Pediatric Patient-Centered Transitions From Hospital to Home: Improving the Discharge Medication Process
OBJECTIVES: Medications prescribed at hospital discharge can lead to patient harm if there are access barriers or misunderstanding of instructions. Filling prescriptions before discharge can decrease these risks. We aimed to increase the percentage of patients leaving the hospital with new discharge medications in hand to 70% by 18 months.
METHODS: We used sequential plan-do-study-act cycles from January 2015 to September 2016. We used statistical process control charts to track process measures, new medications filled before discharge, and rates of bedside delivery with pharmacist teaching to the inpatient pediatric unit. Outcome measures included national patient survey data, collected and displayed quarterly, as well as caregiver understanding, comparing inaccuracy of medication teach-back with and without medications in hand before discharge.
RESULTS: Rates of patients leaving the hospital with medications in hand increased from a baseline of 2% to 85% over the study period. Bedside delivery reached 71%. Inaccuracy of caregiver report during a postdischarge phone call decreased from 3.3% to 0.7% (P < .05) when medications were in hand before discharge. Patient satisfaction with education of new medication side effects increased from 50% to 88%.
CONCLUSIONS: By using an engaged interprofessional team, we optimized use of our on-site outpatient pharmacy and increased the percentage of pediatric patients leaving the hospital with new discharge medications in hand to >80%. This, accompanied by increased rates of bedside medication delivery and pharmacist teaching, was associated with improvements in caregiver discharge-medication related experience and understanding.
Hospital-to-home transitions present safety risks to patients. Several pediatric collaboratives have formed to study and improve safety during this critical handoff.1–3 Discharge medications are a key component to safe hospital discharge. Challenges with medication access and caregiver understanding of administration instructions can lead to medication errors, hospital readmissions, and poor outcomes.4–6 To eliminate unanticipated barriers to access, recent efforts have been focused on filling prescriptions through a contracted pharmacy and delivery before discharge. Having medications in hand at discharge decreased readmission rates for pediatric patients with asthma.7,8 Teaching caregivers with home medications in hand can improve the understanding of medication use, increase awareness of side effects, and reduce administration errors.5,9 This is especially important in pediatrics, for which liquid medication formulations present an even greater likelihood for dosing errors.5 The teach-back education technique and requesting caregivers to repeat back instructions can improve caregiver understanding and prevent administration errors.10
In 2014, our hospital became 1 of 4 pilot sites for Project Improving Pediatric Patient-Centered Care Transitions (IMPACT), an American Academy of Pediatrics–affiliated quality improvement research collaborative aiming to implement and test a pediatric transitions bundle.1 In the first year of this project, 7% of caregivers reached via a postdischarge phone call were unable to teach-back the medication plan accurately. Additionally, patient experience survey responses related to newly prescribed medications were below national benchmarks. Our Project IMPACT interprofessional improvement team identified discharge medications as an area of vulnerability and formed a subgroup to focus on this area. We hypothesized that family-centered, discharge medication–related outcomes could be improved by filling prescriptions before discharge and performing medication-related discharge teaching with medications in hand by using the teach-back technique. We aimed to increase the percentage of patients leaving the hospital with new discharge medications in hand to 70% at 18 months. We anticipated that leaving the hospital with medications in hand would enable higher quality teaching, improve patient or caregiver experience, and provide better understanding of medication side effects and administration instructions.
The Barbara Bush Children’s Hospital is an urban, academic children’s hospital within the Maine Medical Center (MMC), a 600-bed hospital located in Portland, Maine. The inpatient pediatric unit (IPU) has 37 beds, excluding the newborn nursery, NICU, and PICU. The pediatric hospitalist service is a teaching service, with resident and medical students involved in the care of ∼1100 patients per year. This is approximately half of all patients admitted to the IPU, with the remainder cared for by pediatric subspecialty or surgical services. During the study period, demographic data were collected for all pediatric hospitalist patients discharged from the hospital; 93% were English speaking, 56% had Medicaid coverage, 18% had complex chronic medical conditions,11 and the average length of stay was 3.04 days. Interpreter Services provided live or telephone interpretation for discharge education, including medication instructions, for all non-English speakers.
As part of Project IMPACT, an interprofessional improvement team used monthly plan-do-study-act cycles to implement a 4-part bundle (including a discharge readiness checklist, teach-back education, timely and complete handoff to the primary care provider, and a postdischarge phone call).1 To support participation in Project IMPACT, the hospital provided funding for a nurse to perform postdischarge phone calls and a research assistant to perform chart reviews.
