P0132 - Improving Documentation of Post-Discharge Issue Mitigation

Background: Poor understanding of discharge instructions can lead to post-discharge issues (PDIs) such as missed follow-up appointments, medication errors, and failure to activate contingency plans. Literature shows that PDIs occur in 20-25% of discharged patients. Post-discharge phone calls (PDPCs) are a recommended best-practice to identify and mitigate PDIs. Thorough documentation of the PDPC is necessary to update all providers to PDIs and mitigation strategies. A current state assessment at our institution showed variability in documentation of PDPC content and PDI mitigation. Thus, we sought to create a caller training program and standard documentation template to optimize PDPCs and maximize the benefit to patient safety.

Objective: Our primary aim was to improve the rate of documentation of PDI mitigation from 65% to 100% over 12 months.

Methods: Over a 16-month period of this observational time series, an interdisciplinary QI team used the Model for Improvement to perform planned sequential interventions (Figure 1). All patients discharged from the acute care neuroscience unit within a free-standing tertiary care pediatric hospital were eligible for a PDPC. The main outcome measure was the documentation of PDI mitigation. Process measures included PDPC template use and completion. Balancing measures included identification of PDIs, phone call attempt and completion rate, and caller perceptions of ease of documentation. Key interventions included creation of a documentation template, template training sessions with callers, and team data sharing and feedback. A clinical report generated from the electronic medical record collected process and balancing measure data. Chart review determined documentation of PDI mitigation. Caller perceptions were collected by survey. Data was analyzed using statistical process control charts. API rules for special cause variation were applied.

Results: The documentation of PDIs mitigated showed an overall increase from 65% to 91% over 16 months (Figure 2). Both template use and completion increased from zero to 100% and 98%, respectively. The number of PDIs identified and phone call completion rate remained unchanged (14% and 44%, respectively). Phone call attempts increased from 40% to 59%. There was no change in caller perceptions of ease of documentation.

Discussion: Interventions led to an increase in rate of documentation of PDI mitigation in our population. The identification and mitigation of PDIs serves as a protective measure against the safety risks that present at the time of discharge. In our study, caller expertise and buy-in were critical in improving PDI mitigation. The key intervention was data sharing to promote team engagement. However, engagement declined without frequent reminders, indicating further work is required to embed this change in the system. We postulate this improved documentation of PDI mitigation will allow all healthcare team members to understand patient issues faced at discharge and more easily identify significant changes made to the care plan.