1. Patient safety in the Transition from the Hospital to the PCP
Re-Engineering the Hospital Discharge
Patient safety in the Transition from the Hospital to the PCP
Brian Jack MD
Dept of Family Medicine
Boston Medical Center
4/25/2019

2. Errors + Hospital Discharge
High rates of medical errors at discharge now well documented
Readmission by 90-days:
20% of hospitalized patients
Can improving the discharge process reduce errors and reduce unplanned rehospitalization?
4/25/2019

3. An Etiologic Classification of Errors at Hospital discharge
4/25/2019

4. What happens?
60 yo women with Congestive Heart Failure takes the same medicines after discharge as before, plus her new ones; she is readmitted with renal failure requiring long term dialysis.
50 yo Spanish speaking women doesn’t understand how to get to outpatient Stress test, she misses it and next presents with sudden death.
4/25/2019

5. Kaplan-Maier Survival Rehospitalization by Discharge Day
Days to Rehospitalization 20 40 60 80
0.4
0.6
0.8
1.0
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
4/25/2019

6. Errors at Discharge - Process Evaluation
4/25/2019

7. Example of Root Cause Analysis
42 year old man with
Abdominal pain with nausea, vomiting, diarrhea
Chest pain - sometimes exertional, sometimes at rest
30 admissions in 42 months
Can’t something be done?
4/25/2019

8. Top 300 account for 25.8% of all charges
Cumulative Percent of Charges for the 300 Most Frequent Users – Boston CareNET 2003
Total Charges 2003 = $186,136,650
Total Members = 56,535
Top 300 account for 25.8% of all charges
Cumulative Percent of Charges for 300 most Frequent Users 25 20 15
% of total charges 10 5 50
100
150
200
250
300
Number of Patients
4/25/2019

9. Factors influencing re-hospitalization
4/25/2019

10. Errors at Discharge - Process Evaluation
4/25/2019

11. Process mapping of Hospital Discharge Step 1 - Collective Assessment
4/25/2019

12. Process mapping of current discharge process
Step 2 - Communication and Coordination
4/25/2019

13. Process mapping of current discharge process Step 3 - Completion
4/25/2019

14. Errors at Discharge - Process Evaluation
4/25/2019

15. Re-engineering the Discharge
Iterative Group Process
Identification of Potential Failures
Prioritization
4/25/2019

16. Principles of the Newly Re-Engineered Hospital Discharge
Re-engineered Discharge must contain:
Explicit delineation of roles and responsibilities
Patient education throughout the hospitalization
Easy Information flow
from the PCP
among the hospital team
back to the PCP
Written Discharge Plan
4/25/2019

17. Principles of the Newly Re-Engineered Hospital Discharge
Written discharge plan:
addresses medications
dietary and other lifestyle modifications
follow-up care
patient education
instructions about what to do if their condition changes
completed before discharge
Those at-risk should have the discharge plan reinforced after discharge.
All information must be organized and delivered to the PCP.
4/25/2019

18. Principles of the Newly Re-Engineered Hospital Discharge
Waiting until the discharge order is written before beginning the discharge process is error-prone.
Efficient and safe hospital discharge is significantly more challenging if the case management staff works only the 7AM to 3 PM shift.
All patients should have access to his/her discharge information in their language and at their literacy level.
Discharge processes must be benchmarked, measured and subject to continuous quality improvement programs.
4/25/2019

19. Errors at Discharge - Process Evaluation
4/25/2019

20. Probabilistic Risk Assessment Predictors of Re-hospitalizations
Secondary analysis of a retrospective cohort of 2,500 CHC patients admitted < 6 mo.
Primary outcome variable – 90 day readmission
4/25/2019

21. Prediction Model for Re-hospitalization
4/25/2019

22. Probabilistic Risk Assessment using Standardized Screening Tools
Sensitivity: 63-91%
Specificity: 97%
22 items yes/no and Likert scale; use scoring algorithm
2.5
Anxiety
Patient Health Questionnaire
Sensitivity: 88%
Specificity: 88%
9 item 4-point Likert scale
Depression
Internal consistency: 86-88%
Extensively validated
PCS: 0-100
MCS: 0-100 5
Health Related Quality of Life
SF-12
Compare to Optimal Benchmark Scores
24 item
5-point Likert scale 10
Patient Satisfaction
Patient Satisfaction survey
Sensitivity: 50-80%
Specificity: 90%
0-30
Mental Status
Mini-Mental Status Exam
Validation /
Psychometrics
Range of Response
Time
min
Domain
Measured
Screening Tool
4/25/2019

23. Probabilistic Risk Assessment using Standardized Screening Tools
Internal consistency: 86-95%
Overall accuracy: 85%
0-10 2
Substance Abuse
Drug Abuse
Screening Test
Harmful drinking: Sensitivity: 57-97%
Specificity: 78-96%
Abuse or dependence:Sensitivity: 61-96%
Specificity: 85-96% 3
Alcoholism
Alcohol Use Disorder Identification Test
Internal consistency: %
Test-retest reliability: %
3 separate scores 10
Social Support
Norbeck Social Support Questionnaire
Sensitivity: 36-56%
Specificity: 61-84%
0-21 5
Nutrition
Nutrition Screening checklist
Validation /
Psychometrics
Range of Response
Time
(min)
Domain
Measured
Screening
Tool
4/25/2019

24. Three Tier Approach Who will Fund the Top Tier
4/25/2019

25. The TRANSFER Trial Flowsheet of Research methods
4/25/2019

26. Review of 5 most recent hospitalizations
4/25/2019

27. Psychosocial and Functional Risk factors for 90-day Re-hospitalization
Adjusted Odds Ratio (95% CI)
P-value
SF-12 Physical function
0.95 ( )
0.07
PHQ-Depression
2.08 ( )
0.02
Norbeck Social support
1.00 ( )
0.47
4/25/2019

28. Thank You David Anthony Chris Manasseh Jeff Greenwald Anand Kartha
VK Chetty
Maria Rizzo Depaoli
Cornelia Walsh
Kathleen McKenna
Lee Strunin
Larry Culpepper
Brian Jack
4/25/2019