Cases & Commentaries

Discharge Fumbles

Spotlight Case
Commentary By Alan Forster, MD, MSc

Case Objectives

  • List the types of adverse events that
    occur at discharge
  • Identify the characteristics that
    identify patients at high risk for errors at discharge
  • Understand the provider's role in
    reducing adverse events at discharge
  • Create an action plan for patient,
    provider and institutions to improve patient safety at
    discharge

Case & Commentary

Case #1
A 59 year-old man with severe but well-controlled congestive heart
failure, on spironolactone and other appropriate medications, was
discharged following a brief hospitalization for leg cellulitis.
His pre-admission medication regimen was included on his discharge
orders. Within days of discharge, the patient began to feel
lethargic and nauseated. He presented to the emergency department
(ED) with these complaints and was found to be in acute renal
failure, with a serum potassium level of 7.1 and a sodium level of
122. Upon review of his discharge orders, it was discovered that
the spironolactone was mistakenly prescribed at a dose 8 times
higher than his admission dose.

Case #2
A patient was admitted for atypical chest pain. During the course
of her stay, she was evaluated by neurology for memory deficit. She
was placed on Reminyl (galantamine hydrobromide, a medication for
Alzheimer's disease), 4 mg twice daily to be increased to 8 mg
twice daily in one month. Upon discharge, an order was written to
"discharge on current medications." The patient presented to the ED
the following day with mental status changes. She was found to be
profoundly hypoglycemic. Review of her discharge medications
revealed an inadvertent addition of Amaryl (glimepiride, a
medication for diabetes). It was determined that the pharmacy
mistook the original order for Reminyl as Amaryl.

Patient safety problems, similar to the two
illustrative cases, are exceedingly common in the early discharge
period. Recent studies performed in three hospitals and two
countries demonstrate that approximately 1 in 5 medical patients
experience an adverse event during the first several weeks after
hospital discharge.(1,2) Many of
these events result in symptoms only; however, approximately one
third of them are associated with disability and half of them are
associated with use of additional health services. The following
discussion describes types of post-discharge adverse events, their
epidemiology, important health system factors contributing to them,
and potential solutions.

Types of adverse events affecting patients
after discharge
Several types of adverse events may occur following discharge. The
most prevalent are medication related, also known as adverse drug
events (ADEs). As illustrated in these cases, ADEs, which
include outcomes where an error in drug ordering or prescription
filling harms the patient, account for about two thirds of all
adverse events. However, ADEs more commonly include reactions
typically associated with a medication's known pharmacologic
activity; for example, constipation secondary to narcotic
analgesics.

Although ADEs make up the majority of adverse
events, there are other important types as well. With shortened
length of stays, nosocomial infections often become clinically
apparent only after patients go home. Procedural complications,
such as a post-lumbar puncture headache, may also have a delayed
onset. Lastly, diagnostic and therapeutic errors account for
approximately 10% of post-discharge adverse events.

The frequency of diagnostic and therapeutic
errors may be underestimated. Patients in the post-discharge
research studies were followed for, at most, one month. This may be
too short a follow-up duration to identify poor outcomes related to
such errors. For example, if a hospitalist fails to arrange
appropriate follow-up for a patient with a solitary pulmonary
nodule on chest radiograph, it may be several months before the
problem becomes clinically apparent.

Patient and health system factors contributing
to post-discharge adverse events
Very little is known about factors associated with post-discharge
adverse events. With respect to patient factors, longer lengths of
stay, a diagnosis of diabetes mellitus, and more medications
prescribed at discharge all appear to confer increased
risk.(2,3) With
respect to number of medications, the risk does not appear to be
linear. The risk appears to be stable, or gradually increase, until
the number of prescribed medications exceeds 12, at which point it
dramatically increases. On first glance, being prescribed 12
medications appears extraordinary; however, this is not terribly
unusual nowadays. In addition to the number of medications, the
type of drug is also important. The following medication classes
are associated with higher risk and therefore demand close
attention: corticosteroids, anticoagulants, diabetic medications,
antibiotics, and narcotic analgesics.(3)

Regarding the discharge process itself, a lack of
preparation appears to be associated with adverse events. Patients
who are unable to remember a discussion with their care provider
about the side effects of their medication are at a three-fold
greater risk of experiencing an adverse event than patients who can
recall such information.(3) Other
preparatory work that might be important are reconciling pre- and
post-hospital medication profiles, going over follow-up plans, and
providing patients options for what to do if things go wrong.

