Thrown in at the deep end: a qualitative study with physicians on the purpose and challenges of discharge interviews

OBJECTIVES

Against the backdrop of poor discharge communication in hospitals, this study explores the purpose of discharge interviews from the physicians' perspective and the challenges they are confronted with. Discharge interviews are legally required in Germany as part of the discharge management. Led by the ward physician, the discharge interview should summarize relevant information about the hospital stay, medication, lifestyle interventions and follow-up treatment.

METHODS

Semi-structured interviews with n = 12 physicians were conducted at Heidelberg University Hospital between February and April 2020. Qualitative content analysis was carried out using MAXQDA.

RESULTS

Physicians reported gaining information, providing information, and answering open-ended questions as the purpose of the discharge interview. Challenges in conducting discharge interviews were related to finding a common language, patient-related challenges, conditions of everyday ward life, and lack of training. Physicians reported receiving no explicit training on discharge interviews. While professional experience seems to mitigate the lack of training, some physicians expressed a prevailing sense of insecurity.

CONCLUSION

The lack of preparation for discharge interviews in medical school makes it particularly challenging for physicians to translate their theoretical knowledge into patient-centered discharge communication. Medical training on discharge interviews should be expanded in terms of theoretical input on the ideal content, its purpose and potential (e.g. in reducing readmissions), as well as practical exercises.

Improving Discharge Teaching for Adult Patients with an Ileostomy

LOCAL PROBLEM

Discharge teaching is essential to the self-care and successful recovery of colorectal surgery patients, yet the trend toward shorter hospital stays for patients with new ileostomies limits opportunities for patient education. As a result, discharged patients at our institution are initiating calls to providers with questions that could have been addressed prior to discharge.

PURPOSE

The aim of this quality improvement (QI) project was to decrease patient-initiated postdischarge inquiries using a frequently asked questions (FAQs) handout at discharge.

METHODS

A retrospective chart review of inquiries to the outpatient clinic over the six-month period between July 2020 and January 2021 revealed common concerns, among them bowel movements, home health care, medications, wound care, stoma issues, pathology reports, diet, and activity-related issues. Based on these concerns, a FAQs handout was developed to review with patients prior to discharge. Data from three postdischarge time periods (0 to 72 hours, 72 hours to 21 days, and 0 to 21 days) in the three months from June to September 2021 were analyzed to determine the impact of the intervention on the frequency and content of the patient inquiries.

RESULTS

Use of the FAQs handout led to a decrease in total patient-initiated postdischarge inquiries from 46 in the preintervention period to five in the postintervention period, and fewer topics of concern prompted patients' postintervention inquiries. There was also a pre-to-postintervention reduction in the proportion of patients who made calls to the outpatient clinic in each of the three postdischarge time periods, the greatest of which-from 49% to 15% of patients-was significant and occurred in the 72-hour-to-21-day period.

CONCLUSION

This QI project demonstrated that a change in discharge teaching by adding a FAQs handout to the protocol could be effective.

Improving the Quality of Written Discharge Instructions: A Multisite Collaborative Project

BACKGROUND AND OBJECTIVES

Written discharge instructions help to bridge hospital-to-home transitions for patients and families, though substantial variation in discharge instruction quality exists. We aimed to assess the association between participation in an Institute for Healthcare Improvement Virtual Breakthrough Series collaborative and the quality of pediatric written discharge instructions across 8 US hospitals.

METHODS

We conducted a multicenter, interrupted time-series analysis of a medical records-based quality measure focused on written discharge instruction content (0-100 scale, higher scores reflect better quality). Data were from random samples of pediatric patients (N = 5739) discharged from participating hospitals between September 2015 and August 2016, and between December 2017 and January 2020. These periods consisted of 3 phases: 1. a 14-month precollaborative phase; 2. a 12-month quality improvement collaborative phase when hospitals implemented multiple rapid cycle tests of change and shared improvement strategies; and 3. a 12-month postcollaborative phase. Interrupted time-series models assessed the association between study phase and measure performance over time, stratified by baseline hospital performance, adjusting for seasonality and hospital fixed effects.

RESULTS

Among hospitals with high baseline performance, measure scores increased during the quality improvement collaborative phase beyond the expected precollaborative trend (+0.7 points/month; 95% confidence interval, 0.4-1.0; P < .001). Among hospitals with low baseline performance, measure scores increased but at a lower rate than the expected precollaborative trend (-0.5 points/month; 95% confidence interval, -0.8 to -0.2; P < .01).

CONCLUSIONS

Participation in this 8-hospital Institute for Healthcare Improvement Virtual Breakthrough Series collaborative was associated with improvement in the quality of written discharge instructions beyond precollaborative trends only for hospitals with high baseline performance.

Orthodontic and oral health literacy in adults

Objective

The primary aim of the study was to determine levels of literacy in both oral health and orthodontics in an adult population. The secondary study aim was to investigate differences in literacy between males and females.

Methods

Participants included individuals 18 years or older seeking dental treatment at the East Carolina University (ECU) School of Dental Medicine. To determine levels of oral health literacy (OHL) and orthodontic literacy (OrthoL), validated instruments were administered, including the Rapid Estimate of Adult Literacy in Medicine and Dentistry, the Oral Health Literacy Instrument and its separate scales, and a questionnaire on orthodontic literacy. Summary statistics were computed, and statistical significance was set at 0.05.

Results

One hundred seventy-two individuals participated in the study and had a mean age of 55.03 (range:18–88). Greater than 70% of the sampled population exhibited inadequate or marginal oral health knowledge. Additionally, greater than 70% of the sample possessed no more than an 8th grade reading level, with regard to basic medical and dental terms. Higher education was weakly associated with higher OrthoL and OHL. Higher age was also weakly associated with lower OrthoL and OHL. Males on average exhibited significantly higher OHL (p < .05) but there were no OrthoL differences between males and females. Dental visit frequency was not associated with OrthoL or OHL.

Conclusion

Low levels of OrthoL and OHL were observed in the study. While males demonstrated a higher level of OHL than females, neither age nor the occurrence of dental appointments significantly influenced levels of literacy.

Improving patient understanding on discharge from the short stay unit: an integrated human factors and quality improvement approach

This intervention used a systems approach to improve patient understanding on discharge from the adult acute medicine short stay unit (SSU). Patient understanding was assessed across five domains: diagnosis, medication changes, follow-up care, return instructions and knowing who their consultant was. The aim of this approach was that at least 90% of patients achieved near-complete understanding (score >4) on questionnaire across all five discharge domains by the end of April 2021. Pre-intervention most patients received verbal instructions and only a minority received written information. Through staff interviews, we identified the electronic discharge document (EDD) as a practical source of written information. However, testing with patients showed that the format required substantial redesign to be written in patient-friendly language, using signposting, spacing information out and avoiding jargon. The effect of this intervention was assessed with a structured telephone questionnaire, which included both a patient self-rated score and a comparative understanding score to assess true patient understanding of the revised EDD. Pre-intervention 29 discharged patients were interviewed across 10 days and post-intervention 10 patients were interviewed in 7 days. Patients consistently over-rated their understanding of discharge information. Only one patient achieved the aim of comparative understanding >4 across all domains post-intervention. Understanding improved across all but one of the domains, the exception being medication changes. An important unanticipated consequence was that interviews identified inconsistencies in EDD information and gaps in patient understanding, which required escalation to the SSU team. In summary, this intervention improved patient understanding across four of the five domains. However, further work is required on process reliability for the redesigned EDD and on improving understanding of medication changes. Furthermore, the interviews revealed clinically important inconsistencies in EDD information and gaps in patient understanding.

