Download DISCHARGE TIME OUT - Society of Hospital Medicine

The “DISCHARGE TIME OUT”
Andrew P. Modest, MD
Harvard Vanguard/Mount Auburn Hospital
Boston Association of Academic Hospitalists in Medicine
and
Nancy Torres-Finnerty, MD
Beth Israel Deaconess Medical Center
Boston Association of Academic Hospitalists in Medicine
Goals:
a) to provide an effective teaching tool that targets the discharge process
b) to focus the inpatient team on the importance of care transitions
c) to practice the skills necessary for effective transfer of care
Background:
A major weakness of the discharge process is the relative lack of attention to
detail from the hospital team at the time of discharge, compared to the admission
process. The energy with which we approach a new admission often dwindles to
that which is needed solely to get the patient out the door. On admission, the
team interviews the patient and/or family, the PMH and medications are
carefully determined, the exam is performed, laboratory studies are reviewed,
and an assessment and plan are discussed and formulated. An equally
thorough, organized, and planned discharge is pivotal to the continuity of the
patient’s care. In addition, the lessons learned during the hospitalization provide
just as important and equally rich an educational opportunity for the whole
team. Little formal education is available to guide a comprehensive approach to
the complex discharge process.
At the time of discharge, we can retrospectively determine how the working
diagnosis on admission is modified by subsequent clinical events and additional
lab data and ultimately evolves into the discharge diagnoses. We can review
complications that arose, both clinical and iatrogenic, which will impact the
patient’s subsequent medical care. Lastly, we can analyze medication errors and
drug interactions and alert future care providers to them.
In our current health care climate, in which clinical acuity is increasing and
length of stay is decreasing, breakdowns in communication can be catastrophic
for the patient. In addition, the recent ACGME work hour rules have led to more
handoffs during a given hospitalization, and teaching hospitals are now at risk
for increased fragmentation of care. Therefore, the importance of strong
communication skills, both verbal and written, cannot be overstated. These skills
are pivotal to the effective transfer of information at the time of discharge.
Exercise:
Analogous to the “Preoperative Time Out” used by surgical teams at the start of
a case, the inpatient team meets briefly for a “Discharge Time Out” at the time of
patient discharge. The selection of patients for this “Discharge Time Out” is left
to the discretion of the team. For maximal benefit, the exercise should occur
before the discharge summary and other discharge paperwork are completed.
The attending physician later returns to review the discharge documents before
the patient is discharged. Feedback is given to the housestaff on a timely basis.
The team will set aside time on rounds to review verbally the following key
elements:
Version 1: step-by-step
1. The clinical course and events of the hospitalization are reviewed
chronologically, including complications and unforeseen clinical events.
The evolution of the working diagnoses and lessons learned are discussed.
2. This is followed by the integration of the clinical data and events into a
problem-oriented assessment and summary of the hospitalization.
3. Principal and relevant Secondary Diagnoses (not symptoms) are identified.
4. Significant test results, which need to be highlighted in the discharge summary
and emphasized in communication with the PCP, are identified.
5. Medication Reconciliation is performed: identification of major medication
changes since admission as well as potential medication errors and adverse drug
events. Highlight which medications the patient should discontinue from their
admission list.
6. Outstanding clinical issues and pending / preliminary test results are
identified to be highlighted to the PCP and the subsequent care team. Decide
which are to be communicated to the patient/family.
7. Specific follow-up plans, including appointments, names, and contact
information of health care providers, are determined.
Version 2: mnemonic
ANALYSIS
clinical course and major events of the hospitalization
LABS
integration of labs and other key data into evolving diagnoses
(not listing ALL hospital data)
ASSESSMENT
a problem-oriented assessment and summary of the key medical issues
CLINICAL DIAGNOSES
identification of Principal and relevant Secondary Discharge Diagnoses
(not symptoms)
ADVERSE EVENTS
medication errors, interactions and other adverse events
SAFETY & STUDIES
medication reconciliation: identification of changes in medications
pending studies/ labs requiring follow-up
APPOINTMENTS
follow-up appointments and plans, including names of health care providers
Of note, when initially introduced to the team, the Discharge Time Out can take
15-30 minutes per patient as a teaching exercise. In hospital practice, our
experience is that the Discharge Time Out can be performed in 5-10 minutes and
actually improves the efficiency of the discharge process.