Planned discharges were identified during morning interdisciplinary rounds, which were attended by providers, nurses, and social workers. After the discharge decision was made, with finalized discharge documentation and medication reconciliation in the electronic medical record, the primary nurse was notified that the patient was ready for discharge and a discharge order was placed. The nurse then paged the provider with a suggested time for the discharge timeout within his or her workflow. The provider could either confirm the time or suggest an alternative. At the time of discharge, the nurse first completed the routine discharge process including the provision of discharge instructions, documentation, and medication lists. These were reviewed with the patient as part of usual care, and any lines or tubes were removed if indicated. Subsequently, either directly following or later in the day, the nurse and the clinician convened with the patient at bedside to perform the discharge timeout during which they reviewed and completed a form that listed the 6-domain checklist.
Using rapid PDSA cycle methodology, we made changes to both the checklist form and the timeout process over the course of the project. Focus groups incorporated feedback from providers, and after initially only including patients cared for by unit-localized medicine teams, by the end of the study period, patients cared for by all medicine house staff teams and then physician assistant staffed teams were included in a stepwise fashion. The timeout checklist form was reformatted to better capture the study outcomes, and the process was altered to decrease the amount of manual provider input and to allow for free-form commenting.
Outcomes and analysis
Completed discharge timeout checklist forms were collected and matched to the unit's discharge logs. The latter was used to identify discharges to home for which no discharge timeout was completed.
The nurses utilized paper copies of the checklist tool to run the timeout and as a documentation tool. The checklist included the names of the provider participants in the timeout and the start and end times. In cases when the timeout did not occur, barriers preventing completion were tracked, such as clinician unavailability. Nursing also documented for each domain if additional education was needed or provided (reinforcement), whether safety issues or good catches were identified, and whether changes to the discharge summary or medication list were made.
The primary process measure was the percentage of discharges home that included a discharge timeout. We also assessed timing of discharges relative to timeout completion. The primary balancing measure was the time to complete the timeout at bedside.
Our primary outcome measures were needed for additional patient education (in general and by domain) and the type and number of safety issues (good catches) identified. Other outcome measures were changes made to the discharge summary or medication list. We collected information on the type of changes that were made when providers documented these changes in free text areas.
To gain insight into the value of this novel process and target potential areas of improvement, clinicians and nurses who had participated in at least 1 discharge timeout were surveyed regarding their satisfaction surrounding several elements of the discharge timeout process.
All statistics were performed using R version 3.3.0 by the R Foundation for Statistical Computing (R Core Team 2016). P values listed are 2-tailed z tests for independent proportions.
Over a 6-month period, 429 discharges to home occurred, and of these, 190 had a discharge timeout performed. In 55 of 190 (28.9%) discharge timeouts, additional education was needed in at least 1 domain. Medications was the most common category requiring education whereas lines and tubes was the least common (Figure 2a). In 24 of 55 (43.6%) discharge timeouts, more than 1 category required education (Figure 2b). In nearly all—53 of 55 (96.4%)—discharge timeouts, additional education was provided, and of these, the doctor of medicine/physician assistant (MD/PA) helped provide education in 35 cases (66.2%). Of the 135 remaining patients who were not recorded as needing more education, 62 (46%) also received additional teaching.
Importantly, the discharge timeout resulted in 24 changes to discharge documentation, and 1 good catch, or potential adverse event, was captured and prevented by the process. Eighteen of the documentation changes were regarding incomplete or inaccurate medication lists; these included either the need for a completely new prescription or a change in the dose or timing of a medication listed. Five patients had a correction made to the details of a follow-up appointment or a completely new appointment made when it was noted that one had not yet been scheduled. One patient needed changes made to home care plans. Lastly, the good catch was finding and removing a peripheral IV catheter still in place. Some discharges required multiple documentation changes, and in total, 21 of 190 discharge timeouts resulted in at least 1 of the above interventions (11.1%).
The estimated average time to perform the timeout was 10.9 minutes (9.9 minutes). Based on survey results (Table 2), both clinicians and nurses felt that the discharge timeout was easy to perform, but expressed some concerns that having to schedule a time for the nurse and clinician to be simultaneously at the bedside might result in delayed discharges. Most agreed that it improved communication with patients as well as between clinicians and nurses. Compared with clinicians, nurses more consistently believed that the discharge timeout improved safety and should be standard of care, but both groups agreed or strongly agreed that they would want a discharge timeout for themselves or their family members.
