Discharge planning @

Bangalore Baptist Hospital

Dr Kingsly Robert Gnanadurai

20/2/2012
 Discharge Planning

Discharge
H&P Order
Rx Plan Written

Patient Discharge
Admission Event
Discharge Process

PATIENT EDUCATION DISCHARGE INSTRUCTIONS

Post-D/C
Follow-up
 Why plan for discharge?
The act of leaving a hospital constitutes a
gap or interruption in care delivery where
information can be lost and risky
discontinuities arise.
Which medicines do I take?
Which home medicines do I resume?

How do I take my BP?

Can I drive?
The role of the Consultant in discharge
planning
The Consultant is responsible for
planning and coordinating the discharge
process.

Consultants must ensure that the

discharge summary is begun upon
admission.

Consultants must review variances from

expected outcomes daily and modify
care accordingly. This promotes timely
interventions. It also alerts the team if
the expected length of stay (LOS)
cannot be achieved.
The role of the residents and nurses in
discharge planning

Residents and nurses must work

together to conduct daily reviews
and revise appropriately
The residents and nurses must review
care outcomes daily and alert the
consultant for any variances that
can extend the expected LOS.
 Discharge planning begins on
admission
Anticipate your patients discharge
needs.
We can prepare their discharge
summaries ahead of time.

Anticipate your patients length of

stay (LOS)
We can tell patients their
expected LOS and ensure that
discharge criteria are achieved
within the expected LOS.

We can begin training our patients to

take care of themselves and their
families to address their health
needs after discharge.
 Discharge planning occurs
throughout confinement

Preventable adverse events following

discharge are almost always related to
issues of communication.
The most frequent adverse events
following discharge involve the use of
medication.
When patients do not clearly understand how
to take their medications, or how their
medications and their diet can interact,
adverse drug events can occur.
Medication reconciliation is part of
discharge planning
The treating doctor must reconcile meds
taken before admission with meds
ordered upon admission.

The treating doctor must reconcile meds

to be taken following discharge with meds
given during confinement and meds taken
before confinement.

Failure to do so leads to medication

confusion, poor patient compliance and
adverse drug reactions.
 Communication after discharge
For good post discharge care, three types of communication
are required:
1. Communication between hospital and patient: diagnoses
and treatments, follow-up plans, symptoms that should
prompt action, and who to contact if things dont go
according to plan
2. Communication between hospital and family/community
providers who will be providing ongoing care to the
patient.
3. Communication between patient and a responsible
clinician if things are not going according to plan after
discharge.
 What are the components of
discharge planning?

1. Providing evidence-based INFORMATION to

your patients
Titrate the amount and content of information against your
patients educational readiness and ability.
2. Ensuring your patients UNDERSTANDING
Challenge your patient to paraphrase and demonstrate
mastery of your educational messages.
3. Reaffirming your THERAPEUTIC ALLIANCE
with your patient.
Constantly validate your patients / familys abilities to care for
themselves and your continuing readiness to support their
efforts. Both of you are in this together as partners!
Discharge planning is mostly easy!
Most BBH patients are confined for acute care and
need only basic discharge planning. In general,
acute care patients need to know how to
Avoid getting sick again
Take their medications and when
Modify their diet if needed
Resume normal activities and when
Call for medical help if needed and whom
Go for a follow-up visit and when
Discharge planning is mostly easy!

For example, patients with uncomplicated acute

infections need to know
1. Basic hygiene practices to avoid repeated exposure to
pathogens
2. Doses, frequencies and durations of all home
medications
3. Diet modifications for recovering GI tract
4. Safety and activity modifications
5. The telephone number to reach in case of medical
emergency
6. The date, time and place of their follow-up visit
 Discharge planning is more
challenging in some patients
Patients with conditions such as these need ongoing care and are at highest
risk for adverse events following discharge.
1. Acute myocardial infarction
2. Chronic renal failure
3. Congestive heart failure Other patients who
4. Hip fractures need detailed
5. Stroke discharge planning
6. Complicated diabetes include patients with
7. Complicated hypertension cancer or recurrent
8. Severe asthma serious diseases and
9. Severe pneumonia those who
10. Chronic lung disease underwent major
debilitating surgery.
 Discharge planning is about going
the extra mile for patients

