Acute Care/Hospitalization

Studies suggest ways to improve the hospital discharge process to reduce postdischarge adverse events and rehospitalizations

After patients are discharged from U.S. hospitals, 13 percent require rehospitalization and one in five patients suffers an adverse event. Many of these problems are due to inadequate postdischarge followup of patients' unresolved medical problems. More patients with unresolved problems would receive outpatient workups if their primary care doctors received the hospital doctors' discharge summary recommendations, concludes a study supported by the Agency for Healthcare Research and Quality (HS14020).

A second AHRQ-supported study (HS14289 and HS15905) describes 11 factors that could be modified during the hospital discharge process to reduce posthospital adverse events and rehospitalizations. Both studies are briefly discussed here.

Moore, C., McGinn, T., and Halm, E. (2007, June). "Tying up loose ends: Discharging patients with unresolved medical issues." Archives of Internal Medicine 167, pp. 1305-1311.

Patients are frequently discharged from the hospital with unresolved medical problems requiring outpatient workups. Yet this study found that more than half (54 percent) of all discharge summaries failed to document the recommended outpatient workups that were clearly documented in the patients' hospital charts. Also, more than one-third (36 percent) of workups recommended by hospital doctors in the discharge summaries were not completed by primary care doctors. Increasing time from discharge to the initial postdischarge visit to the primary care physician decreased by 23 percent the likelihood that a recommended workup was completed. On the other hand, availability of a discharge summary documenting the recommended workup more than doubled the likelihood of workup completion by the primary care doctor. Clearly, it is important to improve the quality and dissemination of discharge information to primary care physicians, note the researchers.

They examined the hospital and outpatient records of 693 patients discharged from a large teaching hospital in 2002 and 2003. Of the 693 patients discharged, 28 percent had outpatient workups recommended by their hospital physicians. The types of workups were diagnostic procedures such as echocardiograms and computed tomographic scans (48 percent), subspecialty referrals (35 percent), and laboratory tests such as monitoring blood viscosity for patients on the anticoagulant warfarin (17 percent).

Greenwald, J.L., Denham, C.R., and Jack, B.W. (2007, June). "The hospital discharge: A review of a high risk care transition with highlights of a reengineered discharge process." Journal of Patient Safety 3(2), pp. 97-106.

These authors cite 11 factors that could be modified during the hospital discharge process to reduce postdischarge adverse events and rehospitalizations. They reviewed the research literature and studied the hospital discharge process at their hospital. They then used these data to identify specific failures of the hospital discharge system that could inform their design of a reengineered discharge process. They reviewed the new process with hospital administrators, physicians, residents, nurses, and ancillary staff, and revised it based on their feedback.

They recommended modifying the following 11 discharge factors to reduce postdischarge adverse events and hospitalizations:

• Educate the patient about their diagnoses throughout their hospital stay.
• Make appointments for clinician follow-up and postdischarge testing. Coordinate appointments with and discuss their importance with the patient.
• Discuss with the patient any tests or studies completed in the hospital and discuss who will be responsible for following up the results.
• Organize postdischarge services. Be sure the patient understands the importance of these services, make an appointment that the patient can keep, and discuss the details of how to receive each service.
• Confirm the medication plan and review it with the patient, including medication side effects.
• Reconcile the discharge plan with national guidelines and critical pathways.
• Review the appropriate steps on what to do if a problem arises, for example, how to contact the primary care doctor or what to do in an emergency.
• Expedite transmission of the discharge summary to the physicians, visiting nurses, and others accepting responsibility for the patients' care after discharge.
• Assess the degree of patients' understanding by asking them to explain the details of their discharge summary plan.
• Give the patient a written discharge plan at the time of discharge.
• Provide telephone reinforcement of the discharge plan and problem solving 2 to 3 days after discharge.

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