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Improving the efficacy of elderly patients' hospital discharge through multi-professional safety briefings and behavioural change.

ABSTRACT: At Leeds Teaching Hospitals NHS Trust doctors type an electronic discharge advice note (eDAN) which includes a prescription for discharge medication, before a patient can be discharged from hospital. In 2014 staff on the Medical Admissions Unit for Older People identified significant delays in the completion of this document, with an average completion time of 138 minutes. This caused patient harm and exacerbated bed management problems as patients remained in hospital longer than necessary to obtain their discharge medication. Ward staff wanted to improve the efficacy of older peoples' discharge by speeding up this process in as safe a manner as possible. A number of interventions were tested, led by junior doctors in a 'bottom-up' leadership strategy. Interventions included a daily discharge briefing to recap discharges and help junior doctors prioritise workload. After several months of sustained effort, the average time to complete eDANs fell by over an hour resulting in discharge medication dispensed earlier in the day and improved patient safety.

SUBMITTER: Corrado J

PROVIDER: S-EPMC4693093 | biostudies-literature | 2015

REPOSITORIES: biostudies-literature

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Improving the efficacy of elderly patients' hospital discharge through multi-professional safety briefings and behavioural change.

Corrado Joanna J Topley Kathryn K Cracknell Alison A

BMJ quality improvement reports 20150909 1

At Leeds Teaching Hospitals NHS Trust doctors type an electronic discharge advice note (eDAN) which includes a prescription for discharge medication, before a patient can be discharged from hospital. In 2014 staff on the Medical Admissions Unit for Older People identified significant delays in the completion of this document, with an average completion time of 138 minutes. This caused patient harm and exacerbated bed management problems as patients remained in hospital longer than necessary to o ...[more]

PMID: 26734435

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Project description:BackgroundUS hospital discharge datasets typically report facility charges (ie, room and board), excluding professional fees (ie, attending physicians' charges).ObjectivesWe aimed to estimate professional fee ratios (PFR) by year and clinical diagnosis for use in cost analyses based on hospital discharge data.SubjectsThe subjects consisted of a retrospective cohort of Truven Health MarketScan 2004-2012 inpatient admissions (n=23,594,605) and treat-and-release emergency department (ED) visits (n=70,771,576).MeasuresPFR per visit was assessed as total payments divided by facility-only payments.Research designUsing ordinary least squares regression models controlling for selected characteristics (ie, patient age, comorbidities, etc.), we calculated adjusted mean PFR for admissions by health insurance type (commercial or Medicaid) per year overall and by Major Diagnostic Category (MDC), Diagnostic Related Group, Healthcare Cost and Utilization Project Clinical Classification Software, and primary International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) diagnosis, and for ED visits per year overall and by MDC and primary ICD-9-CM diagnosis.ResultsAdjusted mean PFR for 2012 admissions, including preceding ED visits, was 1.264 (95% CI, 1.264, 1.265) for commercially insured admissions (n=2,614,326) and 1.177 (1.176, 1.177) for Medicaid admissions (n=816,503), indicating professional payments increased total per-admission payments by an average 26.4% and 17.7%, respectively, above facility-only payments. Adjusted mean PFR for 2012 ED visits was 1.286 (1.286, 1.286) for commercially insured visits (n=8,808,734) and 1.440 (1.439, 1.440) for Medicaid visits (n=2,994,696). Supplemental tables report 2004-2012 annual PFR estimates by clinical classifications.ConclusionsAdjustments for professional fees are recommended when hospital facility-only financial data from US hospital discharge datasets are used to estimate health care costs.

Project description:BackgroundThere is a growing impetus to reorganize the hospital discharge process to reduce avoidable readmissions and costs. The aim of this study was to provide insight into hospital discharge problems and underlying causes, and to give an overview of solutions that guide providers and policy-makers in improving hospital discharge.MethodsThe Intervention Mapping framework was used. First, a problem analysis studying the scale, causes, and consequences of ineffective hospital discharge was carried out. The analysis was based on primary data from 26 focus group interviews and 321 individual interviews with patients and relatives, and involved hospital and community care providers. Second, improvements in terms of intervention outcomes, performance objectives and change objectives were specified. Third, 220 experts were consulted and a systematic review of effective discharge interventions was carried out to select theory-based methods and practical strategies required to achieve change and better performance.ResultsIneffective discharge is related to factors at the level of the individual care provider, the patient, the relationship between providers, and the organisational and technical support for care providers. Providers can reduce hospital readmission rates and adverse events by focusing on high-quality discharge information, well-coordinated care, and direct and timely communication with their counterpart colleagues. Patients, or their carers, should participate in the discharge process and be well aware of their health status and treatment. Assessment by hospital care providers whether discharge information is accurate and understood by patients and their community counterparts, are important examples of overcoming identified barriers to effective discharge. Discharge templates, medication reconciliation, a liaison nurse or pharmacist, regular site visits and teach-back are identified as effective and promising strategies to achieve the desired behavioural and environmental change.ConclusionsThis study provides a comprehensive guiding framework for providers and policy-makers to improve patient handover from hospital to primary care.

