Using Quality Improvement Methodology to Increase Communication of Discharge Criteria on Rounds

OBJECTIVE: Clear communication about discharge criteria with families and the interprofessional team is essential for efficient transitions of care. Our aim was to increase the percentage of pediatric hospital medicine patient- and family-centered rounds (PFCR) that included discharge criteria discussion from a baseline mean of 32% to 75% over 1 year. METHODS: We used the Model for Improvement to conduct a quality improvement initiative at a tertiary pediatric academic medical center. Interventions tested included (1) rationale sharing, (2) PFCR checklist modification, (3) electronic discharge SmartForms, (4) data audit and feedback and (5) discharge criteria standardization. The outcome measure was the percentage of observed PFCR with discharge criteria discussed. Process measure was the percentage of PHM patients with criteria documented. Balancing measures were rounds length, length of stay, and readmission rates. Statistical process control charts assessed the impact of interventions. RESULTS: We observed 700 PFCR (68 baseline PFCR from July to August 2019 and 632 intervention period PFCR from November 2019 to June 2021). At baseline, discharge was discussed during 32% of PFCR. After rationale sharing, checklist modification, and criteria standardization, this increased to 90%, indicating special cause variation. The improvement has been sustained for 10 months. At baseline, there was no centralized location to document discharge criteria. After development of the SmartForm, 21% of patients had criteria documented. After criteria standardization for common diagnoses, this increased to 71%. Rounds length, length of stay, and readmission rates remained unchanged. CONCLUSION: Using quality improvement methodology, we successfully increased verbal discussions of discharge criteria during PFCR without prolonging rounds length.

Evaluation of pharmacy students’ knowledge and perceptions of transitions of care services

Introduction: Studies support incorporation of pharmacists and pharmacy students to improve health and financial outcomes during transition of care (TOC). Standardisation of TOC educational training is currently lacking in pharmacy curricula. Methods: This study employed a cross-sectional, descriptive study with a convenience sample at one college of pharmacy. Students participated in an anonymous Qualtrics survey including items on TOC service understanding and educational training. Results are reported as means and standard deviation for continuous data; frequencies and percentages for categorical data. Results: Of 116 survey responses, 112 provided informed consent. Seventy-eight percent of respondents stated they have learned about TOC and 66% felt they understood what TOC entails. When asked to identify disease states commonly targeted for TOC, 77% responded incorrectly to this item. When asked to select TOC clinical activities, 66% incorrectly selected medication dispensing. Ninety-six percent of respondents replied that additional educational training on TOC would be beneficial. Conclusion: There is a discrepancy in students’ perception of TOC services with their actual knowledge of TOC services based on survey responses.

Methods and Barriers to Communication Between Pharmacists During Transitions of Care

Background Effective communication between pharmacists across healthcare settings is essential to facilitate transitions of care (TOC) and improve patient outcomes. Objective To explore pharmacists’ communication methods and preferences and identify barriers to communication during TOC. Methods A survey was distributed to a convenience sample of pharmacists in California, Connecticut, Illinois, Massachusetts, New Jersey, and Texas. The survey collected information on pharmacists’ demographics, practice settings, and clinical services, and their methods, preferences, and barriers to communication during TOC. Results A total of 308 responses were included in the analysis. The majority of pharmacists practiced in inpatient pharmacy (39.3%) followed by outpatient community pharmacy (23.4%). About 57.8% of pharmacists reported involvement in TOC services. Among respondents, most reported electronic health record (EHR) as their primary method of communication to receive (66.2%) and send (55.5%) information to perform TOC services. Additionally, EHR was reported as the preferred method of communication to receive (75.4%) and send (75.5%) information during TOC. The primary reasons pharmacists reported not utilizing patient health information were lack of information (38.4%), incorrect information (36.7%), delay in receiving information (36.7%), and lack of time (34.5%). Barriers to providing TOC services included poor communication during handoffs (44.2%) and difficulty obtaining needed patient medical information (43.9%). Conclusion This study identified methods and barriers to communication between pharmacists during TOC across healthcare settings. This provides an opportunity for future research to develop interventions to improve communication between pharmacists at different practice settings.

Impact of Pharmacist-Driven Transitions of Care Interventions on Post-hospital Outcomes Among Patients With Coronary Artery Disease: A Systematic Review

