Patrick Yeh, Karen Dahri, Michael Legal, Colleen Inglis, Jenifer Tabamo, Kiana Rahnama, Danielle Froese, and Leslie ChinTo cite: Yeh P, Dahri K, Legal M, Inglis C, Tabamo K, Rahnama K, et al. Optimizing the hospital discharge process: perspectives of the health care team. Can J Hosp Pharm. 2024;77(2):e3544. doi: 10.4212/cjhp.3544
ABSTRACT
Background
Prior research capturing pharmacists’ perspectives on the discharge process has shown that their involvement is essential. Given the multidisciplinary nature of the hospital environment, it is important to understand the perspectives of nonpharmacist health care providers.
Objectives
To explore the perspectives of nonpharmacist health care providers concerning current discharge practices, components of an effective discharge plan, and perceived barriers to an optimal discharge, and to explore their expectations of pharmacists at discharge.
Methods
This qualitative study used key informant interviews of allied health professionals and prescribers at Vancouver General Hospital and North Island Hospital Comox Valley (British Columbia). Participants primarily working on general medicine, family practice, or hospitalist wards were invited to participate.
Results
A total of 16 health care providers participated, consisting of 12 allied health professionals and 4 prescribers. Thematic analysis of the interview transcripts revealed 5 themes for each group. The following 3 themes were common to both groups: systems-related barriers to an optimal discharge; patient- and community-related barriers to an optimal discharge; and patient involvement and education. For allied health professionals, themes of prioritization of patients for discharge and direct communication/teamwork were also key for an optimal discharge. Prescriber-specific themes were limitations related to technology infrastructure and inefficiency of existing collaborative processes. Key responsibilities expected of the pharmacist at discharge included preparing the discharge medication reconciliation and prescriptions, addressing medication-related cost concerns, organizing adherence aids/tools, and providing medication counselling.
Conclusions
Further studies are warranted to investigate optimization of the discharge process through implementation of standardized discharge protocols and electronic health record–related tools. The primary responsibilities of the pharmacist at discharge, as perceived by study participants, were consistent with previous literature.
Keywords: hospital pharmacists, pharmacy services, discharge planning
RÉSUMÉ
Contexte
Des recherches antérieures recueillant le point de vue de pharmaciens sur le processus associé au congé de l’hôpital ont démontré que leur implication est essentielle. Compte tenu de la nature multidisciplinaire du milieu hospitalier, il est important de comprendre les perspectives des prestataires de soins de santé non pharmaciens.
Objectifs
Étudier les points de vue des prestataires de soins de santé non pharmaciens au sujet des pratiques actuelles relatives au congé, des éléments d’un plan de congé efficace et des obstacles perçus à un congé optimal, et, enfin, prendre connaissance des attentes des prestataires à l’égard des pharmaciens au moment du congé.
Méthodologie
Cette étude qualitative a utilisé des entretiens avec des informateurs clés, des professionnels paramédicaux et des prescripteurs au Vancouver General Hospital et au North Island Hospital Comox Valley (en Colombie-Britannique). Les participants travaillant principalement dans les services de médecine générale, de médecine familiale ou d’hospitalisation ont été invités à participer.
Résultats
Au total, 16 prestataires de soins de santé ont participé, 12 professionnels paramédicaux et 4 prescripteurs. L’analyse thématique des transcriptions des entretiens a permis d’identifier 5 thèmes pour chaque groupe. Les 3 thèmes suivants étaient communs aux deux groupes: obstacles au congé optimal liés aux systèmes; obstacles au congé optimal liés aux patients et à la communauté; et participation et sensibilisation des patients. Pour les professionnels paramédicaux, les thèmes de la priorisation des patients pour le congé et de la communication directe/du travail d’équipe étaient essentiels pour un congé optimal. Les thèmes spécifiques aux prescripteurs étaient les limitations liées à l’infrastructure technologique et l’inefficacité des processus de collaboration existants. Les principales responsabilités attendues du pharmacien à la sortie comprenaient la préparation du bilan comparatif des médicaments et des ordonnances au moment du congé, la résolution des problèmes de coûts liés aux médicaments, l’organisation des aides/outils à l’observance et la fourniture de conseils en matière de médication.
Conclusions
D’autres études sont nécessaires pour étudier l’optimisation du processus associé au congé grâce à la mise en œuvre de protocoles standardisés et d’outils liés aux dossiers de santé électroniques. Les principales responsabilités du pharmacien au moment du congé, telles que perçues par les participants à l’étude, correspondaient à la littérature antérieure.
