Improving Hospital Discharge

[NRSKarenRN, BSN, RN]

From : http://PhysiciansNews.com

IMPROVING HOSPITAL DISCHARGE

November 2008

Nearly 18 percent of Medicare patients are readmitted to a hospital within 30 days of discharge, and patients with multiple chronic conditions are readmitted at rates as high as 25 percent, according to Medicare Payment Advisory Commission (MedPAC) estimates, accounting for $15 billion in spending. Research on care transitions suggests that as many as 20 to 30 percent of adverse events following discharge are preventable, and another 30 percent are ameliorable – i.e., their severity could be reduced if corrective measures were instituted earlier and more effectively....

Neglected Problem

A reliable theme in medical research literature is that physicians overestimate patients’ comprehension of medical instructions, including those given at discharge. Patients have difficulty remembering their care plans, even better-educated patients do not adequately understand and remember instructions, and physicians underutilize after-care providers – instead relying too heavily on patients’ information retention, says Jeffrey Greenwald, M.D., associate professor of medicine at Boston Medical Center and member of the Society of Hospital Medicine’s Quality and Patient Safety Committee.

As co-investigator in a study called Project RED (Re-engineered Hospital Discharge), which is funded by the Agency for Healthcare Research and Quality, Greenwald says that half of patients who get traditional discharge instructions can’t name key information, such as why they were in the hospital, a list of their medications, and their follow-up plans. Median age is in the 40s for patients in the study.

"This problem is rampant and underappreciated: the perception is that we do a good job at it," says Greenwald. Contributing to the problem, he says, is the limited amount of time dedicated to the discharge process in an era of shorter hospital stays, inadequate communication with after-care providers, and inadequate systems of after-care. "The level of change required is not insubstantial, and requires multidisciplinary coordination, as well as buy-in from the ‘C-suite’ of hospital leadership," he adds...

Ineffective Discharge planning is my pet peeve. Had a SNF liaison tell me yesterday, patient with stasis ulcers "had no wound care --legs are wrapped" Called liaison up promply as said wrapping legs could be Ace Wrap , Setapress or unna boot dressing and I needed to know specific care . Response was "I'll call the patient.", NO I replied, GO LOOK AT THE CHART. :banghead:

50% of patients discharged from SNF that I call in evening to comfirm address.phone/diagnosis are unable to tell me why in facility past 30 days...very sad and scarry. Only 1/10 SNF sends med list to our homecare agency. Now getting discharge med list from 50% hospitals.

[herring_RN, ASN, BSN]

All too often hospitals rush to discharge.

A telemetry RN was recently expected to admit a new patient, recieve a patient back from the cardiac cath lab, feed a third patient, and discharge another.

She advocated be telling her charge nurse she was "swamped".

The charge nurse admitted the new patient and the manager, who didn't know the patient, did the discharge.

Not at all ideal.She filled out an incident report because in her professional judgment the patient and family did not have adequate discharge teaching.

The manager got that patient out of the hospital and into the car in ten minutes. Manager said, "There was an order to discharge."

[BrightEyes]

I couldn't agree more. The hospital/SNF discharges are absolutely abysmal as a rule. Drives me nuts. The patients really don't have a clue for the most part. Also, a lot of the time I find prescriptions still in the home not even filled because the pt/cg didn't realise it was a rx. I'm talking about the ones that end up at urgent care/ER and the discharge rx's are printed off in most places now on the A4 paper. Most of my older patients don't realise, they expect to see the rx on the smaller prescription pad paper, totally throws them off. The pts don't understand it's a prescription and here we are two days later with no antibiotics filled for the problem we initially went to get help for!!!! I've seen the same with nitrogycerin. Pts don't get it filled, end up back in hospital again for oh, let's see, we went back for "chest pain!!!"

Oh, and then you get the docs that just write admission orders/meds off of old lists they have in the system for the client and then DC home with old list of meds. Pts haven't been on that med for months. Or, what about NO PRESCRIPTIONS given to pt for new meds. Try getting the pcp to order something that the discharge doc ordered on your word alone (obviously not going to) before they get the paperwork. You can't get the pt to see pcp for follow up for three weeks!!!! Let's see, maybe the discharging doc will write/call in the med they should have got rx for, IF you can get them to call you back. No, not happening, "they are no longer our responsibility!!" Nightmare for follow up.

Oh, and what about the DC orders that have the generic and the brand name listed separately....with different dosages and the doc signed off on them!!! No-one catches it and the home health have to fight all the way for clarification. I totally understand how it is in the hospital when nurses are running round like chickens with there heads cut off. I get it, I really do. There just has to be a solution. It's not the nurses fault it's a myriad of failures in the system.

What about the patients that don't have home health, I can't imagine. No wonder there's a readmission rate of 25%, not surprising in the least. Discharge....it's an absolute joke for the most part. I've even been tempted to try and get a job as CM/discharge planner before, because honestly the discharges I see for the most part are atrocious, there has to be a better way!!! Wishful thinking!!! :)

Sorry for the rant, guess it's really a sore point with me!!

[Katie82, RN]

I work as a case manager in a State-sponsored Case Mangement Program that serves the Medicaid population. We are an outsourced program working directly for the State Health Dept. We do not bill for our services, so we are not considered a "Community Agency". I worked previously for a Medicaid MCO in Maryland. I did Short Term Case Management with patients who had just been discharged, with the goal of preventing re-admissions. I found a lot of people falling between the cracks because they were not receiving the services that were ordered by discharge planning, or did not understand how to take medicine, or follow other discharge instructions. My current program is trying to gain access/cooperation from local hospitals that would allow us a list of patients as they are discharged. The hospitals are reluctant to cooperate, using HIPPA as an excuse. We are a government contractor with complete access to patient data from Medicaid. There is so much territoriality in healthcare. Our providers are very cooperative, it's just the hospitals. Almost makes me feel like they are protecting "business" by promoting readmissions.