Health system factors are also important.
Patients see multiple providers before, during, and after a
hospital encounter. These providers are often practicing in
different locations. Communication amongst these providers is, in
most circumstances, very poor. For example, in a recent audit of
discharge summaries at our hospital, the median delay between
patient discharge and discharge summary generation was 14 days. As
well, it may take as much as 7 additional days for a treating
physician to receive the document by mail.(4)

Besides the timeliness of the discharge summary,
its content and availability are two other common deficiencies.
Often, summaries lack important information describing the most
responsible diagnosis, the results of important tests, the
medications prescribed at discharge, or the follow-up
plans.(4) In addition,
although discharge summaries are created for most patients, only a
minority of physicians following the patient actually receive the
document.(5) This often
happens because the hospital sends the letter to the family doctor
but does not send it to the patient's multiple other physicians.
This final point is important, as recent research demonstrates an
association between hospital readmissions and availability of the
discharge summary by the follow-up physician.(5)

Poor 'hospital-to-community' communication is
only one 'system' problem negatively impacting patient safety at
the time of discharge. Patients often have trouble getting in
contact with a physician from the hospital. This is sometimes
required to discuss new symptoms, the side effects of medications,
or that follow-up is not proceeding as planned. Another problem is
the lack of infrastructure to adequately monitor patients'
conditions or test results after they get home. Infrastructure,
such as clinic space on the medical ward, is required so that when
patients need to be closely followed after discharge, either
because their condition is vulnerable or because a problem has
developed, they can be seen by the doctors who cared for them while
hospitalized.(1)

Improving the safety of hospital
discharge
Can the frequency of post-discharge adverse events be reduced?
One-third of post-discharge adverse events are preventable; in
addition, another one third of events are considered 'ameliorable'
(ie, one that is not preventable but whose severity could be
reduced if corrective measures were instituted earlier and more
effectively).(6) An example
of the latter is a patient who develops C. difficile
diarrhea following discharge. Such an event is ameliorable if the
diarrhea goes undetected by the health care team and is then
complicated by severe dehydration or sepsis. On the other hand, if
the diarrhea is picked up early and the patient responds to
treatment, it will not be ameliorable. Overall, close to two-thirds
of post-discharge adverse events are preventable or ameliorable.
Therefore, there is good reason to hope that the safety of the
discharge process can be substantially improved, although empirical
data to support this hope are lacking.

Patient safety at hospital discharge is truly a
system issue. Therefore, interventions to improve care at this
interface will necessarily involve hospital decision makers and a
multi-disciplinary health team, including community-based
providers. However, patients and their family members, as well as
hospital providers, can make important contributions to improving
safety on their own. As there are few randomized trials testing
interventions, most of the suggestions below are based on
extrapolation from the preceding discussions.

Patients have an important role to play during
the post-discharge period (Table 1). They
must be empowered to recognize and speak up about the development
of important new health problems and complications. They must
understand their follow-up plans. Lastly, they need to have a
back-up plan for when things go wrong. Family members should be
encouraged to participate in any education, as patients may have
trouble understanding the information, especially as they are often
quite ill even at the time of discharge.

Hospital providers can also improve care at the
time of discharge (Table 2). For
all patients, they need to anticipate the opportunities for
post-discharge adverse events and put in place appropriate plans to
deal with these. All patients should be prepared for discharge in a
manner as outlined above. Providers need to recognize particularly
vulnerable patients—such as those on high-risk or large
numbers of medications, and patients with multiple diagnoses who
have received intensive treatments in the hospital over prolonged
periods of time—and make special arrangements for them.
Specific interventions could involve arranging an early follow-up
visit, enlisting the help of a pharmacist to provide extra
education before discharge, telephoning the family doctor to let
her know the likely problems that will develop, and arranging home
visits by a nurse. Much of this happens already, but a more
systematic approach to the problem will help.

Various system interventions can be implemented,
but they will require support from a hospital or health care
organization. In-hospital case management with intensive nurse
follow-up has been demonstrated to reduce hospital readmissions,
especially in heart failure patients.(7-10)
Systematic telephone call contact with patients by a pharmacist
within days of discharge has been shown to reduce emergency
department visits in one small study.(11,12)
Automating discharge summary generation will help distribute
hospital information in a timely fashion.(13)
Hospital-based follow up clinics on the medical ward where the
patient was admitted could provide a venue for monitoring
patients.

Conclusion
Safety problems frequently do occur at discharge. Despite a
preliminary understanding of what causes those problems, more
research is needed to better elucidate both the problems and
potential solutions. In the meantime, practitioners, health
planners, and researchers must take sensible steps to prevent the
large burden of adverse events that occurs at or soon after
hospital discharge.

