Ensuring safe discharge with a standardized checklist and discharge pause

BEING DISCHARGED from the hospital is a critical point in a patient's continuum of care. It requires the coordinated involvement of the entire interprofessional team to ensure a safe and successful transition. Even with this coordinated approach, discharge is a transition point susceptible to error.1-3 As part of ongoing quality of care reviews, the acute medicine team at the Hamilton General Hospital (HGH), Hamilton Health Sciences (HHS), analyzed data related to the discharge process and concluded that a lack of structured communication and safety checks may have contributed to errors or omissions. As a result, we embarked on a practice improvement project to address this need. Background The HGH acute medicine program, with 99 acute care beds, provides regional service to a diverse population of more than 1.4 million people. About 2,271 patients are admitted and discharged to and from the acute medicine program annually, for an average turnover of 6.2 patients per day. Team cohesiveness is a challenge due to several factors. As in many healthcare settings, the interprofessional team in this acute medicine program has a dynamic team structure with frequent changes in membership. The acute medicine program at HGH hosts a clinical teaching unit with physician learners who rotate every 2 to 4 weeks. Nursing staff are scheduled on 12-hour rotations, and allied health professionals are formally added to the care team as needed based on medical and nursing assessments. Allied health includes occupational health, pharmacy, physiotherapy, dietary, speech-language pathology, and social work. The complexity of the patient population, dynamic team structures, and high rates of discharge are factors that pose challenges as clinicians try to ensure safe discharge and transition to the community. Implications Discharge from the hospital is a point of care requiring clear communication and a coordinated effort from the entire team. Examples of interventions that help to ensure a safe transition from the hospital include discharge planning, medication reconciliation, patient education, follow-up appointment scheduling, communication with community partners, and summaries of care given in the hospital.4 According to the Canadian Patient Safety Institute, adding structured communication techniques helps teams build a shared situational awareness, optimizes collaboration, adds reliability to the process, and ultimately ensures patient safety.5 When we examined our current discharge process, we determined that team communication was informal and varied depending on those involved. The team decided to implement a more structured and consistent process to communicate the salient information required at discharge. The HGH acute medicine team posed this question: “What process(es) could be instituted at discharge to add structure to the complex interprofessional communication essential to creating quality discharge transitions and reduced error rates?” Literature review A Medline database search was performed using multiple search terms, including patient discharge, patient discharge summaries, pause, time-out, checklist, critical pathways, medical errors, and safety management. Articles for inclusion were limited to English-language publications from 2000 to 2015. The initial search using the first two search terms yielded over 20,000 articles. Further search terms were added and combined, reducing the number of possible articles to 300, from which 26 were selected for full review. Additional resources from the World Health Organization and the Agency for Healthcare Research and Quality were reviewed. Many high-risk industries have implemented checklists to improve safety.6-8 Adopting these safety tools helps to improve team dynamics by addressing communication, aligning team objectives, providing organization and structure, and adding a formal focus on safety.9 Lingard stated that “without effective communication, competent individuals form incompetent teams.”2 Adopting a checklist and formal safety pauses in ORs are significant examples of how such tools have been adapted and used in healthcare to improve patient safety.6,8,10-12 The surgical safety checklist is a structured communication process that's created a culture where ad hoc communication is no longer acceptable.12 All team members are expected to engage in a predictable communication process as outlined by the tool.2 An integrated team checklist is a tool that can help to modify systems as well as individual team member's behaviors.7 Checklists can be modified to be discipline-specific and can help to reduce reliance on memory, standardize processes, improve access to information, and provide opportunities for feedback.7 Beardsley et al. described how a general medicine unit at an academic teaching hospital in North Carolina adopted the surgical concept of a time-out process to reduce prescribing errors at the time of discharge.1 Through the implementation of a discharge time-out and discharge time-out tool, this group reported that discharge prescribing errors were reduced from 34.5% to 13.7%. Communication is a highly complex process; simply completing the checklist isn't a definitive sign of success. Lingard outlined the need for future research into the meaning of silence, the impact that different tools and activities have on the process of communication, and how communication events throughout the continuum of care often invisibly impact patient safety.2 Practice and process improvement In keeping with patient and system complexities, and after reviewing the literature, the HGH acute medicine team adopted the principles of the surgical safety checklist and adapted the tool to create the acute medicine discharge checklist (AMDC). The new tool was needed to meet the specific needs of our patient population. The goal was to add structure to the complex interprofessional communication that's essential to create quality discharge transitions and reduce rates of error. The AMDC was developed through the process of multiple Plan-Do-Study-Act (PDSA) cycles. (See Nursing2017.com for supplemental online content, Acute medicine discharge checklist [AMDC].) PDSA is a quality improvement model in which ideas for change are developed and tested. This method features a rapid succession of test cycles that allow for adaptation and revision before full implementation.13 Major components included in the AMDC checklist strongly reflect common medical and surgical patient needs and areas where a potential “miss” could have significant negative consequences. Examples include the failure to notify thrombosis services of a discharge, failure to organize home oxygen prior to discharge, and prescription errors or omissions. The following key elements are included in the checklist: two-person interprofessional discharge medication reconciliation; confirmation and summary of follow-up appointments and tests; and discharge plan/discharge report communication with patients, families, and/or receiving