Background: Hospital discharge describes the point at which inpatient hospital care ends, with ongoing care transferred to other providers. The coordination of such care typically involves multiple health care providers and social care contributors. The inherent complexity of coordinating a large number of players, often based in different settings and hospitals, leads to hospital discharge being a vulnerable, time-dependent and high-risk episode in the patient’s care.
Purpose: Discharging a patient from the hospital can be an event fraught with error. To improve this situation, we propose a systematic tool that can have a significant impact on the safety and quality of care provided to patients at discharge. We propose a time out or a deliberate pause involving clear communication and verbal confirmation.
Description:
We propose the use of a formal verbal time out process before discharge using the mnemonic DDEMAP (pronounced ‘dē-map’). This tool is used to identify The main components of the time out are D – Diagnosis: discharge primary and secondary diagnoses, D – Destination: where they are going and transportation, E – Equipment: home health or equipment needs, home O2, M – Medications: paying attention to medications initiated or stopped in the hospital, A – Appointments: all follow-up appointments, P – Pending: labs and studies to be followed after discharge.
The provider caring for the patients carries out the verbal discharge time out on the day of or day before discharge. The team including medical students, interns, residents and attending physicians all participate in the time out to ensure a safe and timely discharge of the patient. In order to measure the effectiveness of discharge timeout which has been informally used in our program for 4 years, we sought voluntary help of medical students to gather data for one week on patients they were following. In order to ensure correct data was collected, we provided them training in a didactic session which incorporated role playing discharge timeouts.
We collected 59 responses in one week out of which 73 % patients had a discharge timeout performed by the team. Of the timeouts performed, 78% of them took less than 5 minutes. Additionally, around 79 % of the time the team had significant changes or contributions to the discharge timeout. The most frequent changes made were to medications (50% of the time), although changes were made in all categories. We also surveyed our house staff and attending physicians of whom 90% ranked this tool as 4 or higher on a 5 point scale as being ‘very useful in recognizing issues that might have delayed discharge.’
Conclusions: The literature strongly suggests that the discharge process can be a high-risk time period for patient care. Timeouts have been used in other high-risk situations with very good results. There are a few proposed discharge time out methods in the literature; however our method is unique in that it is easy to remember, requires very little time, and it is effective in identifying changes to discharge plans that can improve the safety of transitions as well as identify tasks that might delay discharge. This method has been well received by housestaff and attendings alike. Given the complexity and increasing number of patients that are cared for by hospitalists, we recommend a standardized approach such as ours be implemented to improve patient safety and the quality of care. We feel that this process can be easily implemented in other institutions without putting a strain on time or resources.