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LR24 / Patient monitoring after discharge SCP

Romania




Type of Patient Safety Practice
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
"Best fit" category of the reported practice
Human factors
Patient safety theme the SCP/clinical risk management practice is aimed at
Clinical risk management practice aimed to determine the feasibility and utility of an IVRS ( interactive voice response system )to monitor patients following hospital discharge( after 48 hours), and to improve patient safety following hospital discharge by identifying all patients with new health issues and connect them to a nurse to clarify and address the problems.
Objective of the CRM practice
Patient care following discharge from hospital is problematic [1,2]. A common factor predisposing patients to post-discharge complications is a failure to monitor their conditions and treatments [1]. Improving patient safety after discharge from hospital requires improved patient monitoring. Failing to do so leads to a significant proportion of so-called ‘ameliorable adverse events’ or complications that should have been less severe if the health system responded appropriately. One method used to improve monitoring includes a hospital-based nurse or pharmacist systematically telephoning all patients to enquire about their status after they get home [3–5]. Although a call-back program seems promising, it is not perfect. First, it is costly to use highly skilled professionals to call patients, especially when such professionals are already in short supply. Furthermore, many factors make a call-back program an inefficient use of their time. Patients will frequently not be at home when called and several attempts must be made to reach them [4–6]. Patients will occasionally wish to discuss matters that are not directly related to their health care. Most of the time patients will not be experiencing problems at the time of call [4]. If a call-back program is to be implemented, a more efficient system would be beneficial. An interactive voice response system (IVRS) could improve post-discharge monitoring [7]. The objective of CRM practice was to determine the feasibility and utility of an IVRS to monitor patients following hospital discharge.[p.346, p.349,13]
Short description of the CRM practice, including any references for further information
It was a prospective cohort study Ottawa Hospital, a tertiary care hospital from Canada. The hospital has 30-bed general internal medicine (GIM) services. The GIM service cares for patients with multi-system or undifferentiated illness. Patients were potentially eligible for the study if they were admitted to the hospital and cared by house staff who are supervised by board-certified internal medicine doctors. Working with each GIM service was a medical liaison nurse who facilitated the care of inpatients, including their transition home. Development of post-discharge survey. Patient care following discharge from hospital is problematic. A common factor predisposing patients to post-discharge complications is a failure to monitor their conditions and treatments. The objective of the post-discharge survey was to identify all patients who would require further attention from a nurse. The tool that was used for home survey: Call Assure, a US patent-pending IVRS solution designed to improve the care of patients following hospital discharge. Post-discharge survey administration By calling patients 2 days following hospital discharge. Patients were called between 9:00 AM and 8:00 PM. . If a call was ‘incomplete’ ( no answer from patient), then the system called back 3 hours later. The system called back every 3 hours until the call was completed, or the person who answered the telephone responded that they did not wish a further follow-up call, or 48 hours had elapsed since the first call.[p.346, p.347,1].
Innovator of the SCP, country of origin
Country of origin -Canada, on a tertiary care hospital that enrolled 77 patients (elderly male, with at least– three common chronic conditions) to be followed up at home after 48 hours from hospital discharge using a interactive voice response system .
Involved health care staff
A IVRS was programmed the to call patients and administer a simple survey 48 hours after discharge. The survey’s objective was to identify all patients with new health problems. Such patients were telephoned by a nurse to clarify and address the problem
Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
Tested in Canada. A prospective cohort study at the Civic Campus of the Ottawa Hospital, on a tertiary care hospital. The patients in the study had universal health care insurance that covers all hospital and doctor services.[ P.347, 1]. The study enrolled 77 patients. Most of the patients were male (68%), were elderly (median age = 65 years) and had multiple medical problems (median – three chronic problems). The most common reason for admission was an acute infection, such as a urinary tract infection or pneumonia, occurring in 32% of admitted patients. Common chronic conditions were hypertension, coronary artery disease and type 2 diabetes mellitus. Most patients lived with a family member in their own home (70%) and reported having a family doctor (90%). [ P.348, 1]
Summary of evidence for effectiveness, including references
Interactive voice response systems (IVRS) are information technologies that could be used to monitor post-discharge patients [7]. An IVRS allows people to interact with a database using a standard telephone. This allows the administration of surveys using IVRS-initiated telephone calls in which a pre-recorded dialogue prompts patients for responses. Patients answer by pressing the key pad of their telephone or through voice recognition software. In the context of providing post-discharge care, one could use the IVRS to screen patients for possible problems. For ‘screen positive’ patients, personal follow-up could result. Theoretically, the IVRS system could minimize the amount of time required by highly skilled professionals to contact and help patients. Therefore, using an IVRS to identify which patients require more attention is theoretically appealing but its feasibility and utility is unknown in elderly patients who have been recently discharged from hospital. Although IVRS is ubiquitous in business, only a few studies have evaluated their impact in health care delivery [7–16]. Feasibility was defined as the proportion of patients reached by the IVRS and the proportion completing an IVRS-based survey. Utility was defined as the percentage of patients whose outcomes could have been changed by the IVRS. The study enrolled 77 patients who were predominantly male (68%), elderly, and chronically ill (median number of co-morbidities=3). Forty patients (51.9%) answered all questions on the survey. Twenty patients (26%, 95% CI 17%- 37%) indicated new or worsening symptoms, problems with their medications, or requested to talk to the clinic nurse. For 10 patients (13%, 95% CI 7%-22%), the IVRS could have made a difference in their outcome [p.346, 1]. In summary, was demonstrated that it is possible to implement an IVRS solution to monitor patients post-discharge. Such a system is usable by patients and meaningful information is captured using it. This preliminary research suggests that it might be possible to significantly reduce post-hospital complications using an IVRS system. However, research addressing the limitations outlined above is required before making firm recommendations about its Effectiveness [p 351, 1].
Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
There are some limitations to the study regarding transferability. First, it was not systematically track the outcomes of all patients studied. Patients who did not respond to the system may have experienced a complication that was missed. Clearly, in order to understand the impact of the system is required to know how many problems were missing using it. Second, were studied a relatively small patient group from a single institution. It is unclear whether other patient types, such as surgical, obstetrical or emergency department patients, would respond to the system in a similar manner. However, the patient group studied had a number of challenges to interacting with technology, suggesting that use of the IVRS may be even better in other groups. A third problem is that they were unable to contact six of the 20 patients indicating a problem on the IVRS. This points to a limitation in the technology not on study design or methods. In future iterations of the IVRS, they will attempt to connect patients directly to a nurse by re-routing the IVRS call to a nurse-staffed tele-health program, rather than emailing the clinical nurse. In summary, was demonstrated that it is possible to implement an IVRS solution to monitor patients post-discharge. Such a system is usable by patients and meaningful information is captured using it. Most importantly, a substantial proportion of IVRS reported problems require either a nurse assessment or intervention. This preliminary research suggests that it might be possible to significantly reduce post-hospital complications using an IVRS system. However, research addressing the limitations outlined above is required before making firm recommendations about its effectiveness and transferability.[p.349,p351,1].
Summary of available information on feasibility, including references
Patient care following discharge from hospital is problematic [1,2]. A common factor predisposing patients to post-discharge complications is a failure to monitor their conditions and treatments[1]. One method used to improve monitoring includes a hospital-based nurse or pharmacist systematically telephoning all patients to enquire about their status after they get home [3–5]. Studies suggest that a call to patients from a pharmacist within a week of discharge significantly reduces return visits to the emergency department [6]. Although a call-back program seems promising, it is not perfect. First, it is costly to use highly skilled professionals to call patients, especially when such professionals are already in short supply. Furthermore, many factors make a call-back program an inefficient use of their time. Patients will frequently not be at home when called and several attempts must be made to reach them [4–6]. Patients will occasionally wish to discuss matters that are not directly related to their health care. Most of the time patients will not be experiencing problems at the time of call [4]. If a call-back program is to be implemented, a more efficient system would be beneficial. Studied only a relatively small patient group (77 patients) from a single institution (a tertiary care hospital). It is unclear whether other patient types, such as surgical, obstetrical or emergency department patients, would respond to the system in a similar manner. [p.351, 13]. Using an IVRS, the study was able to identify several important new health concerns arising following hospital discharge. Subtle changes could increase the feasibility and utility of IVRS technology in improving post-discharge outcomes.[p.346,13] Therefore, using an IVRS to identify which patients require more attention is theoretically appealing but its feasibility and utility is unknown in elderly patients who have been recently discharged from hospital. Although IVRS is ubiquitous in business, only a few studies have evaluated their impact in health care delivery [7–16]. The existing studies of IVRS show moderate improvements in preventive health care practices [10,13,16] or chronic disease management [8,9,11,12,15]. However, none of the studies use an IVRS for management of acutely ill medical patients. Furthermore, most of the studies require the patients to make inbound calls to the IVRS as opposed to receiving an outbound call [8,9,11–13,15]. Patients may not appreciate receiving an automated outbound call from an IVRS. In summary, although there are suggestions that an IVRS will facilitate care of post discharge patients, there is a need for more research before recommendations to implement are made [p.347,13].
Existing implementation tools, including references
1. Call Assure, a US patent-pending IVRS solution designed to improve the care of patients following hospital discharge.2. Call Assure can be run on any modern personal computer (recommended requirements: Pentium processor, 850 MHz CPU, 512 M B RAM), equipped with a telephony card with at least two analogue lines. In addition, Call Assure requires access to an email server (for notification messages) and, optionally, a printer (for reports). 3. The call dialogue for the IVRS was carefully designed. First, got input from the medical liaison nurse to determine the nature of calls they conduct with patients who are recently discharged from hospital. Using this information, were established an initial set of survey questions, which were forwarded to faculty members on the GIM service. Using their feedback, was created an initial call dialogue. After hearing audiotapes of this call dialogue, some more minor adjustments were done to the wording of the questions. The call dialogue as simple as possible, containing three simple questions: Have you any new or worsening questions? Have you any problems that you think might be related to your medications? Would you like us to contact you? The possible responses were limited to the questions to ‘Yes’ or ‘No’[p.347,1].
