Improving Discharge Efficiency in Medically …...included a medical discharge goal order ( Fig 4),...

Improving Discharge Efficiency in Medically Complex Pediatric PatientsAngela M. Statile, MD, MEd, a, b Amanda C. Schondelmeyer, MD, MSc, a, b, c Joanna E. Thomson, MD, MPH, a, b, c Laura H. Brower, MD, a, b Blair Davis, MS, c Jacob Redel, MD, d Julie Hausfeld, BSN, RN, e Karen Tucker, MSN, RN, e Denise L. White, PhD, MBA, b, c Christine M. White, MD, MATa, b, c

aDivision of Hospital Medicine, cJames M. Anderson Center

for Health Systems Excellence, dDivision of Endocrinology,

and eDepartment of Patient Services, Cincinnati Children’s

Hospital Medical Center, Cincinnati, Ohio; and bDepartment

of Pediatrics, University of Cincinnati College of Medicine,

Cincinnati, Ohio

Dr Statile conceptualized and designed the study,

oversaw improvement activities, drafted the

initial manuscript, and reviewed and revised

the manuscript; Drs Schondelmeyer and Brower

participated in the design of the study and

interventions for improvement, drafted the

initial manuscript, and reviewed and revised the

manuscript; Dr Thomson participated in the design

of the study and interventions for improvement,

carried out statistical analysis, drafted the

initial manuscript, and reviewed and revised the

manuscript; Ms Davis and Dr D. White provided

data support, carried out statistical analysis, and

reviewed and revised the manuscript; Dr Redel

and Ms Hausfeld participated in interventions

for improvement and reviewed and revised

the manuscript; Ms Tucker and Dr C. White

conceptualized and designed the study, oversaw

improvement activities, and reviewed and revised

the manuscript; and all authors approved the fi nal

manuscript as submitted.

DOI: 10.1542/peds.2015-3832

Accepted for publication Apr 19, 2016

Address correspondence to: Angela M. Statile,

MD, MEd, Division of Hospital Medicine, Cincinnati

Children’s Hospital Medical Center, 3333 Burnet

Ave, ML 3024, Cincinnati, OH 45229. E-mail: angela.

[email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,

1098-4275).

Copyright © 2016 by the American Academy of

Pediatrics

Children with medical complexity have

multisystem, chronic disease that can

result in frequent hospitalizations. 1, 2

With multiple diagnoses, need

for technology assistance, many

subspecialty providers, and numerous

medications, the discharge planning

process for this population is different

than for otherwise healthy children

hospitalized with acute illnesses.

Although it is essential to address

discharge needs to ensure safe and

effective transition from hospital

to home, hospital physicians

often prioritize treatment of acute

medical problems over discharge

planning. 3, 4 This poses challenges

to providing timely, efficient, and

safe hospital discharges, 3 care

characteristics prioritized by

the Institute of Medicine.5

Furthermore, discharge delays

negatively impact patient flow and

family experience. 6

abstractBACKGROUND AND OBJECTIVE: Children with medical complexity have unique needs

when facilitating transitions from hospital to home. Defining readiness for

discharge is challenging, and preparation requires coordination of family,

education, equipment, and medications. Our multidisciplinary team aimed

to increase the percentage of medically complex hospital medicine patients

discharged within 2 hours of meeting medical discharge goals from 50% to

80%.

METHODS: We used quality improvement methods to identify key drivers and

inform interventions. Medical discharge goals were defined on admission

for each patient. Interventions included implementation of a complex

care inpatient team with electronic admission order set, weekly care

coordination rounds, needs assessment tool, and medication pathway.

The primary measure, percentage of patients discharged within 2 hours

of meeting medical discharge goals, was followed on a run chart. The

secondary measures, pre- and post-intervention length of stay and 30-day

readmission rate, were compared by using Wilcoxon rank-sum and χ2 tests,

respectively.

