Improving patient discharge

There is a growing impetus to reorganize the hospital discharge process to reduce avoidable readmissions and costs. The aim of this study was to provide insight into hospital discharge problems and underlying causes, and to give an overview of solutions that guide providers and policy-makers in improving hospital discharge.

Methods: The Intervention Mapping framework was used. First, a problem analysis studying the scale, causes, and consequences of ineffective hospital discharge was carried out. The analysis was based on primary data from 26 focus group interviews and 321 individual interviews with patients and relatives, and involved hospital and community care providers. Second, improvements in terms of intervention outcomes, performance objectives and change objectives were specified. Third, 220 experts were consulted and a systematic review of effective discharge interventions was carried out to select theory-based methods and practical strategies required to achieve change and better performance. Improving patient discharge

Results: Ineffective discharge is related to factors at the level of the individual care provider, the patient, the relationship between providers, and the organisational and technical support for care providers. Providers can reduce hospital readmission rates and adverse events by focusing on high-quality discharge information, well- coordinated care, and direct and timely communication with their counterpart colleagues. Patients, or their carers, should participate in the discharge process and be well aware of their health status and treatment. Assessment by hospital care providers whether discharge information is accurate and understood by patients and their community counterparts, are important examples of overcoming identified barriers to effective discharge. Discharge templates, medication reconciliation, a liaison nurse or pharmacist, regular site visits and teach-back are identified as effective and promising strategies to achieve the desired behavioural and environmental change.

Conclusions: This study provides a comprehensive guiding framework for providers and policy-makers to improve patient handover from hospital to primary care. Improving patient discharge

Keywords: Patient handoff, Patient discharge, Patient readmission, Intervention mapping, Adverse events

* Correspondence: gijs.hesselink@radboudumc.nl 1Radboud University Medical Center, Scientific Institute for Quality of Healthcare (IQ healthcare), 114 IQ healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands Full list of author information is available at the end of the article

© 2014 Hesselink et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Improving patient discharge

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Hesselink et al. BMC Health Services Research 2014, 14:389 Page 2 of 11 http://www.biomedcentral.com/1472-6963/14/389 Improving patient discharge

Background Patients still experience needless harm and often struggle to have their voices heard, processes are not as efficient as they could be, and costs continue to rise at alarming rates while quality issues remain. A shorter length of hos- pital stay, the decrease in work-hours of health care pro- viders, and the increasing number of patient transitions between departments and institutions requires effective patient handovers, especially those of frail patients with comorbidities [1]. Continuity of care at patient discharge from the hospital is a critical aspect of high quality patient care [2,3]. Highly reliable care requires close cooperation between care providers across organisational boundaries, thereby establishing an interdisciplinary network [4]. Unfortunately, incomplete or incorrect information and communication errors between hospital care providers and the multiple receiving parties often increase the chance of adverse events. These may ultimately lead to life threatening situations, avoidable treatments, un- planned re-hospitalisations [5,6], and extra costs [7-9]. Although studies have identified discharge problems Improving patient discharge

in the social, organisational, linguistic and technical context [10-12], there is insufficient, evidence driven insights into more effective solutions. The effectiveness of most interventions is highly variable and limited in daily practice. Explanations for these disappointing re- sults include the difficulty of changing providers behav- iour and existing practices, non-optimal intervention strategies, inadequate resources devoted to evaluating the impact of interventions, and inadequate methods to design and evaluate interventions [13-15]. A systematic approach for translating discharge problems into custo- mised solutions is lacking. Many clinical intervention developers select their strategies intuitively. Effective interventions need to be theory- and evidence based, and targeted at specific behavioural and environmental factors [16,17]. The aim of our study was to systematically develop a

guiding framework to more effective design of interven- tions that support care providers and policy-makers to improve patient handovers from the hospital to primary care. Improving patient discharge

Methods Intervention mapping (IM) is a systematic, iterative six- step process that helps to develop an intervention, based on theoretical, empirical and practical information [18]. The steps are summarised in Table 1. IM was originally used effectively in the health promotion domain to de- velop programs for smoking cessatation [19], stroke pre- vention [20], asthma management [21], HIV prevention [22], and leg ulcer management [23]. We modified the IM terminology in order to apply it to the quality im- provement domain.

Step 1: Problem analysis We structured the problem analysis by using the PRE- CEDE PROCEED model [24] (see Additional file 1), to analyse and describe the scale, causes, and conse- quences of the health problem and to identify the target population.

Procedure and participants A literature search on the frequency and consequences of ineffective hospital discharge problems was performed [25]. We performed a large qualitative study on patient handovers between acute care hospitals and primary care in five countries, i.e. The Netherlands, Spain, Poland, Sweden, and Italy, to identify the behavioural and envir- onmental determinants influencing ineffective hospital discharge [10-12]. The study adhered to the RATS (Rele- vance, Appropriateness, Transparency, Soundness) guide- lines for qualitative studies. Data collection and analysis consisted of multi-method qualitative research including individual and focus group interviews [26], process maps, artefact analyses [10-12], and Ishikawa diagrams [27] (Table 1). The discharged patients and their care pro- viders were recruited using general and country-specific inclusion criteria (see Additional file 2). The study was approved by the ethics committee of the University Med- ical Center Utrecht — Medical Ethics Committee. Pa- tients were asked for informed consent Improving patient discharge

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