January / February 2010
Enhancing Patient Safety by Automating Discharge Instructions
It has been well documented that providing patients with the tools to become active, informed participants in their own care improves decision quality and prevents overuse of medical options (O’Connor et al., 2004). To that end, many healthcare organizations have automated their informed consent processes to ensure patients receive comprehensive information about upcoming procedures. Often overlooked, however, is the importance of having a standardized method of disseminating post-procedure instructions during patient discharge.
Supplying patients with surgery-specific discharge instructions — for example, “watch for redness or tenderness at the surgical site” or “change dressings twice a day”—in clear, easy-to-understand language helps ensure that patients and their caregivers comply with instructions and lowers the risk of post-treatment complications. Research indicates that supplying discharge instructions to patients reduces the incidence of hospital readmissions (VanSuch et al., 2006). Other studies show that providing incomplete information at discharge can result in patient harm (Pennsylvania Patient Safety Authority, 2008). Despite these findings, however, many hospitals continue to give patient discharge materials in non-standardized formats, some of which are difficult for patients, caregivers, and family members to read and comprehend. Examples of this are handwritten instructions that may not be complete or legible, or generic directions for all operations, which provide no detail specific to the patient’s condition.
Time for a Change
For many years, the Department of Veterans Affairs Medical Center at Portland, Oregon (Portland VAMC), made patient discharge instructions available via patient records software or via paper forms that may have been photocopied numerous times. However, in many cases those documents were too generic or difficult for some patients to read — making it difficult to ensure they understood their care plans.
One indication that the existing approach was inadequate was the strain placed upon nurses staffing the hospital’s health line. Nurses were fielding up to 100 calls per day from recently discharged patients or their caregivers posing questions about post-procedure care. For the most part, the calls dealt with standard post-operative issues: swelling and drainage, pain management concerns, and how much bleeding was normal. Many of the callers had misplaced their discharge instructions or found them incomprehensible. Call center nurses had no effective way to track which instructions specific patients had received — nor were they able to identify the procedure in question or the surgeon who performed it. Unfortunately, because this information was lacking, the nurses often referred patients to the emergency department (ED), or the patients themselves resorted to visiting the ED, for issues that could have been easily resolved on the phone.
Standardization is the First Step
In response to the need for an improved patient discharge process, Portland VAMC initiated a performance improvement project to develop standardized surgery-specific discharge instructions and provide them through an Automated Informed Consent Application (AICA)(iMedConsent™ by Dialog Medical, Atlanta GA).
First the team identified nurses who would each be responsible for a given clinical department. The nurses identified which procedures were most frequently performed in that clinical specialty and developed draft procedure-specific instructions for those most commonly performed. Depending on specialty, the number of documents varied from 2 to 20 distinct instruction sets.
Next, the team approached each section chief to review the draft documents. Last, the instructions, indentified by procedure and presented in a standardized format, were reviewed by the Portland VAMC Forms Committee. Final, approved documents were imported into the AICA and embedded with a series of prompts that collect relevant information, as well as both nurse and patient signatures. Signatures are collected via a digital signature pad, acknowledging receipt and discussion of the instructions.
A key objective of the project was to make sure that instructions given to patients are readily available to all care providers. When materials are printed and provided to the patient, the AICA automatically posts a note in the electronic medical record indicating the patient’s receipt of them. A digital image of the signed instruction document also is saved in the hospital’s document management system. This helps ensure that care providers who receive calls from patients or their caregivers can easily access the correct information — saving valuable staff time and minimizing unnecessary visits and readmissions.
Automation Streamlines the Process
Prior to implementing the AICA solution, surgeons had to consult with nurses to order paper discharge instructions — a process that was not well-standardized. Automation simplified this task while simultaneously documenting the process in the patient’s record. To achieve widespread utilization of the new surgery-specific discharge process, Portland VAMC created custom order sets that enabled surgeons to select the necessary care plan from the order entry component of the computerized patient record system. Nursing staff then pulls the order from the record and prepares the appropriate instruction documents for the patient.
Clinicians who prepare the instructions with the AICA are presented with a series of prompts that indicate discharge medication information and usage directions for prescribed clinical equipment. They can note if the patient routinely takes arthritis medication or an anticoagulant, for instance, and indicate when it is safe to resume the medication; which pain medication was received during the hospital stay; date of next appointments; and other follow-up information. This streamlined processing ensures patients receive accurate, complete instructions — essential for ensuring patient safety.