In January 2015, MMC opened an outpatient pharmacy in the hospital, open 24 hours per day, 7 days per week, enabling discharge prescriptions to be filled on-site. The decision to open a hospital-owned outpatient pharmacy was influenced by the shift toward value-based accountable care across the larger health care organization. The hospital calculated that an outpatient pharmacy could improve patient satisfaction and outcomes and reduce reimbursement penalties for reuse resulting from poor medication adherence.12 As opposed to contracting with a retail pharmacy, a hospital-owned pharmacy presents several advantages, including access to the electronic health record (EHR) for more efficient and accurate medication reconciliation and provider collaboration across the care continuum.
Our Project IMPACT team identified this as a unique opportunity to allow patients to leave the hospital with discharge medications in hand (Fig 1). In December 2015, a discharge medication subgroup (including 3 hospitalist physicians, a nurse manager, a pediatric resident, 2 inpatient pediatric pharmacists, and a medication transitions pharmacist) formed to further focus on improvement. Additional interventions included education outreach to residents, attending and nursing providers with explanation of the benefits of discharging patients with “medications in hand,” emphasizing discharge medication planning in daily interdisciplinary care rounds, and EHR optimization. EHR modifications included routing e-prescriptions to our outpatient pharmacy, creation of a consult to outpatient pharmacy order, and templates for documenting discharge medication delivery and teaching. The consult to outpatient pharmacy order can be entered by physicians, pharmacists, or nurses and serves to identify a patient requiring discharge prescriptions, activate medication preparation, initiate review of insurance coverage and requirements (such as previous authorization), and request bedside delivery. Supplemental Figure 6 depicts a full timeline of interventions. Bedside delivery was primarily performed by outpatient pharmacists who conducted and documented teaching with medications in hand. Routine use of the teach-back education technique has already been reliably adopted across our unit as part of Project IMPACT.1
Study of the Interventions
As part of Project IMPACT, charts are reviewed for all patients discharged from the pediatric hospitalist service, including documentation of discharge education and transcripts from a phone call performed within 3 days of discharge.1 With the initiation of the medication project, we added a question to the phone call script asking whether new medications were filled before discharge. Patients not discharged from the hospital were excluded from the study. Data are entered into a RedCap13 database designed for the multicenter collaborative with additional elements for site-specific projects. We tracked patient satisfaction related to hospital discharge medication experience from Pediatric Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data, which was adopted in the fourth quarter of 2014. We accessed adult HCAHPS data from our institution as a comparison. Additionally, for all patients discharged from our IPU, the outpatient pharmacy tracked the total number of electronically prescribed and written discharge prescriptions, as well as the percentage of those filled at our outpatient pharmacy, associated with a consult to outpatient pharmacy order, delivered to the bedside and with documented pharmacist teachings.
Our primary process measure was percentage of pediatric hospitalist patients with new medications filled before discharge, with a goal to achieve 70% by 18 months. “New” medications were determined by using discharge medication reconciliation fields in our EHR. “Continued” medications or those with dosing changes only were excluded. Success was documented and tracked by a “yes” response to the question “Were medications filled prior to discharge?” on the discharge readiness checklist or from EHR discharge medication reconciliation. A second process measure was bedside delivery rates of medications prescribed to our outpatient pharmacy (as opposed to being picked up by the family before discharge). Our goal was to deliver 70% of medications prescribed to the outpatient pharmacy to the bedside.
Outcome measures were percentage answering “yes, definitely” on Pediatric HCAHPS surveys for 2 discharge medication-related questions (“Before your child left the hospital, did a provider or hospital pharmacist explain in a way that was easy to understand about the possible side effects of these new medications?” and “Before your child left the hospital, did a provider explain in a way that was easy to understand how your child should take these new medications after leaving the hospital?”). Caregiver ability to verify access to new medications and successfully teach-back administration instructions was determined at the time of a postdischarge phone call and tracked for every patient. We tracked percentage of all IPU discharges occurring before noon as a balancing measure.
Statistical process control charts tracked percentage of patients with medications filled before discharge, bedside deliveries, consult to outpatient pharmacy orders, and pre-noon discharges with centerlines used to portray overall average proportions and 3-σ control limits to detect special cause variation. We used Associates for Process Improvement rules for detecting special cause. Odds ratio (OR) analysis compared caregivers’ inability to teach-back medication administration instructions at the time of a postdischarge phone call. Medication-related Pediatric HCAHPS data were collected and displayed over time. Fisher’s exact test compared adult and pediatric HCAHPS responses in the final quarter of the study period.
The MMC Institutional Review Board considered the project to be a local quality improvement initiative. Informed consent beyond standard consent for treatment was not required.
Data from 2014 served as a baseline, with 829 patients discharged from the hospital from the pediatric hospitalist service, of whom 465 (56%) had new medications prescribed, with 2% to 9% filled before discharge (mainly rectal diazepam or 3-day supplies of medications dispensed from the inpatient pharmacy in cases in which barriers to timely filling of prescriptions had been identified). We successfully contacted 459 (55%) of our 2014 patients via postdischarge phone call, and 32 (7%) could not successfully teach-back medication administration instructions.
