Discharge missteps can send seniors back to hospital
■ A column about treating a growing demographic
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Mr. Park, 85, recently was admitted to the hospital with community-acquired pneumonia and, after five days of intravenous antibiotic therapy, he was discharged home.
Mr. Park lives with his daughter. He has hypertension, benign prostate hyperplasia and mild Alzheimer's disease. His medications at home included bisoprolol/HCTZ, 5/6.25 mg; tamsulosin, 0.4 mg; and donepezil, 10 mg once a day. While he was in the hospital, the bisoprolol was switched to 50 mg of metoprolol twice a day because bisoprolol was not on the formulary. At the time of his discharge, an intern reviewed his hospital medication list and wrote out the prescriptions, which were given to Mr. Park by a nurse. Mr. Park's daughter filled the new prescriptions. When he returned home, Mr. Park resumed taking his usual medications, plus the new ones prescribed in the hospital. The combination of bisoprolol and metoprolol made Mr. Park bradycardic and dizzy. He fell on his way to the bathroom. When the emergency medical technicians arrived at his home, his heart rate was just 38 beats per minute. Mr. Park was readmitted to the hospital.
Patients often are discharged from the hospital to their homes unprepared to care adequately for themselves. Because of postdischarge missteps, many involving a medication mistake, patients too often may find themselves back in the hospital. Given the medications Mr. Park was mistakenly taking after he returned home, his dizziness and bradycardia could have been predicted and his readmission avoided.
Mr. Park is not alone. A 2003 study in the Annals of Internal Medicine found that 76 of 400 patients, with an average age of 57, experienced an adverse event after discharge from a tertiary care academic hospital to their homes. Researchers determined that 23 of the events were preventable, and another 24 could have been less severe with appropriate management. The most common adverse events were drug-related. Poor communication is one of the most important reasons for such events.
The risks for very elderly patients are even more apparent, since many have cognitive impairments or several chronic conditions for which they take an array of medications, compounding the likelihood of drug-drug or drug-disease interactions.
A Transitions of Care Consensus Policy Statement developed by several medical societies, including the American College of Physicians and the American Geriatrics Society, cited findings from a study of 2,644 patient discharges. The 2004 study showed that about 40% of the patients had pending test results at the time of discharge and that 10% of the results had required some follow-up action. Yet the patients and their primary care physicians were unaware of the tests. The consensus statement was published in the July/August 2009 Journal of Hospital Medicine.
The prevention of such missteps should be a primary focus of discharge planning, which is required of hospitals by all of the major health care regulatory agencies and accrediting agencies. The Joint Commission has included discharge instructions as a core performance measure in the care of heart failure patients. Hospital performance on this measure is reported publicly on the Centers for Medicare & Medicaid Web site.
There are many reasons transitions can be risky. Among them is the absence of a coordinating agency, according to the Transitions of Care Consensus Policy Statement. Studies indicate that patient-centered medical homes can make a difference.
Among the principles recognized as vital for a seamless transition is clear communication at several levels, whether between hospital physician and primary care physician or among hospital physician, patient and caregiver.
But a 2007 study in the Journal of the American Medical Association found that direct communication between hospital physicians and primary care physicians occurs infrequently and that discharge summaries are rarely available to the primary care doctor at the first postdischarge visit. In a review of 55 studies published between 1970 and 2005, the researchers found that even when discharge summaries were available, they often lacked important information such as diagnostic test results, treatment course, discharge medications, test results pending at discharge, patient or family counseling, and follow-up plans.
Since a patient's family member or caregiver has an important role to play in transitions of care, that person also must receive information at discharge about posthospital needs.
Several studies have shown that discharge from the hospital is a time of anxiety for patients and their families. But it doesn't have to be that way, says Eric Coleman, MD, MPH, professor of medicine at the University of Colorado at Denver and director of the university's Care Transitions Program, a one-month training course for patients with complex needs and their family caregivers. Patients and families work with a coach and learn self-management skills that ensure their needs are met during the transition from hospital to home.
Patients who received this program were significantly less likely to be readmitted to the hospital, Dr. Coleman told a Senate committee in 2008. The program, which received funding from the Robert Wood Johnson Foundation and the John A. Hartford Foundation, was developed with input from patients and caregivers.
A new position paper released Jan. 12 by the American College of Physicians also offers guidance to physicians about establishing and maintaining relationships with patients' caregivers.
Privacy provisions from the Health Insurance Portability and Accountability Act do not preclude the sharing of relevant information with family caregivers, as long as the patient does not object, the ACP states. After reconciling the patient's inpatient and outpatient medications, Mr. Park's daughter should have been contacted at the time of discharge. The physician or the nurse should review the medication list with the patient and caregiver, and educate them on possible side effects.
Barriers of language, education, values and culture may compound the communication difficulties faced by patients, families and caregivers during discharge from hospitals. A 2004 study by the Agency for Healthcare Research and Quality found that low health literacy is linked to higher rates of hospitalization and higher use of expensive emergency services. If a language barrier is identified, the use of a translator is warranted.
This column was written in collaboration with staff writer Susan J. Landers.