Having your child admitted to hospital is a scary time for any parent. Often, one of the first questions they ask is ‘When can we go home?’ But as Amy Tyler, MD, discovered, there are many factors at play in the discharge process.
Dr. Tyler is assistant professor of pediatrics and director of quality for hospital medicine at Children’s Hospital Colorado. In 2011, she became one of the physician leads for a large, multidisciplinary initiative to improve hospital discharge preparedness.
“This was a natural project for me to be involved with,” she said. “I really wanted to make things better for patients and their families, but I’m also the sort of person who loves things to be efficient.”
Yet getting patients, their families and health care teams on the same page proved to be something of a challenge.
“After several hundred hours of process mapping we realized there was a large number of people involved in the discharge process,” Dr. Tyler said. “Many were working in silos. A physician might hold one key to discharging a patient but a social worker would hold another — the information was rarely shared across teams.”
There are many ways hospital discharges don’t go to plan, and all could lead to readmission at a later date.
“It’s not unusual for a patient with complex needs to find they can’t fill their prescription in their hometown,” Dr. Tyler explained. “Some families also struggle to schedule appointments with specialists, or find there are financial barriers to seeing their primary care physician.”
In order to tackle these problems and ensure every patient, and member of the care team, is prepared for discharge, Dr. Tyler and the team began to build a discharge readiness report in the electronic health record.
“The report allows us to track the discharge progress of every patient, every day,” Dr. Tyler said. “Now we can see and address all potential barriers to discharge.”
This new approach is having a real impact. For asthma patients, the team has cut the time to discharge after the patient is deemed ‘medically ready’ from eight to four hours. Another measure, tracking the number of patients who experience discharge-related care failures, fell from 30% to 5% for the target populations.
Jenny Reese, MD, director of inpatient medicine at Children’s Hospital Colorado, said that these results are in part due to Dr. Tyler’s tireless work to hone her skills as an expert in quality improvement and implementation science.
“Dr. Tyler approaches her work on discharge preparedness with dedication to rigorous quality improvement methodology,” Dr. Reese said. “She also ensures there are tools in place in Epic to support processes, and works with key stakeholders to drive compliance. It takes strong leadership skills and collaboration with multiple specialties to truly implement these changes. Despite frequent challenges, Dr. Tyler remains dedicated and tenacious in her work.”
After the initial success of the discharge preparedness project, Dr. Tyler wanted to find ways to empower families and help them take practical steps toward getting their children discharged from the hospital.
Her first initiative to develop a ‘keys to transition’ tool – a checklist that outlines everything a patient and their family have to accomplish before they can go home.
“This included things like how to fill their prescription, when to follow up with their family doctor and how to arrange transport home,” Dr. Tyler said. “We’ve had positive feedback, but we discovered the tool was most helpful when we spent more time discussing the discharge process with patients and their families.”
“Although we, as a health care team, need to start thinking about discharging a patient as soon as they’re admitted, we need to strike a balance as to when to give families that information. Before we plan any future interventions, we’re going to take some time to understand the family perspective in more detail.”
Dan Hyman, MD, chief quality and patient safety officer at Children’s Hospital Colorado, said he is grateful for Dr. Tyler’s efforts to improve the discharge process and the patient and family experience.
“We are fortunate to have people like Dr. Tyler focusing their scholarly efforts on leading improvement initiatives that directly benefit patients, especially while also informing colleagues at other institutions of the best practices for treating common acute pediatric illnesses,” he said. “Amy does a fantastic job leading these while also supporting our maintenance of certification, small grants program and inpatient quality program.”
Dr. Tyler said she is proud of what she and her team have achieved but is aware that future success relies upon sustained effort.
“We all have the same goal, to do the best for the patient and their family,” she said. “We managed to create a great tool to enable discussion; now we just have to keep having those conversations.”
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