Thursday, June 18, 2009

Hospital Discharge - Let's Get it Right

Patients are staying fewer days in the hospital and receiving "post-op" and "post-hospital" care at home. The days of staying 10 days for an appendectomy, or hysterectomy, or pneumonia or joint replacement or just about anything are long gone. These shorter hospital stays require patients to really understand what will happen when they go home. Coordination about appropriate follow-up is essential, as well as medications, pending lab tests etc. In 2007 a study sponsored by the Agency for Healthcare Research and Quality (AHRQ) found that more than 1/3 of patients discharged from a large teaching hospital, failed to get follow up care. Yikes!!!

I was interested to read about a new program that is being piloted in Boston called Project RED (short for Re-engineered Discharge) and led by family medicine doctor Brian Jack. The program uses 11 steps to make sure patients are well cared for at discharge. I will try to give a brief description:
  • Educate the patient about the diagnoses throughout the hospital stay
  • Make follow up appointments and testing for the patient before they go home
  • Discuss any tests or studies from the hospital and make sure there is someone responsible for follow-up
  • Organize post discharge services, including making appointments and guaranteed transport
  • Confirm the medication plan and make sure the patient understands
  • Make sure the discharge plan goes with national guidelines
  • Review steps to take if a problem arises..who to call, what is an emergency
  • Ensure all physicians receive the discharge summary
  • Ask the patients to explain the plan in their own words
  • Give the patient a written discharge plan with medications listed
  • Phone the patient 2-3 days after discharge to resolve problems
By following these steps, Project RED had 1/3 fewer re-admits and 30% fewer emergency visits.

Why isn't everyone doing this? There are absolutely no financial incentives to implement a discharge program such as this. Hospitals are busy, chaotic places and protocols, training and accountability need to be put into place. The rapid admit/discharge pace and obscene amount of stupid charting that is "required" to be done, leaves little time for doing things that really help patient care.

As we talk about health care reform, we also need to institute re-engineered processes that put the patient first and reward caregivers who do it right.


KM said...

I can completely relate to this.
Two years my mother who is usually healthy had a planned hip replacement. As a result of the surgical blood loss, had three units of blood transfused when her vitals were dropping very low. It was done at Kaiser with a very good surgeon but was sent home 2 days post op for me and and another relaive to take care of her. One thing that they did which was helpful when they had her go to an educational PT class ahead of time to practice how it would be after surgery. Also all the tools and equiptment she would need she was informed about so it was ordered ahead of time ready to use when discharged.

The one thing that should have been coordinated better was getting the pain med. when it ran out on the weekend and the doctor was not here to authorize for the pharmacy as well as discharge meds. at time of discharge. Big hold up of 1-2 hrs. with lack of communication between nurses, doctors and pharmacy.

Another thing that should have been explained to family members doing the care giving at home is what symptons and signs of a vasovagal looks like and what needs to be done when that happens. If a vasovagal is not known about can be a very scary situation.

Also when strokes are unrecognized or misdiagnosed and the patient is sent home from the ER they just have to be brought back in to have the CT Scan that should have been ordererd in the first place.

In addition some hospitals put storke patients in a Psych Unit which should not be done when it is a neurolgical and cardiac problem for the CCU and keeps the patient from getting the needed medical treatment to be discharged or transfered sooner, to work at getting what damage of defecites corrected that can be reversed. When a stroke patient is not scanned and sent home with the wrong diagnosis that reduces the time frame window for TPA to be used if possiable or the cork screw procedure to be done when approperiate.

Sounds like a great plan being done in Boston if they can have a discharge person or team to allow time for it.

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