Furthermore, since the AICA integrates with the hospital’s electronic health records system, Portland VAMC also imported a list of all providers. This enabled designation of the responsible physician for each patient clearly on the discharge instruction — valuable information when the nursing health line needs additional clarification on a post-procedural issue or concern.
A Successful Transition
Despite some initial resistance, physician and nurse acceptance of the new process has been strong. They recognize the improvements will lead to better patient care and safety. In the year prior to the program, for example, fewer than 40 discharge instructions were saved in patient electronic records. In contrast, 3,395 instructions had been electronically saved by the end of 2008. Compliance in outpatient surgery, where paper forms are no longer used, has been 100%.
The nursing staff now receives significantly fewer discharge-related calls, and nurses can address patient and caregiver concerns efficiently and accurately. Real-time access to critical information — the procedure and date performed, the surgeon, and specific discharge instructions — permit health line nurses to provide high quality assistance confidently and quickly.
Improved Patient Comprehension and Follow Through
While the new discharge instructions process simplifies efforts for physicians and nurses, patients are the primary beneficiaries. Now that discharge instructions are written in plain language at the eighth grade level, they are easier to read, understand, and follow. The AICA also allows providers to adjust the font size of the printed materials to accommodate patient needs.
In the past, confusing generic discharge documents often required nurses to tailor instructions with specific hand-written notes for each patient. Today, staff members can edit information for each surgery patient electronically and define post-procedure care instructions much more precisely. Some documents include color anatomical images to enhance patient understanding. To optimize use of this resource, Portland VAMC installed color printers where they were not available.
Since many patients don’t retain information immediately following surgery due to stress or the side effects of anesthesia and pain medications, staff members provide patients with a preliminary copy of discharge instructions well in advance of their surgeries. Patients can prepare themselves and their caregivers, and ask questions prior to the procedure. This approach not only helps ensure increased comprehension of the educational materials, but also empowers patients to become more involved in their own care — ultimately resulting in improved compliance with post-procedure instructions, as well as fewer return visits and readmissions to the hospital. Of course, a second copy of the instructions are provided and documented at the time of discharge.
Most significantly, the Portland VAMC has observed a decline in its readmission rate. The rate of hospital readmissions within 14 days of an outpatient procedure for the 1-year period prior to initiating use of the new discharge instruction process was 4.1 readmissions for every 1,000 outpatient procedures performed. In the 1-year period after initiating use of the new discharge instruction process, that rate dropped to 1.5 readmissions for every 1,000 outpatient procedures performed. This equates to a reduction in risk of 2.7 (P=0.03). While it cannot be said that migration to the new automated discharge instruction process was exclusively responsible for the observed decrease in readmission rate, anecdotal observations suggest that delivery of discharge instructions via an AICA was a major factor in this improvement.
Expanding the Process
Thus far, 70 unique discharge instruction sets have been created, and Portland VAMC continues efforts to ensure discharge documents addressing all major medical and surgical procedures are available for distribution to patients. Currently, the team is developing discharge instructions for the inpatient surgery department and outpatient clinics. The ED has also expressed interest in transitioning to the new system.
Additionally, plans are underway to employ a teaching and comprehension assessment tool available via the AICA, to provide a standardized mechanism for confirming patient understanding of discharge instructions.
By moving to an automated discharge instructions process, the Portland VAMC has created an environment that fosters informed, involved patients who are more compliant with instructions and more satisfied with their overall care experience. This satisfaction — and the ability of patients to take a proactive role in their healthcare — translates to enhanced care and improved outcomes.
Pattie Boast is a program specialist in the Operative Care Division at the Veterans Affairs Medical Center in Portland, Oregon. She may be contacted at
Cathy Potts is certified by the American Society for Clinical Pathology as a medical technologist. She works at the Veterans Affairs Medical Center in Portland, Oregon, and may be contacted at
VanSuch, M., Naessens, J. M., Stroebel, R. J., Huddleston, J. M. & Williams, A. R. (2006). Effect of discharge instructions on readmission of hospitalised patients with heart failure: Do all of the Joint Commission on Accreditation of Healthcare Organizations heart failure core measures reflect better care? Quality and Safety in Health Care, 15(6), 414-417.