Best Practices In Patient Follow Up After ED Discharge

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1 Best Practices In Patient Follow Up After ED Discharge Presented By: Eileen M. Dowdy, RN, T&R III Quality Improvement Coordinator Emergency Department

2 INTRODUCTION 603 Bed Suburban Medical Center with 76 Emergency Department beds. 90,000 plus ED visits/year Level 1 Trauma Center, Designated Stroke Center and Chest pain Center, Level 3 NICU, Psychiatric Emergency ED. Emergency Medicine Residency Program County EMS System and Transport Services

3 BACKGROUND Patient Perspective: Who do I call when I have a question about my discharge instructions? What if I can t get a follow up appointment? How will my PMD know what meds I am on now and what tests were done in the ED? What does this test result mean? The pharmacy didn t get the electronic prescription that was sent who do I call? Can you explain the letter I received in the mail?

4 Physician/Staff Perspective: Who reviews the chart in case I missed something? What if I am concerned about the patient not understanding the importance of follow up with their PMD? What if the patient just needs a clinical check? Who follows up on lab/procedure reports that result after the patient is discharged? What if the final radiology read is different than the preliminary read? (incidental finding) Who does the Radiologist call with an amended read? (QA or over read) BACKGROUND

5 Why is this so important? In 1 study published in the Journal of Emergency Nursing as many as 78% of persons discharged from an ED did not clearly understand at least one aspect of their aftercare instructions. 1 A patients transition to home after discharge from the hospital has now been recognized as a high risk time for communication failures and subsequent adverse events. 2 There are no current guidelines published by ACEP or ENA Limited literature about follow up programs BACKGROUND National Quality Forum/HHS s National Quality strategy priorities: Admissions/readmits; care transitions; patient experience of care coordination; cultural and linguistically appropriate services and resources.

6 BACKGROUND Rory Staunton 12 yr. old Boy died of Severe Sepsis in NY, April 1, ,4 Cut to Right arm, within 24 hrs. to PMD with fever, vomiting and pain in leg. Sent to ED and dx with upset stomach and dehydration and discharged. He died 3 days later. Communication between PMD and Emergency MD s Discharged after IV fluids but before last set of vital signs taken Critical Lab reports resulted after discharge No follow up from ED the following day clinical check Rory s Law in NY State

7 OBJECTIVES Provide a safety net for patients and health care providers by having an experienced RN perform a review of discharged patient records for appropriateness and need for further follow up. Establish a mechanism to address the needs of patients/care givers who call the ED to clarify discharge instructions, ask questions about their care or who need assistance with follow up appointments. Improve communication with community physicians and nursing care facilities after a patient is discharged from the ED. Create a best practice for the follow up and tracking of delayed or amended testing results after ED discharge

8 METHODS 3.5 RN FTE s and 2.3 Clerical FTE s cover the follow up office 10 hours per day/ 7 days a week. A computerized tracking board was developed to enable tracking of patients with pending chart reviews, clinical checks, testing results or call backs. All patient/caregiver interactions are documented in the EMR using templates created based on the most frequent interactions. Clerical staff use a standard fax machine to send copies of physician notes, summaries of care provided in the ED, medication prescribed, consults, lab and radiology results to all PMD s or post discharge facilities that will be caring for the patient after discharge.

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19 RESULTS In one week: 1803 patient charts were reviewed by the Follow Up RN s 25 patients who left AMA or walked out were contacted for service recovery 2 returned after speaking with RN 57 patients and their PMD s were notified of abnormal lab results 19 required additional medications or changes in the medication 93 patients and their PMD s were notified of abnormal findings/ amended Radiology readings 4 patients required a change in treatment plan 15 required further imaging studies as an outpatient 3 patients returned to the ED for further treatment based on results 14 patients had clinical checks as requested by the ED Physician 39 patients called the Follow Up Office for clarification of discharge instructions or questions about their ED visit. 21 patients had questions about their medication or prescription 4 patients needed assistance with making follow up appointments

20 NEXT STEPS Research Projects Outcomes National Medical Education Computer generated productivity reports Quality Metrics Closing the Loop Feedback Training Evaluations Core Measures

21 QUESTIONS