Case Objectives

• Understand types and frequencies of adverse events occurring between patient discharge from the hospital and first outpatient appointment.
• Appreciate the unique challenges posed by transition in care from the hospital to outpatient physician.
• Appreciate the problems related to tests pending at hospital discharge and best practices to address them.
• Describe current best practices for reducing patient safety risks associated with hospital discharge.

Case & Commentary: Part 1

Family members brought a 66-year-old man to the emergency department (ED) with acute-on-chronic altered mental status. Several years earlier, the patient had a craniotomy for a brain tumor, which had resulted in mental retardation. The ED obtained routine laboratory tests (including urinalysis and complete blood count [CBC]) that indicated a urinary tract infection (UTI). After a urine culture was obtained in the ED, the patient was started on vancomycin and admitted to the hospital. By day 3, he showed marked improvement and, according to his family, was returning to his "usual self." He was switched to trimethoprim–sulfamethoxazole, an antibiotic he could take by mouth, and discharged home. The plan was for the patient to follow up with his primary care physician in 2 weeks.

Adverse events associated with hospital care may occur even after a patient has been discharged. For example, patients discharged from the hospital within the past week account for approximately 2.3 million ED visits per year; 10% of those visits relate to complications from the recent hospitalization.(1) While the ED staff manages many patients who seek follow-up care after discharge, a full 20% of all Medicare patients are readmitted to the hospital within 30 days.(2) One study concluded that 9%–48% of hospital readmissions are preventable.(3) Given the patient morbidity and health care costs associated with readmission, hospitals and physicians have begun to analyze the discharge process. Common problems surrounding the discharge process include adverse drug events, nosocomial infections, procedural complications, and diagnostic and therapeutic errors.(4)

The transition in care prompted by patient discharge differs significantly from intra-hospital transitions (e.g., end-of-shift handoffs). Intra-hospital care transitions involve two clearly defined care teams (transferring and receiving) that operate within the same health information system and have relatively easy access to one another. Increasingly, the transfer of care involves standardized communication between each team's respective physician and nurse to complete the handoff. Role clarity and standardized handoffs result in the receiving care team understanding that they are now in charge of the patient's care. Even if the transfer of care is done poorly, the patient still is in the hospital and is surrounded by physicians, nurses, and other staff that can assist if the patient becomes ill.

At discharge, however, there is an ambiguity over who owns the care of the patient between discharge and the patient's first appointment with a physician. Furthermore, hospital-based care teams and primary care physicians often exist in different health care systems that are geographically separated and use siloed health information systems. This separation creates significant obstacles to communication, resulting in poor handoff of the care plan, including any pending test results. Finally, patients often have poor access to primary care, resulting in patients having no medical support at crucial times during their postdischarge recovery. Consequently, patient care suffers, and often, patients recently discharged return to the hospital for further care.

Case & Commentary: Part 2

Eleven days later, the patient's family brought him back to the ED after he had become increasingly disoriented and confused. His white blood cell count, which had been normal previously, was now very high (31,000), and his blood pressure was lower than usual. He was admitted to the hospital with the diagnosis of severe sepsis. The admitting nurse noticed that the urine culture results from his prior hospital admission indicated that the patient's infection was not sensitive to trimethoprim–sulfamethoxazole. These test results had become available 2 days after the patient's discharge but had not been reviewed by any of the hospital clinicians responsible for his care or forwarded to his primary care physician. As a result, the patient had continued to take the trimethoprim–sulfamethoxazole. His second hospitalization lasted 7 days. With the correct antibiotic, he made a full recovery.

This case highlights the common challenges surrounding the discharge process. First, patient work-ups are often incomplete and are left to the patient's primary care physician to finish.(5) Outstanding lab results can cause avoidable treatment and diagnosis delays, as with this patient receiving treatment with the wrong antibiotic. Second, the lack of direct (e.g., physician-to-physician phone call) or indirect (e.g., delivery of the discharge summary) communication between the discharging care team and the primary care physician most certainly contributed to this patient's worsening health. Had the patient's discharging care team alerted his primary care physician about the pending urine cultures, the patient could have gotten the correct antibiotics for his UTI. Sadly, though, direct communication between physicians occurs only 3%–20% of the time, and the discharge summary is available at the patient's first follow-up appointment only 12%–34% of the time.(6,7) Third, patients discharged from the hospital often need additional medical attention as they recover from their illness. This need for transitional care is evidenced by the fact that timely follow-up with a nurse or primary care physician can help patients receive the care they need after discharge and help reduce re-hospitalization rates.(8,9) Unfortunately, this patient did not see a physician soon enough after discharge, his condition deteriorated, and he returned to the ED.

