from Narcis: "What is known and objective Medication discrepancies are common at hospital discharge, and medication reconciliation is widely endorsed as a preventive strategy. However, implementation is difficult for instance due to the unreliability of patients medication histories. In the Netherlands, community pharmacies are well-informed about their patients’ pre-admission medication status which enables thorough post-discharge reconciliation. Our aim was to study the frequency and nature of medication discrepancies, missing patient's knowledge and administrative problems at admission to primary care. Methods A cross-sectional study was conducted in pharmacies belonging to the Utrecht Pharmacy Practice network for Education and Research in the Netherlands. Structured checklists were used to evaluate all discharge prescriptions presented by adult patients discharged from the hospital to their own home during the study period. The primary outcome was all possible problems with continuity of care, defined as (i) the number and type of medication discrepancies, (ii) administrative problems and (iii) the necessity for patient education. Results and discussion In forty-four pharmacies, checklists were completed for 403 patients. Most discharge prescriptions (92%) led to one or more problems with continuity of care (n = 1154, mean 2·9 ± 2·0), divided into medication discrepancies (31%), administrative problems (34%) and necessity for further education (35%). Medication discrepancies (n = 356) resulted mainly from missing pre-admission medication (n = 106) and dose regimen changes (n = 55) on the discharge prescription. Administrative problems (n = 392) originated mainly from administrative incompleteness (n = 177), for example missing reimbursement authorization forms, or supply issues (n = 150), for example insufficient pharmacy stock. The patients’ lack of medication knowledge post-discharge was illustrated by the high need for patient education (n = 406). What is new and conclusion Community pharmacists are still confronted with problems due to inadequate documentation at discharge which can inflict harm to patients if not properly addressed. To reduce these problems, a rigorous implementation of the medication reconciliation process at all transition points, standardized electronic transfer of all medication-related information and interdisciplinary collaboration are crucial."
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Objectives: to compare changes over time in the in-hospital mortality and the mortality from discharge to 30 days post-discharge for six highly prevalent discharge diagnoses in acutely admitted older patients as well as to assess the effect of separately analysing the in-hospital mortality and the mortality from discharge to 30 days post-discharge.Study design and setting: retrospective analysis of Dutch hospital and mortality data collected between 2000 and 2010.Subjects: the participants included 263,746 people, aged 65 years and above, who were acutely admitted for acute myocardial infarction (AMI), heart failure (HF), stroke, chronic obstructive pulmonary disease, pneumonia or hip fracture.Methods: we compared changes in the in-hospital mortality and mortality from discharge to 30 days post-discharge in the Netherlands using a logistic- and a multinomial regression model.Results: for all six diagnoses, the mortality from admission to 30 days post-discharge declined between 2000 and 2009. The decline ranged from a relative risk ratio (RRR) of 0.41 [95% confidence interval (CI) 0.38–0.45] for AMI to 0.77 [0.73–0.82] for HF. In separate analyses, the in-hospital mortality decreased for all six diagnoses. The mortality from discharge to 30 days post-discharge in 2009 compared to 2000 depended on the diagnosis, and either declined, remained unchanged or increased.Conclusions: the decline in hospital mortality in acutely admitted older patients was largely attributable to the lower in-hospital mortality, while the change in the mortality from discharge to 30 days post-discharge depended on the diagnosis. Separately reporting the two rate estimates might be more informative than providing an overall hospital mortality rate.
