Re-engineering the “voltage drop”
Nurses—both in and out of the hospital—help bridge the gap at discharge
Keywords: Hospital discharge process innovations lead to significant improvement in patient outcomes
by Tracey Regan
Published in the January 2009 issue of Today's Hospitalist
AS HOSPITALIST GROUPS across the country search for ways to prevent “the voltage drop” that makes the transition out of the hospital so risky for patients, they would do well to look to nurses as a big part of the solution.
That was one of the conclusions of a team of Harvard Medical School researchers who examined the discharge process in a recent study. While the research team designed and tested a four-step process to streamline the transfer of information at discharge, they found that increasing the participation of nurses, especially in
the outpatient setting, was key.
|“Discharging a patient needs to be approached with the same vigilance as admitting.”|
–Richard Balaban, MD
Cambridge Health Alliance
According to Richard Balaban, MD, the study’s lead author, bringing outpatient nurses into the picture helped ensure continuous care after patients left the hospital.
“We try not to think of the process as a discharge, but rather as a transfer,” says Dr. Balaban, who is medical director of Somerville Primary Care, a practice that is part of Cambridge Health Alliance (CHA), a three-hospital health system in the greater Boston area. “We’re learning that discharging a patient needs to be approached with the same vigilance as admitting.’’
How it worked
Dr. Balaban’s team studied patients who were discharged from Somerville Hospital, a community hospital just outside of Boston. Patients in the control group received usual care at discharge, while those in the intervention group were the focus of innovations on both the inpatient and outpatient sides.
Prior to discharge, for instance, hospitalists created a comprehensive discharge report for these patients that included a descriptive overview of the hospitalization; guidelines for further outpatient care, including a list of pending tests; and a list of follow-up appointments.
“Hospital doctors appreciated the guidelines established in the discharge report, as it allowed them to provide key information to patients and their primary care physicians,” says Dr. Balaban, a part-time hospitalist who is also an instructor at Harvard Medical School. “This system puts it in black and white.’’
Patients reviewed the report—which was available in English, Spanish or Portuguese—with a floor nurse before leaving the hospital, and took a copy of the report with them. The hospital also sent an electronic copy to nurses at the patient’s primary care office.
Those outpatient nurses would then call patients a day after discharge to review the report, check on patients’ status and make sure that needed appointments were scheduled. Primary care physicians would then review the discharge report supplemented by notes from their nurses.
Coordinated care and follow-up
The study, which was published in the August 2008 issue of Journal of General Internal Medicine, found that the process reduced problems that are familiar to both inpatient and outpatient physicians. Researchers distilled those problems into three groups: patients who didn’t receive follow-up within 21 days; patients who had a readmission or an ED visit within 31 days; and the failure of an outpatient doctor to complete a work-up recommended by inpatient physicians.
Within the intervention group, only 25.5% had one of those undesirable outcomes. While that number is considerable, it was well below the 55.1% of patients in the control group who experienced one of the problems. Only 14.9% of intervention patients failed to have follow-up within 21 days compared to almost 41% of the control group.
According to Dr. Balaban, the enhanced discharge process formalized the responsibilities for both hospitalists and primary care physicians with a series of steps that all too often are difficult to coordinate.
“There used to be a black hole after discharge, where patients weren’t sure whom to turn to,” Dr. Balaban explains. “This makes it very clear that if anything goes wrong after discharge, the PCP is the one to call.”
Giving nurses a forum
Dr. Balaban chalks some of initiative’s success up to the redundancies his team built into the process. That included several layers of nursing review, as well as reviews from both patients and primary care physicians.
But an even bigger factor was expanding the role for nurses in both settings. In the hospital, a floor nurse reviewed the discharge report with the patient. In addition, other nurses were able to add comments to the discharge report before it was sent electronically to the primary care office.
“Hospital nurses notice family dynamics, a patient’s ability to care for himself or concerns with memory issues— things that could affect a patient’s well-being post-discharge,” Dr. Balaban points out. “In the past, there was no forum for them to share these observations.”
The outpatient nurses, who typically know the patient well, were able to use the full range of their nursing skills in making the follow-up calls. They might note that patients were not taking their medications properly or that symptoms signaled the need for immediate help.
Significantly, the study found that outpatient nurses made critical interventions in 15% of follow-up calls, including scheduling urgent appointments and identifying the need for new prescriptions.
Getting the primary care nurses to make those calls, says Dr. Balaban, wasn’t a hard sell. “They liked it because they were asked to use skills in a proactive manner,” he notes. “Their calls reduced the likelihood that a patient would be calling in two to three days because they were doing poorly. Nurses felt the interaction came at a better time.”
A new standard
The interventions were designed to not take up much in the way of time. Inpatient nurses spent about 15 minutes creating the discharge reports, Dr. Balaban explains, while primary care nurses spent five to 10 minutes on the phone with individual patients. (Outpatient nurses spent 30 to 60 minutes up-front learning to use a call script, Dr. Balaban says, but that made them more efficient later.)
The effort was so successful that CHA is planning to implement the new discharge process system-wide in the coming months. Dr. Balaban admits that having an integrated health care system—where outpatient and inpatient physicians share the same electronic medical record—is one big reason why the research project went as smoothly as it did.
In a typical, fragmented system, where inpatient and outpatient physicians aren’t in the same network, “it’s a lot more challenging to enact systemic changes,” he says. That said, Dr. Balaban thinks that hospitalists everywhere— even those working in low-tech environments—could enact a similar process.
To make that happen on the inpatient side, hospitalists would need to be able to e-mail comprehensive discharge reports to outpatient physicians. On the primary care side, he says, groups would have to commit to implementing post-discharge patient calls.
Ideally, Dr. Balaban adds, more tightly structured discharges “will become a standard in the industry, the same way that medication reconciliation became a standard. Recommendations need to come from advisory or regulatory groups.”
Tracey Regan is a freelance health care writer based in Hoboken, N.J.