RESULTS: The percentage of medically complex patients discharged within 2

hours of meeting medical discharge goals improved from 50% to 88% over

17 months and sustained for 6 months. In preintervention–postintervention

comparison, median length of stay did not change (3.1 days [interquartile

range, 1.8–7.0] vs 2.9 days [interquartile range, 1.7–6.1]; P = .67) and 30-day

readmission rate was not impacted (30.7% vs 26.4%; P = .51).

CONCLUSIONS: Efficient discharge for medically complex patients requires

support of a multidisciplinary team to proactively address discharge needs,

ensuring patients are ready for discharge when medical goals are met.

QUALITY REPORTPEDIATRICS Volume 138 , number 2 , August 2016 :e 20153832

To cite: Statile AM, Schondelmeyer AC, Thomson

JE, et al. Improving Discharge Effi ciency in Medically

Complex Pediatric Patients. Pediatrics. 2016;138(2):

e20153832

by guest on September 26, 2020www.aappublications.org/newsDownloaded from

STATILE et al

In previous work, we improved

discharge efficiency in our general

pediatric hospital medicine (HM)

patients. 7 Through standardization of

discharge goals and implementation

of high-reliability interventions

focused on physician and nursing

processes in the electronic health

record (EHR), 80% of patients are

now discharged from the hospital

within 2 hours of meeting medical

discharge goals.

However, the discharge process for

medically complex patients remained

inefficient; only 50% of patients

on the HM service with neurologic

impairment 8 and/or technology

dependence 9, 10 were discharged


discharge goals. Preliminary work

revealed that the medical team often

overlooked the particular discharge

needs of these medically complex

patients and their families until

after a child was medically ready

for discharge. Discharge planning,

including changes to home care

orders with need for new equipment

and teaching, multiple medication

refills with need for previous

authorization, and specialized

transport home, was not approached

in a standard manner nor addressed

until the end of the stay. We

hypothesized that interventions

focused on optimization of

a standardized discharge

infrastructure for medically complex

patients would improve discharge

efficiency. By using improvement

methods and reliability science, our

multidisciplinary team aimed to

increase the percentage of medically

complex HM patients discharged


discharge goals from 50% to 80%

within 12 months.

METHODS

Setting

Cincinnati Children’s Hospital

Medical Center (CCHMC) is a 522-

bed, free-standing children’s hospital.

Children with medical complexity,

defined as children with neurologic

impairment and/or technology

dependence for the purpose of this

study, are admitted primarily to 2

general HM units staffed by pediatric

registered nurses (RNs), with HM

attending physicians that supervise a

total of 5 teams of pediatric residents

providing direct care. Neurologic

impairment is defined as “functional

and/or intellectual impairments that

result from a variety of neurologic

diseases” (eg, anoxic brain injury,

lissencephaly). 8 Patients with

technology dependence “depend on

medical technology to live or remain

in their current state of health” (eg,

tracheostomy, enteral feeding tube,

cerebral spinal fluid shunt). 9, 10 The

majority of these children (55%)

receive outpatient care at CCHMC’s

Complex Care Center, a medical

home that provides primary care to

620 children with severe, chronic

disease who receive care from ≥3

subspecialists.

Planning the Intervention

Previous process improvement

on acute care patients 7 included

identification of medical goals

for discharge and real-time

documentation of when goals were

met by bedside RNs via an EHR

timestamp ( Fig 1); the same process

was applied to complex patients.

We created a multidisciplinary

group that included HM attending

physicians, RNs, care managers,

pharmacists, pediatric residents,

social workers, and parents of

children with medical complexity.

The group defined the process of

efficient discharge for children with

medical complexity and identified

key drivers ( Fig 2). Interventions

were designed to address top failure

reasons for not leaving within 2

hours of meeting medical goals

before the process was implemented,

specifically transportation concerns,

patient/parent factors, physician

delay, and medication delay ( Fig 3).

Successful interventions were

modified through sequential plan-do-

study-act cycles based on the model

for improvement11 before adopting

into the process.