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Rationale: In order to target rehabilitation needs of survivors of critical illness and their relatives timely and adequately, a thorough needs assessment is recommended when hospital discharge planning is initiated. In light of existing evidence on physical and psychological consequences of critical illness for both patient and family, it is as yet unclear if current hospital discharge procedures suffice to meet the needs of this group. Objectives: To explore hospital discharge experience and to identify perceived barriers and enablers for a positive transition experience from hospital to home or rehabilitation facility as perceived by survivors of critical illness and their families. Methods: We performed a grounded theory study with semi-structured interviews among a group of survivors of critical illness and their relatives (N=35) discharged from 16 hospitals across the Netherlands. Interviews were audio recorded and transcribed verbatim. Using constant comparative methods, initial and focused coding was applied to the data, which were further labeled into major and subcategories, ultimately leading to the identification of key concepts. Triangulation was applied through several reflexivity meetings at different stages of the study. Results: Twenty-two former ICU patients and 13 relatives were interviewed. The mean age was 53 (SD ± 11.2) and 60% were female. Median ICU and hospital length of stay were 14 days (IQR 9.75-24.5) and 35 days (IQR 21.75-57.25) respectively. Thematic analyses led to identification of seven key concepts, representing barriers and enablers to a positive transition experience. 'Existing in a fragmented reality', 'being overlooked' and 'feeling disqualified', were identified barriers and 'feeling empowered', 'encountering empathic and expert professionals', 'managing recovery expectations' and 'family engagement' were identified as enablers for a positive perceived transition experience. Conclusions: Findings of this study suggest that current hospital discharge practice for survivors of critical illness is driven by speed and efficiency, rather than by individual needs assessments, despite advocacies for patient- and family centered care. Discharge strategies should be customized to facilitate adequate and comprehensive assessment of aftercare needs, conducted at the right time and within the right context, encouraging empowerment and a positive perceived transition from hospital to home.
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ObjectiveTo develop, implement and evaluate a personalized patient discharge letter (PPDL) to improve the quality of handoff communication from hospital to home.DesignFrom the end of 2006–09 we conducted a quality improvement project; consisting of a before–after evaluation design, and a process evaluation.SettingFour general internal medicine wards, in a 1024-bed teaching hospital in Amsterdam, the Netherlands.ParticipantsAll consecutive patients of 18 years and older, admitted for at least 48 h.InterventionsA PPDL, a plain language handoff communication tool provided to the patient at hospital discharge.Main Outcome MeasuresVerbal and written information provision at discharge, feasibility of integrating the PPDL into daily practice, pass rates of PPDLs provided at discharge.ResultsA total of 141 patients participated in the before–after evaluation study. The results from the first phase of quality improvement showed that providing patient with a PPDL increased the number of patients receiving verbal and written information at discharge. Patient satisfaction with the PPDL was 7.3. The level of implementation was low (30%). In the second phase, the level of implementation improved because of incorporating the PPDL into the electronic patient record (EPR) and professional education. An average of 57% of the discharged patients received the PPDL upon discharge. The number of discharge conversations also increased.ConclusionPatients and professionals rated the PPDL positively. Key success factors for implementation were: education of interns, residents and staff, standardization of the content of the PPDL, integrating the PPDL into the electronic medical record and hospital-wide policy.
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Pain following burn injuries can be severe and may persist after hospital discharge. The experience of pain is influenced by multiple biological and psychosocial factors. Post-discharge pain may be related to pain experienced during hospitalization as well as anxiety associated with these pain experiences. There are also protective factors; one notable example is optimism. However, the role of optimism in burn-related pain has not yet been investigated. This study aimed to describe the extent of pain measured over 14 consecutive days post-discharge and to examine its relationship with background pain, procedural pain, pain-related anxiety, and optimism. This multi-center longitudinal cohort study was conducted in five burns centres. The results showed that 50 % of the patients had a pain score ≥ 2 on a 0 – 10 scale after discharge, which on average decreased further over the next 14 days. However, a subgroup of patients maintained elevated pain levels. Patients with higher pain scores postdischarge were more likely to have experienced higher levels of background pain and procedural pain in-hospital and they scored lower on optimism. Pain-related anxiety did not independently contribute to pain postdischarge. The results indicate that patients with high pain scores during hospital admission may need specific attention regarding pain management when they leave the hospital. Furthermore, patients may benefit from optimism-inducing interventions in the hospital and thereafter.
