Division of Hospital Medicine
School of Medicine, University of Missouri-Kansas City.
Hosp Pediatr. 2021 Oct;11(10):1033-1048. doi: 10.1542/hpeds.2020-005421. Epub 2021 Sep 15.
Patients are at risk for adverse events during inpatient-to-outpatient transitions of care. Previous improvement work has been targeted at this care transition, but gaps in discharge communication still exist. We aimed to increase documentation of 2-way communication between hospitalists and primary care providers (PCPs) for high-risk discharges from pediatric hospital medicine (PHM) services from 7% to 60% within 30 months.
A3 improvement methodology was used. A list of high-risk discharge communication criteria was developed through engagement of PCPs and hospitalists. A driver diagram guided interventions. The outcome measure was documentation of successful 2-way communication with the PCP. Any documented 2-way discharge communication attempt was the process measure. Via a survey, hospitalist satisfaction with the discharge communication expectation served as the balancing measure. All patients discharged from PHM services meeting ≥1 high-risk criterion were included. Statistical process control charts were used to assess changes over time.
There were 3241 high-risk discharges (442 baseline: November 2017 to January 2018; 2799 intervention and sustain: February 2018 to June 2020). The outcome measure displayed iterative special cause variation from a mean baseline of 7% to peak of 39% but regressed and was sustained at 27%. The process measure displayed iterative special cause variation from a 13% baseline mean to a 64% peak, with regression to 41%. The balancing measure worsened from baseline of 5% dissatisfaction to 13%. Interventions temporally related to special cause improvements were education, division-level performance feedback, standardization of documentation, and offloading the task of communication coordination from hospitalists to support staff.
Improvement methodology resulted in modestly sustained improvements in PCP communication for high-risk discharges from the PHM services.
患者在住院到门诊的护理过渡期面临不良事件的风险。之前的改进工作针对这一护理过渡，但出院沟通仍存在差距。我们的目标是在 30 个月内将儿科医院医学（PHM）服务中高危出院患者的医院医生与初级保健提供者（PCP）之间的双向沟通记录从 7%提高到 60%。
采用 A3 改进方法。通过与 PCP 和医院医生的合作，制定了高危出院沟通标准清单。驱动图指导干预措施。结果衡量标准是与 PCP 成功进行双向沟通的记录。任何有记录的双向出院沟通尝试都是过程衡量标准。通过调查，医院医生对出院沟通期望的满意度作为平衡衡量标准。所有符合≥1 项高危标准的 PHM 服务出院患者均被纳入。使用统计过程控制图评估随时间的变化。
共有 3241 名高危出院患者（442 名基线：2017 年 11 月至 2018 年 1 月；2799 名干预和维持：2018 年 2 月至 2020 年 6 月）。结果衡量标准显示，从平均基线的 7%到 39%的峰值呈迭代特殊原因变化，但呈回归趋势并维持在 27%。过程衡量标准显示，从 13%的基线平均值到 64%的峰值呈迭代特殊原因变化，回归至 41%。平衡衡量标准从基线的 5%不满意恶化至 13%。与特殊原因改进相关的干预措施包括教育、部门级绩效反馈、文档标准化以及将沟通协调任务从医院医生转移到支持人员。
改进方法导致 PHM 服务高危出院患者的 PCP 沟通略有持续改善。