Mots-clés: pharmaciens hospitaliers, services de pharmacie, planification des congés hospitaliers
Transitions of care, such as discharge from hospital, are critical points in a patient’s journey through the health care system, as they are associated with increases in the risk of patient harm and hospital readmission.1 In Canada, approximately 8.5% of patients were readmitted to the hospital within 30 days of discharge in 2010/11, costing the health care system $1.8 billion.1 Literature available at that time suggested that up to 59% of readmissions could potentially be prevented, if those at high risk were identified and their predischarge care improved. Similarly, Auerbach and others2 found that 27% of readmissions within 30 days were potentially preventable and recommended that efforts be made to better identify a patient’s readiness for discharge and to improve communication between health care providers and patients.
Several factors can contribute to medication-related problems at discharge, including intentional and unintentional medication nonadherence, adverse drug events, unintentional medication changes, and poor communication with patients and community health care providers about the discharge plan.3,4 Because of the significant burden that medication-related problems may place on patients and the health care system, pharmacists are in an ideal position to minimize these issues at the time of discharge.5 Previous studies have demonstrated that pharmacist involvement in the discharge process, which may include providing medication education, identifying medication discrepancies, and improving adherence, is vital to success of the discharge.3–6
Our research group has published 2 previous studies exploring the perceptions of British Columbian hospital pharmacists concerning the discharge process.7,8 The first study, which used focus groups, demonstrated that hospital pharmacists believe optimization of the discharge process requires a multifaceted, team-based approach.7 The second study was a survey of hospital pharmacists across British Columbia.8 When asked about key discharge interventions, pharmacists in both studies believed that performing medication reconciliation, providing patient medication education, and ensuring medication adherence were their most important responsibilities for a successful discharge.7,8
Given the multidisciplinary nature of the hospital setting, it is also important to understand the perspectives of nonpharmacist health care providers concerning the discharge process and their expectations of pharmacists at the time of discharge. Previous studies using quantitative methods to explore the opinions of health care providers about clinical pharmacy services9,10 found that pharmacists were expected to complete the medication reconciliation, prepare a patient-friendly medication list, and provide medication counselling, findings that are consistent with our prior research.7,8 However, qualitative methods, such as interviews, are often considered more exploratory in nature, allowing for a greater understanding of the overall situation and identification of behaviours, perceptions, and opinions.
Therefore, to thoroughly characterize the discharge process and to explore the expectations of pharmacists at discharge, a qualitative methodology is preferred. In the study reported here, we sought to explore the perspectives of nonpharmacist health care providers concerning current discharge practices, components of an effective discharge plan, and perceived barriers to an optimal discharge, and also to explore their expectations of pharmacists at discharge and their perceptions of pharmacists’ responsibilities.
A qualitative study design involving key informant interviews was used. Prescribers (physicians and nurse practitioners) and allied health professionals (care management leaders, bedside nurses, social workers, transition services coordinators, patient care coordinators, physiotherapists, and occupational therapists) from the general medicine, family practice, and hospitalist wards at Vancouver General Hospital (VGH) and North Island Hospital Comox Valley (CVH) were eligible to participate. A care management leader is a registered nurse who leads “iCARE rounds” (interdisciplinary rounds for disposition planning), confirms action plans and follow-up for barriers related to care or discharge planning, and initiates tasks to ensure an ideal transition to home. CVH is a community hospital with 150 acute care beds and a hybrid paper-and-electronic medical records system, whereas VGH is a tertiary care teaching hospital with 1000 acute beds and a fully electronic records system.11,12 Discharge supports at VGH include a designated care management leader on each unit, to coordinate disposition planning, and specialized health care providers, known as transition services teams, that primarily focus on helping patients with complex care needs transition to home. Health care providers holding exclusively leadership positions (managers, directors, etc.) and those working in emergency, intensive care, surgical, or outpatient settings were excluded. A $10 Starbucks gift card was offered as an honorarium to each participant.
Hospital administrators used email to send invitations to participate (including a letter of initial contact and a consent form) to staff in their respective areas of responsibility. Study recruitment posters were also posted on the units. Interested staff members contacted the study team directly and were screened by 2 of the authors (P.Y., K.D.) for eligibility. Once the signed consent forms were collected, the link to the baseline demographic survey was distributed by email; participants were instructed to complete this survey before scheduling their interview. Participants were stratified into 2 groups: allied health professionals and prescribers.