During the study period, January 2015 to September 2016, 1425 patients were discharged from the hospital from the pediatric hospitalist service, with 958 (67%) contacted via postdischarge phone call. Of the 873 (61%) patients discharged with new medications, 515 (59%) left the hospital with medications in hand (Fig 2).
In Fig 3, we display improvement over time for our primary process measure, with interpretation of special cause points. Improvement in bedside delivery of medications over time is depicted in Fig 4. Coinciding increased use of the consult to outpatient pharmacy order in the EHR is displayed in Supplemental Fig 7.
Random chart review of patients not discharged with medications in hand was performed at the end of the study and revealed barriers to filling prescriptions before discharge. These included inadequate planning, resource limitation for bedside delivery, and patient preference. Percentage of discharges from the IPU before noon (Supplemental Fig 8) improved and remained steady with a mean of 51% during the study period, save the final data point.
Our first outcome measure in which we tracked patient satisfaction with new medication side effect teaching was included in both adult and pediatric HCAHPS surveys. Pediatric improvement for this question with comparative adult data are displayed in Fig 5A. Comparison of pediatric and adult satisfaction for the final data point showed a statistically significant difference (88% vs 50%, P = .00385, Fisher’s exact test). In Fig 5B, we display performance for a more general medication-related patient experience question (“staff explained how to take new medication”) present on the Pediatric HCAHPS survey only.
As an additional outcome measure, we performed subgroup analysis by using data from follow-up phone calls to assess accuracy of medication instruction teach-back. Although rates of successful teach-back were generally high (93% at baseline), families were less able to teach-back new discharge medication instructions if they did not have medications in hand at the time of discharge (Fig 2). Families discharged without medications in hand were inaccurate 3% of the time, whereas families discharged with medications in hand were only inaccurate 0.7% of the time (OR 0.2052, P = .046).
By optimizing use of an on-site outpatient pharmacy, we increased the percentage of pediatric hospitalist patients discharged with new medications in hand from 2% to 85% over the 21-month study period. Key interventions to achieve our goal were formation of an engaged interprofessional team with strong pharmacy representation, promotion of a consult to outpatient pharmacy order in the EHR to facilitate earlier discharge preparation, and use of bedside delivery services with accompanied pharmacist teaching (Supplemental Fig 9). We hypothesized that discharging pediatric patients with new medications in hand would facilitate hands-on as opposed to verbal and/or theoretical discharge teaching and lead to improved medication-related family experience and patient safety via increased family understanding of correct medication use. Improvements in discharge medication-related patient satisfaction survey scores support that family experience improved. The near-universal ability to teach-back discharge medication instructions at the time of a postdischarge phone call for families who had prescriptions filled before discharge supports the enhanced understanding of medication use and administration instructions, contributing to improved patient safety.
Our endeavor consisted of overlapping interventions (teaching with medication in hand, bedside delivery, and pharmacist teaching), making it difficult to assess which effort was most impactful. Additionally, Project IMPACT includes multiple ongoing efforts to improve hospital-to-home transitions. These certainly benefit our medication-focused initiative. For this reason, we chose medication-specific outcome measures to try to isolate this piece of the discharge process, tracking medication-related HCAHPS scores and medication-related teach-back during the postdischarge phone call.
Hatoun et al7 describe a similar initiative targeted at their pediatric population with asthma that directly measured impact on morbidity, showing significant decreases in reuse rates for patients discharged with medications in hand. Because our population included all diagnoses for patients discharged from our service, we did not choose reuse as an outcome measure, fearing that with low baseline readmission rates (4%–7%) we were underpowered to detect any difference. Interestingly, they cite 3 strategies key to the success of their project: getting inpatient providers to write prescriptions earlier in the admission, improving efficiency of medication preparation at their outpatient pharmacy, and bedside delivery of medications. Similarly, our consult to outpatient pharmacy order in the EHR addresses all 3 of these strategies and was critical to our endeavor.
