A Discharge Planning Template for the Electronic Medical Record Improves Scheduling of Neurology Follow-up for Comanaged Seizure Patients

Study Setting and Population

This study occurred at Children’s Hospital Colorado, a 413-bed freestanding tertiary care teaching hospital with >13 000 inpatient admissions,∼300 nonelective admissions for seizures annually. We participated in a Children’s Hospital Association Discharge Collaborative from October 2011 through October 2012, and this project was 1 of several process improvement initiatives that emerged during the collaborative. Key aims of the collaborative were to create a safer, more efficient, and effective discharge process and to facilitate communication and transparency between disciplines regarding transitional care planning. The study was deemed to be a QI project and was approved by the Children’s Hospital Organizational Research Risk and Quality Improvement Review Panel, precluding the need for institutional review board approval. We included all patients admitted to a Children’s Hospital Colorado hospitalist service with a diagnosis of seizure, comanaged with a neurologist, and discharged from the hospital between January 2012 and June 2013. We excluded electively admitted patients and those discharged from intensive care, subspecialty services, or the epilepsy monitoring unit. To ensure that only comanaged patients were studied, we also excluded patients whose chart did not have any written documentation from neurology or whose only neurology written documentation included a procedure note (EEG interpretation).

Study Timeline

The study occurred between January 2012 and June 2013 (Fig 1). The study time period coincided with the Discharge Collaborative and availability of process improvement specialists and information technology resources to support data collection and analysis

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FIGURE 1

Timeline of DPT development and implementation.

Process Mapping and Intervention

Process mapping and development of the DPT occurred between January and June 2012. An initial version of the DPT was implemented in July 2012, and the DPT was amended in October 2012 (Fig 1).

During the development phase, we elicited feedback from hospitalists, pediatric residents, and neurologists about potential problems with discharge-related communication between the consulting neurology service and the primary hospitalist team. Process mapping (Fig 2) revealed that discharge-related communication often occurred at the end of hospitalization, making it difficult for the primary team to arrange outpatient follow-up. Discharge-related information exchange was sometimes verbal rather than written, and pediatric residents or hospitalists sometimes called neurologists to clarify discharge criteria or to ask whether the patient needed to be seen by the inpatient neurologist on the day of discharge. Outpatient neurologists reported that some families were receiving unrealistic neurology clinic follow-up scheduling instructions and that tests recommended for the outpatient setting were not always completed before the follow-up neurology visit.

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FIGURE 2

Discharge-related communication between hospitalists and consulting neurologists before and after process change.

To standardize transfer of information and facilitate discharge-related communication between the neurology and hospitalist teams, we designed a DPT for the existing neurology consult note template within the EMR. The DPT was designed with input from both neurologists and hospitalists, specifically for use in the setting of hospitalist service patients for whom the neurology service was consulted. We established consensus on the final design of the DPT by presenting it for review at both neurology and hospitalist department meetings.

The template initially comprised 2 parts: “neurology criteria for discharge” and “outpatient planning.” (Fig 3) The neurology criteria for discharge section provided the primary team with parameters on when a patient might be ready to go home from the neurologist’s perspective and whether the neurologist needed to see the patient on the day of discharge. The outpatient planning section provided guidance on outpatient neurology follow-up and recommendations for additional outpatient imaging studies or other tests. The latter section solicited inputs on timing of neurology follow-up and choices of specific neurology provider types or names. This would allow primary team residents and resident liaisons to schedule appropriately through the neurology clinic or at least to include accurate scheduling advice in the discharge instructions.

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FIGURE 3

Example DPT. MRI, magnetic resonance imaging.

Introduction of the DPT coincided with a bedside nursing QI initiative to add or update the patient’s seizure action plan (SAP) before hospital discharge. Three months after its initial implementation, the DPT was amended to include a third section, which provided the nurses with more guidance on accurately completing the patient’s SAP (Fig 2).

Data Collection and Outcomes

Monthly reports were generated for all hospitalist service patients with a diagnosis-related group of seizure (APR-DRG-053), discharged between January 2012 and June 2013. The reports also included primary admitting service and admission/discharge date from which we were able to delineate different inpatient teams and to determine length of stay (LOS) as well as weekend versus weekday discharge.

For each patient’s hospitalization, use of the DPT in neurology consult documentation was determined by chart review. Although the DPT automatically populates neurology consult note templates, the note writer has the ability to manually delete the DPT so that not all finalized neurology consult notes necessarily include the DPT. The note writer may also use an alternative note template that does not include the DPT.

We determined whether neurology follow-up was scheduled before discharge from review of discharge instructions to the parents of each discharged patient. These instructions include all actual scheduled appointments or recommendations for the family to schedule appointments and are documented within the EMR. A printed version is provided to the family at discharge. We counted documentation of a follow-up date and time with the neurology clinic/provider in the discharge instructions as a scheduled appointment. Instructions such as “neurology schedulers will be contacting you to schedule follow-up” or lesser/absent details about follow-up were counted as appointment not scheduled.

The primary outcome was whether a follow-up neurology appointment had been scheduled before hospital discharge (yes/no). The primary predictive variable was time period: 6 months preimplementation or 12 months postimplementation of the DPT. Covariates included LOS categories and weekday versus weekend discharge.

Analysis

We conducted bivariate analysis using the χ² test. Multivariable logistic regression was used to test the association between the primary predictive variable (time period pre- or post-DPT implementation) and the primary outcome (scheduling of outpatient neurology follow-up before discharge), adjusting for available covariates. For the purpose of the analysis, the postimplementation period combined the time period of both initial DPT and amended DPT use because we did not find a significant difference in rates of DPT use before and after the amendment occurred (see Results). Given the skewed distribution of the LOS variable, we performed the analysis with the log-transformed LOS as a continuous variable versus LOS categories and found no difference in the results. LOS categories were used in the final analysis for ease of interpretation. Analysis was performed by using SAS v.9.3