Set plan in place for self-care instruction to ensure safe discharge

Inadequate preparation increases risk of readmissions

A few years ago, patients at Columbus, OH-based Grant-Riverside Methodist Hospitals received a handwritten discharge order from their physicians on a form that had such categories as diet, activity, and medication. It was designed to provide patients with all the information they needed for self-care at home, but a follow-up study provided evidence that the form fell short. Nurses telephoned patients shortly after discharge to determine if they understood the form’s instructions. Most did not.

Of the 80 patients called, 77 could not read the instructions because the handwriting and language were incomprehensible. "We knew we had a problem and decided nursing should be taking more responsibility for discharge instructions," says Mary Szczepanik, BSN, clinical program coordinator at Grant-Riverside Methodist Hospitals.

A new, more detailed form was created that included medication, activity, diet, special instructions, and when to call the doctor. The nurse would transcribe the physician’s orders onto the sheet as well as any other self-care information. If specific instructions were required, such as for a dry dressing change, a separate teaching sheet was attached.

During the implementation period, a form with carbon copies was used, so one copy was given to the patient, one was placed in his or her chart, and one was sent to Szczepanik. "For weeks, I gave each nurse individual written feedback on every form she filled out to make sure it was correct, readable, and complete. The patient needs to know the nursing care piece: how to change a dressing, what to do if the catheter falls out, what are the signs of an infection," she says.

Providing adequate discharge teaching is a problem that plagues hospitals across the country. In an article printed in the May 12 issue of the American Medical Association’s Archives of Internal Medicine, researchers found that physicians routinely overestimated a patient’s understanding of the post-discharge treatment plan. For example, physicians believed that 88.9% of patients understood the potential side effects of their medication, but only 57.4% of patients reported that they understood.

The researchers point out that inadequate preparation for discharge and noncompliance with treatment plans increases the risk of readmission to the hospital.

While patient/physician discussion is important, it is wise to have a well-designed discharge teaching plan in place and not rely too heavily on the physician to provide the instruction, says Denise Thornton, RN, MSN, CDE, patient education coordinator at Methodist Hospitals of Memphis (TN). "It is not uncommon for the patient to say to the nurse after the doctor leaves the room, ‘What did he say?’" she explains.

According to Thornton, there are two reasons for the confusion. First, physicians tend to use language that patients don’t understand. Second, the patient is in a stressful situation and doesn’t always hear everything the physician says. The patient may still be thinking about his or her condition while the physician has gone on to discuss the medication and treatment.

Develop plan to ensure learning

To make sure patients understand the self-care they will need when discharged from Methodist Hospitals, a learning needs assessment is completed upon admission so staff know what the patient needs to learn and what barriers to learning exist. The information is entered on a computerized care plan.

Also, the hospital has standardized teaching plans for different diseases, conditions, and surgeries the nurse initiates upon admission. For example, if the patient is a newly diagnosed diabetic, that teaching plan is selected, and the nurse modifies it according to the individual patient’s learning needs assessment, explains Thornton.

"The plan is already there, but the teaching that takes place is based on the patient’s priorities. Each nurse should take that into account while doing the teaching," she says. To determine a patient’s priorities a nurse would ask such questions as, "What worries you the most?"

At Fairview-University Medical Center in Minneapolis, staff rely on a computerized flow sheet used to document patient education to prompt appropriate teaching. To ensure that patients learn everything they need to know for a safe discharge, an asterisk is placed by all topics deemed essential. "That helps staff prioritize and makes for more efficient teaching. We have clinics attached to the hospital, and we realize that when the patient comes back for the clinic visit, some of the teaching can occur there," says Nancy Goldstein, MPH, patient education program manager at the medical center.

The education deemed essential is taught thoroughly. Patients learn complicated regimens, such as tracheotomy care, at the clinic’s patient education learning center which is staffed with educators. In this center, patients practice with equipment and models until they master the skill.

Also, the hospital has booklets specifically designed for discharge purposes that include information the patient needs for safe self-care. Signs and symptoms of infection, medical follow-up required, emergency phone numbers, and simple instructions are covered in the booklets. Patients receive a discharge booklet following their teaching session in the learning center. If a patient cannot read, the session is tape recorded, and the patient is given a copy of the tape.

Make discharge teaching interdisciplinary

When patients are being sent home on complicated medication regimens or on special diets, incorporate the disciplines with the expertise into the discharge teaching, Thornton advises. To do so, Methodist Hospitals uses an interdisciplinary discharge planning record. The nurse coordinating the patient’s care is responsible for assessing the patients learning needs and bringing in the other disciplines. The coordinating nurse would review the record to make sure the appropriate disciplines had completed their teaching.

Shorter hospital stays are forcing staff to concentrate on the critical teaching while patients are in the hospital so they can be safely discharged. If patients are too sick to be taught, their caregiver learns the essential information. That allows patients to learn all the other information they need to manage their disease in either pre- or post-hospitalization classes and programs when they are feeling better. Therefore, they are better able to learn, says Thornton. Also, it gives patients more autonomy as an adult learner because they can decide whether to attend the class.

"We know they need to know the information, but as an adult learner they need to make the decision. If they aren’t ready to learn, they won’t listen anyway," she says.