The business of caring is a stressful one. Within the hospital, clinicians face an ever-increasing amount of pressure to do more with less, with our work held accountable to metrics and time pressures. Discharge from the hospital is a favorite target of these evaluations and an everyday process in the inpatient setting. For us, it's often a moment of graduation for the patient, a sign of a job well-done -- and yes, sometimes a bit chaotic. It's also a well-recognized time of peril for patients. Within the transitions of care literature you'll find dozens of interventions designed to optimize discharge communication and decrease post-discharge complications, including that dreaded 30-day readmission rate.
Have you ever wondered though, in the back of your mind, whether your patient leaving the hospital is truly prepared to take charge of their health at home? Whether the medication changes you agonized over, the appointments you went above and beyond to arrange, and the instructions you meticulously personalized will make a difference? We have, and we spent 155 hours at the patient bedside to try to find an answer.
Our paper, published earlier this year in JAMA Internal Medicine, provides a unique perspective on what it's like to be that patient on the day of discharge. We directly observed 33 medicine floor patients in two academic medical centers using a technique derived from anthropological research methods: a trained bedside observer sat with a single patient on the morning of their discharge, from 7 a.m. until the time of discharge, and transcribed every patient-staff conversation, no matter how brief. If possible, a short interview was also conducted with the patient afterwards to see if anyone had spoken to them about discharge education prior to that morning. We then took this narrative data and analyzed how many patients received education on six established communication domains: (1) the name and purpose of at least one medication change; (2) the purpose of follow-up appointments; what to expect at home including (3) disease self-management and (4) red flags; and patient-centered communication techniques like (5) teach-back and (6) asking if the patient has any questions. We also recorded time spent at the bedside by each staff member, and which staff member took ownership of which educational domain for which patient -- basically, who said what, and for how long.
The results will likely not surprise you. About half of the patients were not told the reason behind a medication change, the reason for follow-up appointments, instructions for managing their disease after discharge, or even asked if they had any questions. Approximately 80% weren't told about red-flag signs, or symptoms that should prompt them to seek immediate medical attention. Finally, only one patient was asked to teach back his understanding of the discharge plan. Nurses spent, by far, the longest at the bedside at a median of 22.5 minutes (including time giving medications), followed by 4 minutes, 1 minute, and 3 minutes by interns, residents, and attending physicians, respectively.
But what was the most pressing concern for patients on the morning of discharge? It wasn't medications or disease management, but rather the logistics of physically leaving the hospital that day.
So, what does this data mean, and how can we use it to make the discharge process more meaningful for our patients and ourselves? Although nothing can replace system-wide changes that address the root causes of inadequate patient education, we recommend thinking through four points for every patient being discharged:
- Know your substrate: Think about the patient, and their involved family or caregivers. Do they have the mental or emotional bandwidth to focus on post-hospital instructions today? Do they have the literacy necessary to refer back to paper or electronic instructions after they're home? Would they be best served by a conversation today, or a phone call tomorrow after they're back in their familiar home environment?
- Clarify who will say what: Although our data was collected at academic medical centers, no matter where you work, discharge is undoubtedly a team effort. Coordinate with your nursing, social work, and house staff colleagues to decide who will share what information with the patient. Don't be afraid to get specific! Role assumptions are often wrong and will lead to lapses in patient education.
- Use validated communications techniques: The teach-back technique seems to work, and work well. Avoid speaking at patients instead of with them.
- Be clear about logistics: Over and over, the patients we observed asked obvious questions that had nothing to do with their health, such as what time they were leaving the hospital, how they were expected to get home, whether or not they would be able to stay for a lunch tray, and how much they would have to pay for their hospitalization. Know whether your unit or institution has a standard flow for discharge (such as discharge before noon), or offers transportation or transit vouchers for patients. If you know that food insecurity is an issue for your patient, plan their discharge after unit meal times. Have a phone number readily available for your patients where they can direct billing questions and concerns if you're not familiar with the financial details of their hospitalization.
Hospital discharge is a vulnerable time for patients. Each patient is a unique person with their own life story, and their discharge process should be tailored to their situation. And while we're constantly told to do more with less to serve our patients, it's important to remember that discharge is always a collective effort between the healthcare team.
Shreya Trivedi, MD, is a hospitalist at Beth Israel Deaconess Medical Center and an instructor at Harvard Medical School in Boston. Sara Corderman, MD, is a senior resident in the Johns Hopkins Osler Internal Medicine Training Program in Baltimore, and will be working in primary care after residency.