Patients Grouped onto the Complex Care Inpatient Team

In July 2013, we grouped children

with medical complexity into 1

HM team supervised by a subset

of 15 HM attending physicians to

provide specialized care, including

proactive discharge planning, to this

patient population. The patients are

identified at the time of admission by

the RNs who manage bed placement

in our hospital using clinical

information from the admitting

provider. Before this work, these

patients were scattered among all

HM resident teams. Additional staff,

including a dedicated pharmacist,

dietician, care manager, and social

worker, were hired through hospital

e2

FIGURE 1Discharge effi ciency process.


PEDIATRICS Volume 138 , number 2 , August 2016

investment in improving chronic

care. We also partnered closely with

the outpatient Complex Care Center

team, with their attending physicians

and care managers frequently joining

us for patient rounds.

Complex Care–Specifi c Order Set

In September 2013, we tested a

complex care–specific admission

order set in our EHR. The order set

included a medical discharge goal

order ( Fig 4), specific to the needs

of complex patients (eg, baseline

oxygen requirement for 12 hours,

tolerating enteral feeds for 24

hours). This order was placed on

admission, and the provider, with

input from caregivers and other

team members, chose medical

discharge goals from this list or

added other goals relevant to the

patient’s diagnoses. It was then

modified as the patient’s course

evolved. It focused only on medically

relevant items with the intent that

other discharge tasks (eg, home

care orders, medications) were

completed in advance of the patient

meeting medical discharge goals.

Weekly Multidisciplinary Care Coordination Rounds

In October 2013, the improvement

team implemented weekly

multidisciplinary care coordination

rounds. All team members attended

this meeting to discuss discharge

goals and complete discharge-related

tasks, including sending medications

to the pharmacy and completing

home care orders. Any clarifying

questions, such as transportation

needs, were then reviewed with

families at the bedside. Additional

interventions were needed to

coordinate care for patients with

shorter lengths of stay whose

admission did not overlap this

weekly meeting.

e3

FIGURE 2Key driver diagram.

FIGURE 3Preprocess Pareto chart.


STATILE et al

Needs Assessment Tool

In January 2014, a needs assessment

tool was created to help structure

care coordination rounds and ensure

comprehensive discharge for patients

with shorter hospitalizations.

This checklist included 8 essential

discharge tasks specific to patients

with medical complexity ( Fig 5).

Although the items included in

the needs assessment tool were

distinct from medical discharge

goals, these tasks ensured the

logistics of discharge were addressed

throughout the hospitalization.

Initially a paper document, the

needs assessment tool was later

incorporated as a modifiable

document in the EHR, allowing all

members of the team to see the

status of each task. The assessment

was started on admission and

reviewed regularly throughout the

patient’s hospitalization, including

weekly team review at care

coordination rounds, to facilitate

completion of all tasks (eg, new

equipment, home nursing orders) 24

hours before the child was medically

ready for discharge. Specific sections

of the needs assessment tool

were assigned to team members

(eg, home care needs were the

primary responsibility of the care

manager) to improve reliable task

completion. At time of discharge, any

outstanding tasks were completed

by the discharging resident or nurse

practitioner.

Medication Pathway

Because discharge medication

prescribing was a frequent cause

for delay, a medication pathway

was introduced in late January

2014 to identify barriers (eg,

previous authorization) or changes

in regimen (eg, new prescriptions)

in advance of discharge. The team

pharmacist oversaw medication

reconciliation after admission and

tracked medication changes through

hospitalization. The pharmacist also

led a weekly meeting separate from

care coordination rounds in which

all medications were reviewed.

Additionally, our pharmacist

worked with families to identify

home medications requiring refill,

encouraged the team to prescribe

discharge medications early in the

stay, and called pharmacies to ensure

medications were available.

Planning Study of the Intervention

Baseline data before the advent of

the new inpatient complex care team

included medically complex HM

patients, identified by their primary

care relationship with the Complex

Care Center, from July 2012 through

June 2013.

