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A Multidisciplinary Discharge Timeout Checklist Improves Patient Education and Captures Discharge Process Errors

Gao, Michael, C., MD; Martin, Paul, B., MD, MPH; Motal, Julius, MS; Gingras, Laura, F., MD; Chai, Christina, MD; Maikoff, Megan, E., MPA, BSN; Sarkisian, Alex, M., MD, MSc; Rosenthal, Nadine, DNP, RN, CCRN, NEA-BC; Eiss, Brian, M., MD

Quality Management in Healthcare: April/June 2018 - Volume 27 - Issue 2 - p 63–68
doi: 10.1097/QMH.0000000000000168
Strategies for Quality Improvement

Objective: To design and implement a discharge timeout checklist, and to assess its effects on patients' understanding as well as the potential impact on preventable medical errors surrounding hospital discharges to home.

Methods: Based on the structure successfully used for surgical procedures and using the Model for Improvement framework, we designed a discharge checklist to review and assess patients' understanding of discharge medications, catheters, home care plans, follow-up, symptoms, and who to call with problems after discharge. In parallel, we developed a process of integrating the checklist into the discharge process after routine discharge procedures were completed. We used the checklists to assess patients' level of understanding and need for additional education as well as changes in discharge documentation; we also noted whether good catches of significant errors in the discharge process occurred.

Results: Over 6 months of study, 190 discharge timeouts out of 429 eligible discharges were completed. Additional education was provided in 53 of 190 discharge timeouts (27.8%), with 62% of this education being related to medications. Twenty-one (11.1%) discharge timeouts resulted in at least one change to the discharge documentation or a good catch.

Conclusions: A multidisciplinary discharge timeout directly involving the patient can be effective in targeting additional areas for patient education and in potentially reducing preventable adverse events.

NewYork-Presbyterian Hospital, New York (Drs Gao, Martin, Gingras, Chai, Rosenthal, and Eiss, Mr Motal, and Ms Maikoff); Department of Medicine (Drs Gao, Martin, Gingras, Chai, and Eiss), Division of General Internal Medicine, Section of Hospital Medicine (Drs Gao and Martin), Division of General Internal Medicine, Section of Ambulatory Medicine (Drs Gingras and Eiss), and Division of Geriatrics and Palliative Medicine (Dr Eiss), Weill Cornell Medical College, New York; and Tulane University School of Medicine, New Orleans, Louisiana (Dr Sarkisian).

Correspondence: Paul B. Martin, MD, MPH, Weill Cornell Medicine, Hospital Medicine, 525 E 68th St, Box 331, New York, NY 10065 (pam9126@med.cornell.edu).

The authors report no conflicts of interest.

Of the 35 million inpatient hospital discharges annually in the United States,1 nearly 1 in 8 patients experiences a preventable adverse event.2 , 3 Several system-level factors have made transitional care more challenging, which increases vulnerability to medical errors. Patients have increasingly complex chronic conditions4 and polypharmacy is widespread,5 while economic pressures have led to decreased length of hospital stays,6–9 resulting in more acute care being pushed to the posthospital care period. In addition, there has been a proliferation of hospitalists with correspondingly diminished involvement of primary care physicians in inpatient care,10 , 11 leading to additional transitions of care and potential gaps in communication. Fragmentation of care makes discharge documentation, patient education, and disease self-management crucial in bridging the gap from hospital to home; when these components are robust, complete, and accurate, they may insulate against adverse events.12 However, discharge documentation often contains incomplete or erroneous clinical information, including incomplete discharge diagnoses or elements of a hospital course, missing diagnostic test results, incorrect discharge medications, and absent follow-up plans.2 , 13–16 There are also deficiencies in patient knowledge: in previous studies, a majority of patients were unable to name their discharge diagnosis, list their medications, or describe follow-up plans17–19; patients were also frequently unable to describe major side effects or correct medication schedules.20 , 21

Several randomized controlled trials have examined discharge interventions that improve patient education. Jack et al22 and Naylor et al23 trialed advanced practice nurses who assumed continuity of care responsibilities, such as discharge planning and visiting the patient, and found decreased readmissions. Others have tested pharmacist involvement in discharge medication reconciliation and counseling and found improved patient knowledge and decreased drug adverse events.24–26 A recent study piloted a discharge timeout with 2 nurses reviewing discharge medications and found a decrease in medication discrepancies.27

Less well studied in the discharge literature are the effects of these interventions on rare but potentially severe events. Over a 9-month period at our institution, 3 patients were discharged with intravenous (IV) catheters left in place unintentionally. The precise frequency of this type of rare event is unknown, but in other studies, as many as 30% of providers are unaware of central venous catheters present in their patients.28

In surgery, timeouts have been used successfully to ensure that critical processes are executed correctly.29–31 In addition to being effective at preventing common errors, surgical timeouts can catch rare events such as wrong-site surgery.32 , 33 We hypothesized that a similar process might be used to improve critical processes related to patient discharge. Prior studies have described discharge checklists for providers to ensure optimal handoff,34 , 35 nurse-to-nurse and pharmacist-to-physician timeouts for review of medications,27 , 36 and attending-to-house staff timeouts for review of key parts of the discharge plan.37 To our knowledge, no discharge timeouts directly involving the patient have been previously described.

Recognizing a need for a robust, standardized process to enhance the safety of the hospital discharge process, we created and implemented a comprehensive, multidisciplinary, and patient-centered timeout procedure utilizing a checklist to allow for the timely recognition and efficient correction of safety vulnerabilities at the time of hospital discharge.

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METHODS

Design structure

Quality improvement design was undertaken using the Model for Improvement as a framework and Plan-Do-Study-Act (PDSA) methodology. The institutional review board at our institution determined that this was a quality improvement project that met criteria for operational improvement, did not constitute research with human subjects, and was exempt from ethics review.

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Study setting and population

This project was performed on a 28-bed general medicine unit within an 862-bed urban academic tertiary care hospital. All patients from this unit who were discharged to home between March 1 and September 16, 2015, and cared for by a participating internal medicine team were eligible for a discharge timeout (N = 429). Two house staff teams started the pilot on March 1, and after 2 months, the project was expanded to include 7 medicine house staff teams as well as 6 teams staffed by attending physicians working with physician assistants.

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Checklist creation

During the first phase of the project, we assembled a working group consisting of all the major stakeholders, including providers, nursing and nursing leadership, social work, care coordination, and members of our institution's quality improvement division. The work group focused on both creating the initial version of the checklist and developing a suggested discharge timeout process. The checklist assesses patients' understanding in 6 domains chosen based on common associated adverse events (Table 1 and Figure 1): the presence of lines or catheters, home care plans, follow-up care, warning signs and symptoms, postdischarge contacts, and medication reconciliation. Differences noted between discharge plans and the patient's understanding thereof either created opportunities for further teach-back education or alerted providers to errors within the discharge summary.

Figure 1

Figure 1

Table 1

Table 1

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Timeout process

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.

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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.

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RESULTS

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.

Figure 2

Figure 2

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.

Table 2

Table 2

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).

Figure 3

Figure 3

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DISCUSSION

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.

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Limitations

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.

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CONCLUSIONS

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:

care transitions; checklist; hospital discharge; multidisciplinary; patient education; timeout

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