Alan
Forster, MD, MSc
Assistant Professor, University of Ottawa
Scientist, Clinical Epidemiology, Ottawa Health Research
Institute

Faculty Disclosure: Dr. Forster has
declared that neither he, nor any immediate member of his family,
has a financial arrangement or other relationship with the
manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, his commentary
does not include information regarding investigational or off-label
use of pharmaceutical products or medical devices.

References

1. Forster AJ, Murff HJ, Peterson JF, Gandhi TK,
Bates DW. The incidence and severity of adverse events affecting
patients after discharge from the hospital. Ann Intern Med.
2003;138:161-7.[ go to PubMed ]

2. Forster AJ, Clark HD, Menard A, et al. Adverse
events among medical patients after discharge from hospital. CMAJ.
2004;170:345-9.[ go to PubMed ]

3. Forster AJ, Murff HJ, Peterson JF, Gandhi TK,
Bates DW. Adverse drug events occurring following hospital
discharge [abstract]. J Gen Intern Med. 2003;18(Suppl 1):282.

4. van Walraven C, Weinberg AL. Quality
assessment of a discharge summary system. CMAJ.
1995;152:1437-42.[ go to PubMed ]

5. van Walraven C, Seth R, Austin PC, Laupacis A.
Effect of discharge summary availability during post-discharge
visits on hospital readmission. J Gen Intern Med.
2002;17:186-92.[ go to PubMed ]

6. Gandhi TK, Weingart SN, Borus J, et al.
Adverse drug events in ambulatory care. N Engl J Med.
2003;348:1556-64.[ go to PubMed ]

7. Weinberger M, Smith DM, Katz BP, Moore PS. The
cost-effectiveness of intensive postdischarge care. A randomized
trial. Med Care. 1988;26:1092-102.[ go to PubMed ]

8. Naylor MD, Brooten D, Campbell R, et al.
Comprehensive discharge planning and home follow-up of hospitalized
elders: a randomized clinical trial. JAMA. 1999;281:613-20.[ go to PubMed ]

9. Naylor MD, McCauley KM. The effects of a
discharge planning and home follow-up intervention on elders
hospitalized with common medical and surgical cardiac conditions. J
Cardiovasc Nurs. 1999;14:44-54.[ go to PubMed ]

10. Naylor MD. Comprehensive discharge planning
for hospitalized elderly: a pilot study. Nurs Res.
1990;39:156-61.[ go to PubMed ]

11. Nelson JR. The importance of postdischarge
telephone follow-up for hospitalists: a view from the trenches. Dis
Mon. 2002;48:273-5.[ go to PubMed ]

12. Dudas V, Bookwalter T, Kerr KM, Pantilat SZ.
The impact of follow-up telephone calls to patients after
hospitalization. Dis Mon. 2002;48:239-48.[ go to PubMed ]

13. van Walraven C, Laupacis A, Seth R, Wells G.
Dictated versus database-generated discharge summaries: a
randomized clinical trial. CMAJ. 1999;160:319-26.[ go to PubMed ]

Tables

Table 1. Patient/Family Discharge
Checklist

You are about to be discharged from the hospital.
Please be sure you and or/your family members know the answer to
these questions BEFORE you leave

Do you understand why you were
hospitalized, what your diagnosis is, and what treatments you
received?

Are there any test results you are still
waiting for? Who should you contact for those results?

Has a provider reviewed your medications
with you? Do you know which of your home medications to continue,
what the current doses are, and which you should stop taking?

Where and when are your follow-up
appointments?

What are the warning signs of relapse or
medication side effects you should look for?

Who should you contact if you are having
difficulties?

Does your primary care physician know you
were here and that you are leaving?

Table 2. Caregiver Checklist to Improve
Patient Safety at the Time of Discharge

Discharge medications

        Review with the
patient

        Highlight changes
from discharge

        Specifically inform
patient about side effects

Discharge summaries

        Dictate in a timely
fashion

        Include discharge
medications (highlight changes from admission)

        List outstanding
tests and reports that need follow-up

        Give copies to all
providers involved in the patient's care

Communication with patient/family

        Provide patient
with medication instructions, follow-up details, and clear
instructions on warning signs and what to do if things are not
going well

        Confirm that
patient comprehends your instructions

        Include a family
member in these discussions if possible

Communication with the primary
physician

        Make telephone
contact with primary care physician prior to discharge

Follow-up plans

        Discharge
clinic

        Follow-up phone
calls

        Appointments/access
to primary providers