improving discharge efficiency in medically …...included a medical discharge goal order ( fig 4),...
TRANSCRIPT
Improving Discharge Efficiency in Medically Complex Pediatric PatientsAngela M. Statile, MD, MEd, a, b Amanda C. Schondelmeyer, MD, MSc, a, b, c Joanna E. Thomson, MD, MPH, a, b, c Laura H. Brower, MD, a, b Blair Davis, MS, c Jacob Redel, MD, d Julie Hausfeld, BSN, RN, e Karen Tucker, MSN, RN, e Denise L. White, PhD, MBA, b, c Christine M. White, MD, MATa, b, c
aDivision of Hospital Medicine, cJames M. Anderson Center
for Health Systems Excellence, dDivision of Endocrinology,
and eDepartment of Patient Services, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio; and bDepartment
of Pediatrics, University of Cincinnati College of Medicine,
Cincinnati, Ohio
Dr Statile conceptualized and designed the study,
oversaw improvement activities, drafted the
initial manuscript, and reviewed and revised
the manuscript; Drs Schondelmeyer and Brower
participated in the design of the study and
interventions for improvement, drafted the
initial manuscript, and reviewed and revised the
manuscript; Dr Thomson participated in the design
of the study and interventions for improvement,
carried out statistical analysis, drafted the
initial manuscript, and reviewed and revised the
manuscript; Ms Davis and Dr D. White provided
data support, carried out statistical analysis, and
reviewed and revised the manuscript; Dr Redel
and Ms Hausfeld participated in interventions
for improvement and reviewed and revised
the manuscript; Ms Tucker and Dr C. White
conceptualized and designed the study, oversaw
improvement activities, and reviewed and revised
the manuscript; and all authors approved the fi nal
manuscript as submitted.
DOI: 10.1542/peds.2015-3832
Accepted for publication Apr 19, 2016
Address correspondence to: Angela M. Statile,
MD, MEd, Division of Hospital Medicine, Cincinnati
Children’s Hospital Medical Center, 3333 Burnet
Ave, ML 3024, Cincinnati, OH 45229. E-mail: angela.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
1098-4275).
Copyright © 2016 by the American Academy of
Pediatrics
Children with medical complexity have
multisystem, chronic disease that can
result in frequent hospitalizations. 1, 2
With multiple diagnoses, need
for technology assistance, many
subspecialty providers, and numerous
medications, the discharge planning
process for this population is different
than for otherwise healthy children
hospitalized with acute illnesses.
Although it is essential to address
discharge needs to ensure safe and
effective transition from hospital
to home, hospital physicians
often prioritize treatment of acute
medical problems over discharge
planning. 3, 4 This poses challenges
to providing timely, efficient, and
safe hospital discharges, 3 care
characteristics prioritized by
the Institute of Medicine.5
Furthermore, discharge delays
negatively impact patient flow and
family experience. 6
abstractBACKGROUND AND OBJECTIVE: Children with medical complexity have unique needs
when facilitating transitions from hospital to home. Defining readiness for
discharge is challenging, and preparation requires coordination of family,
education, equipment, and medications. Our multidisciplinary team aimed
to increase the percentage of medically complex hospital medicine patients
discharged within 2 hours of meeting medical discharge goals from 50% to
80%.
METHODS: We used quality improvement methods to identify key drivers and
inform interventions. Medical discharge goals were defined on admission
for each patient. Interventions included implementation of a complex
care inpatient team with electronic admission order set, weekly care
coordination rounds, needs assessment tool, and medication pathway.
The primary measure, percentage of patients discharged within 2 hours
of meeting medical discharge goals, was followed on a run chart. The
secondary measures, pre- and post-intervention length of stay and 30-day
readmission rate, were compared by using Wilcoxon rank-sum and χ2 tests,
respectively.
RESULTS: The percentage of medically complex patients discharged within 2
hours of meeting medical discharge goals improved from 50% to 88% over
17 months and sustained for 6 months. In preintervention–postintervention
comparison, median length of stay did not change (3.1 days [interquartile
range, 1.8–7.0] vs 2.9 days [interquartile range, 1.7–6.1]; P = .67) and 30-day
readmission rate was not impacted (30.7% vs 26.4%; P = .51).
