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

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