Deficiencies of discharge: Many patients leave with unclear instructions

The evolving fiscal needs of the U.S. healthcare system have made reducing the number of 30-day readmissions for certain conditions a priority, but despite the laser focus on the issue, discharge planning is still inadequate, researchers reported in a JAMA Internal Medicine study published online Aug. 19.

“Patient perceptions of discharge quality of care and self-rated understanding were high, and written discharge instructions were generally comprehensive although not consistently clear,” wrote the authors, led by Leora I. Horwitz, MD, MHS, of the Yale University School of Medicine in New Haven, Conn. “However, follow-up appointments and advance discharge planning were deficient, and patient understanding of key aspects of postdischarge care was poor.”

For their study, called DISCHARGE (Diagnosing Systemic failures, Complexities and HARm in Geriatric discharges), the researchers studied a group of elderly patients admitted to Yale-New Haven Hospital with acute coronary syndrome, heart failure or pneumonia between May 2009 and April 2010.

They evaluated the discharge process for almost 400 patients through interviews and record reviews.

While 95.6 percent of patients said they understood why they were hospitalized, only 59.6 percent were able to describe their diagnosis after discharge.

The study also found that discharge instructions successfully relayed certain information in audience-appropriate language, such as symptoms to monitor (98.4 percent), instructions about activity (97.3 percent) and dietary recommendations (89.7 percent).

Most patients said they were satisfied with their discharge planning. For example, 90.3 percent of patients said they received written instructions before discharge and 87.6 percent said they were easy to read.

But the researchers found that written information explaining the reasons for hospitalization was too complex for a lay audience. More than a quarter of the written reasons for hospitalization contained medical lingo.

Additionally, only 123 patients were discharged with follow-up appointments and only 54 could remember the details.

Many patients (30 percent) also did not learn about their upcoming discharge until less than a day before and 66 percent of the participants said staff inquired about their post-discharge support system.

“Improving advance discharge planning, follow-up appointment rates, medication reconciliation, and communication with outside clinicians is critical and may require fundamental changes in hospital systems,” the authors concluded. “Improving patient understanding, on the other hand, requires fundamental changes in the way clinicians interact with patients.”

Karin Verlaine Rhodes, MD, MS, of the University of Pennsylvania’s Perelman School of Medicine in Philadelphia, wrote in an invited commentary that discharge planning should be comprehensive and focused on the patient.

“In the hospital-centric environment, processes of care are designed for the convenience of healthcare providers and staff and are more responsive to the financial incentives of payers than the needs and convenience of patients and their families,” she wrote.

She advocated for a “discharge center” led by a multidisciplinary team of specialists.

“The discharge team would serve as patient advocates, attend rounds with the inpatient team, make recommendations, and bear the responsibility of coordinating the transfer of inpatient to outpatient care,” she explained.

The discharge team, she added, would ensure that patients and their caregivers leave the hospital “with a clear understanding of what was accomplished during the hospitalization, along with a list of test results, diagnoses, medications, and knowledge of the adverse effects and symptoms that should prompt return or a follow-up telephone call.”