Patient Transitions: How Can Healthcare Systems Do Better?

By Margaret Rudisill

Vizient Performance Improvement Program Director

I was falling asleep when I got the call that our 4-week-old grandson was being rushed by ambulance from urgent care to the hospital with breathing difficulties as a result of a virus he contracted just weeks after his birth. Living hours away, my husband and I were left wondering what was happening. In all the rush and confusion, our daughter had to navigate the healthcare system by herself while her husband stayed at home to be with their other 2-year-old child. After arriving to the emergency room, the physician examined him and decided he needed to be admitted. Instead of taking my daughter up to a room where she could settle in with her son, she was told a room wasn't available and that she'd have to wait in the ER. We were all overwhelmed with anxiety wondering and questioning if he was receiving the right care. After 16 hours in the ER without food for a nursing mother or a bassinet/crib for her newborn, they finally were taken to a room. Healthcare organizations must do better.

In my over 30 years of healthcare experience, the transition of care dilemma has been the most difficult to solve. Like a challenging puzzle that requires many intricate pieces to fit together at the right time, transitions of care from a hospital to post-acute care is both time-consuming and complex. When a safe and efficient transition cannot be arranged, a domino effect takes place that unfortunately has the biggest impact on the patient. In-hospital complications are higher for patients who are medically ready for discharge but remain hospitalized. Poorly managed transitions can cause a cascade of negative events, such as medication errors, readmissions and delays in treatment — just like what our daughter and grandson experienced. All of this can lead to poor outcomes for both the discharged patient and the admitted patient.

In our grandson's case, he was discharged the following day after admission only to be readmitted 24 hours later. Was this caused by the initial delayed treatment? Properly managing each step of the transition process is crucial to preventing the domino effect and ensure a patient's continuity of care.

Learn from the experts

The frustration of not being able to perfect the transition of care process is felt by frontline staff and administrators alike in the healthcare industry. Through Vizient's Improvement Collaborative, made up of hospitals across the country, we are working to reduce length of stay to improve capacity. The concepts explored by the collaborative's participants include stakeholder buy-in, proactive discharge planning, real-time capacity planning, elimination of delays and visual management system usage. The collaborative members have shared several strategies to implement these concepts including:

• Provide visualization of data for frontline staff to identify high priority actions that will drive positive length of stay changes.
• Establish multidisciplinary rounds to garner input from those working across the disciplines that can impact the patient's discharge.
• Appoint the hospitalist medical director as a leader for the project to provide support and guidance for the providers.
• Evaluate the duplication of referrals to outside agencies such as those to all available skilled nursing facilities in the region for one patient that can trigger bottlenecks in the system.
• Arrange for hospital-provided transportation to address the lack of resources in the community.
• Create and use discharge lounges to free up beds sooner when the patient is medically ready for discharge.

Create a standardized escalation process

Participants in the collaborative often report that the absence of a standardized escalation process leaves them ill-equipped to address barriers that arise such as unavailability of skilled nursing facilities, family who are unwilling or unable to care for the patient at home or a lack of transportation options. Implementing an escalation process can be an effective strategy to ensure that issues are not ignored or delayed until the next scheduled interdisciplinary team meeting. A well-developed plan for addressing obstacles to discharge is necessary for effective transitions of care. Collaborative subject matter experts shared leading practices that could help mitigate the problem:

• Identify clear guidelines to escalate barriers or challenges that prevent prompt discharge of patients.
• Designate a point person or team responsible for overseeing discharge processes and develop a protocol for escalating issues that cannot be solved at the unit level.
• Design specific steps to escalate issues to higher levels of management or clinical staff. By implementing this, issues can be promptly and appropriately addressed rather than neglected.
• Incorporate regular communication and feedback loops to ensure issues are resolved and that solutions are sustainable.

Adopting these practices can foster a culture of continuous improvement and collaboration among team members. Fortunately, our grandson's second admission to the hospital went much smoother. The wait in the ER was only a couple of hours before he was admitted to a room. The ER staff made sure our daughter had nourishment and our grandson received prompt medical care. He was immediately placed on oxygen and slowly weaned over the course of a couple of days. Picture for a moment if that had been their experience to begin with. Just imagine if we could get it right every time.