In a collaborative pilot program, standardization of hospital discharge orders, which greatly improved communication between hospital providers and a home health agency, has shown promise of reducing readmission of heart failure patients within 30 days of discharge.
Only one of nine heart failure patients enrolled according to the new program was readmitted within 30 days—a man who was eligible (under Government insurance) for care and concomitant telemonitoring by a home health agency but declined to participate. Whether his remaining in the project would have prevented readmission is unknown.
Although the hospital, one of several within an academic network, had a slightly lower (22%) readmission rate than the national average (25%), there was clearly room for improvement.
The trouble began with nonstandardized hospital discharge orders, which were written by interns, residents, nurse practitioners, physician assistants, or the attending physician, in their individual style. Lacking standardization, it is not surprising that these orders, when transmitted to the home health agency, omitted basic information, such as the desired blood pressure range, heart rate, or oxygen saturation level. There was confusion, therefore, about which readings constituted a need to alert the physician provider.
So the first step in changing procedure was for hospital and agency staffers to jointly draw up a standardized discharge template, with check boxes to individualize care. The template was based on national guidelines, hospital preferences, and agency protocols.
When the system was put into use, agency nurses praised the completeness of the discharge orders, while administrators expressed the wish that they always receive the information one or two days before actual discharge, so they could coordinate staffing and scheduling.
The tiny pilot was a relatively simple test, in that the patients required nursing and telemonitoring, but not administration of intravenous inotropes.
There were two blips in accurate transmission of information: discharge orders drawn up on the hospital’s electronic database had to be manually re-input into the agency’s database. The researchers emphasize that until systems are integrated for direct electronic transfer, there will be opportunity for error, as occurred in this trial.
Appraising their results, the authors conclude that “complete and consistent home health orders may have potential to improve efficiency and safety of patient care.” They see opportunities to implement the strategy with other patient populations.
Heeke S, Wood F, Schuck J. Improving Care Transitions from Hospital to Home. Standardized Orders for Home Health Nursing With Remote Telemonitoring. J Nurs Care Qual 2013; published online ahead of print, August 9, 2013.
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