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Pain following burn injuries can be severe and may persist after hospital discharge. The experience of pain is influenced by multiple biological and psychosocial factors. Post-discharge pain may be related to pain experienced during hospitalization as well as anxiety associated with these pain experiences. There are also protective factors; one notable example is optimism. However, the role of optimism in burn-related pain has not yet been investigated. This study aimed to describe the extent of pain measured over 14 consecutive days post-discharge and to examine its relationship with background pain, procedural pain, pain-related anxiety, and optimism. This multi-center longitudinal cohort study was conducted in five burns centres. The results showed that 50 % of the patients had a pain score ≥ 2 on a 0 – 10 scale after discharge, which on average decreased further over the next 14 days. However, a subgroup of patients maintained elevated pain levels. Patients with higher pain scores post-discharge were more likely to have experienced higher levels of background pain and procedural pain in-hospital and they scored lower on optimism. Pain-related anxiety did not independently contribute to pain post-discharge. The results indicate that patients with high pain scores during hospital admission may need specific attention regarding pain management when they leave the hospital. Furthermore, patients may benefit from optimism-inducing interventions in the hospital and thereafter.
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In de huidige gezondheidszorg ontvangen patiënten vaak zorg van verschillende zorgverleners, bijvoorbeeld de huisarts (eerstelijns zorg) en de specialist in het ziekenhuis (tweedelijns zorg). Wanneer een patiënt die geneesmiddelen gebruikt in het ziekenhuis opgenomen wordt, brengt dit vaak de betrokkenheid van verschillende voorschrijvers met zich mee. Na ontslag uit het ziekenhuis ontstaan hierdoor vaak zogenoemde geneesmiddelgerelateerde problemen. Informatie over het geneesmiddelengebruik van de patiënt wordt bij het ontslag uit het ziekenhuis namelijk vaak onvolledig overgedragen naar de eerstelijnszorgverleners. Daarnaast wordt de patiënt niet altijd goed geïnformeerd over de veranderingen van zijn geneesmiddelen, zoals bijvoorbeeld over aanpassingen in de dosering of nieuwe geneesmiddelen. De ontstane geneesmiddelgerelateerde problemen kunnen de patiëntveiligheid in gevaar brengen. Ze kunnen bijvoorbeeld resulteren in een ongeplande heropname in het ziekenhuis of andere gezondheidsschade voor de patiënt. Zo ervaart een op de vijf patiënten binnen drie weken na ontslag een bijwerking van een geneesmiddel. De focus van de studies beschreven in dit proefschrift ligt op de periode direct na het ontslag uit het ziekenhuis. We noemen dit de heropname in de eerste lijn. Patiënten, maar ook hun mantelzorgers, voelen zich vaak onvoorbereid voor de thuiskomst. Tijdens de ziekenhuisopname nemen de zorgverleners in het ziekenhuis de zorg voor de patiënt op zich. Het moment van ontslag betekent dat zij zelf de regie over hun gezondheid en geneesmiddelen weer moeten overnemen. Het is daarom van belang om kort na het ontslag uit het ziekenhuis het geneesmiddelengebruik met de patiënt te evalueren om onduidelijkheden over bijvoorbeeld hun nieuwe geneesmiddelenschema weg te nemen. Van oudsher hadden openbaar apothekers als hoofdtaak het bereiden en verstrekken van geneesmiddelen. Tegenwoordig zijn zij echter meer en meer betrokken bij het begeleiden van patiënten met betrekking tot hun geneesmiddelengebruik. Deze andere rol kan cruciaal zijn bij het garanderen van de medicatieveiligheid gedurende en na de overgang van het ziekenhuis naar huis. Daarom is het doel van dit proefschrift om de problemen die optreden bij de heropname in de eerste lijn te ontrafelen en om de rol van de openbaar apotheker hierin te onderzoeken.
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Aims: In-hospital prescribing errors may result in patient harm, such as prolonged hospitalisation and hospital (re)admission, and may be an emotional burden for the prescribers and healthcare professionals involved. Despite efforts, in-hospital prescribing errors and related harm still occur, necessitating an innovative approach. We therefore propose a novel approach, in-hospital pharmacotherapeutic stewardship (IPS). The aim of this study was to reach consensus on a set of quality indicators (QIs) as a basis for IPS. Methods: A three-round modified Delphi procedure was performed. Potential QIs were retrieved from two systematic searches of the literature, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. In two written questionnaires and a focus meeting (held between the written questionnaire rounds), potential QIs were appraised by an international, multidisciplinary expert panel composed of members of the European Association for Clinical Pharmacology and Therapeutics (EACPT). Results: The expert panel rated 59 QIs and four general statements, of which 35 QIs were accepted with consensus rates ranging between 79% and 97%. These QIs describe the activities of an IPS programme, the team delivering IPS, the patients eligible for the programme and the outcome measures that should be used to evaluate the care delivered. Conclusions: A framework of 35 QIs for an IPS programme was systematically developed. These QIs can guide hospitals in setting up a pharmacotherapeutic stewardship programme to reduce in-hospital prescribing errors and improve in-hospital medication safety.