CONCLUSIONS: Efficient discharge for medically complex patients requires
support of a multidisciplinary team to proactively address discharge needs,
ensuring patients are ready for discharge when medical goals are met.
QUALITY REPORTPEDIATRICS Volume 138 , number 2 , August 2016 :e 20153832
To cite: Statile AM, Schondelmeyer AC, Thomson
JE, et al. Improving Discharge Effi ciency in Medically
Complex Pediatric Patients. Pediatrics. 2016;138(2):
e20153832
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STATILE et al
In previous work, we improved
discharge efficiency in our general
pediatric hospital medicine (HM)
patients. 7 Through standardization of
discharge goals and implementation
of high-reliability interventions
focused on physician and nursing
processes in the electronic health
record (EHR), 80% of patients are
now discharged from the hospital
within 2 hours of meeting medical
discharge goals.
However, the discharge process for
medically complex patients remained
inefficient; only 50% of patients
on the HM service with neurologic
impairment 8 and/or technology
dependence 9, 10 were discharged
within 2 hours of meeting medical
discharge goals. Preliminary work
revealed that the medical team often
overlooked the particular discharge
needs of these medically complex
patients and their families until
after a child was medically ready
for discharge. Discharge planning,
including changes to home care
orders with need for new equipment
and teaching, multiple medication
refills with need for previous
authorization, and specialized
transport home, was not approached
in a standard manner nor addressed
until the end of the stay. We
hypothesized that interventions
focused on optimization of
a standardized discharge
infrastructure for medically complex
patients would improve discharge
efficiency. By using improvement
methods and reliability science, our
multidisciplinary team aimed to
increase the percentage of medically
complex HM patients discharged
within 2 hours of meeting medical
discharge goals from 50% to 80%
within 12 months.
METHODS
Setting
Cincinnati Children’s Hospital
Medical Center (CCHMC) is a 522-
bed, free-standing children’s hospital.
Children with medical complexity,
defined as children with neurologic
impairment and/or technology
dependence for the purpose of this
study, are admitted primarily to 2
general HM units staffed by pediatric
registered nurses (RNs), with HM
attending physicians that supervise a
total of 5 teams of pediatric residents
providing direct care. Neurologic
impairment is defined as “functional
and/or intellectual impairments that
result from a variety of neurologic
diseases” (eg, anoxic brain injury,
lissencephaly). 8 Patients with
technology dependence “depend on
medical technology to live or remain
in their current state of health” (eg,
tracheostomy, enteral feeding tube,
cerebral spinal fluid shunt). 9, 10 The
majority of these children (55%)
receive outpatient care at CCHMC’s
Complex Care Center, a medical
home that provides primary care to
620 children with severe, chronic
disease who receive care from ≥3
subspecialists.
Planning the Intervention
Previous process improvement
on acute care patients 7 included
identification of medical goals
for discharge and real-time
documentation of when goals were
met by bedside RNs via an EHR
timestamp ( Fig 1); the same process
was applied to complex patients.
We created a multidisciplinary
group that included HM attending
physicians, RNs, care managers,
pharmacists, pediatric residents,
social workers, and parents of
children with medical complexity.
The group defined the process of
efficient discharge for children with
medical complexity and identified
key drivers ( Fig 2). Interventions
were designed to address top failure
reasons for not leaving within 2
hours of meeting medical goals
before the process was implemented,
specifically transportation concerns,
patient/parent factors, physician
delay, and medication delay ( Fig 3).
Successful interventions were
modified through sequential plan-do-
study-act cycles based on the model
for improvement11 before adopting
into the process.
Patients Grouped onto the Complex Care Inpatient Team
In July 2013, we grouped children
with medical complexity into 1
HM team supervised by a subset
of 15 HM attending physicians to
provide specialized care, including
proactive discharge planning, to this
patient population. The patients are
identified at the time of admission by
the RNs who manage bed placement
in our hospital using clinical
information from the admitting
provider. Before this work, these
patients were scattered among all
HM resident teams. Additional staff,
including a dedicated pharmacist,
dietician, care manager, and social
worker, were hired through hospital
e2
FIGURE 1Discharge effi ciency process.
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PEDIATRICS Volume 138 , number 2 , August 2016
investment in improving chronic
care. We also partnered closely with
the outpatient Complex Care Center
team, with their attending physicians
and care managers frequently joining
us for patient rounds.
