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Transitions of Care: Tips for Safe Discharges

Soibhan Kelley

  • 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

  • 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
  • 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
  • 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)
    • 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
  • Ensure that appropriate resources and follow-up appointments have been requested (PT/OT, skilled or non-skilled nursing HH, PCP follow-up, etc.)

  • 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

Last update: 2022-06-21 14:51:27