All participants completed the baseline demographic survey using the University of British Columbia January 2023 version of Qualtrics software. All interviews were facilitated virtually by the first author (P.Y.) through the primary investigator’s (K.D.) Zoom (version 5.14.10) account. The interview facilitator asked each participant a series of preapproved interview questions (described below). All study material (ID# H22-02496) was approved by the University of British Columbia Behavioural Research Ethics Board and Harmonized Partner Boards (Fraser Health and Island Health). Each interview was audio-recorded using the Zoom recording function and transcribed verbatim by P.Y. The audio files were deleted once the transcriptions had been reviewed by P.Y. and the interviewee for accuracy and authenticity, with corrections made as needed.
The interview questions (Appendix 1) were developed following a detailed literature search.13–15 The questions were then refined by the research team and circulated to previously identified stakeholders for further refinement. Two interview guides were created, one for allied health professionals and the other for prescribers. The main difference between the interview guides was that the prescribers (but not the allied health professionals) were asked to specify, from a predefined list, what they thought were the most and least important discharge interventions.
Within the investigator team, K.D. and M.L. have prior experience in qualitative research and key informant interview methodology. P.Y., K.D., M.L., C.I., and K.R. are clinical pharmacists; J.T. has experience as a front-line nurse; D.F. and L.C. are physicians; and all are familiar and experienced with the patient discharge process.
Descriptive statistical analyses were used to calculate frequencies and percentages for the baseline demographic data. All interview transcripts were analyzed using thematic analysis. One investigator (P.Y.) independently coded the transcripts using NVivo qualitative data analysis software (QSR International). The research group discussed the codes until the final code list had been created. P.Y. then used the final code list to develop overall themes, which were discussed within the research team during 2 separate meetings until consensus was reached concerning the final theme list.
A total of 16 health care providers consented to participate in this study; 12 were allied health professionals and 4 were prescribers. Complete baseline demographic data are presented in Table 1. All interviews were conducted from January to March 2023, and the average interview duration was 21 minutes. Thematic analysis of the interview transcripts generated 13 and 14 codes for the allied health participants and prescribers, respectively; these were organized into 5 themes for each group (Table 2 and Table 3). The following 3 themes were common to the 2 groups: systems-related barriers to an optimal discharge; patient- and community-related barriers to an optimal discharge; and patient involvement and education. Themes specific to allied health participants were prioritization of patients for discharge and direct communication and teamwork are key for an optimal discharge. Prescriber-specific themes were limitations related to technology infrastructure and inefficiency of existing collaboration processes.
TABLE 1 Baseline Characteristics of Participants
TABLE 2 Key Themes, Descriptions, and Relevant Codes for Allied Health Participants
TABLE 3 Key Themes, Descriptions, and Relevant Codes for Prescribers
Many of the study participants identified systems-related issues, including factors that are often out of the individual’s immediate control but may nevertheless affect the discharge process, such as a lack of staff on weekends and holidays, lack of a discharge coordinator, and inconsistencies in discharge responsibilities across different wards. The most frequently cited barrier was a lack of time. Participants also acknowledged that they felt some patients were discharged prematurely because of limited bed availability and pressure from leadership.
A lot of my role is it feels like just getting patients like good enough to be able to leave hospital to have more beds open up … I feel like there’s a few times I can think of like a patient would benefit … from just like a little bit more time rehabbing. (Participant 13)
It’s definitely time, like most people in acute care feel they’re drowning with the current assignments that they have. (Participant 3)
I think there’s a lack of standardization across the organization on a whole … from unit to unit is a different picture of who has the responsibility and who is accountable for what. (Participant 9)
Most participants indicated a lack of community support as a major barrier within this theme:
Community resources. So not having proper support like home support or nursing staff. One of the pharmacy resources that I come across this week, that is, there’s a barrier with somebody going home on insulin and is not able to do the insulin themself and family isn’t able to do it. (Participant 7)
Furthermore, prescribers specified that it was a lack of family physicians that made continuity of care challenging:
So many of these patients don’t have family doctors anymore, which is a huge problem. That is an enormous deterrent to a good discharge because there’s, you know, a family physician is supposed to be sort of the central crossroads of information that should be receiving reports of everything that’s been done. (Participant 14)
Prescribers also found that patients’ poor understanding of their medication changes contributed to a difficult discharge:
I think it’s quite common for patients to end up at home with some confusion about what it is they’re supposed to be taking and then they realize there was some pill that they had at home that wasn’t given to them in the hospital and should they still be taking that or not. (Participant 14)
The majority of participants agreed that patient education was important to an optimal discharge. Participants noted that such education was most effective when it was started early, repeated throughout the admission, and supplemented with written instructions:
I talked to the patient and the family and sort out the plan for them going home … Sometimes I’ll give them a little handwritten sort of checklist, you know, here’s what’s going to happen. (Participant 14)
One of the themes specific to allied health participants was prioritization of patients for discharge interventions. Most participants in this group agreed that the need for prioritization was a consequence of a demanding workload and was done primarily out of necessity. Participants stated that patient prioritization was determined by the complexity of each patient’s medical situation, including factors such as changes from baseline or history of cognitive impairment.
