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Signature hospital discharge

you're going to be doing a lot of hospital discharges over your years of training so we'll hit a few highlights for you okay so the things that I wish to talk about today we're going to go over why the discharge process is on the risky side for our patients we don't always talk about it but how do you tell someone is appropriate for discharge and if so to where there are elements of the discharge process and we're going to talk about each of those individually then I'm going to pause and see if you all have any questions and then we'll stop the recording and we'll have a few tips at the end which we should still have plenty of time for for those for some Cerner suggestions sorry VA at the moment I know you don't have Cerner yet but I hear rumors to the effect that it's in the VA future so you might be interested in some of the shortcuts eventually so okay so one of the things that we do know over time as we have taken our patients to where we have sicker and sicker patients in the hospital so fewer patients are being discharged from the hospital straight to home still is by far the majority well over 3/4 of them are still ready to go from the hospital to home sometimes with some help but it's had dropped like 10% from the 10 years earlier so the direction is for sicker people often needing to go somewhere besides home we have about 10 percent going to long-term sub acute rehab that sort of stuff of those who do go home many of them here you see six and a half percent need some type of home health be it PT nursing what-have-you our numbers may be a little bit higher than this they have about 1% leave against medical advice but but nevertheless that is one of the options for how to leave the hospital approximately two and a half percent leave the hospital via the morgue a very small percentage of our patients but some actually will leave to what's called another short-term hospital acute care hospital perhaps by patient wishes or we don't have services that are offered and we'll go over some of the impact there so what happens when we discharge a patient particularly from our general medical type of wards we know a lot more about the Medicare age population and of course being over 65 as a general rule you know they're going to be a little bit riskier population anyway about one in five or 20% of those patients are readmitted within 30 days of discharge now at the moment you may or may not know there are handful of diagnosis especially that we in medicine are stuck with if a patient is readmitted within 30 days for a COPD exacerbation for a heart failure exacerbation or post myocardial infarction that's counted against the hospital you can come in with a heart failure exacerbation we discharge you in a week later you get hit by a truck and are readmitted doesn't matter that it's not readmitted for the same diagnosis those are counted up and the way Medicare acts now for those things the hospital has a reduction in the amount of money they're paid for all Medicare patients regardless of reason so you could be in with a hip fracture the sum total so it's important to the hospital but it's also important from our point of view is have we messed up somehow something we've done maybe that made that patient more likely to bounce back within 30 days we do know there is some evidence that this is not a really good mark for the quality of care that patients receive that bounced back it could have to do with the severity of their illness we know there are some that have comorbidities sometimes they still are recreational cocaine users and things like that that might bounce back with their heart failure or another mi but it's important for you to realize that there are consequences that may be more global than just to that one particular patient so when you hear people talk about the 30-day readmission rates that's one of the reasons why so when 20 percent of Medicare patients are in this category that are readmitted within 30 days somebody's paying attention to that from our point of view a really important piece of information is that two-thirds of those are related to adverse drug events and we are the kings and queens of prescribing medications right so we need to be aware of that in our discipline less of them are coming back because of procedures which you can see that 70% of the readmission rates are related to a previous procedure okay so these bounce-back cases for whatever reason there is a actually a high association with ongoing disability a third of them will lead potentially to take permanent nursing home placement so we want to be aware the riskiness and anything we can do because two-thirds of these events are preventable or at least modifiable so that they would have potentially had a less severity okay another important reason that discharge timeframe is a little bit risky for patients is we don't always have all of the data back when we send a patient home from the hospital in one study they found that about 40% of their patients had either pending blood work or lab tests that had been obtained but not resulted when the patient had left the hospital and of that 10% of them required some type of intervention based on those results that maybe nobody ever looked at importantly the docks were providers that are seeing those patient and follow-up two-thirds of them were unaware that there was something still pending when their patient left the hospital so risky time period sadly adverse events occur more frequently in teaching hospitals than in large or small community hospitals and some of that has to do with the complexity of patients that