The percentage of discharges home with a discharge timeout increased significantly over the course of our study: in the first 30 days of implementation, only 11 of 55 (20%) of eligible discharges had timeouts completed, but in the last 30 days this increased to 42 of 80 (52.5%) (P = .0001) (Figure 3a). The majority of our discharges occurred between 12 PM and 9 PM, and discharges later than that tended to not have completed timeouts (Figure 3b). Overall, we did not find significant differences in the rate of completion for patients on the PA service (47.1%) versus the house staff service (43.4%) (P = .27).
A recent Patient-Centered Outcomes Research Institute funded national study identified 8 “essential” transitional care components; among them were patient engagement, medication management, and patient education.38 Through this project, we demonstrate that a brief multidisciplinary discharge timeout that directly engages the patient using a brief checklist can be implemented and utilized on a significant percentage of discharges, and has the potential to prevent harm in the postdischarge period in several of these important realms. This intervention identified and corrected vulnerabilities in 1 in 10 patient discharges after the routine discharge process was completed, indicating a potentially significant reduction in errors in transition from inpatient to outpatient care.
There were several process-related successes: the discharge timeout process averaged only 10 minutes of time and, in contrast to much of the previously published transitional care work, no specific additional staff or targeted funding was required. Prior robust studies have shown decreases in downstream outcomes such as readmissions and medication adverse events, typically either by adding additional staff or staff roles or by making major changes to discharge processes.14 , 22 , 23 These may well be worthwhile interventions, and even cost-saving in the long run, but in our current health care economic climate it can be challenging to implement additional roles or take on additional salaries.
Notably, the distribution of time to complete the discharge timeout had a positive skew with an outlier of 62 minutes. This may reflect that our process scaled with patient needs: quick and efficient completion of discharge timeouts in which minimal additional needs were identified and more comprehensive interventions for complicated discharges with multiple gaps in understanding or documentation errors. And despite being limited to 1 unit only, with rapid turnover of house staff, we were able to sustain a 50% adherence rate.
Most importantly, 1 in 10 discharge timeouts uncovered an error in discharge instructions, a lack of scheduled follow-up, an incorrect discharge medication list, or a good catch. Of note, while identifying the peripheral IV line left in place is a true good catch given the clear patient safety implications, early recognition and correction of errors in discharge documentation could also have prevented adverse events. Our process was novel in that it allowed for real-time correction of these discrepancies, and, in turn, provided a systematic approach to reduce preventable adverse events. Our literature review does not find any other such self-contained, comprehensive, patient-centered processes described to date.
Approximately 27% of patients in our study were recorded as needing more education in at least 1 of 6 domains, most often regarding medication reconciliation. This matched other studies as the most frequently identified vulnerability.19 , 21 , 39 Interestingly, we also found that 62 of 135 (46%) patients who were deemed not requiring more education actually received additional teaching. This may represent variance on what is considered a significant lack of understanding or what is considered additional teaching, and will be an important area to clarify in future versions of the checklist form. In either case, the timeout was felt by providers to have a positive impact on patient education in a significant number of cases. And while participants expressed concerns about time required, highlighting the common challenge of “adding work” to an already busy day on the hospital wards, both clinicians and nurses still felt that the discharge process genuinely added value and another layer of safety to usual discharge care.
The study took place on 1 general medical unit at a single institution, which may limit generalizability. Components of the checklist also left room for interpretation, thus possibly skewing results; time required for the timeout was estimated by the participants and did not include travel and wait times, which may add costs. These may be offset by unmeasured benefits, such as a reduced need for additional ad hoc communication between nursing and provider staff to clear up errors that surfaced during the usual discharge process. Next steps will also include measurement of hard outcomes, such as hospital readmission, and measurement of patients' perceptions of their engagement in the discharge process.
A brief multidisciplinary discharge timeout that directly engages the patient can make discharge safer by targeting gaps in patient education for real-time reinforcement and, based on this pilot study, by identifying and correcting potential adverse events 1 out of every 10 times. This study describes a potentially high-yield, robust intervention, which may have an impact akin to utilizing timeouts and checklists in surgical patients. In the near future we plan to improve the process to include a higher percentage of patients and to study outcomes with firm endpoints such as readmissions and medication reconciliation errors. This will verify whether a multidisciplinary timeout utilizing a checklist is valuable and broadly applicable as a patient safety strategy to improve a major source of risk: the transition of the patient from inpatient to outpatient care.
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Keywords:© 2018Wolters Kluwer Health | Lippincott Williams & Wilkins
care transitions; checklist; hospital discharge; multidisciplinary; patient education; timeout