Emergency Department Communication in Persons Living With Dementia and Care Partners: A Scoping Review

OBJECTIVES

To synthesize published research exploring emergency department (ED) communication strategies and decision-making with persons living with dementia (PLWD) and their care partners as the basis for a multistakeholder consensus conference to prioritize future research.

DESIGN

Systematic scoping review.

SETTINGS AND PARTICIPANTS

PLWD and their care partners in the ED setting.

METHODS

Informed by 2 Patient-Intervention-Comparison-Outcome (PICO) questions, we conducted systematic electronic searches of medical research databases for relevant publications following standardized methodological guidelines. The results were presented to interdisciplinary stakeholders, including dementia researchers, clinicians, PLWD, care partners, and advocacy organizations. The PICO questions included: How does communication differ for PLWD compared with persons without dementia? Are there specific communication strategies that improve the outcomes of ED care? Future research areas were prioritized.

RESULTS

From 5451 studies identified for PICO-1, 21 were abstracted. From 2687 studies identified for PICO-2, 3 were abstracted. None of the included studies directly evaluated communication differences between PLWD and other populations, nor the effectiveness of specific communication strategies. General themes emerging from the scoping review included perceptions by PLWD/care partners of rushed ED communication, often exacerbated by inconsistent messages between providers. Care partners consistently reported limited engagement in medical decision-making. In order, the research priorities identified included: (1) Barriers/facilitators of effective communication; (2) valid outcome measures of effective communication; (3) best practices for care partner engagement; (4) defining how individual-, provider-, and system-level factors influence communication; and (5) understanding how each member of ED team can ensure high-quality communication.

CONCLUSIONS AND IMPLICATIONS

Research exploring ED communication with PLWD is sparse and does not directly evaluate specific communication strategies. Defining barriers and facilitators of effective communication was the highest-ranked research priority, followed by validating outcome measures associated with improved information exchange.

Effect of Pharmacist Interventions on Hospital Readmissions for Home-Based Primary Care Veterans

BACKGROUND

Several studies indicate that when patients transition from one level of care to another, errors may occur. Pharmacists can play an integral role in the transitions of care process. At Michael E. DeBakey Veteran Affairs Medical Center, the Home-Based Primary Care (HBPC) service has implemented a streamlined hospital discharge plan to improve 30-day readmission rates after 1 year of HBPC enrollment.

METHODS

Our aim was to identify specific pharmacist interventions to improve the HBPC discharge process and ultimately, improve hospital readmission rates. A Plan-Do-Study-Act quality improvement project was initiated. We conducted a review of veterans enrolled in HBPC from October 2019 to March 2020.

RESULTS

Of 175 patients assessed postdischarge, a medication reconciliation was completed by an HBPC pharmacist in 118 (67.4%) patients. Of the 118 medication reconciliations completed, 92 (78%) interventions were made by HBPC pharmacists. During the 6-month study period, 30-day hospital readmission rates decreased from 19% to 13%.

CONCLUSIONS

This study demonstrates several opportunities for interventions to lower readmission rates. Using the results from this study, education has been provided for the HBPC service and its readmission committee.

Recommendations for the Design and Delivery of Transitions-Focused Digital Health Interventions: Rapid Review

Background

Older adults experience a high risk of adverse events during hospital-to-home transitions. Implementation barriers have prevented widespread clinical uptake of the various digital health technologies that aim to support hospital-to-home transitions.

Objective

To guide the development of a digital health intervention to support transitions from hospital to home (the Digital Bridge intervention), the specific objectives of this review were to describe the various roles and functions of health care providers supporting hospital-to-home transitions for older adults, allowing future technologies to be more targeted to support their work; describe the types of digital health interventions used to facilitate the transition from hospital to home for older adults and elucidate how these interventions support the roles and functions of providers; describe the lessons learned from the design and implementation of these interventions; and identify opportunities to improve the fit between technology and provider functions within the Digital Bridge intervention and other transition-focused digital health interventions.

Methods

This 2-phase rapid review involved a selective review of providers’ roles and their functions during hospital-to-home transitions (phase 1) and a structured literature review on digital health interventions used to support older adults’ hospital-to-home transitions (phase 2). During the analysis, the technology functions identified in phase 2 were linked to the provider roles and functions identified in phase 1.

Results

In phase 1, various provider roles were identified that facilitated hospital-to-home transitions, including navigation-specific roles and the roles of nurses and physicians. The key transition functions performed by providers were related to the 3 categories of continuity of care (ie, informational, management, and relational continuity). Phase 2, included articles (n=142) that reported digital health interventions targeting various medical conditions or groups. Most digital health interventions supported management continuity (eg, follow-up, assessment, and monitoring of patients’ status after hospital discharge), whereas informational and relational continuity were the least supported. The lessons learned from the interventions were categorized into technology- and research-related challenges and opportunities and informed several recommendations to guide the design of transition-focused digital health interventions.

Conclusions

This review highlights the need for Digital Bridge and other digital health interventions to align the design and delivery of digital health interventions with provider functions, design and test interventions with older adults, and examine multilevel outcomes.

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2020-045596

Audit of postoperative readmissions and patient messages following endoscopic transnasal transsphenoidal surgery

Objectives:To identify the reasons for patient messages, phone calls and Emergency Department (ED) visits prior to the first postoperative visit following discharge after endoscopic transnasal transsphenoidal (eTNTS) surgery. Design: Retrospective review of patients at a tertiary care academic center who underwent eTNTS for resection of a sellar region tumor between May 2020-August 2021. Patient, tumor, and surgical characteristics were collected, along with post-operative, post-discharge, and readmission information. Regression analyses were performed to investigate risk factors associated with post-discharge phone calls, messages, ED visits, and readmissions. Main Outcome Measures: Number of and reasons for phone calls, patient messages, and ED visits between hospital discharge and the first postoperative visit. We additionally determined whether these reasons were addressed in each patient’s discharge instructions. Results: A total of 98 patients underwent eTNTS during the study period. Median length of hospital stay was 2-days (Interquartile range [IQR] 1-4days), at which point most patients (82%) were provided with eTNTS-specific discharge instructions. First postoperative visit took place 9-days after discharge (IQR 7-10days). Within that time, 54% of patients made/sent at least one phone call or electronic message and 17% presented to the ED. Most common reasons for call/message were nasal care, appointment scheduling, symptom and medication questions. Conclusions: Through this work, we highlight the most common reasons for resource utilization via patient phone calls, messages, and ED visits among our cohort to better understand any shortfall or gap in the discharge process that may reduce these events.