As illustrated by this case, tests pending at discharge (TPADs) are common, occurring with approximately 40% of patients discharged from the hospital.(10) Almost 10% of TPADs potentially require physician action.(10) Consequently, failure to follow up on TPADs can lead to delays or missed opportunities for diagnosis and treatment of illnesses.(11) Moreover, the impact of TPADs extends beyond the patient. In fact, failure to follow up on TPADs is the source of 25% of all diagnosis-related malpractice lawsuits for one insurer.(12)

The epidemiology of TPADs has not been well studied. At our institution, we found that almost 82% of our TPADs were microbiology data (e.g., blood or sputum cultures) followed by toxicology (3.4%) and urine studies (3.0%).(13) Other tests commonly ordered in the hospital, like CBCs and chemistry panels, are rarely pending at discharge simply because their turnaround time is, on average, a few hours. As is evident from the case described above, microbiology tests have a high potential to impact patient care and require timely follow-up to ensure correct treatment. However, because, more often than not, microbiology TPADs do not alter the care plan, physicians have difficulty prioritizing TPAD management as part of their busy daily workflow.

Despite a call to action by The Joint Commission in 2005 (14), managing TPADs remains a low priority for health care providers. In a survey of the leaders of seven Divisions of Hospital Medicine at academic centers across the country, along with the leaders of seven departments at our institution, we found that most leaders recognized the importance of TPAD follow-up, but none had a formal policy requiring their physicians to complete timely follow-up of TPADs.(15) The majority of the leaders did not use a systems-based approach to TPAD management, relying instead on individual physicians to ensure timely TPAD follow-up.(15) Yet relying on individual providers to complete timely TPAD follow-up is inadequate at best. Had a system been in place to ensure that a physician—either the discharging team or the patient's primary care physician—followed up on the pending urine cultures and antibiotic sensitivities, this patient would not have become ill again.

The lack of systems to help physicians manage pending tests efficiently is a sore spot for many health care providers. In fact, Poon and colleagues (10) found that neither hospitalists nor primary care physicians are satisfied with how they manage pending tests. Recently, however, studies have identified techniques to help physicians improve their ability to identify and manage pending test results.(16,17) First, physicians and practices that have high patient safety awareness manage pending tests more effectively. Second, the presence of technology, especially an electronic medical record, improved the ability of physicians to manage pending tests.

Several large programs have focused on improving the discharge process for patients. These projects, including Project RED (Re-Engineering the Discharge [18]), Project BOOST (Better Outcomes for Older adults Through Safer Transitions [19]), and the Care Transitions Initiative (20), share common interventions. These interventions include:

• Improving patient and family education by using the "Teach Back" method and patient-friendly discharge forms.
• Improving medication education and reconciliation at discharge.
• Improving communication between the discharging physician and the provider or care team assuming care for the patient.
• Increasing access to health care professionals during the discharge period by providing a discharge "coach," postdischarge phone calls, and scheduling appointments for patients with their primary care physician within 1 week of discharge.

While these efforts vary in cost and resource use, they have been shown to improve the care of patients at the time of discharge.(18,20) Such efforts will likely become even more valuable when the Centers for Medicare and Medicaid Services limits its reimbursements to hospitals for patients readmitted within 30 days of discharge, as is presently planned.

In summary, transitions of care, and in particular, the discharge process, are ripe with opportunity for patient harm. One such opportunity for harm occurs when test results are pending at the time of a care transition. Despite their best intentions, practitioners cannot manage these tests on their own. It is imperative, therefore, that physicians work with their practice or health system to develop systematic, computer-based processes to ensure timely follow-up of pending test results. Until these processes are in place, patients will continue to suffer harm.

Take-Home Points

• Adverse events after discharge are common and include adverse drug events, nosocomial infections, procedural complications, and therapeutic and diagnostic errors.
• Patients are particularly vulnerable to adverse events at discharge because the discharge care transition differs significantly from other care transitions.
• Tests pending at discharge (TPADs) are common and can impact patient care.
• Successful TPAD management requires physicians to have high safety awareness and to use technology for assistance.

Chase Coffey, MD, MS Senior Staff, Division of Hospital Medicine Henry Ford Health System

Henry Ford Medical Group

Quality Associate

Henry Ford West Bloomfield Hospital

Faculty Disclosure: Dr. Coffey declares that he has no financial arrangements or other relationship with the manufacturers of any commercial products discussed in this continuing education activity. In addition, his commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

References

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