Planning for Patient Safety: Exploring Strategies To Reduce a Person’s Risk of Adverse Events When Transitioning Between Day Hospital and Community Based Care
“On behalf of the Project Team, we are eager to share our findings in the hopes that we can work together to further improve our day hospital discharge practices”……Dr. Cornelia van Ineveld, Team Lead.
Four Winnipeg day hospitals participated in a research project funded by the Canadian Patient Safety Institute that examined communication practices related to patient discharge. Geriatric day hospitals provide outpatient multidisciplinary assessment and rehabilitation to older adults with complex health and issues. Patients usually attend the programs weekly for three to four months. During this time the day hospital team works closely with the patient, family members, family physicians, Home Care coordinators and community pharmacists.
Over the past 18 months, members of the project team have been busy leading focus groups and interviews, while day hospital team members have spent weeks reviewing chart elements, and representatives from stakeholder groups have now participated in the multidisciplinary strategizing session which brings us to the end of the study. As a result of great participation by health care providers, discharged day hospital patients and their families, community pharmacists, home care workers, and health care policy-makers; the study team has learned a great deal about the day hospital discharge practices.
The project team does not believe the issues identified in this study to be unique to the geriatric day hospitals; the identified issues may be present in any programs operating across multiple sites, or programs managing patients with complex chronic diseases. From the study data, we have developed four key themes along with pertinent recommendations to address areas for improvement as follows:
1. Need for more consistent documentation and communication practices among day
hospitals
One thing that became clear very quickly into this study was how very differently each of the day hospitals operate on a daily basis with significant differences in documentation practices and the terminology used between day hospitals in Winnipeg. For example, each site had a different way of contacting referring agencies, tracking key correspondence, completing review letters and discharge letters.
Risk issues such as falls or social isolation were documented in the patient charts using different terms. This may not only create difficulties when comparing risk assessment and management processes across sites, but may, more importantly create confusion among the community agencies/ providers.
Action Steps
- Establish consistent elements for key documents across all sites (i.e. assessment letter, team plan. review letter, discharge letter)
- Develop a uniform process across sites for initial communication with referring agencies and family physicians
- Develop a uniform process across sites for communication of specialized correspondence
- Create a common set of risk terms with definitions so that language is used consistently across the day hospital sites
2. Need for pharmacy support in all day hospitals in Winnipeg
Not surprisingly, there exist many medication issues within any the day hospital patient population. In at least 25% of the reviewed day hospital patient charts, patients were on greater than 10 medications; while in 22% of patient charts, a concern was identified regarding a patient’s ability to manage medications. There were also times whereby medication lists generated at admission were not updated prior to discharge, even though changes to medications had occurred. Written communication with community pharmacists was also seemingly infrequent. Day hospital sites seemed inconsistent in their provision of a discharge medication list.
Clinicians consistently have recognized the need for increased access to pharmacy, yet to date lobbying efforts have remained unsuccessful. The multidisciplinary strategizing session discussed ways that the day hospitals could work with community pharmacists in their locale, however, the message was the need to have dedicated pharmacy support at each site. Session participants agreed that all day hospitals should have either a pharmacist on site, or access to a “shared” pharmacist for several Geriatric Rehabilitation sites.
Action Steps
- Incorporate a medication reconciliation process at time of assessment and discharge at all day hospitals
- Ensure that health care providers, patients, and community pharmacists receive an updated medication list incorporating any medication changes at discharge
- Develop a proposal for increasing the pharmacy support to the day hospitals
3. Integration of risk assessment
The comprehensive geriatric assessment process is effective in identifying and evaluating safety issues in the frail elderly. In fact, day hospitals consistently identify risk issues beyond those indicated in the referral. Nevertheless on occasion, we have also found that some issues identified by the referring agency may not be carried through to the assessment, team plan or discharge. One contributing factor is likely the current process of documenting and communicating initial findings.
The main vehicle for communicating initial findings is the assessment letter which conveys key diagnoses and medical recommendations. These letters are generally completed by the geriatrician; and , often does not summarize the risk assessments made by other members of the day hospital clinical team. Each day hospital teams meets to develop care plans, however the process, documentation and follow-up communications sent to community agencies/providers differs significantly at each site.
Developing consistency within this process across sites, and adding in processes whereby key members of the clinical teams assesses, documents and communicates potential risks would strengthen this process. In turn, potential risks identified at this stage should then be reviewed at discharge, thereby decreasing the likelihood of losing track of a risk issue.
Action Steps
- Use of the chart review form created by thus project as a template to develop a “risk
review” checklist to be used at care planning and discharge - Develop a uniform approach to documenting and communicating a team care plan across sites
4. Developing a follow-up process
The profile of a “typical” patient attending day hospital is an individual considered to be at high risk of functional decline in the first three months after discharge; which precipitated widespread agreement of a follow-up process for patients discharged from a day hospital. This is determined to be imperative for the higher risk patients. It was also suggested that for select patients, there be a weaning process from day hospital, with scheduled phone contacts, and follow up appointments.
The current model of practice is based on a short period of intense case management and support followed by discharge. This meets the needs of patients with a defined illness requiring rehabilitation. Stakeholders felt that for the frail older adult with non-specific functional decline, neurodegenerative illness or with complex social situations an “admit/ discharge” approach does not meet their needs and frequently leads to re-referral or the seeking out of other health care system resources.
Action Steps
- Develop a uniform approach across sites to identify high risk discharges
- Develop and implement a follow-up program at each site
The detailed findings and recommendations from this project are available as a Final Report accessible on the Manitoba Institute for Patient Safety website. The report has been disseminated widely to clinicians working in the day hospitals, community stakeholders and policy makers. The Day Hospital Coordinating Committee will have responsibility for overseeing the implementation of the project recommendations.
We wish to thank the many clinicians and stakeholders who contributed their time, energy, thoughts and enthusiasm to this project.
We invite you to incorporate this update into your in-house publications….
For further information, please visit our webpage linked to the Manitoba Institute for Patient Safety website located at www.mbips.ca.
This project is made possible through a grant from
The Canadian Patient Safety Institute.
In-kind sponsorship provided by:
Riverview Health Centre, University of Manitoba, Winnipeg Regional Health Authority and the Manitoba Institute for Patient Safety.