Lets face it. Discharge planning is not yet in

our culture of hospital care.
But one day, when we or our loved ones
become patients, we will appreciate the
extra efforts of our physicians and nurses
to make sure we stay safe and
connected to the hospital while
recovering in our homes.
 Summary of presentation
1. Planning for discharge promotes efficient, safe, timely and
coordinated separation of patients from the hospital while
ensuring that patients are effectively handed over to
community health care providers.
2. Discharge planning begins upon admission and continues
throughout confinement.
3. The consultant leads the health care team in discharge
planning.
4. Information, understanding and therapeutic alliance are
essential components of discharge planning
5. Discharge planning for chronic care patients anticipates
many health care needs
 DS review
1. Examinations findings at admission require to be
written in a little more detail. At times, supplementary
clinical exam reveals certain findings not seen at
admission. These also require to be written up in the
discharge summary.
For example: an unconscious head injury patient is admitted.
Subsequently, after he regains consciousness, it is
discovered that he is blind in one eye. This has grave legal
repercussions, if it is not noted in the discharge summary.

2. If a patient is discharged on request or against

medical advice, then, as far as possible, a line to the
effect that "...relatives were informed about the risks
and consequences of taking the patient out of
hospital under the circumstances..." etc. needs to be
added. This is not being uniformly written up.
 DS review
3. Right - Left disorientation (neurologically, 'allochiria' !!) in
some cases (e.g. AA 18075), where x-rays state 'left' knee
but the patient was operated upon on his 'right' knee. This,
again, can have legal repercussions.

4. In at least one chart, the name says " Mr " but within the
body of the summary, some paragraphs indicate " she " while
referring to the patient. This is very obviously a typographical
error. However, looking at the D/S from the patient's point of
view, he will definitely not be happy.

5. Condition at discharge states " satisfactory ". This is a

clinically meaningless word. At minimum, impairment of
activities of daily living, status of healing of any wounds, level
of sensorium where relevant, important test results where
clinically relevant (examples: blood sugar at discharge,
serum creatinine at discharge, CT brain at discharge, and so
on).
 Are you an effective discharge
planner?
1. Planning for discharge must begin
a. On the day of discharge
b. 24 hours before discharge
c. 48 hours before discharge
d. On the day of admission

Answer: d. Discharge planning must begin on

admission. You can start writing the Discharge
Summary.
 Are you an effective discharge
planner?

2. Planning and coordinating an effective

discharge process is the ultimate
responsibility of the
a. Nurses
b. Residents
c. Consultant
d. BBH

Answer: C.
 Discharge planning @
Bangalore Baptist Hospital
 Teach-Back

Way to confirm that you have explained

what the patient needs to know
Not a test of the patient but rather a test
of how well you explained a concept
Should be used with every patient;
never assume literacy or health literacy
All staff should know how to do it
 Teach-Back Steps*
1. Use simple lay language; explain the concept or demonstrate the
process avoiding technical terms; use a professional translator if
a language barrier exists

2. Ask the patient or caregiver to repeat the concept in his or her

own words or to demonstrate the process

3. Identify and correct misunderstandings or an incorrect procedure

4. Ask the patient or caregiver to repeat the concept or repeat the

process to demonstrate understanding

5. Repeat steps 3 and 4 until clinician is convinced comprehension

and ability to perform process is adequate and safe

* Society of Hospital Medicine

 Teach-Back: Place
Responsibility on Yourself
I want to be sure I didnt leave anything out that I should
have told you. Would you tell me what you are to do so that
I can be sure you know what is important? (Doak et al.)
I want to be sure that I did a good job explaining your
blood pressure medications because this can be
confusing. Can you tell me what changes we decided to
make and how you will now take the medication? (Pfizer
Web site)
When you go home and your grandchild asks you what
the doctor said about your heart, how are you going to
explain this to your grandchild? (Schillinger interview on
AHRQ Web site)
 Teach-Back Technique
Do not ask a patient, Do you understand?
Do not ask yes/no questions
Ask patients to explain or demonstrate how
they will undertake a recommended
treatment or intervention
Ask open-ended questions
Assume that you have not provided
adequate teaching if the patient does not
explain correctly. Re-teach in a different
way.
Teach-Back Show Me
Method

From the U.S. Health Resources and Services Administration