Reducing Adverse Events in Post-discharge Transitions of Care Programs

Pat Stricker, RN, MEd
Senior Vice President
TCS Healthcare Technologies

Adverse events have been tracked for years, but mostly as they relate to issues that occur during a hospitalization, or during drug or clinical trials.  Adverse events refer to harm from medical care rather than underlying disease and are defined as:

• "an injury that was caused by medical management (rather than the underlying disease) and that prolonged the hospitalization, produced a disability at the time of discharge, or both."
• "an unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment, or hospitalization, or that results in death."
• “any unfavorable and unintended sign (e.g., an abnormal laboratory finding), symptom, or disease temporarily associated with the use of a drug, without any judgment about causality or relationship to the drug.” (Used in drug and clinical trials)
• An injury that occurs due to “negligent care that falls below the standards expected of clinicians in the community.”

Adverse events can be:

• Preventable: “due to an error or failure to apply an accepted strategy for prevention” or "avoidable by any means currently available unless that means was not considered standard care."
• Ameliorable: “not preventable, but the severity of the injury could have been substantially reduced if different actions or procedures had been performed or followed." 

While numerous studies have been conducted to identify adverse events occurring during hospital stays and trials, there are only a few that address adverse events that occur after a patient is discharged from the hospital and transitioned to home or an outpatient facility. Because the process of transitioning a patient from a hospital setting to home can lead to patient safety and quality issues if not done correctly, more emphasis needs to be placed on trying to study and identify the causes for post-discharge adverse events.

Statistics on Post-discharged Adverse Events

A 2003 study found that nearly one in five patients (76 of 400 patients) suffered adverse events within 5 weeks of being discharged from the hospital to home. Of these:

• 29.5 percent were found to be preventable and 30.7 percent were ameliorable (could have been reduced in severity by changing patient care procedures).
• All were identified as being caused by “system problems in the hospital,” with 60 percent due to communication problems between the hospital staff and the patient or primary care physician.
• The most common problems were related to drugs (66 percent), many of which could have been avoided or mitigated. Another 17 percent were related to medical procedures.

A study of elderly patients found that 14.1 percent had one or more medication discrepancies, resulting in 14.3 percent of the patients being re-hospitalized within 30 days. 49.2 percent of the discrepancies were categorized as “system” issues.

Another study found that nearly 40 percent of patients are discharged with test results pending and 10 percent of these require some action. A similar number are discharged with orders to complete a diagnostic workup as an outpatient, placing them at risk if the workup is not completed in a timely manner or not done at all.

In addition, literature reviews identified other issues related to adverse events: 

• Two-thirds of post-discharge adverse events are due to medications. The other one-third involve nonsurgical procedures, therapeutic errors, hospital acquired infections, diagnostic errors, pressure ulcers and falls.
• Most of the adverse events are either preventable or could have been reduced in severity.  
• Nearly 20 percent of Medicare patients are re-hospitalized within 30 days of discharge, making post-discharge adverse events a high priority for the U.S. healthcare system.
• Rural patients are most vulnerable for adverse events because they may not receive timely follow-up care by a local provider after discharge or may not have an electronic health record, causing an information transfer delay.

Causes

The studies have provided good insight into many of the causes of post-discharge adverse events, and further studies will help us focus on them in more detail. However, changes in the overall healthcare system over the past 15-20 years have also caused significant effects, both positively and negatively, in our delivery of care processes. 

• The average length of a hospital stay has been significantly reduced, resulting in transferring tasks and procedures that would have previously been done in the hospital to the patient’s home after discharge. These now become the responsibility of the patient, family, caregiver or home care providers.  
• Hospitalists now manage patients while in the hospital and then transfer the care back to the patient’s primary physician upon discharge. This can be a benefit if one of the physicians notices something that is overlooked by another. However, this can also cause a lack of continuity of care, if discharge summaries or discussions with the primary care physician are not done at the time the care is being transferred. A delay in information transfer or faulty communication can result in adverse events.
• The advent of the Medical Home model has provided a patient-centered, comprehensive model in which physicians assume responsibility for their patient’s overall healthcare and coordination of his/her care across the continuum, regardless of the setting. However, in order for this to work, good communication among all team members is essential, and unfortunately lack of timely communication is often an issue.   

This communication issue is highlighted in a summary of the literature conducted by the Society of Hospital Medicine/Society of General Internal Medicine Task Force. They found that lack of communication adversely affects post-discharge care transitions.