Complex Care–Specifi c Order Set
In September 2013, we tested a
complex care–specific admission
order set in our EHR. The order set
included a medical discharge goal
order ( Fig 4), specific to the needs
of complex patients (eg, baseline
oxygen requirement for 12 hours,
tolerating enteral feeds for 24
hours). This order was placed on
admission, and the provider, with
input from caregivers and other
team members, chose medical
discharge goals from this list or
added other goals relevant to the
patient’s diagnoses. It was then
modified as the patient’s course
evolved. It focused only on medically
relevant items with the intent that
other discharge tasks (eg, home
care orders, medications) were
completed in advance of the patient
meeting medical discharge goals.
Weekly Multidisciplinary Care Coordination Rounds
In October 2013, the improvement
team implemented weekly
multidisciplinary care coordination
rounds. All team members attended
this meeting to discuss discharge
goals and complete discharge-related
tasks, including sending medications
to the pharmacy and completing
home care orders. Any clarifying
questions, such as transportation
needs, were then reviewed with
families at the bedside. Additional
interventions were needed to
coordinate care for patients with
shorter lengths of stay whose
admission did not overlap this
weekly meeting.
e3
FIGURE 2Key driver diagram.
FIGURE 3Preprocess Pareto chart.
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STATILE et al
Needs Assessment Tool
In January 2014, a needs assessment
tool was created to help structure
care coordination rounds and ensure
comprehensive discharge for patients
with shorter hospitalizations.
This checklist included 8 essential
discharge tasks specific to patients
with medical complexity ( Fig 5).
Although the items included in
the needs assessment tool were
distinct from medical discharge
goals, these tasks ensured the
logistics of discharge were addressed
throughout the hospitalization.
Initially a paper document, the
needs assessment tool was later
incorporated as a modifiable
document in the EHR, allowing all
members of the team to see the
status of each task. The assessment
was started on admission and
reviewed regularly throughout the
patient’s hospitalization, including
weekly team review at care
coordination rounds, to facilitate
completion of all tasks (eg, new
equipment, home nursing orders) 24
hours before the child was medically
ready for discharge. Specific sections
of the needs assessment tool
were assigned to team members
(eg, home care needs were the
primary responsibility of the care
manager) to improve reliable task
completion. At time of discharge, any
outstanding tasks were completed
by the discharging resident or nurse
practitioner.
Medication Pathway
Because discharge medication
prescribing was a frequent cause
for delay, a medication pathway
was introduced in late January
2014 to identify barriers (eg,
previous authorization) or changes
in regimen (eg, new prescriptions)
in advance of discharge. The team
pharmacist oversaw medication
reconciliation after admission and
tracked medication changes through
hospitalization. The pharmacist also
led a weekly meeting separate from
care coordination rounds in which
all medications were reviewed.
Additionally, our pharmacist
worked with families to identify
home medications requiring refill,
encouraged the team to prescribe
discharge medications early in the
stay, and called pharmacies to ensure
medications were available.
Planning Study of the Intervention
Baseline data before the advent of
the new inpatient complex care team
included medically complex HM
patients, identified by their primary
care relationship with the Complex
Care Center, from July 2012 through
June 2013.
Data describing our cohort were
extracted from the EHR, including
age, gender, primary insurer,
reported race and ethnicity,
complex chronic conditions (CCCs), 12
technology dependence, and
discharge diagnoses. CCCs were
defined as “any medical condition
that can be reasonably expected
e4
FIGURE 4Complex care–specifi c medical discharge goal order screenshot. © 2015 Epic Systems Corporation. Used with permission.
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FIGURE 5Needs assessment tool.
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STATILE et al
to last at least 12 months (unless
death intervenes) and to involve
either several different organ
systems or one system severely
enough to require specialty pediatric
care and probably some period of
hospitalization in a tertiary care
center.” 12 CCCs were grouped into
11 categories (eg, gastrointestinal,
respiratory). Technology dependence
(eg, tracheostomy) was defined
using the “dependence upon medical
technology” or “device” subcategory
within relevant CCC categories.
CCCs and technology dependence
categories are not mutually exclusive
(ie, a patient may have a diagnosis
in >1 CCC or technology dependence
category).