Pragmatic trials of pain therapies: a systematic review of methods

ABSTRACT

Pragmatic randomised clinical trials aim to directly inform clinical or health policy decision making. Here, we systematically review methods and design of pragmatic trials of pain therapies to examine methods, identify common challenges, and areas for improvement. Seven databases were searched for pragmatic randomised controlled clinical trials that assessed pain treatment in a clinical population of adults reporting pain. All screening steps and data extractions were performed twice. Data were synthesised descriptively, and correlation analyses between prespecified trial features and PRECIS-2 (PRagmatic-Explanatory Continuum Indicator Summary 2) ratings and attrition were performed. Protocol registration: PROSPERO-ID CRD42020178954. Of 57 included trials, only 21% assessed pharmacological interventions, the remainder physical, surgical, psychological, or self-management pain therapies. Three-quarters of the trials were comparative effectiveness designs, often conducted in multiple centres (median: 5; Q1/3: 1, 9.25) and with a median sample size of 234 patients at randomization (Q1/3: 135.5; 363.5). Although most trials recruited patients with chronic pain, reporting of pain duration was poor and not well described. Reporting was comprehensive for most general items, while often deficient for specific pragmatic aspects. Average ratings for pragmatism were highest for treatment adherence flexibility and clinical relevance of outcome measures. They were lowest for patient recruitment methods and extent of follow-up measurements and appointments. Current practice in pragmatic trials of pain treatments can be improved in areas such as patient recruitment and reporting of methods, analysis, and interpretation of data. These improvements will facilitate translatability to other real-world settings-the purpose of pragmatic trials.

Discharge from the trauma centre: exposure to opioids, unmet information needs and lack of follow up-a qualitative study among physical trauma survivors

Background

Physical trauma is associated with mortality, long-term pain and morbidity. Effective pain management is fundamental in trauma care and opioids are indispensable for treating acute pain; however, the use and misuse of prescribed opioids is an escalating problem. Despite this, few studies have been directed towards trauma patients in an early phase of rehabilitation with focusing on experiences and perspectives of health and recovery including pain and persistent use of prescribed opioids with abuse potential. To explore pre- and post-discharge trauma care experiences, including exposure to opioids, physical trauma survivors were recruited from a major trauma centre in Norway that provides the highest level of surgical trauma care.

Method

Qualitative exploratory study. Individual semi-structured interviews were conducted among 13 trauma patients with orthopedic injuries, known to be associated with severe pain, six weeks post-discharge. The interviews were recorded, transcribed verbatim, and thematically analyzed with an interdisciplinary approach.

Results

The overarching theme was that discharge from the trauma centre and the period that immediately followed were associated with feelings of insecurity. The three main themes that were identified as contributing to this was (a) unmet information needs about the injury, (b) exposure to opioids, and (c) lack of follow-up after discharge from the hospital. Participants experienced to be discharged with prescribed opioids, but without information about their addictive properties or tapering plans. This, and lack of attention to mental health and psychological impact of trauma, gave rise to unmet treatment needs of pain management and mental health problems during hospitalization and following discharge.

Conclusion

The findings from this study suggest that in addition to delivery of high-quality biomedical trauma care, health professionals should direct more attention to psychosocial health and safe pain management, including post-discharge opioid tapering and individually tailored follow-up plans for physical trauma survivors.

Teaching plain language to medical students: improving communication with disadvantaged patients

BACKGROUND

Low health literacy underpins health inequality and leads to poor adherence to medical care and higher risk of adverse events and rehospitalization. Communication in plain language, therefore, is an essential skill for health professionals to acquire. Most medical education communication skill programs focus on verbal communication, while written communication training is scarce. ETGAR is a student delivered service for vulnerable patients after hospital discharge in which, amongst other duties, students 'translate' the medical discharge letters into plain language and share them with patients at a home visit. This study ascertains how this plain language training impacted on students' written communication skills using a tool designed for purpose.

METHODS

Students, in pairs, wrote three plain language discharge letters over the course of a year for patients whom they encountered in hospital. The students handed over and shared the letters with the patients during a post-discharge home visit. Structured feedback from course instructors was given for each letter. An assessment tool was developed to evaluate students' ability to tell the hospitalization narrative using plain and clear language. First and last letters were blindly evaluated for the entire cohort (74 letters; 87 students).

RESULTS

Students scored higher in all assessment categories in the third letters, with significant improvement in overall score 3.5 ± 0.8 vs 4.1 ± 0.6 Z = -3.43, p = 0.001. The assessment tool's reliability was high α = 0.797, it successfully differentiated between plain language categories, and its score was not affected by letter length or patient's medical condition.

CONCLUSIONS

Plain language discharge letters written for real patients in the context of experience-based learning improved in quality, providing students with skills to work effectively in an environment where poor health literacy is prevalent. ETGAR may serve as a model for learning written communication skills during clinical years, using the assessment tool for formative or summative evaluation.

Nurses' Perspectives on Health Education and Health Literacy of Older Patients

In the context of population aging, enhancing the health of older patients has become an urgent issue for public health. Health education and health literacy need to be further understood from the healthcare providers’ standpoint to increase older patients’ effective application of such information into their daily lives. We aimed to further understand nurses’ perspectives on the education of older patients and their health literacy, as nurses are one of the frontline providers interacting with older patients. In total, 16 nurses and nurse practitioners who had 5 or more years of clinical experience participated. Data were collected via face-to-face interviews and emails. Data analysis followed the thematic analysis suggested by Braun and Clarke. Five themes emerged from the analysis, as follows: attitudes that are hard to change; physical and cognitive functional barriers to understanding teaching materials; family caregivers—surrogate vs. gatekeeper; major contexts that moderate the elderly’s health literacy; and strategies to enhance teaching effectiveness and health literacy. These findings illustrate the conditions pertinent to communication with older adults from the patients’, providers’ and healthcare delivery viewpoints. Systemic assistance and interventions specialized for older patients and their healthcare providers need to be developed and tested to improve clinical practice and patient health literacy.

Goals of care or goals of life? A qualitative study of clinicians' and patients' experiences of hospital discharge using Patient-Oriented Discharge Summaries (PODS)

Background

Recognizing the need for improved communication with patients at the point of hospital discharge, a group of clinicians, patients, and designers in Toronto, Canada collaborated to develop a standardized tool known as the Patient-Oriented Discharge Summary (PODS). Although quantitative results suggest PODS helps mitigate gaps in knowledge, a qualitative inquiry from the clinician and patient perspective of psychiatric hospital discharge using PODS has not been widely explored. Our aim was to explore clinicians’ and patients’ experiences with PODS.

Methods

We used a qualitative thematic analysis to explore clinicians’ (n = 10) and patients’ (n = 6) experiences with PODS. We used convenience sampling to identify and invite potential participants at the Center for Addiction and Mental Health in Toronto, Canada to participate in semi-structured interviews between February 2019 and September 2019. Data were analyzed using a thematic analysis approach to develop descriptive themes.

Results

Emerging themes from the data between clinicians and patients were both different and complementary. Clinicians described PODS using the concept of “goals of care.” They relayed their experiences with PODS as a discrete event and emphasized its role in meeting their “goals of care” for discharge planning. Patients provided more of a “goals of life” perspective on recovery. They characterized PODS as only one facet of their recovery journey and not necessarily as a discrete or memorable event. Patients focused on their outcomes post-discharge and situated their experiences with PODS through its relation to their overall recovery.

