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hospital discharge

Complications: - 20% of older adults experience an adverse drug event after hospital discharge [4]* - 1/3 considered preventable - 17% involve drugs on Beer's list [4] - benzodiazepines, proton pump inhibitors & celecoxib most common [19] - intensifying antihypertensives at hospital discharge associated with harm without reduction of cardiovascular events [15,20] - hypoglycemia in diabetics the last day of hospitalization associated with higher readmission rates & postdischarge mortality [16] - 10% of inpatients with diabetes receive intensification of their treatment at a VAMC before discharge, usually with insulin; half deemed unnecessary [18] - hospital readmission * < 50% of patients can list their diagnoses, their medications or their purpose at hospital discharge [7] * see transition of care for patient risk factors for poor outcomes Management: - patients should receive a list of medications at the time of discharge & be informed of previous medications that have been discontinued or changed [2] - discharge medication education program for high-risk patients, including scheduling a post-hospital discharge telephone follow-up within 2-3 days of discharge reduces hospital readmission rate (RR=0.57) [17] - transitional care management after hospital discharge [12] - associated with reduced mortality & lower cost among Medicare beneficiaries - first became reimbursable by Medicare in 2013 - covers the first 30 days after discharge - includes non-face-to-face follow-up (telephone) within 2-3 days after discharge, plus an office visit within 7-14 days [2] - rarely used [12] - successful hospital-to-home transitional care programs all center around interprofessional care coordination teams [21] - a transition care provider (hospitalist transitions coach) is a component of an interprofessional care coordination team [21] - explicit communication with the primary care physician is fundamental to a successful transition of care after hospitalization [2] - virtual postdischarge ward teams did not prevent hospital readmissions among high-risk medical patients [5] - a nurse-led, in-hospital discharge intervention among high-risk elderly failed to prevent readmissions or emergency department visits [6] - ~60% of automated notifications of actionable tests pending at hospital discharge with documented follow-up in the medical record [11] - hospital discharge summary* [2] - follow-up in 1 week for heart failure hospitalization [2,13] - physical therapy & occupational therapy * 1% increase in 30-day readmissions for every 3-day delay in hospital discharge summary [9] - mean time to hospital discharge summary completion is 8 days [9] - 43% of hospital readmissions occur before hospital discharge summary available [9] Notes: - patients who cannot be discharge to home may be discharged to - skilled nursing facility (SNF) - long-term acute care hospital (LTAC) [10] - discharge to home with home health care associated with higher rates of hospital readmission, with differences in mortality or functional outcomes, but with lower Medicare payments [14] - priotitizing hospital discharge before noon does not result in earlier discharge or diminished length of hospital stay [22]

Related

hospital hospitalization Kohlman Evaluation of Living Skills (KELS) length of stay (LOS) transition of care; health care transition

General

inpatient discharge (includes hospital discharge)

References

  1. Kane RL. Finding the right level of posthospital care: "We didn't realize there was any other option for him". JAMA. 2011 Jan 19;305(3):284-93. PMID: 21245184
  2. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2022.
  3. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007 Sep;2(5):314-23. PMID: 17935242
  4. Kanaan AO et al. Adverse drug events after hospital discharge in older adults: Types, severity, and involvement of Beers criteria medications. J Am Geriatr Soc 2013 Nov; 61:1894 PMID: 24116689
  5. Dhalla IA et al. Effect of a postdischarge virtual ward on readmission or death for high-risk patients: A randomized clinical trial. JAMA 2014 Oct 1; 312:1305 PMID: 25268437
  6. Goldman LE et al. Support from hospital to home for elders: A randomized trial. Ann Intern Med 2014 Oct 7; 161:472 PMID: 25285540
  7. Makaryus AN, Friedman EA. Patients' understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005 Aug;80(8):991-4. PMID: 16092576
  8. Roy CL, Poon EG, Karson AS et al Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19;143(2):121-8. PMID: 16027454
  9. Hoyer EH, Odonkor CA, Bhatia SN et al. Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland. J Hosp Med 2016 Jun; 11:393. PMID: 26913814
  10. Makam AN, Nguyen OK, Xuan L et al. Factors associated with variation in long-term acute care hospital vs skilled nursing facility use among hospitalized older adults. JAMA Intern Med 2017 Feb 5 PMID: 29404575
  11. Dalal AK, Schaffer A, Gershanik EF, et al. The impact of automated notification on follow-up of actionable tests pending at discharge: a cluster-randomized controlled trial. J Gen Intern Med. 2018 Mar 12; PMID: 29532297 https://psnet.ahrq.gov/resources/resource/31998
  12. Bindman AB, Cox DF Changes in Health Care Costs and Mortality Associated With Transitional Care Management Services After a Discharge Among Medicare Beneficiaries. JAMA Intern Med. Published online July 30, 2018. PMID: 30073240 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2687989 - Huckfeldt P, Neprash H, Nuckols T. Transitional Care Management Services for Medicare Beneficiaries - Better Quality and Lower Cost but Rarely Used. JAMA Intern Med. Published online July 30, 2018. PMID: 30073322 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2687985
  13. Lee KK, Yang J, Hernandez AF, Steimle AE, Go AS. Post-discharge Follow-up Characteristics Associated With 30-Day Readmission After Heart Failure Hospitalization. Med Care. 2016 Apr;54(4):365-72. PMID: 26978568 Free PMC Article
  14. Werner RM, Coe NB, Qi M et al Patient Outcomes After Hospital Discharge to Home With Home Health Care vs to a Skilled Nursing Facility. JAMA Intern Med. Published online March 11, 2019. PMID: 30855652 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2727848
  15. Anderson TS, Jing B, Auerbach A et al Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge. JAMA Intern Med. Published online August 19, 2019 PMID: 31424475 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2747871
  16. Spanakis EK, Umpierrez GE, Siddiqui T et al. Association of glucose concentrations at hospital discharge with readmissions and mortality: A nationwide cohort study. J Clin Endocrinol Metab 2019 Sep 1; 104:3679 PMID: 31042288 Free PMC Article https://academic.oup.com/jcem/article/104/9/3679/5433626
  17. Crannage AJ, Hennessey EK, Challen LM. Implementation of a discharge education program to improve transitions of care for patients at high risk of medication errors. Ann Pharmacother. 2019. February 19, 2020 PMID: 31868004 https://psnet.ahrq.gov/issue/implementation-discharge-education-program-improve-transitions-care-patients-high-risk
  18. Anderson TS et al. Prevalence of diabetes medication intensifications in older adults discharged from US Veterans Health Administration hospitals. JAMA Netw Open 2020 Mar 2; 3:e201511. PMID: 32207832 Free PMC Article https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2763233
  19. Weir DL, Lee TC, McDonald EG et al. Both new and chronic potentially inappropriate medications continued at hospital discharge are associated with increased risk of adverse events. J Am Geriatr Soc 2020 Jun; 68:1184 PMID: 32232988 https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.16413
  20. Rastogi R, Sheehan MM, Hu B, Shaker V, Kojima L, Rothberg MB. Treatment and outcomes of inpatient hypertension among adults with noncardiac admissions. JAMA Intern Med 2020 Dec 28; PMID: 33369614 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2774562
  21. Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  22. Burden M et al. Discharge in the a.m.: A randomized controlled trial of physician rounding styles to improve hospital throughput and length of stay. J Hosp Med 2023 Apr; 18:302 PMID: 36797598 https://shmpublications.onlinelibrary.wiley.com/doi/10.1002/jhm.13060