The primary outcome measure
was defined as the percentage of
medically complex patients, admitted
to the 2 primary units for HM
patients, who were discharged within
2 hours of meeting medical discharge
goals. We focused on these 2 units
becuase they already followed the
discharge process based on medical
goals from our previous work. 7
Median length of stay (LOS) was a
secondary outcome measure. To
ensure that our work in expediting
discharge did not negatively impact
readmission, 30-day readmission
rate was evaluated as a balancing
measure.
Analysis
We examined cohort demographic
and clinical characteristics using
descriptive statistics. A run chart
was used for analysis of our primary
outcome measure. Established rules
identified special cause variation for
run charts; specifically, 8 consecutive
points above or below the centerline,
which would occur <0.4% of the
time by chance, led to a midline
shift. 13 –17 For analysis of pre- and
postintervention outcomes of LOS
and 30-day readmission rate, we
excluded patients admitted during
the intervention period (September
22, 2014–March 23, 2015). Pre- and
postintervention median LOS were
compared by using Wilcoxon rank-
sum test. Pre- and postintervention
30-day readmission rates were
compared by using χ2 test.
RESULTS
Of the 385 encounters during
the study period (July 2012–May
2015), there were 227 unique
patients; 13 patients were
admitted in both preintervention
and postintervention timeframes.
The 227 patients were 54% male
with a median age of 5.3 years
(interquartile range [IQR] 2.2–
15.6). The majority were white
(66.1%) and non-Hispanic (92.9%)
with public primary insurance
(71.4%). Nearly three-quarters
of children had diagnoses in ≥4
CCC categories, with the most
common being neuromuscular
(75.8%), gastrointestinal (73.1%),
and congenital (65.6%). Nearly
80% of children were technology
dependent, most commonly in
the gastrointestinal category
(70.9%). There were no significant
differences in demographics
or clinical characteristics of
admitted patients pre- versus post-
intervention. The most common
discharge diagnoses in both pre-
and postintervention periods were:
(1) pneumonia (30% vs 22%), (2)
bronchiolitis (13% vs 13%) and
(3) vomiting and/or diarrhea (12%
vs 8%). Approximately 4% of total
HM discharges were attributable
to the group of medically complex
patients included in the study, which
accounted for ∼17% of our bed days.
The percentage of medically complex
patients discharged within 2 hours
on our 2 study units increased from
50% to 80% within 7 months
( Fig 6). Our initial shift to goal
occurred after the institution of
the needs assessment tool and
medication pathway.
Although we initially reached
our goal in October 2014, we
experienced a downward shift of
our outcome measure, with the
median percentage of eligible
patients discharged within 2 hours
of meeting medical discharge
goals decreasing to 63%. This shift
coincided with a rapid increase in
our overall hospital census starting
in August 2014. The increased
census on the units of interest may
have led bedside providers, such as
RNs covering other patients with
competing care demands, to stray
from proactive discharge planning
for our complex patients. With
interventions aimed at increasing
process reliability, including more
directed role assignment to team
members so that each provider
was aware of his/her specific task
responsibilities, we were able to
increase our median back above
goal, even with continued high
census. This improvement has
sustained at goal for 6 months.
Median LOS, our secondary measure,
did not significantly change between
pre- and postintervention (3.1
days [IQR, 1.8–7.0] vs 2.9 days
[IQR, 1.7–6.1]; P = .67). In addition,
our balancing measure, 30-day
readmission rate, was not negatively
impacted pre- and postintervention
(30.7% vs 26.4%; P = .51).
DISCUSSION
Through interventions focused on
proactive discharge planning for
medically complex patients, we
were successful in increasing the
percentage of patients discharged
within 2 hours of meeting medical
goals from 50% to 88%. Our most
impactful interventions included
standardizing discharge planning
processes and identifying discharge
barriers earlier. Although patients
left soon after meeting discharge
goals, the decrease in LOS was not
significant.
An overall improvement in the
efficiency of our process is valuable
even without LOS decline. By
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PEDIATRICS Volume 138 , number 2 , August 2016
anticipating discharge needs early,
we were better able to predict
timing of discharge, which facilitates
anticipating bed capacity on our
units. Additionally, our providers
noted a perceived workload
decompression, because the tasks
were no longer left for completion
on day of discharge. Our process
also allowed families to clearly
delineate their home needs so
that details were planned well in
advance of medical readiness. With
our detailed process and dedicated
team members, we also believe we
decreased the likelihood for errors
in the postdischarge timeframe, such
as inaccurate prescriptions or home
nursing orders. Readmission rates
were also not affected in our study,
suggesting that tracking medical
goals is a reasonable method to
determine when patients are ready
for discharge, and that our process
change did not lead to patients being
discharged too early.