Data describing our cohort were

extracted from the EHR, including

age, gender, primary insurer,

reported race and ethnicity,

complex chronic conditions (CCCs), 12

technology dependence, and

discharge diagnoses. CCCs were

defined as “any medical condition

that can be reasonably expected

e4

FIGURE 4Complex care–specifi c medical discharge goal order screenshot. © 2015 Epic Systems Corporation. Used with permission.


PEDIATRICS Volume 138 , number 2 , August 2016 e5

FIGURE 5Needs assessment tool.


STATILE et al

to last at least 12 months (unless

death intervenes) and to involve

either several different organ

systems or one system severely

enough to require specialty pediatric

care and probably some period of

hospitalization in a tertiary care

center.” 12 CCCs were grouped into

11 categories (eg, gastrointestinal,

respiratory). Technology dependence

(eg, tracheostomy) was defined

using the “dependence upon medical

technology” or “device” subcategory

within relevant CCC categories.

CCCs and technology dependence

categories are not mutually exclusive

(ie, a patient may have a diagnosis

in >1 CCC or technology dependence

category).

The primary outcome measure

was defined as the percentage of

medically complex patients, admitted

to the 2 primary units for HM

patients, who were discharged within

2 hours of meeting medical discharge

goals. We focused on these 2 units

becuase they already followed the

discharge process based on medical

goals from our previous work. 7

Median length of stay (LOS) was a

secondary outcome measure. To

ensure that our work in expediting

discharge did not negatively impact

readmission, 30-day readmission

rate was evaluated as a balancing

measure.

Analysis

We examined cohort demographic

and clinical characteristics using

descriptive statistics. A run chart

was used for analysis of our primary

outcome measure. Established rules

identified special cause variation for

run charts; specifically, 8 consecutive

points above or below the centerline,

which would occur <0.4% of the

time by chance, led to a midline

shift. 13 –17 For analysis of pre- and

postintervention outcomes of LOS

and 30-day readmission rate, we

excluded patients admitted during

the intervention period (September

22, 2014–March 23, 2015). Pre- and

postintervention median LOS were

compared by using Wilcoxon rank-

sum test. Pre- and postintervention

30-day readmission rates were

compared by using χ2 test.

RESULTS

Of the 385 encounters during

the study period (July 2012–May

2015), there were 227 unique

patients; 13 patients were

admitted in both preintervention

and postintervention timeframes.

The 227 patients were 54% male

with a median age of 5.3 years

(interquartile range [IQR] 2.2–

15.6). The majority were white

(66.1%) and non-Hispanic (92.9%)

with public primary insurance

(71.4%). Nearly three-quarters

of children had diagnoses in ≥4

CCC categories, with the most

common being neuromuscular

(75.8%), gastrointestinal (73.1%),

and congenital (65.6%). Nearly

80% of children were technology

dependent, most commonly in

the gastrointestinal category

(70.9%). There were no significant

differences in demographics

or clinical characteristics of

admitted patients pre- versus post-

intervention. The most common

discharge diagnoses in both pre-

and postintervention periods were:

(1) pneumonia (30% vs 22%), (2)

bronchiolitis (13% vs 13%) and

(3) vomiting and/or diarrhea (12%

vs 8%). Approximately 4% of total

HM discharges were attributable

to the group of medically complex

patients included in the study, which

accounted for ∼17% of our bed days.

The percentage of medically complex

patients discharged within 2 hours

on our 2 study units increased from

50% to 80% within 7 months

( Fig 6). Our initial shift to goal

occurred after the institution of

the needs assessment tool and

medication pathway.

Although we initially reached

our goal in October 2014, we

experienced a downward shift of

our outcome measure, with the

median percentage of eligible

patients discharged within 2 hours

of meeting medical discharge

goals decreasing to 63%. This shift

coincided with a rapid increase in

our overall hospital census starting

in August 2014. The increased

census on the units of interest may

have led bedside providers, such as

RNs covering other patients with

competing care demands, to stray

from proactive discharge planning

for our complex patients. With

interventions aimed at increasing

process reliability, including more

directed role assignment to team

members so that each provider

was aware of his/her specific task

responsibilities, we were able to

increase our median back above

goal, even with continued high

census. This improvement has

sustained at goal for 6 months.

