From the 2021 HVPAA National Conference
Heather Balch (University of Utah Department of Internal Medicine), Kencee Graves
Readmissions after hospital discharge are known to increase cost to the healthcare system and increase patient days in the hospital. Readmissions are often caused by adverse events, many of which are thought to be preventable. Studies have found that of those who experience an adverse event after discharge 20-25% of them are readmitted to the hospital. Twenty-five percent of readmissions are considered avoidable, and of those considered avoidable, many could have been prevented during the index admission. A previous study found that seven day readmissions were more likely to be preventable than 30 day readmissions.
To investigate opportunities for improvement in the care of patients readmitted to a single academic medical center within seven days of their discharge from the same center.
A multidisciplinary, multispecialty committee at an academic medical center made up of nursing, inpatient and outpatient providers, physical therapy, respiratory therapy, pharmacy, and case management reviewed randomly selected patients who were readmitted within seven days of discharge to look for opportunities for improvement in the patients’ care. The opportunities for improvement (OFI’s) were entered into the Safety Learning System (c) software under pre-specified categories.
From January 2020 to March 2021 the committee reviewed 37 cases. A total of 279 OFI’s were found. Opportunities for improvement were identified in the following categories, reported here as the percentage of patients who experienced that OFI: opportunities for improvement in documentation (18.6%), transitions of care (14.3%), communication (13.5%), treatment/care opportunities (11.5%), diagnostic opportunities (9.2%), medication/blood opportunities (7.9%), and recognition of deteriorating patient (5.7%). Inadequate follow up plan was noted in 38% of patients, Inconsistent/incomplete messaging to patient/family was noted in 27% of patients, 19% of patients had a medication reconciliation OFI (16% had an error on the medications on the discharge summary), and 19% had an OFI in the adequacy of care or treatment plan for the degree of illness. There were opportunities for improvement in the physician documentation in 49% of the patients, which most often was related to the clinical scenario not being accurately reflected in the documentation.
Patients are particularly vulnerable to adverse events following a hospitalization. The committee found opportunities for improvement in our system in establishing an adequate follow up plan on discharge, especially for patients who have a higher degree of illness, communicating with the patients and their families, and ensuring adequate medication reconciliation at discharge. The most common medication reconciliation OFI was the discharge medications not being updated on the discharge summary. This can lead to confusion between outpatient providers and their patients. Inaccurate charting by physicians was seen often, which contributes to confusion by future providers as to the care the patient received in the hospital.
Effort in our system should be directed at ensuring standardized, adequate patient follow up and communication regarding discharge instructions. System wide improvements to the discharge process are being investigated, especially in looking at integrating the electronic medical record into common pitfalls in the discharge process, particularly regarding discharge medications. Many opportunities for improvement exist in the transition out of the hospital and should be targeted for future quality improvement projects.