In our previous efforts to improve
discharge efficiency, 7 we focused
on acute care patients admitted
with general medical diagnoses.
Although medically complex patients
were included in those efforts, we
struggled to discharge this subset
of patients in a timely fashion,
due to previous interventions not
being designed for coordination of
extensive outpatient needs. By first
standardizing the way we define
medical discharge goals in this
patient population and making this
order readily available in the EHR
order sets, admitting providers were
better able to apply the previous
process of defining discharge goals
on admission without interfering
with their workflow. This early
intervention facilitated later changes
aimed at standardizing discharge
processes.
As experts in the care of their
children, it was essential that
family members be engaged in
our improvement processes.
Medical goals were discussed and
modified with family input, and
discharge needs were identified
through interactions with our
multidisciplinary team members,
including our dietician, social worker,
pharmacist, and care manager.
Consideration for family schedules,
home equipment and medication
refills needed, and transportation
availability allowed us to reach
the common goal of readiness
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FIGURE 6Run chart for primary measure, percentage of HM patients with medical complexity discharged within 2 hours of meeting medical discharge goals.
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STATILE et al
for discharge when medically
appropriate.
Care coordination rounds were
instrumental in achieving reliable
completion of tasks before discharge.
By meeting as a team at a designated
time outside of rounds, we confirmed
that medical goals were updated
and social barriers identified. Key to
our success, the needs assessment
tool allowed tasks to be outlined
and tracked over time, facilitating
efficient discussion. This is similar to
adult studies that found success by
incorporating needs assessments into
their discharge planning bundles. 18 –22
In adults on a general medical service, 21
in adults with heart failure, 22 and in
elderly patients, internal medicine
teams demonstrated that by assessing
patients’ needs, they were able to
target interventions to individual
patients 19, 20 Our study used a similar
approach to identify individual patient
needs in our pediatric population
and target interventions (eg, assist
with transportation arrangement)
to facilitate a smooth transition to
home. One area included in the needs
assessment tool that often required
extensive coordination was discharge
medication preparedness. Medication
errors can lead to confusion at
home, adverse drug reactions, and
increased reutilization, 23 so attention
to performing comprehensive
reconciliation before discharge
was essential. Our pharmacist-
led medication pathway ensured
communication among prescribers,
families, and pharmacies. The input
of a pharmacist in predischarge
medication reconciliation is well-
described in adult hospitals as a way
to improve accuracy of medication
lists. 20, 23 – 28 Our study adds to this
literature, because our pharmacist-led
medication pathway was critical to
our process.
We limited this improvement
initiative to patients on our 2 main
HM units because those units used
the medically ready discharge
process from our previous work. 7
This led to a relatively low number
of patients included in this study,
which may have led to an increase
in variability, especially early
in data collection. We noted
even after an increase in our
biweekly numbers, however, that
the centerline of 50% remained
consistent and thus feel this is
reflective of the true baseline.
Our study population was limited
in that it did not include patients
with traditionally longer LOS,
such as those with ventilator
dependence, because they are
admitted to other units. By this, we
may have selected for a population
of medically complex patients
with shorter LOS, influencing our
ability to detect significant changes
in the secondary measure of LOS.
Importantly, LOS did not increase
during this project, nor was there an
increase in readmissions, suggesting
that patient care and discharge
using this new process did not
contribute to increased return for
admission because of an expedited
discharge. We also did not include
other medically complex patient
populations in our scope; by first
applying the process to our HM
patients, we now have experience to
support buy-in from other specialty
providers. We will continue to
follow our secondary measures as
we spread this process to other
services at our hospital, which will
allow us to measure our impact on a
larger scale.
The creation of a multidisciplinary
team with a variety of expertise
influenced our ability to improve
rapidly, which potentially limits
the generalizability of our study.
However, many of our key
interventions, such as meetings
to facilitate care coordination
and a tool to track discharge
task completion, could be easily
implemented in environments
where such a team is not available,
and the failures we addressed in our
process are likely common to many
settings.