My immediate priority would be equipment needs. So, if I’m seeing someone or if anyone has a drastic change in function, I’d immediately prioritize them for discharge. (Participant 1)
Most participants identified direct communication as a key factor in an optimal discharge, as the results of discussions within the health care team are immediate and actionable. Daily rounds help health care providers involved in discharges stay informed of any evolving needs of patients before their transition to home.
We do rounds every day with the whole team and kind of go through every patient and talk about what’s going on and what our plans are moving forward so they can be discharged … I try and have face-to-face conversations with people. I find that that works best for us. (Participant 7)
All prescribers agreed that preparing the discharge medication reconciliation was time-consuming and prone to errors. They indicated that the current electronic heath record (EHR) system does not allow a discharge prescription to be printed; instead, they had to prepare the discharge prescription by hand or create a separate electronic document.
I think with medication reconciliation, that’s what takes time … I have to type in those new medications and tick the right box on the Word document … it’s not automatic. It’s not fail-safe. (Participant 11)
Another theme was the perceived lack of collaboration between prescribers and allied health professionals. Prescribers expressed that they would ideally like to be involved in daily interprofessional rounds; however, there was a consensus that their demanding workload made attending difficult:
And there’s a structured team meeting in the morning, but that’s at a time that the physicians can’t always attend because it’s first thing in the morning to determine discharges. (Participant 15)
Furthermore, most prescribers acknowledged there was a lack of direct communication, given that their usual mode of communication was through written chart notes:
Right, so written progress note is one thing … “Please ask physiotherapy to assess mobility”, right then the unit clerk calls them … I don’t usually have time to call all those people individually. (Participant 14)
Both allied health participants and prescribers agreed that the responsibilities expected of the pharmacist at discharge should include preparing the discharge medication reconciliation and prescription, addressing concerns about medication costs, organizing adherence aids/tools, and providing medication counselling
Prescribers reported 4 components that they believed were essential to a successful discharge plan: coordination of care with the interdisciplinary team, discharge dictation, discharge prescription, and liaison with outpatient providers.
This study explored the perspectives of various health care providers concerning current discharge practices, barriers to an optimal discharge plan, and key responsibilities of the pharmacist.
Prescribers suggested several components that make up an effective discharge plan. Despite most prescribers agreeing that coordination of care with the interdisciplinary team was essential, time limitations often prevented them from participating in discharge rounds. Furthermore, allied health participants frequently cited a need to prioritize patient discharges as a direct consequence of a lack of time. Some participants described inconsistency in their responsibilities across different wards, which suggests a lack of standardization in the discharge process. These findings, which highlight potential system-wide problems that could limit efficient collaboration processes, were consistent with previous literature suggesting the need to improve staffing and identify strategies to promote collaboration.13–15 In Ontario, Canada, a provincial agency created a standardized discharge planning tool to facilitate discharge planning by health care staff, with the goal of reducing hospital readmissions.16 This protocol subdivides each discharge into 3 stages (pre-transition, transition planning, and post-transition), each with specific practices and goals. This proactive approach allows practitioners to identify ongoing patient care needs, implement individualized care plans, and ensure continuity of care after the discharge.16 The implementation of a standardized discharge protocol not only facilitates clear and consistent roles for each health care provider, but also promotes collaboration.