Conclusions

PODS was experienced differently by clinicians and patients. Clinicians experienced PODS as helpful in orienting them to the fulfillment of goals of care. Patients did not experience PODS as a particularly memorable intervention. Due to the information advantage that clinicians have about PODS, it is not surprising that clinicians and patients experienced the PODS differently. This study expanded our understanding of hospital discharge from clinicians and patients perspectives, and suggests that there are additional areas that need improvement.

Effects of pharmacy interventions at transitions of care on patient outcomes

PURPOSE

An interdisciplinary group developed a care transitions process with a prominent pharmacist role.

METHODS

The new transitions process was initiated on a 32-bed medical/surgical unit. Demographics, reconciliation data, information on medication adherence barriers, medication recommendations, and time spent performing interventions were prospectively collected for 284 consecutive patients over 54 days after the pharmacy participation was completely implemented. Outcome data, including 30-day readmission rates and length of stay, were retrospectively collected.

RESULTS

When comparing metrics for all intervention patients to baseline metrics from the same months of the previous year, the readmission rate was decreased from 21.0% to 15.3% and mean length of stay decreased from 5.3 days to 4.4 days. Further improvement to a 10.2% readmission rate and a 3.6-day average length of stay were observed in the subgroup of intervention patients who received all components of the pharmacy intervention. Additionally, greater improvements were observed in intervention-period patients who received the full pharmacy intervention, as compared to those receiving only parts of the pharmacy intervention, with a 10.2-percentage-point lower readmission rate (10.2% vs 20.4%, P = 0.016) and a 1.7-day shorter length of stay (3.6 days vs 5.3 days; 95% confidence interval, 0.814-2.68 days; P = 0.0003). For patients receiving any component of the pharmacy intervention, an average of 9.56 medication recommendations were made, with a mean of 0.89 change per patient deemed to be required to avoid harm and/or increased length of stay.

CONCLUSION

A comprehensive pharmacy intervention added to a transitions intervention resulted in an average of nearly 10 medication recommendations per patient, improved length of stay, and reduced readmission rates.

A mixed methods study examining teamwork shared mental models of interprofessional teams during hospital discharge

BACKGROUND

Little is known about how team processes impact providers' abilities to prepare patients for a safe hospital discharge. Teamwork Shared Mental Models (teamwork-SMMs) are the teams' organised understanding of individual member's roles, interactions and behaviours needed to perform a task like hospital discharge. Teamwork-SMMs are linked to team effectiveness in other fields, but have not been readily investigated in healthcare. This study examines teamwork-SMMs to understand how interprofessional teams coordinate care when discharging patients.

METHODS

This mixed methods study examined teamwork-SMMs of inpatient interprofessional discharge teams at a single hospital. For each discharge event, we collected data from the patient and their discharge team (nurse, physician and coordinator) using interviews and questionnaires. We quantitatively determined the discharge teams' teamwork-SMM components of quality and convergence using the Shared Mental Model Scale, and then explored their relationships to patient-reported preparation for posthospital care. We used qualitative thematic analysis of narrative cases to examine the contextual differences of discharge teams with higher versus lower teamwork-SMMs.

RESULTS

The sample included a total of 106 structured patient interviews, 192 provider day-of-discharge questionnaires and 430 observation hours to examine 64 discharge events. We found that inpatient teams with better teamwork-SMMs (ie, higher perceptions of teamwork quality or greater convergence) were more effective at preparing patients for post-hospital care. Additionally, teams with high and low teamwork-SMMs had different experiences with team cohesion, communication openness and alignment on the patient situation.

CONCLUSIONS

Examining the quality and agreement of teamwork-SMMs among teams provides a better understanding of how teams coordinate care and may facilitate the development of specific team-based interventions to improve patient care at hospital discharge.

Discharge Instruction Comprehension and Adherence Errors: Interrelationship Between Plan Complexity and Parent Health Literacy

OBJECTIVE

To examine associations between parent health literacy, discharge plan complexity, and parent comprehension of and adherence to inpatient discharge instructions.

STUDY DESIGN

This was a prospective cohort study of English/Spanish-speaking parents (n = 165) of children ≤12 years discharged on ≥1 daily medication from an urban, public hospital. Outcome variables were parent comprehension (survey) of and adherence (survey, in-person dosing assessment, chart review) to discharge instructions. Predictor variables included low parent health literacy (Newest Vital Sign score 0-3) and plan complexity. Generalized estimating equations were used to account for the assessment of multiple types of comprehension and adherence errors for each subject, adjusting for ethnicity, language, child age, length of stay, and chronic disease status. Similar analyses were performed to assess for mediation and moderation.

RESULTS

Error rates were highest for comprehension of medication side effects (50%), adherence to medication dose (34%), and return precaution (78%) instructions. Comprehension errors were associated with adherence errors (aOR, 8.7; 95% CI, 5.9-12.9). Discharge plan complexity was associated with comprehension (aOR, 7.0; 95% CI, 5.4-9.1) and adherence (aOR, 5.5; 95% CI, 4.0-7.6) errors. Low health literacy was indirectly associated with adherence errors through comprehension errors. The association between plan complexity and comprehension errors was greater in parents with low (aOR, 8.3; 95% CI, 6.2-11.2) compared with adequate (aOR, 3.8; 95% CI, 2.2-6.5) health literacy (interaction term P = .004).

CONCLUSIONS

Parent health literacy and discharge plan complexity play key roles in comprehension and adherence errors. Future work will focus on the development of health literacy-informed interventions to promote discharge plan comprehension.

Effects of iPad Video Education on Patient Knowledge, Satisfaction, and Cardiac Rehabilitation Attendance

PURPOSE

The purpose of this project was to examine the outcomes of using video education as an adjunct to standard discharge education for patients receiving percutaneous coronary intervention. Outcomes included knowledge about heart disease and discharge instructions, satisfaction with the video education, and the percentage of patients with cardiac rehabilitation referrals who attended their first cardiac rehabilitation session.

METHODS

This project analyzed data on 224 participants. A video delivered via an iPad was used to provide adjunct discharge education to patients who underwent percutaneous coronary intervention procedures and were on the 24-hour overnight postrecovery unit. Participants completed a test to gauge knowledge learned. Descriptive statistics, the paired t test, and the Fisher exact test were used to evaluate the efficacy of this education.

RESULTS

A paired t test showed significant knowledge improvement between the pretest percentage correct (mean = 88.97) and the posttest (mean = 96.62): t = -9.657, df = 223, P < .001. A majority of the patients (86.3%, n = 183) were very satisfied with the video education, and 98.1% (n = 208) stated it improved their knowledge and confidence about caring for their heart disease. Despite these reported improvements, there was no significant increase in cardiac rehabilitation attendance (P = .80).

CONCLUSION

Patients of all ages embraced the use of video education on iPads as an adjunct to standard discharge education. Patients felt more confident and informed on discharge about the expectations of caring for their heart disease and the need for cardiac rehabilitation. Despite knowing the benefits of cardiac rehabilitation, it remained an underutilized resource for these patients.

A Congregation Transition of Care Program Using Faith Community Nurses and Volunteer Faith-Based Nurses

Transition of Care Models can reduce the 30-day hospital readmission rate up to 67% by offering coordination and continuity of care. The purpose of this project was to evaluate a Congregation Transition of Care (CTOC) program in faith-based communities with the use of a faith community nurse and volunteer faith-based registered nurses. Descriptive statistics were used to describe findings, revealing a CTOC program can be effective in reducing 30-day readmissions in the faith community.

