Avoid problem areas in striving for safe transitions
Verbal communication is key
All clinicians and hospital discharge planners seek safe transitions of care for their patients. But a variety of obstacles make this a challenge.
For instance, it's not always easy for clinicians and discharge planners to identify the patient's next provider of care, says Jennifer S. Myers, MD, assistant professor of clinical medicine and patient safety officer at the Hospital of the University of Pennsylvania in Philadelphia. Myers spoke about teaching safe transitions at the 2009 Annual Meeting of the Hospital Medicine Association, held May 14-17, 2009, in Chicago, IL.
"Not all providers ask their patients about their primary medical providers upon admission, but they should," Myers says. "This way it is easier to plan for discharge and think about who is taking over care of the patient next through the continuum of the hospital stay."
However, if patients do not have a primary care provider, then there should be a process at the hospital for finding one, she suggests.
"If they have insurance, then the insurance company could suggest a doctor," Myers says. "If they don't have insurance, then they might be eligible for government medical assistance or would need to be referred to some city, state, or government-run practices that provide free care or on a sliding scale payment basis."
From a patient's perspective, a safe transition is when the inpatient and outpatient physicians all know the same information about what has transpired in the hospital, Myers says.
"Ideally, this is done before they see the patient in the office, and, ideally, it's both written and verbal," Myers says.
Myers describes some of the chief issues that impact safe transitions:
Give thought to creating discharge summaries and transmitting information to the community provider. "There might be some constraints, like a lack of information systems, for immediately transmitting information to the patient's doctor's office," Myers says. "Or maybe the patient doesn't know to bring the discharge instructions to the next doctor."
A best practice is to have the communication of discharge built into the discharge process, so that nurses, discharge planners, and physicians do not just give patients a prescription and then send them home, Myers says.
"We have to make sure there's an authentic communication with the next provider of care," Myers says. "This is a large area of risk, and, on the flip side, improvement for hospitalists, because we are always re-discharging patients."
Discharge summaries should be succinct and readable and represent what happened only in the hospital, she suggests.
"Many residents make them lengthy and difficult to find the important information," Myers adds.
Results might be pending at discharge. "Another problem is when results are pending at discharge," Myers says. "Occasionally, there will be a lab result that's not back, and the patient is well enough to go home."
A hospital discharge process should address who will be responsible for obtaining those results when they come back after discharge.
Hospital lengths of stay continue to decrease. "Hospital admissions are shorter now," Myers says. "This is true particularly in teaching hospitals."
Hospitals and clinicians are doing more for patients in a shorter period of time, she adds.
"Someone might be admitted to get a lot done, and then they're discharged two days later, so you really have to catch your breath," Myers says.
The same clinical work that would have been done over a week's hospital stay in the past no longer exists. So, the time period for communication just got shorter, yet the need to communicate still exists.
Hospital admissions shorter
The shortening of the hospital admission has led to time pressures that may cause providers to leave out the discharge communication step, Myers notes.
Electronic health records (EHRs) could help with safer transitions: With an electronic computer entry, discharge instruction sheet, and discharge summary, hospitals could have the patient's discharge information populated electronically as the patient is leaving the hospital, Myers says.
"We have created an electronic discharge instruction form," Myers says. "This allows most of the outpatient clinics at Penn to view the discharge diagnoses, medications, and follow-up plans in their electronic medical records."
Although the hospitals at Penn still rely on paper records, the orders are in the computer.
"However, the first piece of electronic documentation in our hospital was around the discharge," Myers says.
"Now when the discharge summary is done, it will automatically appear in the primary care physician's mailbox if the primary care physician is in our health system," Myers says. "So, this helps with a portion of our patients with Penn providers, but not our community physicians."
Verbal communication to community providers is top priority. Hospital discharge planners and clinicians should keep in mind that electronic discharge information should never take the place of verbal communication, Myers says.
"Under the Handoff National Patient Safety Goals [from The Joint Commission], it is very explicit that regardless of what setting you're in, the next provider of care needs verbal communication and time to ask questions during transitions of care," Myers explains.
"For years in healthcare, many clinical providers have left discharge communication up to the patient, which is not really fair," Myers says. "Many patients are savvy, but most are not savvy enough to transmit their complete hospital course and their doctors' summative thoughts."
Source
For more information, contact:
Jennifer S. Myers, MD, Assistant Professor of Clinical Medicine and Patient Safety Officer, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104. Telephone: (215) 662-3797; email: [email protected].
All clinicians and hospital discharge planners seek safe transitions of care for their patients. But a variety of obstacles make this a challenge.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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