The effect of a pharmacist-led multidisciplinary transitions-of-care pilot for patients at high risk of readmission.

OBJECTIVES: To evaluate the feasibility and effect of a pharmacist-led transitions-of-care (TOC) pilot targeted to patients at high risk of readmission on process measures, hospital readmissions, and emergency department (ED) visits. SETTING: Academic medical center in Colorado. PRACTICE DESCRIPTION: Pharmacists enrolled patients identified as high risk for readmission in a TOC pilot from July 2014 to July 2015. The pilot included medication reconciliation, medication counseling, case management or social work evaluation, a postdischarge telephone call, and an expedited primary care follow-up appointment. PRACTICE INNOVATION: Implementation and evaluation of the pharmacist-led TOC pilot program with risk score embedded into the electronic health record. EVALUATION: Comparison of TOC-related process measures and clinical outcomes between pilot patients and randomly matched control patients included readmissions or ED visits at 30 and 90 days. RESULTS: We enrolled 34 pilot patients and randomly matched them to 34 control patients. The intervention took an average of 57.1 minutes for pharmacists to deliver. More pilot patients had a case management or social work note compared with control patients (88% vs. 59%; P = 0.006 [statistically significant]). Readmission rates in pilot versus nonpilot patients, respectively, were 18% versus 24% (P = 0.547) at 30 days and 27% versus 39% (P = 0.296) at 90 days. The composite outcome of a readmission or ED visit in pilot versus nonpilot patients was 24% versus 30% (P = 0.580) at 30 days and 36% versus 49% (P = 0.319) at 90 days. CONCLUSION: A pharmacist-led TOC pilot demonstrates potential for reducing hospital readmissions. The intervention was time intensive and led to creation of a TOC pharmacist role to implement medication-related transitional care.

The Effectiveness of a Multidisciplinary Electronic Discharge Readiness Tool: Prospective, Single-Center, Pre-Post Study.

BACKGROUND: In the face of hospital capacity strain, hospitals have developed multifaceted plans to try to improve patient flow. Many of these initiatives have focused on the timing of discharges and on lowering lengths of stay, and they have met with variable success. We deployed a novel tool in the electronic health record to enhance discharge communication. OBJECTIVE: The aim of this study is to evaluate the effectiveness of a discharge communication tool. METHODS: This was a prospective, single-center, pre-post study. Hospitalist physicians and advanced practice providers (APPs) used the Discharge Today Tool to update patient discharge readiness every morning and at any time the patient status changed throughout the day. Primary outcomes were tool use, time of day the clinician entered the discharge order, time of day the patient left the hospital, and hospital length of stay. We used linear mixed modeling and generalized linear mixed modeling, with team and discharging provider included in all the models to account for patients cared for by the same team and the same provider. RESULTS: During the pilot implementation period from March 5, 2019, to July 31, 2019, a total of 4707 patients were discharged (compared with 4558 patients discharged during the preimplementation period). A total of 352 clinical staff had used the tool, and 84.85% (3994/4707) of the patients during the pilot period had a discharge status assigned at least once. In a survey, most respondents reported that the tool was helpful (32/34, 94% of clinical staff) and either saved time or did not add additional time to their workflow (21/24, 88% of providers, and 34/34, 100% of clinical staff). Although improvements were not observed in either unadjusted or adjusted analyses, after including starting morning census per team as an effect modifier, there was a reduction in the time of day the discharge order was entered into the electronic health record by the discharging physician and in the time of day the patient left the hospital (decrease of 2.9 minutes per additional patient, P=.07, and 3 minutes per additional patient, P=.07, respectively). As an effect modifier, for teams that included an APP, there was a significant reduction in the time of day the patient left the hospital beyond the reduction seen for teams without an APP (decrease of 19.1 minutes per patient, P=.04). Finally, in the adjusted analysis, hospital length of stay decreased by an average of 3.7% (P=.06). CONCLUSIONS: The Discharge Today tool allows for real time documentation and sharing of discharge status. Our results suggest an overall positive response by care team members and that the tool may be useful for improving discharge time and length of stay if a team is staffed with an APP or in higher-census situations.

Development and Implementation of a Multidisciplinary Electronic Discharge Readiness Tool: User-Centered Design Approach.

BACKGROUND: Typical solutions for improving discharge planning often rely on one-way communication mechanisms, static data entry into the electronic health record (EHR), or in-person meetings. Lack of timely and effective communication can adversely affect patients and their care teams. OBJECTIVE: Applying robust user-centered design strategies, we aimed to design an innovative EHR-based discharge readiness communication tool (the Discharge Today tool) to enable care teams to communicate any barriers to discharge, the status of patient discharge readiness, and patient discharge needs in real time across hospital settings. METHODS: We employed multiple user-centered design strategies, including exploration of the current state for documenting discharge readiness and directing discharge planning, iterative low-fidelity prototypes, multidisciplinary stakeholder meetings, a brainwriting premortem exercise, and preproduction user testing. We iteratively collected feedback from users via meetings and surveys. RESULTS: We conducted 28 meetings with 20 different stakeholder groups. From these stakeholder meetings, we developed 14 low-fidelity prototypes prior to deploying the Discharge Today tool for our pilot study. During the pilot study, stakeholders requested 46 modifications, of which 25 (54%) were successfully executed. We found that most providers who responded to the survey reported that the tool either saved time or did not change the amount of time required to complete their discharge workflow (21/24, 88%). Responses to open-ended questions offered both positive feedback and opportunities for improvement in the domains of efficiency, integration into workflow, avoidance of redundancies, expedited communication, and patient-centeredness. CONCLUSIONS: Survey data suggest that this electronic discharge readiness tool has been successfully adopted by providers and clinical staff. Frequent stakeholder engagement and iterative user-centered design were critical to the successful implementation of this tool.

Effect of general anesthesia in infancy on long-term recognition memory in humans and rats.

Anesthesia in infancy impairs performance in recognition memory tasks in mammalian animals, but it is unknown if this occurs in humans. Successful recognition can be based on stimulus familiarity or recollection of event details. Several brain structures involved in recollection are affected by anesthesia-induced neurodegeneration in animals. Therefore, we hypothesized that anesthesia in infancy impairs recollection later in life in humans and rats. Twenty eight children ages 6-11 who had undergone a procedure requiring general anesthesia before age 1 were compared with 28 age- and gender-matched children who had not undergone anesthesia. Recollection and familiarity were assessed in an object recognition memory test using receiver operator characteristic analysis. In addition, IQ and Child Behavior Checklist scores were assessed. In parallel, thirty three 7-day-old rats were randomized to receive anesthesia or sham anesthesia. Over 10 months, recollection and familiarity were assessed using an odor recognition test. We found that anesthetized children had significantly lower recollection scores and were impaired at recollecting associative information compared with controls. Familiarity, IQ, and Child Behavior Checklist scores were not different between groups. In rats, anesthetized subjects had significantly lower recollection scores than controls while familiarity was unaffected. Rats that had undergone tissue injury during anesthesia had similar recollection indices as rats that had been anesthetized without tissue injury. These findings suggest that general anesthesia in infancy impairs recollection later in life in humans and rats. In rats, this effect is independent of underlying disease or tissue injury.