By Christopher Cheney
Hospital discharge is a complex process involving the primary care team, which can include residents, interns, fellows, nurse practitioners, physician assistants, and other staff members in addition to the attending physician.
Without a thorough discharge summary and completed medication reconciliation, postacute-care teams can be bewildered, and patients can be at risk of costly readmissions. Research has linked readmissions to poor communication and poor care coordination between hospitals and primary care providers.
Amy O’Linn, DO, a hospitalist and physician lead for enterprise readmission reduction at Cleveland Clinic, says an efficient discharge process is about patient safety.
“There can be medication errors, side effects, and confusion after a discharge if we don’t get it right,” O’Linn says.
To strengthen the patient handoff process from acute to postacute care, Cleveland Clinic created a new discharge checklist to improve discharge summaries and medication reconciliation. According to the Ohio Hospital Association, the goal of the new process was to “achieve a 100% completion rate on all discharge medication reconciliations and discharge summaries prior to a patient leaving the hospital.”
Since the new discharge checklist was established, the completion rate for medication reconciliation at Cleveland Clinic’s main campus has increased from about 88.0% to 98.7%, and the completion rate for discharge summaries at Cleveland Clinic’s main campus has increased from 58% to 80%.
In March, the Ohio Patient Safety Institute awarded Cleveland Clinic with the Acute Care Best Practice Award for the health system’s development of the new discharge checklist.
The Cleveland-based health system’s discharge checklist, which was implemented in November 2018, has two components: a medication reconciliation document and a discharge summary.
1. Medication reconciliation
“The discharge medication list has been reconciled with the medications the patient was previously taking at home and the medications the patient was taking in the hospital. The medication discharge list is the final list that the patient receives, [and it] is very valuable. Without a completed, signed-off list, the patient does not know what to take,” O’Linn says.
The medication reconciliation document is a mandatory step in Cleveland Clinic’s new discharge process, she says. “It’s a hard stop. The patient cannot leave the campus until the medication list is signed off by the primary care team.”
2. Discharge summary
Although completion of a discharge summary is not absolutely required to discharge a patient, it is a Cleveland Clinic policy and nearly as essential as medication reconciliation, O’Linn says.
Under the health system’s discharge summary policy, there are 18 elements in the document, including admission date, discharge date, chief primary complaint when the patient came to the hospital, discharge disposition, and the medication list. Clinicians are also encouraged to include “the story” of the hospital admission, she says.
“What we are encouraging providers to do is answer key questions: What brought the patient to the hospital? What happened during the hospital stay? And what is the plan going forward? The 18 elements that are part of our policy are not as useful in detailing the story of a hospital stay. The story is where the money is—it’s what happened and what’s going to happen now,” O’Linn says.
Crafting the discharge checklist
A multidisciplinary team at Cleveland Clinic developed the discharge checklist, she says.
“We had the information technology people; we had Epic, who had to make the technical hard stop [in our EHR]. We had strong help from the pharmacists because there is nothing more painful for a provider than to have a Band-Aid or piece of gauze on a medication reconciliation—we took out some medicines and other things that don’t need to be reconciled like insulin syringes. We had nursing managers and care management. We worked with documentation specialists, who helped get the word out to the providers.”
One of the primary barriers to the new discharge checklist effort was fear, O’Linn says.
“People were afraid that if we made a hard stop for the medication reconciliation, then patients would never leave the hospital. After we worked through the process for a couple of months, we came out knowing we could do this. It did not affect the length of stay. The day we launched, we were nibbling our fingernails, but we never got a call. We had all lines open to help people who had trouble, but everything was OK.”
Advising other adopters
Incorporating a new discharge list into a health system’s electronic health record is a key step, O’Linn says. The EHR flags discharges that do not have medication reconciliations.
“You can work with your electronic medical record to make this happen. Some of our hospitals have tried to use nursing as the people who stop the line for a shaky discharge or an incomplete medication reconciliation, but that takes a lot of nursing strength and can create uncomfortable encounters,” she says.
Support from the C-suite is also critically important.
“The culture change needs to come from the top. The administration needs to say, ‘We are going to protect the patient.’ The whole reason we were able to do this is because our CEO, Dr. Tomislav Mihaljevic, said we had to do it. He said we couldn’t let patients leave without a med list. Without his support from the very top, we could not have done this at the grassroots,” O’Linn says.