• Direct communication between hospital physicians and the primary care physicians occurs in only 3-20 percent of cases.
• A discharge summary is only available 12-34 percent of the time for the first post-discharge visit and on 51-77 percent of the time 4 weeks after discharge. This delay affected the quality of care in about 25 percent of the follow-up visits.
• Discharge summaries often lack key information, e.g., discharge medications, treatments, hospital summary, diagnostic test results, pending test results, follow-up plans and patient or family counseling.
• In addition to lack of communication and continuity among providers and the lack of timely, accurate, detailed discharge summaries, the following problems were also noted as reasons for post-discharge adverse events:

           - Lack of accurate, up-to-date medication reconciliation causing medication discrepancies

           - Inaccurate assessments of the patient’s ability to care for themselves after discharge

           - Failure to plan for appropriate resources to help the patient with the transition to home

           - Inability of rural patients to follow-up in a timely manner with their local provider due to distance and lack of transportation 

Strategies and Recommendations

As a result of studies and the attention being focused on transitions of care, numerous care recommendations have been identified to help reduce adverse events. For organizations developing a post-discharge transition of care program, the following key strategies should be incorporated in the program to make it successful:      

• Primary care physicians need to be contacted at the time of discharge and provided with key elements of the discharge summary, medication changes, significant lab results or pending tests, new treatments and follow-up plans.
• A nurse needs to be assigned to manage the overall post-discharge process for patients. 
• A clinical pharmacist should be part of the healthcare team to follow-up with patients within five days after discharge to review medications and assess for potential problems.
• All team members must be held accountable for their share of the care transition process. They must carry out their responsibilities and assure that nothing “falls through the cracks.”
• Medication reconciliation must be done to ensure chronic medications were not stopped and new medications are safe.
• Care transition interventions should be patient-specific, such as goal-oriented patient goals, conducting follow-up phone calls, and linking patients to community resources.
• Education for patients and their families to assure they understand their diagnosis, changes in medication therapy, follow-up instructions, changes in drug therapy and who to contact with questions or problems. This should be done prior to discharge and again after discharge once they reach their home or outpatient facility.
• Principles recommended by the Transitions of Care Consensus Policy Statement (TOCCC), developed as a joint collaboration by six physician organizations/associations. These principles address quality gaps in transitions between inpatient and outpatient settings and should be included in transition of care programs:  accountability; coordination of care; involvement of the patient and family member; all patients and their family/caregivers should have a medical home or coordinating clinician; patients and/or their family/caregivers need to know who is responsible for their care at every point in the care transition; and national standards with standardized metrics that lead to quality improvement and accountability.
• Standards developed by the TOCCC describe components needed for implementing these principles: coordinating clinicians; care plans and transition record; communication infrastructure; standard communication formats; transition responsibility; timeliness; community standards; and measurement.
• Health information technology (HIT) applications are also essential to being able to effectively communicating and disseminating information to all members of the healthcare team.

NOTE: Next month’s article will go into detail on the types of HIT that should be considered and how it can be used to improve the post-discharge care transition process.  

Additional Resources and Tools

For those interested in developing a post-discharge transition of care program, the following sites provide helpful resources and tools. The first two resources are documents that definitely should be reviewed.

• NTOCC’s Position Paper (page 5) describes additional key elements needed to assure smooth, safe and effective transitions of care. In summary they include: developing standardized processes; establishing accountability; increasing the use of case management and professional care coordination; developing performance measures; and implementing payment systems that align incentives. In addition, on page 27, NTOCC recommends developing: best practices; quality measures that reflect process standards and expected outcomes, including the patient care experience; and incentives for sharing information across all care settings, based on accountability and ultimate outcomes.
• The Transitions of Care Consensus Policy Statement (TOCCC), developed by the American College of Physicians (ACP), Society of Hospital Medicine (SHM), Society of General Internal Medicine (SGIM), American Geriatric Society (AGS), American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM), recommends a set of data elements that should always be part of a transition record: principal diagnoses and problem list; medication list, including over the counter (OTC)/herbals, allergies, and drug interactions; clear identification of medical home/coordinating physician and contact information; patient’s cognitive status; and test results/pending results and normal value ranges and explanation for patients. In addition, they also suggest additional elements that should be included: emergency plan with person and contact number; treatment and diagnostic plan; prognosis and goals of care; advance directives, power of attorney, and consent; planned interventions, durable medical equipment, wound care, etc.; and assessment of family caregiver status.  
• The National Learning Consortium offers a resource paper, Care Coordination Tool for Transition to Long-Term and Post-Acute Care, to train and support care professionals on key clinical information needed for inclusion in care records when providing a transition of care program. It is a good overview of a care transition program and what needs to be included.
• The American Academy of Ambulatory Care Nursing provides a toolkit that includes 18 resources and tools for the following four areas: Care Coordination and Transition Management, Risk Stratification or Assessment, Hand-Off Communication, and Patient Education.  

Conclusion

Improving transition of care is a key safety and quality issue today in healthcare. Studies are needed to identify and analyze areas that may be able to predict the occurrence of adverse events, especially in post-discharge transitions. This will provide the data needed to develop screening tools to proactively identify post-discharge risk factors that can reduce adverse events during these vulnerable transitions of care from the hospital to home.

Pat Stricker, RN, MEd, is senior vice president of Clinical Services at TCS Healthcare Technologies. She can be reached at pstricker@tcshealthcare.com.