Originally published December 2014
Readmissions continue to be a focus of quality improvement initiatives in Canada and internationally because they place such a strain on healthcare systems. But preventable readmissions also have serious implications for patients, physicians, and healthcare providers caring for them. According to the Canadian Institute for Health Information, nearly 8.5% of patients in Canada are readmitted to an acute care hospital within a month of their initial discharge.1
The CMPA identified 75 medico-legal cases that closed between 2009 and 2013 involving inadequate discharge planning — of which the vast majority led to an unplanned readmission. In these cases, discharge planning included assessing the patient to determine whether they were fit for discharge, making appropriate arrangements for continuing medical care, and providing the patient with clear written or verbal follow-up instructions including information on when and who to contact, and where best to seek medical attention.
Nearly two-thirds of readmissions occurred after a surgical intervention, while the rest were after hospitalization for a medical, obstetric, or psychiatric condition.
Most readmissions in surgical care followed same-day or overnight-stay gastro-intestinal, gynecologic, orthopaedic, and urologic surgeries. The majority of patients were readmitted within a week of discharge, most often the next day. These patients usually required additional surgery or intensive care. A small number of patients died from their complications.
Readmissions were largely due to surgical complications being recognized late. When peer experts reviewed the care, they identified premature discharge as a common theme, and various risk factors, including difficult surgery, unstable vital signs, ongoing pain, or co-morbidities that would have necessitated a longer period of observation. Premature discharge was often attributed to physicians not re-assessing the patient before discharge or nursing not communicating their concerns about a patient's condition. In a few cases, physicians failed to review post-operative investigations that they had ordered.
In a considerable number of cases, ineffective discharge planning, including inadequate follow-up and suboptimal transitions of care, was the main driver for readmission. Underlying all of these cases was poor communication — between physicians; between nurses and physicians; and between physicians and patients. Miscommunication between physicians and patients most often involved the discharge discussion and included not advising patients of the symptoms and signs that would alert them to seek medical attention, and when and where to access that care.
Most of the patients in non-surgical cases were readmitted within 10 days of discharge. Patients were sometimes found to have been discharged before their medical condition had been completely addressed, or were readmitted because the underlying condition had continued or progressed, which most often included infections and cancers.
Expert review identified two main problem areas in these cases: follow-up of investigations and discharge planning. Overlooked test results were often significant and should have been acted on. In some cases where medical trainees were involved in the discharge, the experts were critical of attending physicians who did not personally review the medical record or assess the patient. When examining discharge planning, the experts were critical of poor coordination of home care, particularly for patients with multiple health issues or who were not considered safe or ready for discharge.
Two cases illustrate these findings. The first demonstrates the consequences of a premature patient discharge following day surgery and highlights the importance of effective communication between a nurse and a physician about a change in a patient's condition. The second shows the repercussions of inadequate discharge planning and coordination of care.
Case 1: Premature discharge, lack of communication
During a laparoscopic right salpingo- oophorectomy on a 35-year-old woman, a gynecologist encounters difficulty and removes a large ovarian cyst by posterior colpotomy. After the surgery, the patient requires oxygen to maintain appropriate oxygen saturation. She is admitted overnight, but the nurse does not notify the most responsible physician. Throughout the night, the patient develops a fever and continues to require supplemental oxygen. Early the next morning, the patient complains of severe abdominal pain and is unable to void. Another gynecologic resident on the team does not assess the patient but verbally prescribes a parasympathomimetic to stimulate urination. Throughout the morning, the patient is febrile, hypotensive, and tachycardic. She eventually voids and is discharged later that morning without being reassessed by the team.
Three days later, the patient presents to the emergency department in early stages of septic shock. Her white blood count is elevated, and an abdominal CT scan shows findings consistent with bowel perforation. She undergoes a Hartmann procedure with colostomy for a rectal tear. Her post-operative course is complicated by hemorrhage, abdominal and pelvic abscesses, prolonged ventilation, and pulmonary embolism.
A legal action ensues. The main experts' criticism is that the patient should not have been discharged, as earlier diagnosis of the rectal tear would likely have been made and led to a less complicated post-operative course. Defence experts were also critical of the nurses for not advising the gynecologist of the patient's abnormal vital signs in the hours following surgery, and of the resident for prescribing without formally assessing the patient. This failed communication resulted in missed opportunities to reassess the patient. Without expert support, a settlement is paid to the patient, shared by the CMPA and the hospital.
Case 2: Inadequate discharge planning and care coordination
A family physician (FP) prescribes antivirals and antibiotics for a hospitalized elderly woman with facial herpes zoster and associated cellulitis. The patient has multiple co-morbidities including diabetes mellitus, atrial fibrillation, and severe chronic obstructive pulmonary disease requiring oxygen supplementation. The patient's condition improves three weeks later, and the FP discontinues the antivirals. The FP meets with her family to plan her discharge for the Sunday. The patient is transferred home, but home oxygen is not set up, medications are not sent with her, and home care services are not arranged. The patient's condition declines, and she is readmitted a few days later.
A regulatory authority (College) complaint follows. The investigative committee reminds the family physician to make plans for discharging patients as far in advance as possible.
Strategies to reduce readmissions
Many readmissions identified in the analysis of CMPA cases may have been avoided had different actions been taken before the patient's discharge. The following strategies are based on expert opinions in the cases analyzed:
- Review pertinent clinical documentation, test results, and consultation reports before discharging patients.
- Consider reassessing patients, as required, before discharging them.
- Use multidisciplinary teams to assess patients' home care requirements, when appropriate.
- If another physician assumes care after discharge, provide pertinent information in a timely manner, such as patients' clinical condition and treatment plan.
- Reconcile patients' medications before discharge.
- Consider using a structured communication tool, including a discharge summary, for sharing information during transitions of care.
- Provide clear written and verbal discharge instructions to your patients or their caregivers, including symptoms and signs that should alert them to seek further medical attention and where to find that care.
- Ensure follow-up care is arranged and advise your patients who will be providing this care.
- Verify that the roles and responsibilities of each physician are clear to patients and to the other physicians and healthcare providers. In Québec, discharge instructions to patients must include the contact information for the team that provided the care.2
- Document your discharge instructions in the medical record.
- Canadian Institute for Health Information, "All-Cause Readmission to Acute Care and Return to the Emergency Department" Ottawa, Ont.: CIHI, 2012
- Collège des médecins du Québec, Procédures et interventions en milieu extrahospitalier, Guide d'exercice du Collège des médecins du Québec, August 2011, Accessed November 2014 from: http://www.cmq.org/fr/Public/Profil/Commun/AProposOrdre/Publications/%7E/media/Files/Guides/Guide-Procedures-Interventions-ExtraHosp-2011.ashx?11229