we tend to have but we also have a lot of people involved in the care multiple members of the team multiple teams we would like to be better than small or large community hospitals so one of the ways to tackle that is first we need to be aware okay so until the not-too recent past not too distant past anyway discharges the focus on safety and discharges is a relatively recent phenomenon so it's been tackled here in the last decade and I factors that may improve the safety have been identified and we're going to try to emphasize the ones that we know a little bit about I will tell you there is little good solid evidence that any one factor improves the overall safety of your discharges and your readmission rates a bunch of the things that I am going to talk about in a multifactorial if multiple things are done there is some evidence still not overwhelming evidence but some evidence that you can improve safety and readmission so we're going to talk about that but regardless we would like to do a high level of care so we will hit some of those discharges can be very unplanned you know have an opportunity a moment and you get somebody out the door quickly and maybe we haven't had time to educate or assess or make sure of all of the things we will be talking about that makes discharges risking we are now in a hospitalist and a ambulatory world the same doctor is not taking care of that patient from the get-go and then seeing them and follow-up not only that we are in a world where this week it's this hospital list and they came in and then they've handed it off to this hospital list and they've been in the intensive care unit and these specialists have seen the patients so there is a lot of working parts in terms of different providers interacting so who's who's wrapping their arms around the whole picture so that's an opportunity for glitches and because of the multiplicity of providers the communication can break down between us but it also can break down between patients and one of the things you will hear if you're in the hospital's world is what was the patient satisfaction survey that sort of stuff one of the things in a teaching hospital like this that we get dinged on frequently is physician to patient communication and that is often because one team or part of the team will tell a patient on thing and somebody else comes in and tells them something completely differently we confuse the patient so that's important okay and lastly on this slide less than half of patients just discharged from an academic general medicine service know their diagnosis why they were even in the hospital they don't know their treatment plan or the side effects so there's a lot of opportunities so kind of in summary hospital discharges are complex we often have have unintended readmissions that can occur especially when the patient follow-up is unclear and without defined rules in terms of who's doing what we may not pay very much attention to the patient's understanding or their caregivers understanding and their ability not just their understanding but their ability when the patient leaves us we mentioned the fragmented care that can contribute to this complexity and ultimately we need to be thinking of a patient-centered approach to their medication use and access and treatment options so kind of background so what are the elements of the discharge process I've got six items listed here we'll go over each of them discharge planning medication reconciliation the discharge summary itself patient education instructions what happens post discharge from the hospitalist perspective and then lastly I'll go over a discharge checklist on that alright one of the things you need to think about is discharge planning starts almost immediately after they hit the door I like to tell my teams you tackle the ABCD s airway breathing circulation disposition so one a B and C are stable you need to be thinking about disposition right away right away that could be even is this patient going to be placed in observation or is this patient going to be placed in patient because if you think your best guess is this person needs to go to a rehab facility at discharge you're going to prefer to put them as an inpatient so it starts right from the beginning starts as part of your history and physical which can include their social support network their living conditions their medication plan you'll hear this over and over again what meds are they on are they taking them are they able to get them so from the beginning you're finding out all that information as we learn we don't wait till the last day as we learn what we are diagnosing them with we need to be teaching the patient every day and as we evolve will ultimately get to discharge instructions and an actual discharge event related to when you write your discharge order and then there's some post discharge follow-up that will hit on okay so you've got somebody you think is about ready to be discharged you need to be aware of ultimately where you think they're going to be ready to go home or ready to be discharged to so part of that decision-making is what is their cognitive status what is their current activity level and functional status what's their home like do they have stairs they have to get into but they can't do anything but go on a wheelchair right now do they have any support it may not be family but sometimes close friends neighbors what-have-you are willing to help out do they have nobody are they homeless all of those factors will play into whether a patient is appropriate for discharge because they have to have a safe place for us to discharge them can they obtain their medications and services do they