Completeness of Written Discharge Guidance for English- and Spanish-Speaking Patient Families

OBJECTIVES

Written discharge guidance for hospitalized pediatric patients should include language-appropriate key elements to ensure positive discharge outcomes. Our objective in this study was to determine the completeness of written pediatric discharge guidance and to test the hypothesis that Spanish-speaking families with limited English proficiency (LEP) receive less complete written discharge guidance than English-speaking families.

METHODS

We conducted a retrospective review of written discharge guidance provided to 100 English- and 100 Spanish-speaking families at an urban nonfreestanding children's hospital to assess the inclusion of key elements: follow-up plan, contingency plan, telephone contact, discharge medications, discharge diagnosis, and hospital course. We compared the completeness of discharge guidance (number of elements provided among number of applicable elements) between English- versus Spanish-speaking families.

RESULTS

When evaluating discharge guidance for the presence of key elements in any language, there was no significant difference between English- and Spanish-speaking families. However, the mean completeness of language-appropriate discharge guidance for English- and Spanish-speaking families was 87.8% (95% confidence interval [CI] 84.4%-91.1%) and 16.0% (95% CI 11.5%-20.4%), respectively. The ordinal logistic regression examining the association between the number of key element deficits and English- (reference group) versus Spanish-speaking families demonstrated an adjusted odds ratio of 339.8 (95% CI 112.4-1027.5).

CONCLUSIONS

Few Spanish-speaking families with LEP receive written discharge guidance in their preferred language. Complete, language-appropriate discharge guidance was identified as an area for improvement efforts to work toward improving care provided to families with LEP.

Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update

BACKGROUND

This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery.

METHODS

A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly.

CONCLUSIONS

The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.

Factors Affecting the Levels of Satisfaction With Nurse-Patient Communication Among Oncology Patients

BACKGROUND

Nurse-patient communication is of the utmost importance to oncology patients.

OBJECTIVE

The aim of this study was to investigate the factors influencing the level of satisfaction with nurse-patient communication among oncology patients during their daily routine procedures.

METHODS

In this observational study, 25 registered nurses and 94 patients were recruited from an oncology unit. The patients were asked to complete a concern checklist before and after each admission, administration of medication, and wound-dressing procedure. Nonverbal cues expressed by the nurses and patients were noted on the checklist during these nursing procedures.

RESULTS

The results showed that patients at stage 3 cancer and patients receiving admission procedures were significantly more satisfied with their communication with nurses compared with those who were more concerned about the impact of the disease on self-care.

CONCLUSIONS

Cancer stage, time of admission, and psychological concern related to self-care ability are the potential factors affecting the satisfaction level of nurse-patient communication.

IMPLICATIONS FOR NURSING

Emphasis could be placed on utilizing the time of admission to interact with patients in a busy environment to strive for better communication with oncology patients. The results underscore the importance of applying the self-care enhancement approach for hospitalized cancer patients.

Multicultural Transitions: Caregiver Presence and Language-Concordance at Discharge

INTRODUCTION

Patients with low health literacy (HL) and minority patients encounter many challenges during hospital to community transitions. We assessed care transitions of minority patients with various HL levels and tested whether presence of caregivers and provision of language-concordant care are associated with better care transitions.

METHODS

A prospective cohort study of 598 internal medicine patients, Hebrew, Russian, or Arabic native speakers, at a tertiary medical center in central Israel, from 2013 to 2014.HL was assessed at baseline with the Brief Health Literacy Screen. A follow-up telephone survey was used to administer the Care Transition Measure [CTM] and to assess, caregiver presence and patient-provider language-concordance at discharge.

RESULTS

Patients with low HL and without language-concordance or caregiver presence had the lowest CTM scores (33.1, range 0-100). When language-concordance and caregivers were available, CTM scores did not differ between the medium-high and low HL groups (68.7 and 66.9, respectively, p = 0.118). The adjusted analysis, showed that language-concordance and caregiver presence during discharge moderate the relationship between HL and patients' care transition experience (p < 0.001).

CONCLUSIONS

Language-concordance care and caregiver presence are associated with higher patients' ratings of the transitional-care experience among patients with low HL levels and among minorities.

Discharge communication practices and healthcare provider and patient preferences, satisfaction and comprehension: A systematic review

Purpose

To systematically review the available evidence about hospital discharge communication practices and identify which practices were preferred by patients and healthcare providers, improved patient and provider satisfaction, and increased patients' understanding of their medical condition.

Data sources

OVID Medline, Web of Science, ProQuest, PubMed and CINAHL plus.

Study selection

Databases were searched for peer-reviewed, English-language papers, published to August 2016, of empirical research using quantitative or qualitative methods. Reference lists in the papers meeting inclusion criteria were searched to identify further papers.

Data extraction

Of the 3489 articles identified, 30 met inclusion criteria and were reviewed.

Results of data synthesis

Much research to date has focused on the use of printed material and person-based discharge communication methods including verbal instructions (either in person or via telephone calls). Several studies have examined the use of information technology (IT) such as computer-generated and video-based discharge communication practices. Utilizing technology to deliver discharge information is preferred by healthcare providers and patients, and improves patients' understanding of their medical condition and discharge instructions.

Conclusion

Well-designed IT solutions may improve communication, coordination and retention of information, and lead to improved outcomes for patients, their families, caregivers and primary healthcare providers as well as expediting the task for hospital staff.

Competency-Based Medical Education and the Ghost of Kuhn: Reflections on the Messy and Meaningful Work of Transformation

The transition, if not transformation, to outcomes-based medical education likely represents a paradigm shift struggling to be realized. Paradigm shifts are messy and difficult but ultimately meaningful if done successfully. This struggle has engen dered tension and disagreements, with many of these disagreements cast as either-or polarities. There is little disagreement, however, that the health care system is not effectively achieving the triple aim for all patients. Much of the tension and polarity revolve around how more effectively to prepare students and residents to work in and help change a complex health care system.Competencies were an initial attempt to facilitate this shift by creating frameworks of essential abilities needed by physicians. However, implementation of competencies has proven to be difficult. Entrustable professional activities (EPAs) in undergraduate and graduate medical education and Milestones in graduate medical education are recent concepts being tried and studied as approaches to guide the shift to outcomes. Their primary purpose is to help facilitate implementation of an outcomes-based approach by creating shared mental models of the competencies, which in turn can help to improve curricula and assessment. Understanding whether and how EPAs and Milestones effectively facilitate the shift to outcomes has been and will continue to be an iterative and ongoing reflective process across the entire medical education community using lessons from implementation and complexity science. In this Invited Commentary, the author reflects on what got the community to this point and some sources of tension involved in the struggle to move to outcomes-based education.