Finally, the target of our
improvement, the discharge process,
is limited in that it is inherently
people dependent. Although we
used the EHR to standardize as
much as possible, our frontline
providers must be engaged for it to
be successful.
CONCLUSIONS
The discharge needs of medically
complex patients require the
support of a multidisciplinary
team. By defining medical goals and
discharge needs early, tracking tasks
over time, and designating roles to
team members, we ensured that
discharge tasks were complete when
patients were medically ready for
discharge.
ACKNOWLEDGMENTS
We appreciate the dedication of
our team, including: Suzan DeCicca,
MSW, LSW; Stacey Litman-Padnos,
MSW, LSW; Julie Ostrye, PharmD;
Becky Brehob-Bucker, RD; Derek
Fletcher, MD; David Hall, MD;
Michelle Cobble, BSN, RN; Matthew
Carroll, MD; Steven Smith, MD;
Emily Goodwin, MD; Meghan Hofto,
MD; Hilary Flint, DO; Marshall
Ashby; Shelly Miller; Margaret
DeOliveira; CCHMC inpatient and
Complex Care Center care managers;
CCHMC pediatric residents; and
HM advanced practice nurses and
attending physicians.
ABBREVIATIONS
CCC: complex chronic condition
CCHMC: Cincinnati Children’s
Hospital Medical Center
EHR: electronic health record
HM: hospital medicine
IQR: interquartile range
LOS: length of stay
RN: registered nurse
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REFERENCES
1. Cohen E, Kuo DZ, Agrawal R, et al.
Children with medical complexity:
an emerging population for clinical
and research initiatives. Pediatrics.
2011;127(3):529–538
2. Simon TD, Berry J, Feudtner C, et al.
Children with complex chronic
conditions in inpatient hospital
settings in the United States.
Pediatrics. 2010;126(4):647–655
3. Apkon M, Friedman JN. Planning for
effective hospital discharge. JAMA
Pediatr. 2014;168(10):890–891
4. Berry JG, Blaine K, Rogers J, et al
A framework of pediatric hospital
discharge care informed by legislation,
research, and practice. JAMA Pediatr.
2014;168(10):955–962; quiz 965–6
5. Institute of Medicine. Crossing the
Quality Chasm: A New Health System
for the 21st Century. Washington, D.C.:
National Academy Press; 2001
6. Shepperd S, Lannin NA, Clemson LM,
McCluskey A, Cameron ID, Barras SL.
Discharge planning from hospital to
home. Cochrane Database Syst Rev;
2013:(1):CD000313
7. White CM, Statile AM, White DL, et al.
Using quality improvement to optimise
paediatric discharge effi ciency. BMJ
Qual Saf. 2014;23(5):428–436
8. Berry JG, Poduri A, Bonkowsky JL,
et al. Trends in resource utilization by
children with neurological impairment
in the United States inpatient health
care system: a repeat cross-sectional
study. PLoS Med. 2012;9(1):e1001158
9. Feudtner C, Feinstein JA, Zhong W,
Hall M, Dai D. Pediatric complex
chronic conditions classifi cation
system version 2: updated for ICD-
10 and complex medical technology
dependence and transplantation. BMC
Pediatr. 2014;14:199
10. Feudtner C, Villareale NL, Morray B,
Sharp V, Hays RM, Neff JM. Technology-
dependency among patients
discharged from a children’s hospital:
a retrospective cohort study. BMC
Pediatr. 2005;5(1):8
11. Langley GJ, Moen R, Nolan KM,
Nolan TW, Norman CL, Provost LP.
The Improvement Guide: A Practical
Approach to Enhancing Organizational
Performance, 2nd ed. San Francisco:
Jossey-Bass; 2009
12. Feudtner C, Hays RM, Haynes G, Geyer
JR, Neff JM, Koepsell TD. Deaths
attributed to pediatric complex
chronic conditions: national trends
and implications for supportive care
services. Pediatrics. 2001;107(6).
Available at: http:// pediatrics.
aappublications. org/ content/ 107/ 6/
e99.