have transportation not only from the hospital but to any follow-up treatment or appointments that you have lined up for them and if they need it or is there any community assistance available that they could access that might allow you to discharge the patient so if you think a patient's going to be discharged home they need to be able to obtain their medications and administer their own medication or have a caregiver support person that can do that for them can they do their own self-care activities or have someone able and willing to do that for them are they able to eat an appropriate diet oh we just took out their dog HOF tube you know they have nothing else we have an assess their speech their swallowing that sort of stuff so now are they able to maintain adequate hydration and nutrition and can we help arrange follow-up with appropriate providers and can they get there so that's somebody that they need all that criteria it's appropriate to discharge them home there are inpatient rehab facilities and here in town obviously Frasier is our acute care inpatient rehab facility to be eligible to go to that they have to typically be able to participate in at least three hours of therapy per day and at those facilities typically they are supervised by a physician at least three times a week mm-hm long-term acute care hospitals sometimes our patients out of the ICU might meet criteria for that usually if that's the case if somebody anticipates going to need long-term supports it's best to get that consideration done while they're still in the ICU for example a long-term acute care hospital can manage someone who's chronically on a ventilator needs prolonged IV therapy needs daily monitoring so there's some criteria for that if they get too well they're not eligible for a long-term acute care hospital they usually anticipate those folks are going to be in that facility at least twenty-five days okay what we're more experienced with is folks that who are not eligible to go home we try to get them into a sub acute rehab and at least for our Medicare eligible or Medicare insured patients they have to spend that three midnight rule that 72-hour section not 72 hours it's actually three Midnight's to qualify for their insurance to pay for their sub acute rehab they have to have some skilled need be it physical therapy occupational speech therapy or skilled nursing of some kind that of at least an hour a day to qualify so if they're too good their insurance company won't pay for that it's very hard to get somebody straight from the hospital to long term nursing home the nursing homes are also affiliated with a sub acute rehab but for their financial reasons they want to get the benefit of the higher reimbursement at least of a sub acute rehab say before they are converted into a long-term patient so we don't always know that but that that's their thinking on that so sometimes we'll get resistance if they are again not needing any skill okay all right where we talked about the risk of medications medication reconciliation should start right away for one reason it gets those annoying pop-ups that come over and over again when you click on a patient and you haven't done their admission reconciliation the sooner you do that the sooner that goes away it's important for ongoing inpatient care so we know we're not missing anything but it also makes ultimately our discharge medication reconciliation easier the good thing here is we do have ancillary support there are folks down in the ER pharmacy techs that will begin that and nurses that will begin that process for us but it isn't always complete many times on our word teams etc you will have a pharmacist or pharmacy student or pharmacy resident who will contact pharmacies for you to get appropriate doses and that sort of thing so get it done as soon as possible as I said it actually helps with current care but it also makes discharging easier okay one of the things that we often don't think about but is important as you're anticipating discharge is a couple of things is can the patient afford them if you prescribe them maybe they keep bouncing back because nobody's asked them why they're not taking their medication and it might be the copay is too high they might be injured but the copay is that still it's $100 a month even with my copay can they understand how to take whatever are they using their inhaler for example properly and then of course as part of the ultimate discharge reconciliation we do a lot of clicking and it imports we need to highlight especially for patients medications that were stopped or medications that were continued but at a different dose range I think it's easier sometimes to pay attention to the new medications added because they'll have a new prescription or what have you but in our documentation is that something that if we highlight I've had patients that they've been taking two of the same medicines they come back in you know I've been taking lisinopril and and something else picked one that was I've used the generic so long I've forgotten the brand the brand name but but anyway they're taking two of the same medication and they may have consequences because they couldn't tell it was any different so and if they're getting their medications filled at multiple pharmacies they may not that may not be picked up by one of our safety net opportunities which is other team members okay and just as a real quick you know if you're in the admin management and medications here you can see that and all of these that are highlighted and orange have not been reconciled yet and once you and it even tells you here you have nine unreconciled so the sooner it's done the better