Effectiveness of Oral Hygiene Instructions Given in Computer-Assisted Format versus a Self-Care Instructor

Background: This randomized, single-blinded, controlled study compares the effectiveness of two modes of delivering the same set of oral hygiene instructions: those loaded on a computer-assisted teaching format versus those given personally by a self-care instructor. Methods: 60 participants with mild to moderate periodontitis were randomized to either the computer-teaching format or the self-care instructor. Plaque score and bleeding indices were assessed at baseline and at 4 week re-evaluation to compare the instructional modalities. Results: At baseline, there was no difference in the parameters between the two groups. At re-evaluation, all parameters were significantly improved compared to baseline; however, there was no difference between any parameters in the computer group versus the instructor. Plaque score was significantly different between younger and older participants, such that participants under 50 years old had lower plaque scores when they received instructions using the computer format (72.5 ± 12.6 vs. 87.2 ± 10.4; p < 0.001). Additionally, in those under-50 year olds, plaque scores were significantly better in the group using the computer format (87.2 ± 10.4 vs. 78.3 ± 15.6; p = 0.03). Conclusion: Computer teaching formats and self-care instructors are both effective means of communicating oral hygiene instructions. Computer-assisted instruction format effectiveness may amplify as the population ages. Applications of computer formats teaching oral hygiene instructions and cost effectiveness comparison studies warrant significant future investigation.

Trauma patient discharge and care transition experiences: Identifying opportunities for quality improvement in trauma centres

BACKGROUND

Challenges delivering quality care are especially salient during hospital discharge and care transitions. Severely injured patients discharged from a trauma centre will go either home, to rehabilitation or another acute care hospital with complex management needs. This purpose of this study was to explore the experiences of trauma patients and families treated in a regional academic trauma centre to better understand and improve their discharge and care transition experiences.

METHODS

A qualitative study using inductive thematic analysis was conducted between March and October 2016. Telephone interviews were conducted with trauma patients and/or a family member after discharge from the trauma centre. Data collection and analysis were completed inductively and iteratively consistent with a qualitative approach.

RESULTS

Twenty-four interviews included 19 patients and 7 family members. Participants' experiences drew attention to discharge and transfer processes that either (1) Fostered quality discharge or (2) Impeded quality discharge. Fostering quality discharge was ward staff preparation efforts; establishing effective care continuity; and, adequate emotional support. Impeding discharge quality was perceived pressure to leave the hospital; imposed transfer decisions; and, sub-optimal communication and coordination around discharge. Patient-provider communication was viewed to be driven by system, rather than patient need. Inter-facility information gaps raised concern about receiving facilities' ability to care for injured patients.

CONCLUSIONS

The quality of trauma patient discharge and transition experiences is undermined by system- and ward-level processes that compete, rather than align, in producing high quality patient-centred discharge. Local improvement solutions focused on modifiable factors within the trauma centre include patient-oriented discharge education and patient navigation; however, these approaches alone may be insufficient to enhance patient experiences. Trauma patients encounter complex barriers to quality discharge that likely require a comprehensive, multimodal intervention.

Handing Off the Older Patient: Improved Documentation of Geriatric Assessment in Transitions of Care

OBJECTIVES

To improve assessment and documentation of function, cognition, and advance care planning (ACP) in admission and discharge notes on an Acute Care of the Elderly (ACE) unit.

DESIGN

Continuous quality improvement intervention with episodic data review.

SETTING

ACE unit of an 866-bed academic tertiary hospital.

PARTICIPANTS

Housestaff physicians rotating on the ACE unit (N = 31).

INTERVENTION

Introduction of templated notes, housestaff education, leadership outreach, and posted reminders.

MEASUREMENTS

Documentation of function, cognition, and ACP were assessed through chart review of a weekly sample of the ACE unit census and scored using predefined criteria.

RESULTS

Medical records (N = 172) were reviewed. At baseline, 0% of admission and discharge notes met minimum documentation criteria for all 3 domains (function, cognition, ACP). Documentation of function and cognition was completely absent at baseline. After the intervention, there was marked improvement in all measures, with 64% of admission notes and 94% of discharge notes meeting minimum documentation criteria or better in all 3 domains.

CONCLUSION

A quality improvement intervention using geriatric-specific note templates, housestaff training, and reminders increased documentation of function, cognition and ACP for postacute care.

Post discharge issues identified by a call-back program: identifying improvement opportunities

OBJECTIVES

The period following discharge from the hospital is one of heightened vulnerability. Discharge instructions serve as a guide during this transition. Yet, clinicians receive little feedback on the quality of this document that ties into the patients' experience. We reviewed the issues voiced by discharged patients via a call-back program and compared them to the discharge instructions they had received.

METHODS

At our institution, patients receive an automated call forty-eight hours following discharge inquiring about progress. If indicated by the response to the call, they are directed to a nurse who assists with problem solving. We reviewed the nursing documentation of these encounters for a period of nine months. The issues voiced were grouped into five categories: communication, medications, durable medical equipment/therapies, follow up and new or ongoing symptoms. The discharge instructions given to each patient were reviewed. We retrieved data on the number of discharges from each specialty from the hospital over the same period.

RESULTS

A total of 592 patients voiced 685 issues. The numbers of patients discharged from medical or surgical services identified as having issues via the call-back line paralleled the proportions discharged from medical and surgical services from the hospital during the same period. Nearly a quarter of the issues discussed had been addressed in the discharge instructions. The most common category of issues was related to communication deficits including missing or incomplete information which made it difficult for the patient to enact or understand the plan of care. Medication prescription related issues were the next most common. Resource barriers and questions surrounding medications were often unaddressed.

CONCLUSIONS

Post discharge issues affect patients discharged from all services equally. Data from call back programs may provide actionable targets for improvement, identify the inpatient team's 'blind spots' and be used to provide feedback to clinicians.

Ready to Go Home? Patients' Experiences of the Discharge Process in an Enhanced Recovery After Surgery (ERAS) Program for Colorectal Surgery

BACKGROUND

With the adoption of enhanced recovery after surgery (ERAS) programs, patients are being discharged earlier and require more post-discharge teaching, educational materials, and information.

OBJECTIVE

The purpose of this study is to assess satisfaction, discharge needs, and follow-up concerns of patients within an ERAS implementation program (iERAS).

METHODS

Between 2012 and 2015, the iERAS program was undertaken at an academic hospital where 554 patients having elective colorectal surgery were enrolled. After discharge, patients were sent a survey containing multiple choice questions, preference ranking, and open-ended questions. Free-text responses were analyzed through a thematic approach.

RESULTS

Overall, 496 patients were mailed surveys and 219 (44.2%) completed the survey. Ninety-three percent were satisfied with the discharge information, and 90% felt they were ready for discharge. Eighty-six percent of patients saw their surgeon at 6 weeks, and 88% were satisfied with this follow-up plan. Some patients felt they had inadequate post-operative information, including how to resolve complications while at home and lack of reliable information for common post-operative occurrences. Patients with ostomies wanted more information about what to expect post-discharge and what symptoms were normal. Support from the homecare team and having a surgical nurse available were considered to be essential.

CONCLUSIONS

Improved post-operative education for surgical patients prior to discharge within iERAS is required to facilitate patient-centered discharge planning. Such interventions may help decrease unplanned hospital visits during the immediate post-discharge period.

Low Health Literacy Is Associated with Increased Transitional Care Needs in Hospitalized Patients

OBJECTIVE

To examine the association of health literacy with the number and type of transitional care needs (TCN) among patients being discharged to home.

DESIGN, SETTING, PARTICIPANTS

A cross-sectional analysis of patients admitted to an academic medical center.