facilities. Portions of the AMDC checklist can be signed off as completed any time during the patient's admission. On the day the patient is being discharged, a day of discharge pause (DDP) is completed. The DDP is a formal meeting between two licensed healthcare professionals before the patient is discharged. At this time, a formal review of the AMDC is completed to ensure all elements have been addressed. This 2-minute review is an opportunity to discover and correct any omissions or errors. (See Summarizing the AMDC and DDP.) The checklist was initially reviewed by members of the interdisciplinary team (nursing, allied health, physicians) for content, design, and usability. It was pilot tested on a small sample of patients and revised based on feedback received during the PDSA cycles before full implementation to all acute medicine patients. When defining our intervention population, inclusion and exclusion criteria were considered. However, because our team recognized that reducing errors at discharge could benefit the entire acute medicine population, we provided the intervention to all patients admitted to the acute medicine inpatient units. We developed a standardized and interactive staff education plan and delivered it to all current interprofessional team members. We also incorporated it into the orientation process for all new staff, including physician learners. Feedback indicated the team was receptive to the proposed change and found the tool easy to use. Nursing and physician leadership support has been visible and consistent throughout the development and implementation of this change in practice and process. An AMDC toolkit has been developed to help disseminate it across HHS, as needed. Results The acute medicine program implemented the AMDC and DDP in March 2015. The physicians', nurses', and allied health teams' adoption of this process improvement initiative was impressive. Data were collected to determine the rate of compliance with tool completion and how many patient safety issues were identified by using the tool. From March to October 2015, 1,125 patients were assessed for discharge, and 1,064 of these patients were discharged to the community, including home, retirement home, long-term-care facility, or rehabilitation. During this period, no checklists were completed for 61 patients for various reasons; for instance, because the patient had died or chose to leave the hospital against medical advice. From the 1,064 discharge checklists initiated, 147 patients, or 14% of patients, were identified as having safety concerns before discharge. By using the AMDC and DDP, 167 safety concerns were identified and corrected before patients left the hospital. Errors that were avoided ranged from missed communication with community agencies to significant errors or omissions in medication prescriptions. Of the 1,064 discharge checklists initiated, 851 were fully completed, representing an 80% completion and compliance rate. After the 7-month intensive implementation timeframe, we examined tool completion to assess the sustainability of this quality improvement initiative. From October 2015 to January 2016, the data revealed a completion and compliance rate of 73%. As a result, we reinforced the importance of completing the AMDC and DDP to the healthcare team. Subsequent data from January to March 2016 revealed a completion and compliance rate of 81%. Limitations and future directions The AMDC has helped our team add structure to the complex interprofessional communication essential to creating safe discharge transitions. Lingard, however, reminds us that we shouldn't oversimplify the significance of a team coming together for 2 minutes for a communication briefing.2 She proposes that future research needs to move beyond tool compliance to examine the impact of tool completion on communication practices. Tool completion doesn't automatically mean better communication. Next steps for our HGH acute medicine team will be to examine the communication practices during AMDC completion with a focus on improving team interactions and verbal communication strategies between team members. Including the patient and family during the DDP also needs to be considered. In the current process, patients and families only receive discharge information; future revisions need to incorporate patients and families as active participants who contribute information and feel comfortable sharing concerns. Given the successful testing and implementation of the AMDC tool in the acute medicine units, dissemination of this practice across other clinical areas has begun. Through additional PDSA cycles, the content of the AMDC tool can be revised to address the needs of any patient population. Expanding use of the tool to additional clinical areas would let us examine readmission rates before and after tool implementation. It would also provide an opportunity to better identify and document adverse safety issues identified by the tool. In retrospect, our quality improvement team believes that using the AMDC may have identified more safety issues than were formally recorded because we didn't have a clear definition about what constitutes a safety issue. This hindered communication. Future PDSA cycles will need to address not only tool content and process but will also need to focus on opportunities for more robust data collection. Tool measures up The data collected support the continued use of the AMDC as a tool to reduce safety issues at discharge by adding structure to a complex interprofessional communication process. Data also support an ongoing focus on process, sustainability, and the examination of the communication practices of team members through continued auditing and PDSA cycles. Summarizing the AMDC and DDP On admission When the patient arrives on the unit, a paper copy of the DDP is added to the front of the patient's medical record. Day of discharge or 1 to 2 days before discharge The AMDC is initiated after a patient is identified as having a possible discharge date in 1 to 2 days. The interprofessional team checks off components on the AMDC when they're completed. Allied health identifies when a patient is cleared for discharge and indicates what services have been arranged (such as home care and equipment). Business clerks identify when documents have been prepared for transfer, transportation has been arranged, and follow-up appointments have been scheduled. The prescriber and nurse/pharmacist review the discharge scripts when the prescriptions have been written. A photocopy of the prescription is placed in the medical record. Day of discharge Before the patient leaves, two nurses complete the DDP. Two nurses review the AMDC to ensure all components have been addressed. Prescriptions are checked against the photocopies to ensure no changes have occurred since the original medication check was completed. (If needed, the physician is contacted to clarify any changes noted.) After all components have been addressed, the patient can be discharged.

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