okay so we've talked about are they appropriate for discharge and starting to plan that and their medication reconciliation before we ultimately let them leave we need to be thinking about our discharge summary you're supposed to complete your discharge summary here you'll fail within 48 hours right isn't that what they tell you 48 hours yes - no maybe okay these are Joint Commission standards for your discharge summary and I will tell you this is kind of a bare minimum why were they in the hospital significant findings did they have any procedures specific treatments that we provided while they were here what condition were they when we discharged them any patient and family instructions and most importantly not the attending signature so that's kind of a bare minimum but remember that the discharge summary for one thing is our primary way we communicate with the aftercare providers the PCP what have you so if we don't do it in a timely fashion they don't get it they don't know what to expect we are very lucky here at University Hospital we have nurse clinicians on our medical ward teams and they will bend over backwards to help make sure that this communication is done in a timely fashion but I can tell you they frequently are bothered because they've made a timely follow-up for the patient and we don't and they will send that complete a discharge summary to the follow-up providers and if we haven't finished it not so good so it has an important impact it's easier than it ever has been before now that we're lectrons back when you had to dictate you know it took forever but it is important from a safety point of view to get those done as soon as possible and absolutely before the patient is seen and follow-up so they could receive the information that is very important that you're going to share with them okay and I've already mentioned the patients often don't know what they're on their follow up etc okay again you're lucky with our nurse clinicians they do this part but if you are at a place where you don't have one and you're in charge of scheduling your own follow the patient follow-up appointments for your patients it's important to ask them you know is there a time of the week time of the day they can or cannot show up if you make them on a morning appointment and they can't get there because their rides only available in the afternoon there will be a no-show so our nurse clinicians ask - do they have a ride to get to these appointments and they actually make these appointments for us and save yourself a little reminder for those patients discharged over the weekend and they will do it for you Monday the pending lab tests and other tests part of our job is to make sure that we don't miss them I don't talk about medical-legal very often but one of the things that we all need to know is if we ordered it we are responsible no matter really who we say so there is a way of doing a communication message to yourself to say follow up on mrs. Jones aana or whatever if to send out lab and you keep that reminder until you've checked it off of your list you can say you're going to divert to the PCP to follow up you know I'm not going to trust that the lawyer is going to accept that hand off if we ordered the test in and it's in it and it's an important test so pay attention to that as part of the process take ownership of it if it was important enough for us to order we should follow up on it okay so a little bit more than what the Joint Commission requires this is a lot of what we asked you to do in our discharge summaries obviously you have to have the admitting diagnosis or they quote problem that led to hospitalization you have to have a principal final diagnosis and as an aside like for your coders sometimes we don't know and they have a couple of things like a classic want to say you've got somebody who's come in they're short of breath they have COPD they have congestive heart failure and they have some symptoms of both of those and you treat both of those all right I don't know which one of those pays the hospital more I don't need to decide that I can say it's my principal final diagnosis acute left systolic heart failure exacerbation with acute COPD exacerbation with hypoxic you on chronic hypoxic respiratory failure they can pick whichever one pays the most to the hospital they can pick whichever one is the major comorbidity because a lot of times you know people try to just pick one diagnosis you don't have to anything else you can list under secondary diagnosis if they are things that we treated and managed in the hospital you don't have to list all their chronic medical problems there we do want to talk about their key findings and test results a pet peeve of mine is when you cut and paste the full radiology reports and leave them in there the more you have in your summary the less someone's going to process so a couple copy and paste that's fine but delete everything that is not important sometimes the important stuff is in the body not just the summary you know that better than whoever is going to receive that patient so make them short make them brief make it a summary don't make it a complete copy of their holes time they were in the hospital brief Hospital course especially for patients that have been in the hospital for a while it is much more effective to do this in a problem focus fashion don't do it day at this day this happened and then that happened if you do it problem focused you can do it in a much more succinctly we must have the condition at discharge in cluded and that has a bunch of things like diet and activity weight-bearing you're driving limitations that sort of thing where where they being