Strong anecdotal support for bedside delivery of medications emerged in our monthly meetings and is supported by reports from other hospitals.14 This service is especially “family-centered” for pediatric caregivers who may have to coordinate child care to pick-up prescriptions. We strongly emphasized use of the delivery service in each of our plan-do-study-act cycles. The downside of bedside delivery is potential for discharge delays, so we tracked percentage of unit discharges before noon as a balancing measure. Improving percentage of prenoon discharges suggest that our endeavor did not lead to significant discharge delays on average. The exception is the final quarter of 2016, when rates dropped below the lower confidence limit. The team struggled to explain this decrease, hypothesizing that July house staff turnover may have contributed. Throughout the study period, we have worked to initiate delivery service earlier in the discharge process by using the consult order to limit delays in filling prescriptions, coordinate bedside delivery, and prevent any pharmacy process challenges. Daily interdisciplinary care rounds provided an opportunity to activate this order on the day before anticipated discharge. We identified evening hours as a convenient time for families to receive teaching, uninterrupted by rounding teams, testing, or consults. We were eventually able to obtain support for an additional pharmacist to work afternoon and/or evening hours. The increase in prescription volume and demand for bedside delivery helped to support the additional resources. Other lessons learned included establishing a pathway for families to transfer prescription refills to their local pharmacy or arrange refills by mail from our pharmacy. As a children’s hospital within an adult hospital, we were able to use adult HCAHPS responses as an internal control. Although adult patients had access to the outpatient pharmacy resource, with a larger number of patients and care teams, they were not subject to the same medication-targeted improvement project. The pediatric-specific improvements, especially in the side effect–related HCAHPS question, support that our successful outcomes were linked to collaborative interventions as opposed to simply access to the outpatient pharmacy.
The improved scores involving caregiver ability to teach-back medication administration instructions represent improved understanding for patients discharged with medications in hand. However, we noted improvement from baseline even in patients discharged without medications in hand (7%–3%). This is likely due to more global, ongoing improvement efforts with Project IMPACT to implement a pediatric hospital-to-home transitions bundle. Specifically, the inclusion of teach-back as a discharge education strategy for all instructions (including medications) may result in a higher degree of understanding, even for patients who fill their medications after discharge. Another limitation of that outcome measure is its reliance on successful phone contact. Like other published reports of postdischarge phone calls, we failed to connect with just over 30% of our patients.15 This limits our ability to generalize from phone call data. In fact, we hypothesize that patients we do not reach may be more vulnerable to misunderstanding because phone contact is contingent on phone access and caregiver availability, both of which can be challenges for socioeconomically disadvantaged populations.
Another limitation of our study is that successes are potentially context dependent. Availability of the on-site, outpatient pharmacy was critical to the success of our project, as was our strong interprofessional partnership and engaged group of inpatient and outpatient pharmacists. Although it is costly to open an outpatient pharmacy, some costs can be offset by increasing prescription volume. Providing employee prescriptions, discharge prescriptions, outpatient clinic patient services, and specialty pharmacy programs all contribute to volume. Additionally, with only 40% of hospital patients covered by private insurance, our organization qualified for the federal 340B Drug Pricing Program, which requires drug manufacturers to sell outpatient medications to eligible health care organizations at a reduced cost. These cost savings improve profit margins and benefit indigent or underinsured patients who otherwise could not afford necessary medications.
Although smaller hospitals or exclusively children’s hospitals may not be able to support a similar financial proposal to open an on-site outpatient pharmacy, Sauers-Ford et al16 describe a successful medications in hand discharge project for pediatric patients with asthma that uses a local pharmacy partnership, suggesting that discharge with medications in hand could be possible in most settings. A planned next step of this project is to test discharge with medications in hand across several hospitals from Project IMPACT. If successful, this will further support that successes are not context specific or dependent on availability of an on-site outpatient pharmacy.
Unit-wide buy-in has been excellent for the project, and our rates of new discharge medications filled before discharge continue to increase as shown in Fig 3. Unit-based culture now results in discharge with medications in hand unless there is a specific reason not to, such as family preference, suggesting that the process has crossed a sustainability threshold. With this in place, the next steps include comparing patient experience and outcomes with nurse versus pharmacist discharge medication teaching, attempting to measure impact on morbidity more directly with high-risk populations, and performing a cost-analysis of the program.
None of the work could have occurred without support from our outpatient pharmacists: Jaimie Charron, Owen Theriault, Bill Hewitt, Teegan French, Peter O’Gagnon, Jim Leonetti, Diana Tsai- Leonard, and Linh Dang; the other members of our hospital-to-home transitions improvement team: Kelly Anctil, Jonathan Bausman, Aggie Bellevue, Shannon Bennett, Abihijit Bhattacharyya, Nancy Bouthot, Sarah Bunting, Danielle DiCesare, Jennifer Hayman, Jennifer Jewell, Nicole Manchester, Anna Martens, Teresa Morgan, Joel McMullin, Elizabeth Murphy, Logan Murray, Steve Prato, Brandy Robertson, Clare Ronan, Ina St. Onge, Matthew St Onge, and Susan Talbot; the Project IMPACT Pilot Site Leaders: David Cooperberg, Snezana Osorio, and Sandra Gage; and Wendy Craig for data analysis support.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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