Median LOS, our secondary measure,

did not significantly change between

pre- and postintervention (3.1

days [IQR, 1.8–7.0] vs 2.9 days

[IQR, 1.7–6.1]; P = .67). In addition,

our balancing measure, 30-day

readmission rate, was not negatively

impacted pre- and postintervention

(30.7% vs 26.4%; P = .51).

DISCUSSION

Through interventions focused on

proactive discharge planning for

medically complex patients, we

were successful in increasing the

percentage of patients discharged


goals from 50% to 88%. Our most

impactful interventions included

standardizing discharge planning

processes and identifying discharge

barriers earlier. Although patients

left soon after meeting discharge

goals, the decrease in LOS was not

significant.

An overall improvement in the

efficiency of our process is valuable

even without LOS decline. By

e6 by guest on September 26, 2020www.aappublications.org/newsDownloaded from


anticipating discharge needs early,

we were better able to predict

timing of discharge, which facilitates

anticipating bed capacity on our

units. Additionally, our providers

noted a perceived workload

decompression, because the tasks

were no longer left for completion

on day of discharge. Our process

also allowed families to clearly

delineate their home needs so

that details were planned well in

advance of medical readiness. With

our detailed process and dedicated

team members, we also believe we

decreased the likelihood for errors

in the postdischarge timeframe, such

as inaccurate prescriptions or home

nursing orders. Readmission rates

were also not affected in our study,

suggesting that tracking medical

goals is a reasonable method to

determine when patients are ready

for discharge, and that our process

change did not lead to patients being

discharged too early.

In our previous efforts to improve

discharge efficiency, 7 we focused

on acute care patients admitted

with general medical diagnoses.

Although medically complex patients

were included in those efforts, we

struggled to discharge this subset

of patients in a timely fashion,

due to previous interventions not

being designed for coordination of

extensive outpatient needs. By first

standardizing the way we define

medical discharge goals in this

patient population and making this

order readily available in the EHR

order sets, admitting providers were

better able to apply the previous

process of defining discharge goals

on admission without interfering

with their workflow. This early

intervention facilitated later changes

aimed at standardizing discharge

processes.

As experts in the care of their

children, it was essential that

family members be engaged in

our improvement processes.

Medical goals were discussed and

modified with family input, and

discharge needs were identified

through interactions with our

multidisciplinary team members,

including our dietician, social worker,

pharmacist, and care manager.

Consideration for family schedules,

home equipment and medication

refills needed, and transportation

availability allowed us to reach

the common goal of readiness

e7

FIGURE 6Run chart for primary measure, percentage of HM patients with medical complexity discharged within 2 hours of meeting medical discharge goals.


STATILE et al

for discharge when medically

appropriate.

Care coordination rounds were

instrumental in achieving reliable

completion of tasks before discharge.

By meeting as a team at a designated

time outside of rounds, we confirmed

that medical goals were updated

and social barriers identified. Key to

our success, the needs assessment

tool allowed tasks to be outlined

and tracked over time, facilitating

efficient discussion. This is similar to

adult studies that found success by

incorporating needs assessments into

their discharge planning bundles. 18 –22

In adults on a general medical service, 21

in adults with heart failure, 22 and in

elderly patients, internal medicine

teams demonstrated that by assessing

patients’ needs, they were able to

target interventions to individual

patients 19, 20 Our study used a similar

approach to identify individual patient

needs in our pediatric population

and target interventions (eg, assist

with transportation arrangement)

to facilitate a smooth transition to

home. One area included in the needs

assessment tool that often required

extensive coordination was discharge

medication preparedness. Medication

errors can lead to confusion at

home, adverse drug reactions, and

increased reutilization, 23 so attention

to performing comprehensive

reconciliation before discharge

was essential. Our pharmacist-

led medication pathway ensured

communication among prescribers,

families, and pharmacies. The input

of a pharmacist in predischarge

medication reconciliation is well-

described in adult hospitals as a way

to improve accuracy of medication

lists. 20, 23 – 28 Our study adds to this

literature, because our pharmacist-led

medication pathway was critical to

our process.