13. Carey RG. How do you know that
your care is improving? Part I: Basic
concepts in statistical thinking. J
Ambul Care Manage. 2002;25(1):80–87
14. Provost LP, Murray SK. The Health
Care Data Guide: Learning From Data
for Improvement. San Francisco, CA:
Jossey-Bass; 2011
15. Benneyan JC. Use and interpretation of
statistical quality control charts. Int J
Qual Health Care. 1998;10(1):69–73
16. Benneyan JC. Statistical quality
control methods in infection control
and hospital epidemiology, part
I: Introduction and basic theory.
Infect Control Hosp Epidemiol.
1998;19(3):194–214
17. Benneyan JC. Statistical quality
control methods in infection control
and hospital epidemiology, Part II:
Chart use, statistical properties, and
research issues. Infect Control Hosp
Epidemiol. 1998;19(4):265–283
18. Desai AD, Popalisky J, Simon TD,
Mangione-Smith RM. The effectiveness
of family-centered transition
processes from hospital settings to
home: a review of the literature. Hosp
Pediatr. 2015;5(4):219–231
19. Dedhia P, Kravet S, Bulger J, et al.
A quality improvement intervention
to facilitate the transition of older
adults from three hospitals back
to their homes. J Am Geriatr Soc.
2009;57(9):1540–1546
20. Koehler BE, Richter KM, Youngblood L,
et al Reduction of 30-day postdischarge
hospital readmission or emergency
department (ED) visit rates in high-
risk elderly medical patients through
delivery of a targeted care bundle.
J Hosp Med. 2009;4(4):211–218
21. Jack BW, Chetty VK, Anthony D, et al.
A reengineered hospital discharge
program to decrease rehospitalization:
a randomized trial. Ann Intern Med.
2009;150(3):178–187
22. Naylor MD, Brooten DA, Campbell RL,
Maislin G, McCauley KM, Schwartz
JS. Transitional care of older adults
hospitalized with heart failure: a
randomized, controlled trial. J Am
Geriatr Soc. 2004;52(5):675–684
23. Mueller SK, Sponsler KC, Kripalani
S, Schnipper JL. Hospital-based
medication reconciliation practices:
a systematic review. Arch Intern Med.
2012;172(14):1057–1069
24. Murphy EM, Oxencis CJ, Klauck JA,
Meyer DA, Zimmerman JM. Medication
reconciliation at an academic
medical center: implementation
of a comprehensive program
from admission to discharge. Am J
Health Syst Pharm. 2009;66(23):
2126–2131
25. Keeys C, Kalejaiye B, Skinner M,
et al Pharmacist-managed inpatient
discharge medication reconciliation:
a combined onsite and telepharmacy
model. Am J Health Syst Pharm.
2014;71(24):2159–2166
26. Holland DM. Interdisciplinary
collaboration in the provision of a
pharmacist-led discharge medication
reconciliation service at an Irish
teaching hospital. Int J Clin Pharm.
2015;37(2):310–319
27. Musgrave CR, Pilch NA, Taber DJ,
et al Improving transplant patient
e9
FINANCIAL DISCLOSURE: The authors have indicated that they have no fi nancial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated that they have no potential confl icts of interest to disclose.
by guest on September 26, 2020www.aappublications.org/newsDownloaded from
STATILE et al
safety through pharmacist dis-
charge medication reconciliation.
Am J Transplant. 2013:13(3):
796–801
28. Sarangarm P, London MS, Snowden SS,
et al Impact of pharmacist discharge
medication therapy counseling
and disease state education:
Pharmacist Assisting at Routine
Medical Discharge (project PhARMD).
Am J Med Qual. 2013;28(4):
292–300
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DOI: 10.1542/peds.2015-3832 originally published online July 13, 2016; 2016;138;Pediatrics
Christine M. WhiteBlair Davis, Jacob Redel, Julie Hausfeld, Karen Tucker, Denise L. White and
Angela M. Statile, Amanda C. Schondelmeyer, Joanna E. Thomson, Laura H. Brower,Improving Discharge Efficiency in Medically Complex Pediatric Patients
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DOI: 10.1542/peds.2015-3832 originally published online July 13, 2016; 2016;138;Pediatrics
Christine M. WhiteBlair Davis, Jacob Redel, Julie Hausfeld, Karen Tucker, Denise L. White and
Angela M. Statile, Amanda C. Schondelmeyer, Joanna E. Thomson, Laura H. Brower,Improving Discharge Efficiency in Medically Complex Pediatric Patients
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