Patients’ poor understanding of their medications and their discharge plan was a frequently highlighted patient-related barrier. With their extensive medication background, pharmacists are uniquely positioned to help address this barrier. The pharmacists who participated in our previous 2 studies7,8 and participants in the current study agreed that patient education, including medication counselling, was one of the key responsibilities on which pharmacists should focus at discharge. However, time has often been cited as a limitation: in previous studies, pharmacists were observed to spend most of their time assessing patients and developing care plans, attending bedside rounds, and implementing recommendations, with only 3% of their time allocated to counselling patients.7,8,17 Enhanced communication methods, such as postdischarge follow-up, have also been identified as crucial components of an effective discharge plan and continuity of care.3,4 Furthermore, specialized transition-of-care teams have been implemented to streamline care coordination and reduce readmission rates.18 For example, Hitch and others19 found an 8.9% reduction in 30-day readmission rates with a 3-step discharge approach consisting of referral to a nurse case manager, medication reconciliation completed by a pharmacist, and outpatient follow-up appointments with a physician. Similarly, Dizon and Reinking20 observed a 2.3% reduction in 30-day readmission rates with a multidisciplinary transition-of-care program. Although tertiary care hospitals such as VGH may have already implemented additional supports for discharge planning (e.g., care management leader, transition services teams), stakeholders at community hospital sites should consider implementing such initiatives to improve continuity of care after discharge.
In the current study, prescribers highlighted an EHR- related challenge to an optimal discharge, suggesting that the integration of discharge-related tools may help to optimize the discharge process. However, these results are related specifically to the limited technology infrastructure at the community hospital, CVH (where all of the prescriber participants were based), whereas discharge prescriptions are generated automatically at the tertiary care hospital, VGH. Nonetheless, previous studies have shown the effectiveness of discharge optimization tools in enhancing interdisciplinary communication and minimizing discharge delay. As one example of the potential value of discharge optimization tools, Kelly and Cardy21 described the implementation of a colour-coded “dot” system to represent anticipated time until discharge (e.g., green = discharge in < 12 hours; yellow = anticipated discharge in 12–24 hours; red = anticipated discharge in 24–48 hours); after introduction of the system, hospital length of stay for postoperative surgical patients declined from 8.73 days to 7.31 days, and physicians’ satisfaction with communication increased from 3 to 4 (on a 5-point Likert scale). Similarly, when the same system was implemented in a pediatric hospital, the proportion of discharges occurring before noon increased from 16.4% to 19.3%.22 As technology advances, we can anticipate the implementation of fully electronic medical records systems across more community and tertiary care hospitals. Automating administrative tasks that pertain to discharge planning can increase efficiency and accuracy, possibly allowing more time for health care professionals to focus on other patient care activities.
In this study, participants’ expectations of the role of the pharmacist at discharge were consistent with the interventions that pharmacists believe to be their primary responsibilities (i.e., discharge medication reconciliation and patient medication education).7,8 These interventions have been demonstrated to have important impacts; for example, pharmacy-led medication reconciliation resulted in a 66% reduction in medication discrepancies, and a meta-analysis found a reduction in the odds of readmission with pharmacy-supported transition-of-care interventions, including medication reconciliation, patient education, and patient-centred follow-up.3,23
This study had several limitations. First, all of the prescribers were recruited from CVH, a community hospital, which had limited technology infrastructure pertaining to the usability of its EHR. This may limit the generalizability of these results to other clinical settings. Second, all participants were recruited from either a tertiary care or community hospital in a specific geographic location, with unique practice models and support systems at each site, which could further limit the generalizability of the results. Lastly, we assumed that theoretical data saturation was achieved despite the small sample size. However, there may be additional thoughts and perceptions of allied health professionals and prescribers that were not captured in this study.
Several barriers to an optimal discharge plan were identified, and further studies looking into the optimization of the discharge process with the implementation of standardized discharge protocols and EHR-related tools are therefore warranted. Overall, participants in this study believed that the primary responsibilities of the pharmacist at the time of discharge should include completing the discharge medication reconciliation and providing patient medication education, findings that are consistent with previous literature.
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Address correspondence to: Dr Karen Dahri, Vancouver General Hospital, 855 West 12th Avenue, Vancouver BC V5Z 1M9, email: karen.dahri@vch.ca
Competing interests: For projects unrelated to the work reported here, Karen Dahri has received grants from the Canadian Institutes of Health Research, the UBC Students as Partners Fund, and the BC Ministry of Health; consulting fees from TRC Healthcare; honoraria from Pear Tree Healthcare, UBC Continuing Pharmacy Professional Development, and the Pharmacists in Primary Care Network; and support for travel related to her role as the BC delegate for the Canadian Society of Hospital Pharmacists. No other competing interests were declared.
Funding: The honoraria for participants were funded from the unrestricted start-up research funds of the primary investigator (K.D.). No other funding was received.
Submitted: September 6, 2023
Accepted: November 6, 2023
Published: May 8, 2024
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© 2024 Canadian Society of Hospital Pharmacists | Société canadienne des pharmaciens d’hôpitaux
Canadian Journal of Hospital Pharmacy, VOLUME 77, NUMBER 2, 2024