We limited this improvement

initiative to patients on our 2 main

HM units because those units used

the medically ready discharge

process from our previous work. 7

This led to a relatively low number

of patients included in this study,

which may have led to an increase

in variability, especially early

in data collection. We noted

even after an increase in our

biweekly numbers, however, that

the centerline of 50% remained

consistent and thus feel this is

reflective of the true baseline.

Our study population was limited

in that it did not include patients

with traditionally longer LOS,

such as those with ventilator

dependence, because they are

admitted to other units. By this, we

may have selected for a population

of medically complex patients

with shorter LOS, influencing our

ability to detect significant changes

in the secondary measure of LOS.

Importantly, LOS did not increase

during this project, nor was there an

increase in readmissions, suggesting

that patient care and discharge

using this new process did not

contribute to increased return for

admission because of an expedited

discharge. We also did not include

other medically complex patient

populations in our scope; by first

applying the process to our HM

patients, we now have experience to

support buy-in from other specialty

providers. We will continue to

follow our secondary measures as

we spread this process to other

services at our hospital, which will

allow us to measure our impact on a

larger scale.

The creation of a multidisciplinary

team with a variety of expertise

influenced our ability to improve

rapidly, which potentially limits

the generalizability of our study.

However, many of our key

interventions, such as meetings

to facilitate care coordination

and a tool to track discharge

task completion, could be easily

implemented in environments

where such a team is not available,

and the failures we addressed in our

process are likely common to many

settings.

Finally, the target of our

improvement, the discharge process,

is limited in that it is inherently

people dependent. Although we

used the EHR to standardize as

much as possible, our frontline

providers must be engaged for it to

be successful.

CONCLUSIONS

The discharge needs of medically

complex patients require the

support of a multidisciplinary

team. By defining medical goals and

discharge needs early, tracking tasks

over time, and designating roles to

team members, we ensured that

discharge tasks were complete when

patients were medically ready for

discharge.

ACKNOWLEDGMENTS

We appreciate the dedication of

our team, including: Suzan DeCicca,

MSW, LSW; Stacey Litman-Padnos,

MSW, LSW; Julie Ostrye, PharmD;

Becky Brehob-Bucker, RD; Derek

Fletcher, MD; David Hall, MD;

Michelle Cobble, BSN, RN; Matthew

Carroll, MD; Steven Smith, MD;

Emily Goodwin, MD; Meghan Hofto,

MD; Hilary Flint, DO; Marshall

Ashby; Shelly Miller; Margaret

DeOliveira; CCHMC inpatient and

Complex Care Center care managers;

CCHMC pediatric residents; and

HM advanced practice nurses and

attending physicians.

ABBREVIATIONS

CCC: complex chronic condition

CCHMC: Cincinnati Children’s

Hospital Medical Center

EHR: electronic health record

HM: hospital medicine

IQR: interquartile range

LOS: length of stay

RN: registered nurse



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DOI: 10.1542/peds.2015-3832 originally published online July 13, 2016; 2016;138;Pediatrics

Christine M. WhiteBlair Davis, Jacob Redel, Julie Hausfeld, Karen Tucker, Denise L. White and

Angela M. Statile, Amanda C. Schondelmeyer, Joanna E. Thomson, Laura H. Brower,Improving Discharge Efficiency in Medically Complex Pediatric Patients

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DOI: 10.1542/peds.2015-3832 originally published online July 13, 2016; 2016;138;Pediatrics

Christine M. WhiteBlair Davis, Jacob Redel, Julie Hausfeld, Karen Tucker, Denise L. White and

Angela M. Statile, Amanda C. Schondelmeyer, Joanna E. Thomson, Laura H. Brower,Improving Discharge Efficiency in Medically Complex Pediatric Patients

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