MEASUREMENTS

Nurses administered the Brief Health Literacy Screen and documented TCNs along 10 domains: caregiver support, transportation, healthcare utilization, high-risk medical comorbidities, medication management, medical devices, functional status, mental health comorbidities, communication, and financial resources.

RESULTS

Among the 384 patients analyzed, 113 (29%) had inadequate health literacy. Patients with inadequate health literacy had needs in more TCN domains (mean = 5.29 vs 4.36; P < 0 .001). In unadjusted analysis, patients with inadequate health literacy were significantly more likely to have TCNs in 7 out of the 10 domains. In multivariate analyses, inadequate health literacy remained significantly associated with inadequate caregiver support (odds ratio [OR], 2.61; 95% confidence interval [CI], 1.37-4.99) and transportation barriers (OR, 1.69; 95% CI, 1.04-2.76).

CONCLUSIONS

Among hospitalized patients, inadequate health literacy is prevalent and independently associated with other needs that place patients at a higher risk of adverse outcomes, such as hospital readmission. Screening for inadequate health literacy and associated needs may enable hospitals to address these barriers and improve postdischarge outcomes.

Parental Management of Discharge Instructions: A Systematic Review

CONTEXT

Parents often manage complex instructions when their children are discharged from the inpatient setting or emergency department (ED); misunderstanding instructions can put children at risk for adverse outcomes. Parents' ability to manage discharge instructions has not been examined before in a systematic review.

OBJECTIVE

To perform a systematic review of the literature related to parental management (knowledge and execution) of inpatient and ED discharge instructions.

DATA SOURCES

We consulted PubMed/Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane CENTRAL (from database inception to January 1, 2017).

STUDY SELECTION

We selected experimental or observational studies in the inpatient or ED settings in which parental knowledge or execution of discharge instructions were evaluated.

DATA EXTRACTION

Two authors independently screened potential studies for inclusion and extracted data from eligible articles by using a structured form.

RESULTS

Sixty-four studies met inclusion criteria; most (n = 48) were ED studies. Medication dosing and adherence errors were common; knowledge of medication side effects was understudied (n = 1). Parents frequently missed follow-up appointments and misunderstood return precaution instructions. Few researchers conducted studies that assessed management of instructions related to diagnosis (n = 3), restrictions (n = 2), or equipment (n = 1). Complex discharge plans (eg, multiple medicines or appointments), limited English proficiency, and public or no insurance were associated with errors. Few researchers conducted studies that evaluated the role of parent health literacy (ED, n = 5; inpatient, n = 0).

LIMITATIONS

The studies were primarily observational in nature.

CONCLUSIONS

Parents frequently make errors related to knowledge and execution of inpatient and ED discharge instructions. Researchers in the future should assess parental management of instructions for domains that are less well studied and focus on the design of interventions to improve discharge plan management.

Elucidating the information exchange during interfacility care transitions: Insights from a Qualitative Study

OBJECTIVE

To explore the perceptions of patients, their caregivers and healthcare professionals associated with the exchange of information during transitioning from two acute care hospitals to one rehabilitation hospital.

DESIGN

An exploratory qualitative study using semi-structured interviews and observation.

PARTICIPANTS AND SETTING

Patients over the age of 65 years admitted to an orthopaedic unit for a non-elective admission, their caregivers and healthcare professionals involved in their care. Participating sites included orthopaedic inpatient units from two acute care teaching hospitals and one orthopaedic unit at a rehabilitation hospital in an urban setting.

FINDINGS

Three distinct themes emerged from participants' narrative of their transitional care experience: (1) having no clue what the care plan is, (2) being told and notified about the plan and (3) experiencing challenges absorbing information. Participating patients and their caregivers reported not being engaged in an active discussion with healthcare professionals about their care transition plan. Several healthcare professionals described withholding information within the plan until they themselves were clear about the transition outcomes.

CONCLUSION

This study highlights the need to increase efforts to ensure that effective information exchanges occur during transition from acute care hospital to rehabilitation settings.

Discharge Teaching, Readiness for Discharge, and Post-discharge Outcomes in Parents of Hospitalized Children

PURPOSE

This study explored the sequential relationships of parent perceptions of the quality of their discharge teaching and nurse and parent perceptions of discharge readiness to post-discharge outcomes (parental post-discharge coping difficulty, readmission and emergency department visits).

DESIGN/METHODS

In this secondary analysis of data from a longitudinal pilot study of family self-management discharge preparation, the correlational design used regression modeling with data from a convenience sample of 194 parents from two clinical units at a Midwest pediatric hospital. Data were collected on the day of discharge (Quality of Discharge Teaching Scale; Readiness for Hospital Discharge Scale), at 3weeks post-discharge (Post-Discharge Coping Difficulty Scale), and from electronic records (readmission, ED visits).

RESULTS

Parent-reported quality of discharge teaching delivery (the way nurses teach), but not the amount of content, was positively associated with parent perception (B=0.54) and nurse assessment (B=0.16) of discharge readiness. Parent-reported discharge readiness was negatively associated with post-discharge coping difficulty (B=-0.52). Nurse assessment of discharge readiness was negatively associated with readmission; a one point increase in readiness (on a 10 point scale) decreased the likelihood of readmission by 52%.

CONCLUSION

There is a sequential effect of quality of discharge teaching delivery on parent discharge readiness, which is associated with parent coping difficulty and child readmission.

PRACTICE IMPLICATIONS

Efforts to improve discharge outcomes should include strategies to build nurse teaching skills for high-quality delivery of discharge teaching. In addition, routine nurse assessment of discharge readiness can be used to identify children at risk for readmission and trigger anticipatory interventions.

Patient experience with discharge instructions in postdischarge recovery: a qualitative study

OBJECTIVES

We examined the role of discharge instructions in postoperative recovery for patients undergoing colorectal surgery and report themes related to patient perceptions of discharge instructions and postdischarge experience.

DESIGN

Semistructured interviews were conducted as part of a formative evaluation of a Project Re-Engineered Discharge intervention adapted for surgical patients.

SETTING

Michael E. DeBakey VA Medical Center, a tertiary referral centre in Houston, Texas.

PARTICIPANTS

Twelve patients undergoing elective colorectal surgery. Interviews were conducted at the two-week postoperative appointment.

RESULTS

Participants demonstrated understanding of the content in the discharge instructions. During the interviews, participants reported several positive roles for discharge instructions in their postdischarge care: a sense of security, a reminder of inhospital education, a living document and a source of empowerment. Despite these positive associations, participants reported that the instructions provided insufficient information to promote access to care that effectively addressed acute issues following discharge. Participants noted difficulty reaching providers after discharge, which resulted in the adoption of workarounds to overcome system barriers.

CONCLUSIONS

Despite concerted efforts to provide patient-centred instructions, the discharge instructions did not provide enough context to effectively guide postdischarge interactions with the healthcare system. Insufficient information on how to access and communicate with the most appropriate personnel in the healthcare system is an important barrier to patients receiving high-quality postdischarge care. Tools and strategies from team training programmes, such as team strategies and tools to enhance performance and patient safety, could be adapted to include patients and provide them with structured methods for communicating with healthcare providers post discharge.