discharged to they're going home they go into a facility I've put in red because it's very important medications that discharged you can import some of that but again I want you to be in charge of highlighting things that are different from when they came into the hospital your document is going to include any follow-up plans it may include because sometimes we do follow-up testing you've got an echocardiogram ordered in two in a week before your follow-up appointment so that should be listed there any anticipated problems you know that's a lot of times as in their instructions if you get fever if you get chest pain if whatever the put that in there sometimes we give suggestions to the follow-up provider in terms of what we expect what we've done they might need more tweaking of their diuretics or more potassium but what if you have some suggestions to the provider who will be seeing the patient at the first follow-up visit list them in there again in red anything that's pending if your sub specialist your consultants had any specific recommendations include those we're supposed to document patient education and I think that often happens under the nursing component I will tell you we don't yet have what I would consider an optimal patient education a patient discharge education packet handout if you look at them they include a lot of extraneous stuff being a stroke center I don't know if you've noticed all of our just church packets have signs and symptoms of stroke even though that may not be relevant and it may actually detract our patients paying attention to the things that we want them to pay attention to that are related to why they came in the hospital so ultimately going forward a bit awesome if we can get a more patient-centered discharge education packet than we currently have the numbers are on there who to call etc and then lastly copy to whichever providers need to receive a copy definitely the primary care and so specialists etc that will be seeing the patient in follow-up how do we know if our patient knows what's going on with their whole illness and their management there are a variety of tools that have been developed and we'll talk about some of them talk about our actual job of teaching the patient there's a technique to teach back the upper levels have definitely been exposed to this I don't know if the interns have encountered that it often happens with dr. Kubiak in the clinic where you get some training on teach back it's not just can they regurgitate facts do they actually comprehend what's going on and then there's an SV 3 thing that will help assess some of this so teaching the patient do they know why they were admitted to the hospital do they know their limitations their current condition when we're ready to send them out do they have any clue as to what their current medications are so when we add new medications we don't have to wait till the day of discharge to begin teaching about this medication lisinopril it causes you know it's for your blood pressure it's for your heart failure do let your doctor know if you start getting up coughs that you haven't previously had on that medication as an example there are a variety of ways we can do the teach back methods that incorporate the patient's health literacy language language and culture issues that may impede or block their understanding it could be how we talk we might be doing too much medical jargon so be aware of that so first what is teach back so teach back show me methods show me as if it's actually something mechanical let's say an inhaler used for example so you start the health system providers were giving a new concept either new health information change in management what have you so the clinician goes in and explains or demonstrates then the next step is the clinician assesses the patient's recall and their comprehension and where appropriate that we ask the patient to demonstrate can you give yourself that insulin shot for example you see what they've said back to you you tweak it clarify it and then you reassess and hopefully you get to a point where you're not going around this loop but one time but you go through it until you realize that this method is not going to work and then you get a back-up plan but this is very effective for many people and it picks up things that you may not have appreciated what's going on and then as I said if we do this we actually can it's been shown you can get improve adherence to medication use follow-up etc proper techniques so as part of the teach spec one of the things that we as the providers need to do is we take the onus on ourselves so that if they don't understand it's our fault we didn't explain properly so I want to make sure I didn't leave anything out that I should have told you so can you tell me let me know what to do so that I'll be sure I know what's important ok so just kind of ask them to reflect back what they have heard you say I want to be sure I did a good job explaining your blood pressure medications but because this can be confusing can you tell me what changes we decided to make and how you're going to take your medications now going forward with the changes we've made another way is how are they going to communicate this is someone else in the family so when you go home and your grandchild asks you what the doctor said about your heart how are you going to explain it to your grandchild so the different ways of phrasing it all the while your goal is to see have you done a job effective job communicating with the patient what's actually going on with them and how to manage it ok so one of the things the patient actually may know quite well and reflect back quite well