Time to teach
By Stacey Butterfield
Everybody believes somebody should do it, but nobody has the time to figure out whose job it is. Such is the problematic status of patient discharge education, according to a recent study by hospitalists at the University of California San Francisco (UCSF).
They surveyed over 100 nurses, interns and hospitalists about their beliefs and practices regarding discharge education. The survey listed 13 elements of needed education (such as discharge diagnosis, medication changes, and follow-up appointments) and asked the clinicians who should be responsible for completing each element, how often they themselves complete it, and how often they communicate with other clinicians about it.
Dr. Michelle Mourad, ACP Member, at right, and Ellen Kynoch, assistant patient care manager. Photo courtesy of Dr. Mourad.
On most of the elements, the clinicians agreed that responsibility for educating patients should be shared, but in actuality, they reported that nurses usually handled the tasks and there was little communication between nurses and physicians about education. There were two elements that were found to be especially the physician's responsibility—summary of hospital findings and pending results—and they were also found especially lacking. “These were the elements least often discussed by any provider,” the study concluded.
Lead author Michelle Mourad, MD, ACP Member, an assistant professor of medicine at UCSF, recently spoke with ACP Hospitalist about these problematic findings, and the potential for hospitalists and hospitals to improve discharge education for their patients.
Q: What motivated you to conduct this research?
A: While attending on the wards with residents, it was apparent to me that they had no idea how invested the nurses were in discharge education. We have some very passionate nurses who are extremely involved in improving discharge process. Improving communication between nurses and physicians can be an effective tool in improving discharge education.
I was working with a medical student who started partnering with nurses and wondered why communication was so fragmented on the day of discharge. In looking [for] a solution, we realized we first needed to know what the nurses, residents/ internists and hospitalists were doing, so we could standardize best practice around communication with patients at this very critical time in their hospitalization.
Q: Were you surprised by any of the results?
A: Sadly, I wasn't surprised at how little nurses and physicians communicated. I was surprised at how little physicians communicated about the things that everybody agreed were physician responsibilities. I thought that if physicians said, ‘Oh, it's my job to communicate about pending tests,’ physicians would actually communicate about pending tests.
Q: Before your study, do you think the clinicians involved knew that discharge education was not being handled well?
A: It's definitely acknowledged, at least at our institution, that leaving discharge communication to everyone's best intentions will not be a good long-term solution going forward. Now that we've recognized the importance of discharge communication, we need to standardize that in some fashion. Everybody has very good intentions, but if there's no system change put into place to ensure that it happens and happens well, it will be lost in the realm of competing priorities. Taking care of a sick patient is generally going to be higher in priority than the patient who is going home that day.
Q: What do you see as the most promising solutions?
A: We are definitely not alone at UCSF in looking for solutions for this. The most tech-savvy solution in this came from Project RED, which used Louise, the computer-animated discharge coach. (See the March 2011 ACP Hospitalist.) I don't know that all places have the resources to implement an advanced technological solution, which will likely limit its spread, so I do think that we need an interim solution. I would love to utilize technology in other ways through a standardized checklist within the electronic medical record. That checklist might include completion of a standard set of best practices in discharge education, like the ones we put in [our] paper.
[At UCSF] we're trying to change the time when we discharge patients. We're exploring how a discharge huddle between the nurses and the teams in the morning can improve efficiency. On morning rounds, one could prioritize patients going home, and with the nurse at the bedside, review the elements of the discharge plan in a standardized fashion, discussing necessary follow up, patient education needs, med changes and home care.
Then the team goes and spends 15 minutes of intense work making sure that all of those boxes have been checked so that the patient is ready to go early. You've increased communication, and you've increased efficiency. And I'm sure if I was a patient, I would feel much more reassured that everybody on my team is on the same page about what is happening when I'm going home.
Q: Efficiency is a priority for most hospitalists. Can discharge education be improved without taking up more time?
A: That is the optimal goal. I think everybody is short on time, so thinking about doing something better always raises the fear of having to spend more time doing it. I hope that solutions come in the form of innovations like Louise that improve care, but also might improve efficiency as well.
Q: Do you have any advice to hospitalists dealing with this issue now?
A: The first step is to raise it to the forefront of people's awareness. Examine your practices in how you communicate with nurses and how you communicate with patients at the time of discharge to make sure there's synergy rather than redundant work.
Build time into your day or a system into your practice to make sure discharge education is happening in a standardized way. That might be in a system of rounding on discharging patients, a checklist, or a designated clinician who always provides specific information. Perhaps the case manager is always responsible for going through with the patient what home care they're receiving, or the nurse is always responsible for talking about what to do when symptoms worsen at home. The physician's job is then to summarize the hospital stay and talk about the purpose of the follow-up appointments and any pending tests or studies.
Hospital discharges are such chaotic times for patients. They're so much looking forward to going home that having them hear what they need to hear is challenging. Enabling all clinicians to communicate in a systematic fashion at the time of discharge is of key importance.
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