Improving the seniors' transition from hospital to the community: a case for intensive geriatric service workers

BACKGROUND

Limited continuity of care, poor communication between healthcare providers, and ineffective self-management are barriers to recovery as seniors transition back to the community following an Emergency Department (ED) visit or hospitalization. The intensive geriatric service worker (IGSW) role is a new service developed in southern Ontario, Canada to address gaps for seniors transitioning home from acute care to prevent rehospitalization and premature institutionalization through the provision of intensive support and follow-up to ensure adherence to care plans, facilitate communication with care providers, and promote self-management. This study describes the IGSW role and provides preliminary evidence of its impact on clients, caregivers and the broader health system.

METHODS

This mixed methods evaluation included a chart audit of all clients served, tracking of the achievement of goals for IGSW involvement, and interviews with clients and caregivers and other key informants.

RESULTS

During the study period, 632 clients were served. Rates of goal achievement ranged from 25%-87% and in cases where achieved, the extent of IGSW involvement mostly exceeded recommendations. IGSWs were credited with improving adherence with treatment recommendations, increasing awareness and use of community services, and improving self-management, which potentially reduced ED visits and hospitalizations and delayed institutionalization.

CONCLUSIONS

The IGSW role has the potential to improve supports for seniors and facilitate more appropriate use of health system resources, and represents a promising mechanism for improving the integration and coordination of care across health sectors.

Cognitive Dysfunction, Medication Management, and the Risk of Readmission in Hospital Inpatients

OBJECTIVES

To determine whether cognitive dysfunction, in particular impaired executive function, may be a risk factor for early readmission in older adults independently managing their medications.

DESIGN

Prospective observational study.

SETTING

Tertiary hospital.

PARTICIPANTS

Individuals aged 65 years and older discharged to home from the medicine service of a tertiary hospital (N = 452).

MEASUREMENTS

Participants underwent a cognitive assessment including the Short Blessed Test (SBT), the executive function component of the Montreal Cognitive Assessment, and the Trail-Making Test Part B (TMT-B). Hospital use and demographic data were obtained. A logistic regression model was used to fit the likelihood of readmission on the basis of participant characteristics, medication management, and cognitive performance. Likelihood of hospital readmission within 30 days was determined.

RESULTS

For participants managing medications themselves, adjusted 30-day odds of readmission increased 13% on average with each point decrease in SBT score (P = .003) and 9% on average with each 0.01 decrease in TMT-B score (P = .02). For participants who were independent in medication management with more than seven medications, the odds of 30-day readmission increased 16% on average with each point decrease in SBT score (P = .01) and 15% on average with each 0.01 decrease in TMT-B score (P = .03).

CONCLUSION

Cognitive dysfunction, particularly executive dysfunction, is a risk factor for readmission in individuals managing their own medications. This risk is greater in individuals taking more than seven medications. The interaction of cognitive function, medication management, and number of medications may enhance risk-stratification efforts to identify individuals at risk of early readmission.

Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland

OBJECTIVE

Hospital discharge summaries can provide valuable information to future providers and may help to prevent hospital readmissions. We sought to examine whether the number of days to complete hospital discharge summaries is associated with 30-day readmission rate.

PATIENTS AND METHODS

This was a retrospective cohort study conducted on 87,994 consecutive discharges between January 1, 2013 and December 31, 2014, in a large urban academic hospital. We used multivariable logistic regression models to examine the association between days to complete the discharge summary and hospital readmissions while controlling for age, gender, race, payer, hospital service (gynecology-obstetrics, medicine, neurosciences, oncology, pediatrics, and surgical sciences), discharge location, length of stay, expected readmission rate in Maryland based on diagnosis and illness severity, and the Agency for Healthcare Research and Quality Comorbidity Index. Days to complete the hospital discharge summary-the primary exposure variable-was assessed using the 20th percentile (>3 vs ≤3 days) and as a continuous variable (odds ratio expressed per 3-day increase). The main outcome was all-cause readmission to any acute care hospital in Maryland within 30 days.

RESULTS

Among the 87,994 patients, there were 14,248 (16.2%) total readmissions. Discharge summary completion >3 days was significantly associated with readmission, with adjusted odds ratio (OR) (95% confidence interval [CI]) of 1.09 (1.04 to 1.13, P = 0.001). We also found that every additional 3 days to complete the discharge summary was associated with an increased adjusted odds of readmission by 1% (OR: 1.01, 95% CI: 1.00 to 1.01, P < 0.001).

CONCLUSION

Longer days to complete discharge summaries were associated with higher rates of all-cause hospital readmissions. Timely discharge summary completion time may be a quality indicator to evaluate current practice and as a potential strategy to improve patient outcomes. Journal of Hospital Medicine 2016;11:393-400. 2016 Society of Hospital Medicine.

Opportunities to improve clinical summaries for patients at hospital discharge

BACKGROUND

Clinical summaries are electronic health record (EHR)-generated documents given to hospitalised patients during the discharge process to review their hospital stays and inform postdischarge care. Presently, it is unclear whether clinical summaries include relevant content or whether healthcare organisations configure their EHRs to generate content in a way that promotes patient self-management after hospital discharge. We assessed clinical summaries in three relevant domains: (1) content; (2) organisation; and (3) readability, understandability and actionability.

METHODS

Two authors performed independent retrospective chart reviews of 100 clinical summaries generated at two Michigan hospitals using different EHR vendors for patients discharged 1 April -30 June 2014. We developed an audit tool based on the Meaningful Use view-download-transmit objective and the Society of Hospital Medicine Discharge Checklist (content); the Institute of Medicine recommendations for distributing easy-to-understand print material (organisation); and five readability formulas and the Patient Education Materials Assessment Tool (readability, understandability and actionability).

RESULTS

Clinical summaries averaged six pages (range 3-12). Several content elements were universally auto-populated into clinical summaries (eg, medication lists); others were not (eg, care team). Eighty-five per cent of clinical summaries contained discharge instructions, more often generated from third-party sources than manually entered by clinicians. Clinical summaries contained an average of 14 unique messages, including non-clinical elements irrelevant to postdischarge care. Medication list organisation reflected reconciliation mandates, and dosing charts, when present, did not carry column headings over to subsequent pages. Summaries were written at the 8th-12th grade reading level and scored poorly on assessments of understandability and actionability. Inter-rater reliability was strong for most elements in our audit tool.

CONCLUSIONS

Our study highlights opportunities to improve clinical summaries for guiding patients' postdischarge care.

Communication in Hong Kong Accident and Emergency Departments: The Clinicians' Perspectives

In this article, we report findings from the first qualitatively driven study of patient–clinician communication in Hong Kong Accident and Emergency Departments (AEDs). In light of the Hong Kong Hospital Authority’s policy emphasis on patient-centered care and communication in the public hospitals it oversees, we analyze clinicians’ perceptions of the role and relevance of patient-centered communication strategies in emergency care. Although aware of the importance of effective communication in emergency care, participants discussed how this was frequently jeopardized by chronic understaffing, patient loads, and time pressures. This was raised in relation to the absence of spoken interdisciplinary handovers, the tendency to downgrade interpersonal communication with patients, and the decline in staff attendance at communication training courses. Participants’ frequent descriptions of patient-centered communication as dispensable from, and time-burdensome in, AEDs highlight a discrepancy between the stated Hong Kong Hospital Authority policy of patient-centered care and the reality of contemporary Hong Kong emergency practice.