what you have said and we often stop there okay you need to take your insulin twice a day I want you to check your blood Sugar's four times a day and I want you to bring that that blood sugar log in with you when you go see your doctor okay do you see yourself able to follow those instructions nope I'm afraid of needles I'm not going to do it you know you know you may you just may not have even thought about asking that question but they have a very strong opinion about their answer to that and we skip this uh-huh no I don't think I can do that because I can't I don't have transportation I'm not going to be able to make that follow-up appointment so they want to please you so they may not volunteer that information so we need to know their willingness and ability to do some of the things that we're trying to make happen because otherwise it doesn't and they may be bouncing back within that 30-day time window so they may have functional barriers could be a memory problem environmental barriers and then they have attitudinal barriers not everybody trusts doctors and sometimes that's for good reason so we just need to be aware of that because we don't we do them no good if we're at loggerheads you know we're saying one thing and they're hearing something entirely differently or or not just not interested in what we have to offer and then you kind of score with the next steps ours what what do you want out of the health system you know if you're not willing to follow our recommendations you'll do you have an alternative Sean asked me three all of our patients should be able to do this what's my main problem what do I need to do to manage that main problem what happens if I don't manage that thing that's important okay you're up all night urinating if you don't take your insulin okay just you can make it as relevant to them it increases your risk of foot amputation they may not care about that but they might care about nocturia so make it relevant you know Chris is your risk of death you may not be important to them okay post discharge activities again you are lucky here because your nurse clinicians do a lot of this for you and that is like making sure that the discharge summary gets sent in a timely fashion to the post care follow-up providers it is as you can see here the discharge summary reaches the PCP by the first follow-up visit in only 12 to 34 percent of their follow-up visits there's some suggestion particularly in the Medicare population that if they are seen within the first week after discharge they are less likely to be readmitted it's not good and solid but some suggestion that it's beneficial it isn't going to be beneficial if the PCP doesn't have the information about the hospital because they won't know and sometimes others turn right around and readmit the patient to you okay so that actually can be counterproductive you're trying to keep them out of the hospital you've sent them for follow-up and they up don't go back to the hospital you have a team or whatever action okay we we do this actually before have they gotten all their services home he'll find up any durable medical equipment that they need follow-up our nurse clinicians call our patients 48 to 72 hours after discharge depending on where they are you know weekend and that kind of stuff to see if they've had any problems filling their medications or any other issues or any confusion that may or may not help reduce readmissions it doesn't hurt it it might help it we know that much okay so there are these redesigned re-engineered discharge checklists much more detailed than just the Joint Commission we've gone over all of these pretty much the medicine reconciliation the discharge plan should include those things we highlighted we need to have their follow-up appointments lined up any outstanding pending lab tests and radiology needs to be dealt with in terms of who's going to take ownership of following up for those things do they have any therapy home health outpatient physical therapy outpatient antibiotic anything like that have we arranged that appropriately does the patient have a risk written discharge plan ideally one that is at their educational level that they can understand in their language where appropriate what is the patient to do should they have any problems that develop who's going to answer those questions for them have we educated them have we assess their understanding have we assessed their willingness to participate in those activities that we think that they are going to be doing have we finished our discharge summary in 48 hours and made sure it was sent enough fashion to the outpatient follow-up providers got our post discharged phone call lined up so I think the most important thing for us to remember about the whole discharge process it's my favorite part of medical care right you're excited when you get to discharge something actually it's not you like to take care of neat people with fun diagnosis but it's important it's a very risky time for our patients common things happen medication problems failure to follow up labs failure to communicate with their follow-up providers we have an opportunity with our patients to do the best we can and by recognizing that this is just as important as getting that static with cardiogram or getting antibiotics on board in terms of the patient's ultimate well-being we need to do a good job we need to communicate effectively and do our best to avoid preventable complications that lead to people coming back and coming back sometimes with then ongoing disabilities related to whatever we may have not done optimally when we discharge them 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