Dealing with short discharge opportunities

Admissions from ED leave little time to plan

When patients are admitted through the emergency department (ED) and multiple clinicians are involved with competing priorities in their care, discharge planning can be challenging.

One solution is to improve communications between providers while targeting more effective patient communication at discharge.

"We identified communications with regard to discharge and education as being very important," says Katie Starkey, MS director of patient experience initiatives at Albert Einstein Healthcare Network in Philadelphia.

The goal was to improve patient education and make it routine to follow up with primary care physicians (PCPs) to give them more information about the patient's hospitalization, she adds.

"There are a number of competing priorities that make it more difficult to make sure patients have everything they need when they leave the hospital," says Mary Beth Kingston, RN, MSN, NEA-BC, vice president and chief nurse executive at Albert Einstein Healthcare Network.

"About 80% of our admissions come through the ED, so we are less able to have scheduled admissions than other organizations," Kingston explains. "Our length of stay averages about 4.7 days, so that's a pretty tight LOS."

Although discharge planning begins at admission, it's still difficult to ensure patients have the information and other things they need at discharge, she adds.

"We can't discuss the discharge prior to admission like you can with surgical patients," notes Cindy McGlone, MBA, vice president, healthcare services at Albert Einstein Healthcare Network.

"We're trying to increase our patient satisfaction with the discharge process," McGlone says.

The health care organization's survey identified two discharge-related questions to target, Starkey says.

"When we looked at our results compared with the national average, we were below where we wanted to be on these items," she explains. "So, we implemented changes with our discharge instructions, which has improved our performance."

For example, a question on the survey asked patients, "Did you receive written instructions about the symptom or problem when you went home?"

After changing the discharge form to improve instructions, the hospital has seen an improvement in this area, Starkey says.

Identifying communication at discharge as a possible quality improvement initiative was a first step to improving the entire discharge process.

The hospital's discharge planning team has found that the first 24 hours after admission are a crucial time for the discharge process.

"Within the first 24 hours, the patient is assessed with a care management assessment," says Donna Antenucci, RN, senior director of care management.

Nurses do the initial assessment, and a multidisciplinary team that includes nurses, physicians, a case manager, and a social worker does a daily round, looking at all of the patient's issues, she adds.

"We look at what the patient's previous status was and how we can get the patient back to baseline," Antenucci says.

The multidisciplinary team also includes physician residents, says Steve Sivak, MD, FACP, The Paul J. Johnson Chairman, department of medicine at the health system. Sivak also is a clinical professor of medicine at Jefferson Medical College and medical director of Einstein Community Health Associates, internal medicine and family practice in Philadelphia.

"We have a large patient population and a large residency, and we work hard to integrate this into the discharge process," Sivak says. "The team meets each morning to discuss patients, and we give residents a period of time after rounds to accomplish some of the tasks we identified at rounds."

The goal is to identify patients who have been given a discharge date, particularly as the patient is closer to discharge, he adds. It's also necessary to make patient education as effective and efficient as possible, since there is little time to repeat and reinforce teaching. One of the more effective ways to teach patients as part of discharge planning is to use the teach-back method.

"We use teach-back and have hands-on instruction to make sure nurses are using it as intended," says Justine Sgrillo, RN, clinical manager of nursing.

"We taught nurses how to speak simply," Sgrillo says. "It was a huge initiative, and we thought it'd be a simple process; but it was more difficult than we thought."

In the typical hospital's discharge process culture, nurses will meet with patients, read discharge instructions, and ask if patients understand, Sgrillo explains.

"Most patients will say, 'Yes,' because they don't want to show you what they don't understand, or maybe they don't understand what they don't understand," she says.

Plus, nurses are crunched for time and are trying to get through this part of discharge planning as quickly as they can. The key is to show nurses how important teach-back is, beginning with showing them patient survey results, Sgrillo suggests.

"We've done some health literacy work, teaching nurses to bring the educational level down to the patient's level of understanding," Sgrillo says. "We showed them statistics about how patients learn better through repetition, and we gave them statistics on how much is forgotten immediately after it's taught."

The hospital held an hour-long workshop on patient education and health literacy, says Christine Charles, MS, patient education coordinator.

"The video showed how patients felt about going to the doctor, and we had nurses role-play, practicing their interactions and good communications with patients," Charles says.

Spot checks during discharge planning also help.

"We do that weekly," Sgrillo says. "We do a lot of one-on-one teaching, and we look at copies of forms to see who is doing it well and who is not."

By making follow-up visits to the unit, discharge planning leaders give nurses an opportunity to ask questions and discuss issues that arise, Charles says.

"There's a point person on the unit who presents as a resource," Charles adds. "So, when I'm not available, other nurses can provide guidance for nurses."

Managers give nurses examples of well-written discharge forms. A typical discharge sheet might be a couple of pages long, with dense text, and a writing level that proves to be a stumbling block to patients who have low-level literacy, she notes.

One helpful tool is Project BOOST's PASS forms, which provide discharge instructions in a patient-friendly format, she adds. Albert Einstein Healthcare Network is involved with Project BOOST.

"Patient PASS: A Transition Record" is a one-page form that covers the essential information in boxed sections. For example, the form's main section reads, "If I have the following problems.... I should...." Under the first part, there are five numbered lines, and under "I should" there are matching numbered lines.

Another box, titled "My appointments" lists four places to write appointments, dates, and times.

A third box, also followed by numbers with space for writing, reads, "Tests and issues I need to talk with my doctor(s) about at my clinic visit." And there are boxes for "Important contact information," followed by a place for patient or caregiver and providers to sign and a separate section for "Other instructions."

Another important strategy is to help the patient with scheduling follow-up appointments, Sgrillo says.

"You need to go over this with patients, because they won't attend a follow-up appointment if you don't find days that will work for them," she says. "Whatever is called for, we'll make the appointment, because we think that's so important in preventing readmission."

The hospital has had some success with its new discharge instructions, according to recent survey results, Sgrillo says.

"Our first quarterly scores show that 81.7% agreed that the nurse explained things understandably, and this compares with a 55% national average," she says.

The problem with any initiative is that staff interest is high at first, but then it will slack off.

"It has its peaks and lows, and we need to work on sustainability," Sgrillo says. "Interest drops off after six months, so we need to reinvigorate."