Project description:ObjectiveThe overarching objective of the scoping review was to examine peer reviewed and grey literature for best practices that have been developed, implemented and/or evaluated for delayed discharge involving a hospital setting. Two specific objectives were to review what the delayed discharge initiatives entailed and identify gaps in the literature in order to inform future work.DesignScoping review.MethodsElectronic databases and websites of government and healthcare organisations were searched for eligible articles. Articles were required to include an initiative that focused on delayed discharge, involve a hospital setting and be published between 1 January 2004 and 16 August 2019. Data were extracted using Microsoft Excel. Following extraction, a policy framework by Doern and Phidd was adapted to organise the included initiatives into categories: (1) information sharing; (2) tools and guidelines; (3) practice changes; (4) infrastructure and finance and (5) other.ResultsSixty-six articles were included in this review. The majority of initiatives were categorised as practice change (n=36), followed by information sharing (n=19) and tools and guidelines (n=19). Numerous initiatives incorporated multiple categories. The majority of initiatives were implemented by multidisciplinary teams and resulted in improved outcomes such as reduced length of stay and discharge delays. However, the experiences of patients and families were rarely reported. Included initiatives also lacked important contextual information, which is essential for replicating best practices and scaling up.ConclusionsThis scoping review identified a number of initiatives that have been implemented to target delayed discharges. While the majority of initiatives resulted in positive outcomes, delayed discharges remain an international problem. There are significant gaps and limitations in evidence and thus, future work is warranted to develop solutions that have a sustainable impact.

Project description:ObjectiveTo understand how different outcomes are achieved from adult patients receiving hospital discharge letters from inpatient and outpatient settings.DesignRealist review conducted in six main steps: (1) development of initial theory, (2) searching, (3) screening and selection, (4) data extraction and analysis, (5) data synthesis and (6) programme theory (PT) refinement.Eligibility criteriaDocuments reporting evidence that met criteria for relevance to the PT. Documents relating solely to mental health or children aged <18 years were excluded.AnalysisData were extracted and analysed using a realist logic of analysis. Texts were coded for concepts relating to context, mechanism, outcome configurations (CMOCs) for the intervention of patients receiving discharge letters. All outcomes were considered. Based on evidence and our judgement, CMOCs were labelled 'positive' or 'negative' in order to clearly distinguish between contexts where the intervention does and does not work.Results3113 documents were screened and 103 were included. Stakeholders contributed to refining the PT in step 6. The final PT included 48 CMOCs for how outcomes are affected by patients receiving discharge letters. 'Patient choice' emerged as a key influencer to the success (or not) of the intervention. Important contexts were identified for both 'positive' CMOCs (eg, no new information in letter) and 'negative' CMOCs (eg, letter sent without verifying patient contact details). Two key findings were that patient understanding is possibly greater than clinicians perceive, and that patients tend to express strong preference for receiving letters. Clinician concerns emerged as a barrier to wider sharing of discharge letters with patients, which may need to be addressed through organisational policies and direction.ConclusionsThis review forms a starting point for explaining outcomes associated with whether or not patients receive discharge letters. It suggests several ways in which current processes might be modified to support improved practice and patient experience.

Project description:670 patients attend Wansbeck General Hospital each year for elective and emergency permanent pacemaker insertion or modification. Elective patients for new devices attend the cardiology department on the day of procedure and are clerked onto the cardiology ward after insertion. Patients are discharged home the following day with a letter typed by a junior doctor. Prior to October 2011, junior doctors were unaware of any guidelines regarding content of discharge letters due to poor accessibility. Vital information such as pacemaker model and indication for implantation were frequently absent from the typed summaries. In October 2011, the cardiology department reviewed the guidelines establishing the information required in all discharge summaries for pacemaker implantation and these guidelines were published on the ward in an easy to follow proforma for any junior doctor typing letters. Eight essential criteria should be included in each letter; date and indication for insertion, pacemaker type, make and model, access route, complications, chest x-ray and device check results, and follow-up details. Finally, a copy of the letter was to be sent to the cardiology department for clinic follow-up. Ten letters were audited prior to the proforma being issued. 0 letters contained 100% of the required information. Main criteria missing in most letters included indication for insertion (50%), make of device (0%), the route of access (10%) and cc to cardiology department (0%). 70 letters were audited in October 2012, one year following introduction of the discharge proforma.100% of letters contained all of the eight essential criteria required by the departmental guidelines. 53% of the letters were also received by the cardiology department. In conclusion, a set of easy to follow guidelines in the form of a published document on the cardiology ward has produced dramatic improvement in the quality of e-discharge letters for patients undergoing permanent pacemaker implantation.

Dataset Information

Improving the efficacy of elderly patients' hospital discharge through multi-professional safety briefings and behavioural change.

Publications

Improving the efficacy of elderly patients' hospital discharge through multi-professional safety briefings and behavioural change.

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