Potential for/description of patient involvement in the CRM practice, including references
Patients that were potentially eligible for the intervention were identify by the medical liaison nurse and asked if they wished to participate in the study. If they agree, they were approached in order get information regarding the IVRS system, and explain to them in 5 minutes about Call Assure and how they should answer the survey. Then, their demographic data including their phone number entered into the study database. When the patient was discharged, was added the discharge date. On a daily basis, Call Assure queried the study database to determine newly discharged patients. For these patients, the following data were sent to Call Assure: the phone number, the medical team, the discharge date and a unique identifier. For the purposes of this pilot study, were generated unique identifiers for patients to maintain privacy. Only the medical liaison nurse and study personnel had access to the key required to link this identifier to patient information. Starting 2 days following discharge, Call Assure would initiate surveys. For patients responding ‘Yes’ to the screening questions, an email was sent to the medical liaison nurse. The medical liaison nurse then attempted to reach these patients to determine their reason for having a positive screen survey.
Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
[1] Forster, Alan ;Walraven Van, Carl (2007): Using an interactive voice response system to improve patient safety following hospital discharge. Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice. [2]. Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K. & Bates, D. W. (2003) The incidence and severity of adverse events affecting patients following discharge from the hospital. Annals of Internal Medicine , 138 (3), 161–167. [3]. Forster, A. J., Clark, H. D., Menard, A., Dupuis, N., Chernish, R., Chandok, N. & van Walraven, C. (2004) Adverse events affecting medical patients following discharge from hospital. Canadian Medical Association Journal , 170 (3), 345–349. [4]. Nelson, J. R. (2001) The importance of post discharge telephone follow-up for hospitalists: a view from the trenches. [Review]. American Journal of Medicine, 111 (9B), 43S–44S. [5]. Jones, J., Clark, W., Bradford, J. & Dougherty, J. (1988) Efficacy of a telephone follow-up system in the emergency department. Journal of Emergency Medicine , 6 (3), 249–254. [6]. Jones, P. K., Jones, S. L. & Katz, J. (1990) A randomized trial to improve compliance in urinary tract infection patients in the emergency department. Annals of Emergency Medicine , 19 (1), 16–20. [7]. Dudas, V., Bookwalter, T., Kerr, K. M. & Pantilat, S. Z. (2001) The impact of follow-up telephone calls to patients after hospitalization. American Journal of Medicine , 111 (9B), 26S–30S. [8]. Biem, H. J., Turnell, R. W. & D’Arcy, C. (2003) Computer telephony: automated calls for medical care. Clinical and Investigative Medicine – Medecine Clinique et Experimentale , 26 (5), 259–268. [9]. DeMolles, D. A., Sparrow, D., Gottlieb, D. J. & Friedman, R. (2004) A pilot trial of a telecommunications system in sleep apnea management. Medical Care , 42 (8), 764–769. [10]. Weiler, K., Christ, A. M., Woodworth, G. G., Weiler, R. L. & Weiler, J. M. (2004) Quality of patient-reported outcome data captured using paper and interactive voice response diaries in an allergic rhinitis study: is electronic data capture really better? Annals of Allergy,Asthma and Immunology, 92 (3), 335–339. [11]. Le Baron, C. W., Starnes, D. M. & Rask, K. J. (2004) The impact of reminder-recall interventions on low vaccination coverage in an inner city population. Archives of Pediatrics and Adolescent Medicine , 158 (3), 255–261. [12]. Mahoney, D. F., Tarlow, B. J. & Jones, R. N. (2003) Effects of an automated telephone support system on caregiver burden and anxiety: findings from the REACH for TLC intervention study. Gerontologist ,43 (4), 556–567. [13]. Stuart, G. W., Laraia, M. T., Ornstein, S. M. & Nietert, P. J. (2003) An interactive voice response system to enhance antidepressant medication compliance. Topics in Health Information Management , 24 (1), 15–20. [14]. Pinto, B. M., Friedman, R., Marcus, B. H., Kelley, H., Tennstedt, S. & Gillman, M. W. (2002) Effects of a computer-based, telephone counseling system on physical activity. American Journal of Preventive Medicine , 23 (2), 113–120. [15]. Lopez-Beret, P., Pinto, J. M., Romero, A., Orgaz, A., Fontcuberta, J. & Oblas, M. (2001) Systematic study of occult pulmonary thromboembolism in patients with deep venous thrombosis. Journal of Vascular Surgery , 33 (3), 515–521. [16]. Alemi, F., Stephens, R. C., Javalghi, R. G., Dyches, H., Butts, J. & Ghadiri, A. (1996) A randomized trial of a telecommunications network for pregnant women who use cocaine. Medical Care , 34 (10 Suppl.): OS10–20. [17]. Leirer, V. O., Morrow, D. G., Pariante, G. & Doksum, T. (1989) Increasing influenza vaccination adherence through voice mail. Journal of the American Geriatrics Society , 37 (12), 1147–1150.
Reviewer
Dr. Teodora Ciolompea,
National School of Public Health and Management, Romania
Organisation
National School of Public Health and Management
Any additional information on the CRM (e.g. implementation barriers and drivers)
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