain that all of a patient's medications had been reconciled, he notes. The way the previous process worked, the nurse wouldn't know that a physician was waiting to check on a medication dose before prescribing it, he explains.

"Now, the nurse knows when I am done with prescription orders, and the discharge instructions can be completed," Pal says. "The instructions are dependent on the orders, and if the orders are not complete, then the instructions are not complete."

• It involved a pharmacist in medication reconciliation. "Our administration provided a pharmacist to the unit to provide medication counseling and reconciliation," he says.

This change is on a trial basis, and data should be available soon.

"The unit surveyed patients on the value of having a pharmacist counsel them and provide a medication calendar, and patients reported being very satisfied," Pal says.

"We're trying to examine where pharmacy best can provide assistance with reconciliation because they've been proven to be valuable, but we're not yet at that point where we can afford a pharmacist for everything," he adds. "We're waiting for data to see how much of an impact it has had on the readmission rate."


For more information, contact:

• Aroop Pal, MD, Assistant Professor and Hospitalist, Kansas University Medical Center, Division of General and Geriatric Medicine, 5026 Wescoe, Mailstop #1020, 3901 Rainbow Blvd., Kansas City, KS 66160. Web site: