Test of a Family-Centered Discharge Tool Emily Henke, Portland State University

PI: Tamara Wagner, M.D., Oregon Health & Science University

Aim

Improve the patient and family experience of the transition from hospital to home by creating and implementing a patient-centered, interdisciplinary discharge document tool.

Background

Pediatric patients are discharged from the hospital with the expectation that their family members will continue to provide the care necessary for their complete recovery at home. Family members generally have very little or no medical training, but they are required to execute highly technical medical tasks at home (e.g. caring for a central line, administering intravenous antibiotics, administration of nutritional supplementation through gastric tubing, coordinating the administration of multiple medications, etc.). Healthcare providers who may be highly trained in provider-to-provider handoffs are often poorly informed about best practices in handing off care to patients and families—this communication is a non-standardized and highly variable process (Jack et al., 2009).

Patient-provider communication at discharge can have serious impacts for patients and the hospital: recent research suggests that patients who have a clear understanding of their post-hospital care, including how to take medications and when to make a follow-up appointment are up to 30% less likely to require re-admission or re-evaluation in an emergency department (Jack et al., 2009), and CMS has begun to penalize hospitals for preventable readmissions (Health Policy Brief, 2013).

To ease the transition from hospital to home for both patients and their family members, the hospital care team at Doernbecher Children’s Hospital (DCH) sends each patient home with an EHR-generated instructional discharge document called the After Visit Summary (AVS), which is intended to guide family members in caring for their child at home.

Problem & Intervention

Problem: An internal review found DCH AVS documents to be of variable quality and utility: they frequently lacked critical information, contained conflicting information and used complex medical terms that could be difficult for a layperson to understand. Intervention: In order to improve the content and quality of the AVS discharge documents, the DCH Pediatric Quality and Clinical Informatics Teams partnered to change the AVS EHR platform, testing the change in one DCH unit. They developed a new EHR-based

discharge tool, called the Transition to Home Discharge Tool (THDT).

Figure 1. The THDT is designed so that each provider/discipline involved in a patient’s care contributes to the discharge document. The THDT reminds providers of elements required for a successful discharge document using checklists and provides a fillable form for written notes.

References: Health Policy Brief: Medicare Hospital Readmissions Reduction Program. (November 12, 2013).

Health Affairs. Retrieved 11/25/13 from http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=102

Jack, B. W., Chetty, V. K., Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E., Forsythe, S. R., ... Culpepper, L. (January 01, 2009). A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Annals of Internal Medicine, 150, 3, 178-87.

Results

Intervention Assessment Methods

An assessment of the existing AVS documents and the THDT AVS documents was conducted in order to understand the THDT’s impact on AVS content and parental understanding of care needed at home. Assessment methods used were document scoring and family surveys, with scoring metrics and survey questions based on key discharge document components derived from interviews with families of patients who were approaching discharge, review of the available medical literature on hospital discharge documents, and consultation with DCH pediatric hospitalists. Participating patients discharged in July and August of 2013 received the existing AVS documents; participating patients discharged in September, October and November received the THDT AVS documents.

Document scoring A document scoring tool was used to assign each AVS a numeric score, based on inclusion of the following 14 key components. Reason for admission Description of treatment needed at home Recommended activity level Recommendation for return to school/community activities Dietary instructions All medication names All medication doses All medication routes All medication frequencies Criteria for seeking medical re-evaluation List of subspecialty consultations obtained during hospitalization List of recommended follow-up appointments Absence of conflicting information Utilization of lay language

Family surveys Researchers called families to survey them about their satisfaction with the discharge documents they received and to assess their level of understanding of the information provided to them in the documents. Interview questions asked families if the key components were included and clear, and also asked: Did you keep the discharge document? Was there any information you wish had been included on your child’s discharge paperwork? On a scale of 1-10, how helpful did you think your discharge document was in caring for your child at home? Do you have any additional comments about your child’s discharge paperwork that you would like to share with us?

Lessons Learned Researchers have been able to enroll and contact only a small number of families thus far, and it is too early to draw conclusions about the THDT from the data. However, the family survey data appears to indicate that families were satisfied with the existing AVS documents, which is contrary to the research team’s predictions. Document scores were more consistent with researchers’ predictions: the THDT discharge documents include more useful, family-centered information than the existing discharge documents (though the THDT AVS documents still did not receive perfect scores). For the THDT to spread throughout the hospital, more research will be required. If this study were to be repeated, we would ask families to compare pre- and post-test AVS documents and indicate which document they would prefer. Without this head-to-head comparison, families may not know how their discharge documents could be better. Additionally, it would be ideal for non-provider research assistants to survey families post-discharge, as some patients and families may not be comfortable indicating dissatisfaction with the AVS documents directly to their providers, and this may bias survey results.

Conclusions

Factors that contributed to the success of this project were providers’ shared desire for high-quality discharge process and documentation, interdisciplinary development of the tool, frequent reassessment of the tool and the hospital administrations’ support for improving discharge processes. Barriers to success included the perception of increased workload for providers who were not previously involved in discharge processes as well as the fact that the existing discharge tool was not removed from the EHR during the test of the THDT, creating a hybrid discharge model that was confusing for some users. We learned that in addition to improving communication between provider and patient, the THDT may facilitate better communication between providers, which may also improve the discharge experience for patients and families.

Document scoring: Data collection is ongoing; reported results are preliminary. Researchers calculated the percentage of key components included in each AVS. The average score for the existing AVS documents was 68% (n=8). The average score for the THDT AVS documents was 78% (n=2). Table 1 displays the frequency of key components in the existing AVS documents and the THDT AVS documents. Family survey: Data collection is ongoing; reported results are preliminary. Researchers were able to contact only five families (4 received the existing AVS documents, 1 received the THDT documents) for surveys. All families surveyed indicated that they were satisfied with the discharge documents they received. The average helpfulness score in the existing AVS group was 8.5/10; the parent who received the THDT AVS rated the discharge document an 8/10.

Frequency of key components in existing AVS vs. THDT

MEDICAL LANGUAGE “Patient was diagnosed with osteomyelitis from MSSA”

LAY TERMS “Your child was admitted to the hospital for a bacterial

infection of the bone”

GENERAL ACTIVITY RECOMMENDATIONS “Activity restrictions: gentle weight bearing until pain is

improved”

PRACTICAL ACTIVITY RECOMMENDATIONS “Encourage walking activity several times per day” and “Your

child can participate in school and other public activities when symptoms have resolved”

NO WOUND CARE OR BATHING INSTRUCTIONS

WOUND CARE AND BATHING INSTRUCTIONS “Keep site clean and dry” and “Patient should not take a

shower while her PICC line is in place, she may take baths with the arm outside the tub until the line is removed”

LIMITED FOLLOW-UP INSTRUCTIONS “Please bring this document with you when you follow up

with your doctor, pharmacist or other healthcare provider”

FOLLOW-UP APPTS SCHEDULED AND LISTED “Your medical equipment training appointment is tomorrow at noon at your house” and “We will see you in the pediatric

infectious disease clinic at 4pm on 12/3/13”

NO CRITERIA FOR SEEKING URGENT RE-EVALUATION WARNING SIGNS LISTED

“Seek additional medical attention for worsened pain or return of fever”

Existing tool (Before) THDT (After)

Figure 2: Qualitative improvements observed by researchers. Due to the design of this study, patients and their families did not make head-to-head comparisons of the existing AVS and THDT documents. During document scoring, researchers observed these differences in AVS content and utility.