Transitions of Care: Tips for Safe Discharges¶
Soibhan Kelley
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Discharge from hospital represents a period of vulnerability for patients. Medical errors (especially medication errors) following discharge are exceedingly common and can lead to adverse events
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At VUMC we are fortunate to have the Discharge Care Center
- Multidisciplinary team including nurses, social workers, care coordinators, and pharmacists
- Phone number is included on discharge paperwork and patients can contact them 24/7. The DCC also reaches out to patients through an automated system
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How residents can promote safe discharges:
- Communicate with patient’s outpatient team (i.e. PCP)
- Typically achieved through the discharge summary
- Include a list of specific, actionable follow-up tasks and assign a responsible party.
- Place in easy-to-view spot at the top of the summary
- Ex: Instead of writing “follow-up BMP after initiation of furosemide,” write “PCP to check BMP in 2 weeks after initiation of furosemide”
- Include any pending studies and appointments from hospital admission
- All relevant parties should receive a copy of the discharge summary (see appendices section for mechanics of discharge process)
- It is useful to send patient with a printed copy of the discharge summary if they will follow-up outside VUMC
- For high-risk discharges (patients with poor health literacy, hx of being lost to follow-up, patients following up outside VUMC) consider calling PCP’s office to set follow-up
- Typically achieved through the discharge summary
- Communicate with patient’s outpatient team (i.e. PCP)
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Complete an accurate and thorough medication reconciliation
- An accurate discharge medication list depends on having a complete admission medication reconciliation (utilize pharmacy consult!)
- Three steps to medication reconciliation:
- Verification: Performing a Best Possible Medication History
- Clarification: Checking that medications and doses are appropriate
- Reconciliation: Record all medication changes
- Seek to use at least two sources of information
- Keep a list of any held or changed medications in your hospital course. Medication changes can be lost when not communicated during team transitions
- Review medication changes on rounds and with pharmacist on day of discharge (bonus points for day prior to discharge)
- Three steps to medication reconciliation:
- Highlight any significant medication changes on discharge summary
- Can include as follow-up tasks if pertinent (ex: PCP to follow-up BP in 2 weeks. Losartan held on d/c due to AKI but anticipate need to reinitiate once Cr normalizes)
- Be sure to communicate any changes with the patient and/or caregiver
- An accurate discharge medication list depends on having a complete admission medication reconciliation (utilize pharmacy consult!)
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Ensure that appropriate resources and follow-up appointments have been requested (PT/OT, skilled or non-skilled nursing HH, PCP follow-up, etc.)
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Effectively communicate discharge plan to patient
- Discuss medication changes, tasks for patient to complete, follow-up appointments
- Key points should also be written in the patient instructions box
- Useful to include educational sheets in the AVS (searchable in discharge navigator)
- Utilize the teach-back method to ensure your instructions were effectively communicated
- Discuss medication changes, tasks for patient to complete, follow-up appointments
Last update:
2022-06-21 14:51:27