Background

The post–hospital discharge period can be dangerous. A classic study found that nearly 20% of patients experience adverse events within 3 weeks of discharge, nearly three-quarters of which could have been prevented or ameliorated. Adverse drug events are the most common postdischarge complication, with hospital-acquired infections and procedural complications also causing considerable morbidity. More subtle discharge hazards relate to the nearly 40% of patients who are discharged with test results pending and a comparable proportion who are discharged with a plan to complete the diagnostic workup as an outpatient. Failure to follow up on these test results and plans places patients at additional risk.

These disturbing but common patient safety threats can be attributed to several problems in discharge planning and postdischarge care. Discontinuity between inpatient and outpatient providers is common, and studies have shown that traditional communication systems (such as the dictated discharge summary) generally fail to reach outpatient providers in a timely fashion and often lack essential information. Patients frequently receive new medications or have medications changed during hospitalizations. Lack of medication reconciliation results in the potential for inadvertent medication discrepancies and adverse drug events—particularly for patients with low health literacy, or those prescribed high-risk medications or complex medication regimens.

Source: Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165:424-429. [go to PubMed]

Even if communication between providers is timely and accurate, and appropriate steps are taken to ensure medication safety, patients and their families still assume a large burden of care after discharge. Accurately assessing patients' abilities to care for themselves after discharge can be difficult and requires a coordinated multidisciplinary effort. Failure to enlist appropriate resources to help with the transition from hospital to home (or another health care setting) may leave patients vulnerable. Finally, the fragmented nature of the health care system may limit individual hospitals' incentive to improve their discharge process, despite the benefits to patients that may result.

Preventing Adverse Events after Discharge

Ensuring safe care transitions requires a systematic approach. Three key areas must be addressed prior to discharge:

• Medication reconciliation: The patient's medications must be cross-checked to ensure that no chronic medications were stopped and to ensure the safety of new prescriptions. 
• Structured discharge communication: Information on medication changes, pending tests and studies, and follow-up needs must be accurately and promptly communicated to outpatient physicians. 
• Patient education: Patients (and their families) must understand their diagnosis, their follow-up needs, and whom to contact with questions or problems after discharge.

Currently, no consensus exists on the best methods to prevent adverse events after discharge. Various medication reconciliation approaches have been advocated, but as yet none has been proven to lead to improved clinical outcomes. The same is true for structured discharge communications. A promising approach uses specially trained staff to meet with patients before (and sometimes after) discharge to reconcile medications, instruct patients and caregivers in self-care methods, prepare patient-centered discharge instructions, and facilitate communication with outpatient physicians. The Care Transitions trial and the Project RED study used variations of this method, and both successfully reduced readmissions and emergency department visits after discharge. Other promising interventions include discharge "checklists" to standardize the discharge process, and structured postdischarge phone calls to patients. Electronic health records offer great potential for improving information transfer between inpatient and outpatient physicians, and for developing standardized discharge instructions for patients.

Evaluating the magnitude of care transition problems and the effect of interventions is hampered by the lack of a standard outcome measurement. Hospital readmission rates are often used, but most adverse events after discharge cause patient harm without requiring readmission. A three-item patient survey measure has been developed to measure patient satisfaction with the transition process; hospitals are being encouraged to add these items to standard patient satisfaction questionnaires.

Current Context

Hospitals are not currently required to formally track or report adverse events after discharge. The Centers for Medicaid and Medicare Systems (CMS) are considering requiring hospitals to report risk-adjusted 30-day readmission rates, and in late 2008 began pilot testing such a measure for patients with heart failure.