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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.