Background Transitions of care (ToC) aim to provide continuity while preventing loss of information that may result in poor outcomes such as hospital readmission. Readmissions not only burden patients, they also increase costs. Given the high prevalence of coronary artery diseases (CAD) in the United States (US), patients with CAD often make up a significant portion of hospital readmissions. Objective To conduct a systematic review evaluating the impact of pharmacist-driven ToC interventions on post-hospital outcomes for patients with CAD. Methods MEDLINE, Scopus, and CINAHL were searched from database inception through 03/2020 using key words for CAD and pharmacists. Studies were included if they: (1) identified adults with CAD at US hospitals, (2) evaluated pharmacist-driven ToC interventions, and (3) assessed post-discharge outcomes. Outcomes were summarized qualitatively. Results Of the 1612 citations identified, 11 met criteria for inclusion. Pharmacist-driven ToC interventions were multifaceted and frequently included medication reconciliation, medication counseling, post-discharge follow-up and initiatives to improve medication adherence. Hospital readmission and emergency room visits were numerically lower among patients receiving vs not receiving pharmacist-driven interventions, with statistically significant differences observed in 1 study. Secondary prevention measures and adherence tended to be more favorable in the pharmacist-driven intervention groups. Conclusion Eleven studies of multifaceted, ToC interventions led by pharmacists were identified. Readmissions were numerically lower and secondary prevention measures and adherence were more favorable among patients receiving pharmacist-driven interventions. However, sufficiently powered studies are still required to confirm these benefits.

Emergency department physicians’ distribution of time in the fast paced-workflow-a novel time-motion study of drug-related activities

Background In the emergency department physicians are forced to distribute their time to ensure that all admitted patients receive appropriate emergency care. Previous studies have raised concerns about medication discrepancies in patient’s drug lists at admission to the emergency department. Thus, it is important to study how emergency department physicians distribute their time, to highlight where workflow redesign can be needed.Aim to quantify how emergency department physicians distribute their time between various task categories, with particular focus on drug-related tasks.Method Direct observation, time-motion study of emergency department physicians at Diakonhjemmet Hospital, Oslo, Norway. Physicians’ activities were categorized in discrete categories and data were collected with the validated method of Work Observation Method By Activity Timing between October 2018 to January 2019. Bootstrap analysis determined 95% confidence intervals for proportions and interruption rates.Results During the observation time of 91.4 h, 31 emergency department physicians were observed. In total, physicians spent majority of their time gathering information (36.5%), communicating (26.3%), and documenting (24.2%). Further, physicians spent 17.8% (95% CI 16.8%, 19.3%) of their time on drug-related tasks. On average, physicians spent 7.8 min (95% CI 7.2, 8.6) per hour to obtain and document patients’ drug lists.Conclusion Emergency department physicians are required to conduct numerous essential tasks and distributes a minor proportion of their time on drug-related tasks. More efficient information flow regarding drugs should be facilitated at transitions of care. The presence of healthcare personnel dedicated to obtaining drug lists in the emergency department should be considered.

Uninterrupted HIV treatment for women: Policies and practices for care transitions during pregnancy and breastfeeding in Côte d’Ivoire, Lesotho and Malawi

Transitions between services for continued antiretroviral treatment (ART) during and after pregnancy are a commonly overlooked aspect of the HIV care cascade, but ineffective transitions can lead to poor health outcomes for women and their children. In this qualitative study, we conducted interviews with 15 key stakeholders from Ministries of Health along with PEPFAR-supported and other in-country non-governmental organizations actively engaged in national programming for adult HIV care and prevention of mother-to-child-transmission of HIV (PMTCT) services in Côte d’Ivoire, Lesotho and Malawi. We aimed to understand perspectives regarding transitions into and out of PMTCT services for continued ART. Thematic analysis revealed that, although transitions of care are necessary and a potential point of loss from ART care in all three countries, there is a lack of clear guidance on transition approach and no formal way of monitoring transition between services. Several opportunities were identified to monitor and strengthen transitions of care for continued ART along the PMTCT cascade.

Understanding Barriers to Healthcare Access for Heart Failure Patients during the COVID-19 Pandemic

Early outpatient follow-up within two weeks after hospital discharge is an effective strategy for improving transitions of care in older patients with heart failure (HF). However, implementing timely follow-up care for HF patients has been challenging, especially during the COVID-19 pandemic. This convergent mixed-methods study identified patients’ barriers to accessing care and ascertained their recommendations for addressing these barriers. We enrolled 264 HF patients admitted to the Duke Heart Center between May 2020 and August 2021. A standardized survey and electronic health records (EHR) were used to collect patients’ sociodemographic, psychosocial, behavioral, and clinical data. For patients who reported some difficulty accessing their healthcare (n=30), semi-structured interviews were conducted to understand these barriers. Data were analyzed using rapid analysis techniques. Barriers to accessing care varied across participants, with scheduling an appointment being the most common barrier (12 of the 30 responses). Participants indicated that job-related conflicts, providers’ availability, or COVID-19 contributed most to the difficulty in scheduling an appointment. Some participants experienced more difficulties during the pandemic due to fewer appointments available for non-acute and non-COVID-19 related needs. Transportation was another critical barrier, which was often associated with the participants’ physical functional status. Participants identified the benefits of using telemedicine to address access to care barriers; however, they shared their concerns that telemedicine visits may not be sufficient to assess their HF conditions. Study findings highlight the need for more continual, tailored, and patient-centered interventions to improve access to care in older HF patients.