Perspectives on Safety
Patient Safety During Hospital Discharge
Patients are admitted to the hospital in the United States 35 million times per year.(1) The discharge period—when patients are transitioned from one care setting to another—is a period of heightened risk and can often be chaotic. Approximately 20% of patients experience adverse events in the first 3 weeks after discharge, with 61% of those events regarded as preventable or ameliorable.(2) Risks include, but are not limited to, deterioration related to the reason for hospitalization, adverse drug reactions, hospital-acquired infections, and other problems unrelated to the reason for hospitalization. There are a number of interventions that may reduce risk of harm after discharge.
A Breakdown in Communication
During the discharge process, there must be a transfer of knowledge from the inpatient to the subsequent care team—whether it be the patient's outpatient providers or providers at a transitional facility. With much of inpatient care moving to the hospitalist model in the United States, hospitalized patients are commonly cared for by physicians who specialize in treating inpatients. Studies show that the hospitalist model reduces length of stay and cost of care (3); however, the model makes it more important than ever to improve communications and handoffs between inpatient and outpatient providers.
The discharge summary is a cornerstone of inpatient-to-outpatient provider communication. In one study, patients whose primary physicians received a discharge summary and were seen for follow-up were less likely to be readmitted (4). However, discharge summaries are frequently not transmitted, which can increase the risk of harm. For example, only 12% to 34% of discharge summaries reach outpatient providers prior to the patient's first post-hospitalization appointment (5), and one-third of tests recommended by inpatient teams for outpatient follow-up are never obtained by after care providers.(6)
Patient education is also crucial to safe patient discharges. Patient, as well as family and caretaker, engagement in health care decision-making and treatment is associated with improved treatment outcomes.(7) Providers must communicate key information required for patients to manage their condition(s) after discharge to promote successful transition from the hospital. However, providers often overestimate patients' understanding of written or verbal explanations. Studies show that, at the time of discharge, more than half of patients could not recall details of follow-up appointments, only 60% could accurately describe their admission diagnosis, and 26% had discharge information written in language that was unintelligible to the patient.(8) A variety of factors may contribute to breakdowns in patient education—from demographic factors such as low health literacy or language barriers to lack of written materials and time constraints to provide adequate education.
Although patient-focused discharge plans can reduce hospital length of stay and readmission (9), there is currently no consensus regarding how best to ensure patient safety around hospital discharge.(10) Hospital accreditation requires discharge planning to include medication reconciliation, patient education, and communication to outpatient providers. Such interventions, along with care coordination, should occur starting on the day of admission and should be reviewed daily by care teams. Predischarge checklists can help ensure patients have the appropriate services and support.(11) When discharging patients, verbal telephone handoffs that discuss key transitional information may be more reliable than relying on discharge paperwork that might be incomplete or lost in the multitude of paper and electronic information passed to providers. Team-based care coordination with inpatient and outpatient case managers, pharmacists, and visiting nurses can help ensure appropriate medical follow-up and prescription use.
Oftentimes, the patient or caretaker assumes full responsibility of all patient care postdischarge. Patients with clear understanding of their postdischarge instructions are 30% less likely to be readmitted or visit the emergency department.(12) Structured communication techniques to enhance patient education include evaluating patient health literacy, using language appropriate to patient understanding, utilizing visuals, and practicing the teach-back method.(13-15) Simple interventions like a leaflet to explain hospital diagnoses and new medication details have been shown to increase patient understanding of their diagnosis from 77% to 100%, and medication understanding from 27% to 71%.(16) Interventions should not simply provide information to patients but should also serve as an opportunity for patients to ask questions and be more active participants in their health care.
Many institutions have developed multipronged approaches to enhancing postdischarge care. One example is Project RED (Reengineered Discharge), which includes 11 components that manage patient education, postdischarge care, and postdischarge phone calls.(12) The Care Transitions Intervention is another example. In this program, designated transition coaches empower patients and their caregivers to take active roles during transitions.(17)
In addition to programs like these, there is an opportunity today to identify high-risk patients based on clinical histories, demographics, or screening tools, and then to implement targeted interventions. Improvements in health care technology enhance our abilities to assess risks and deliver interventions, ranging from communication with providers via telemedicine to mobile applications that help patients follow a postdischarge plan. These new workflows and interventions can be incorporated into electronic health records through risk calculators, patient portals, and daily reminders to review discharge materials and to interact with the care team following discharge.
Expanding Our Understanding of Patient Safety Risks
Our understanding of patient safety hazards during the peridischarge period is also expanding to a broader concept of generalized risk. Almost one-fifth of Medicare patients are readmitted within 30 days of discharge, but the cause of readmission correlates with the original admission diagnosis only 29% to 37% of the time.(18,19) It appears that, while the system may have successfully treated the acute cause of hospitalization, the hospitalization itself has conferred additional generalized risk for illness and deterioration. Contributing factors to this state—dubbed post-hospital syndrome by Krumholz—include derangement of physiological systems like sleep, nourishment, physical conditioning, and cognitive functioning. Polypharmacy, erratic schedules, and diet restrictions disturb a patient's ability to recover and fend off other health issues postdischarge. Impaired mobility from deconditioning increases the risk of falls, as well as preventing the patient from resuming life as normal or complying with postdischarge instructions.(19)
As we consider the Post-Hospital Syndrome, we should also incorporate more holistic efforts to create a more patient-centered hospital environment. This may involve a variety of interventions: changing room decor and meals, reducing unnecessary studies and medications, and promoting early activity and normal sleep patterns. Transparency regarding daily schedules reduces confusion and stress from disruptions.
Besides facing the risks of hospitalization, patients also face significant risks upon discharge from the hospital. Risks are varied, spanning from progression of underlying disease to emergence of new problems not present prior to admission. Multiple interventions have some efficacy in reducing risk of harm following discharge. Improving communication with patients, reaching out to patients in their home, and engaging primary care providers to "pull patients back in" to care in the post-hospital environment are among the most important interventions to prevent deterioration, reduce readmissions, and to help patients return to prior function most effectively.
Katherine Liang Clinical Informatics UMass Memorial Health Care Medical Student University of Massachusetts Medical School
Eric Alper, MD Hospital Medicine Vice President/Chief Clinical Informatics Officer UMass Memorial Health Care Professor of Medicine University of Massachusetts Medical School
2. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138:161-167. [go to PubMed]
5. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297:831-841. [go to PubMed]
13. White M, Garbez R, Carroll M, Brinker E, Howie-Esquivel J. Is "teach-back" associated with knowledge retention and hospital readmission in hospitalized heart failure patients? J Cardiovasc Nurs. 2013;28:137-146. [go to PubMed]
15. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2:314-323. [go to PubMed]
16. Nicholson Thomas E, Edwards L, McArdle P. Knowledge is power. a quality improvement project to increase patient understanding of their hospital stay. BMJ Qual Improv Rep. 2017;6(1). [go to PubMed]