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Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Dutch Research Council INTRODUCTION Cardiac rehabilitation (CR) is the cornerstone of secondary prevention. After hospital discharge, patients have to wait for participation in CR while often feeling overwhelmed by their cardiac event and in need of tailored information and support. PURPOSE The objective of this study was to develop a remote (digital) intervention to bridge the gap from hospital discharge to CR. METHODS We developed an intervention by completing the first three steps of the intervention mapping protocol. Step 1: identification of information- and support needs from the literature and semi-structured interviews. Step 2: Describing performance objectives for the intervention and selecting determinants. Step 3: Generation of program themes and theory based change methods. RESULTS (Step 1) The following Information- and support needs were identified from the literature (n = 33) and semi structured interviews (n = 22): information about pathology and intervention, medication and side effects, daily physical activities, psychological distress, body signals and social support. Advanced communication and pedagogical skills of the health care provider and the ability to build trust were described as important prerequisites for the intervention. (Step 2) The following performance objectives were formulated: (1) Patients gain knowledge on how their cardiac illness and procedure affects their bodies and health, (2) Patients gain knowledge about medication and side effects, (3) Patients know which daily physical activities they can and can’t do after hospital discharge and are physically active, (4) Patients and informal caregivers can deal with psychological distress and know how to discriminate between harmful and harmless body signals. Objectives were described per determinant (knowledge, skill, attitude, social influence, self-efficacy and outcome expectation). (Step 3) A comprehensive remote intervention was developed using theory based coaching strategies, a digital patient platform and information videoclips. CONCLUSION This study describes the information and support needs of patients after cardiac hospitalization and offers a remote intervention that bridges the gap form hospital discharge to CR. Abstract Figure. BRIDGE2CARE
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BACKGROUND: Physical activity (PA) levels might be a simple overall physical function indicator of recovery in acutely hospitalized older adults; however it is unknown which amount and level of PA is associated with recovery. Our objective was to evaluate the amount and level of post discharge PA and its optimum cut-off values associated with recovery among acutely hospitalized older adults and stratified for frailty.METHODS: We performed a prospective observational cohort study including acutely hospitalized older adults (≥ 70 years). Frailty was assessed using Fried's criteria. PA was assessed using Fitbit up to one week post discharge and quantified in steps and minutes light, moderate or higher intensity. The primary outcome was recovery at 3-months post discharge. ROC-curve analyses were used to determine cut-off values and area under the curve (AUC), and logistic regression analyses to calculate odds ratios (ORs).RESULTS: The analytic sample included 174 participants with a mean (standard deviation) age of 79.2 (6.7) years of whom 84/174 (48%) were frail. At 3-months, 109/174 participants (63%) had recovered of whom 48 were frail. In all participants, determined cut-off values were 1369 steps/day (OR: 2.7, 95% confidence interval [CI]: 1.3-5.9, AUC 0.7) and 76 min/day of light intensity PA (OR: 3.9, 95% CI: 1.8-8.5, AUC 0.73). In frail participants, cut-off values were 1043 steps/day (OR: 5.0, 95% CI: 1.7-14.8, AUC 0.72) and 72 min/day of light intensity PA (OR: 7.2, 95% CI: 2.2-23.1, AUC 0,74). Determined cut-off values were not significantly associated with recovery in non-frail participants.CONCLUSIONS: Post-discharge PA cut-offs indicate the odds of recovery in older adults, especially in frail individuals, however are not equipped for use as a diagnostic test in daily practice. This is a first step in providing a direction for setting rehabilitation goals in older adults after hospitalization.
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