Stephanie Rennke, MD; Oanh K. Nguyen, MD; Marwa H. Shoeb, MD; Yimdriuska Magan, BS; Robert M. Wachter, MD; Sumant R. Ranji, MD
Note: The Agency for Healthcare Research and Quality reviewed contract deliverables to ensure adherence to contract requirements and quality, and a copyright release was obtained from the Agency for Healthcare Research and Quality before submission of the manuscript.
Disclaimer: All statements expressed in this work are those of the authors and should not in any way be construed as official opinions or positions of the University of California, San Francisco; the Agency for Healthcare Research and Quality; or the U.S. Department of Health and Human Services.
Financial Support: From the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services (contract HHSA-290-2007-10062I).
Potential Conflicts of Interest: Dr. Rennke: Grant (money to self and to institution): AHRQ; Support for travel to meetings for the study or other purposes: AHRQ; Payment for writing or reviewing the manuscript (money to self and to institution): AHRQ; Provision of writing assistance, medicines, equipment, or administrative support (money to institution): AHRQ; Consultancy: Society Hospital of Medicine. Dr. Ranji: Grant (money to institution): AHRQ. Dr. Magan: Grant (money to institution): AHRQ. Dr. Wachter: Grant (money to institution): AHRQ; Support for travel to meetings for the study or other purposes (money to institution): AHRQ; Board membership: Chair of the American Board of Internal Medicine; Grants/grants pending (money to institution): AHRQ; Payment for lectures including service on speakers' bureaus: honorarium for lectures from more than 100 health care organizations, mostly on patient safety, health care quality, and hospitalists; Royalties: Lippincott Williams & Wilkins, McGraw-Hill; Payment for development of educational presentations: QuantiaMD; Payment for development of educational presentations (money to institution): IPC-The Hospitalist Company; Stock/stock options: PatientSafe Solutions, CRISI, EarlySense; Other: Compensation from John Wiley & Sons for writing “Wachter's World” blog, Benioff endowed chair in hospital medicine, funded by the US-UK Fulbright Commission for a sabbatical at Imperial College London from July to December 2011, unpaid member of the Board of Directors, Quality Committee of Salem Hospital. All other authors have no dislosures. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-2573.
Requests for Single Reprints: Stephanie Rennke, MD, University of California, San Francisco, UCSF Mount Zion Medical Center, 1600 Divisadero Street, San Francisco, CA 94115-1945; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Rennke: University of California, San Francisco, UCSF Mount Zion Medical Center, 1600 Divisadero Street, San Francisco, CA 94115-1945.
Dr. Nguyen: University of California, San Francisco, UCSF Laurel Heights, Campus Box 1211, 3333 California Street, San Francisco, CA 94143.
Drs. Shoeb and Ranji: Department of Medicine, University of California, San Francisco, 533 Parnassus Avenue, Box 0131, San Francisco, CA 94143.
Dr. Magan: Division of Hospital Medicine, University of California, San Francisco, 533 Parnassus Avenue, Box 0131, U-129, San Francisco, CA 94143.
Dr. Wachter: Department of Medicine, University of California, San Francisco, 533 Parnassus Avenue, Box 0120, San Francisco, CA 94143.
Author Contributions: Conception and design: S. Rennke, O.K. Nguyen, M.H. Shoeb, S.R. Ranji.
Analysis and interpretation of the data: S. Rennke, O.K. Nguyen, M.H. Shoeb, Y. Magan, S.R. Ranji.
Drafting of the article: S. Rennke, O.K. Nguyen, M.H. Shoeb, Y. Magan, S.R. Ranji.
Critical revision of the article for important intellectual content: S. Rennke, O.K. Nguyen, M.H. Shoeb, Y. Magan, R.M. Wachter, S.R. Ranji.
Final approval of the article: S. Rennke, O.K. Nguyen, M.H. Shoeb, R.M. Wachter, S.R. Ranji.
Obtaining of funding: R.M. Wachter.
Administrative, technical, or logistic support: Y. Magan.
Collection and assembly of data: S. Rennke, O.K. Nguyen, M.H. Shoeb, Y. Magan, S.R. Ranji.
Hospitals now have the responsibility to implement strategies to prevent adverse outcomes after discharge. This systematic review addressed the effectiveness of hospital-initiated care transition strategies aimed at preventing clinical adverse events (AEs), emergency department (ED) visits, and readmissions after discharge in general medical patients. MEDLINE, CINAHL, EMBASE, and Cochrane Database of Clinical Trials (January 1990 to September 2012) were searched, and 47 controlled studies of fair methodological quality were identified. Forty-six studies reported readmission rates, 26 reported ED visit rates, and 9 reported AE rates. A “bridging” strategy (incorporating both predischarge and postdischarge interventions) with a dedicated transition provider reduced readmission or ED visit rates in 10 studies, but the overall strength of evidence for this strategy was low. Because of scant evidence, no conclusions could be reached on methods to prevent postdischarge AEs. Most studies did not report intervention context, implementation, or cost. The strategies hospitals should implement to improve patient safety at hospital discharge remain unclear.
Table 1. Taxonomy of Interventions to Improve Transitional Care at Hospital Discharge
Table 2. Summary Strength of Evidence and Findings
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David Bittleman, MD
Intercoastal Medical Group, Sarasota, FL 34232
April 14, 2013
Rothman Index may aid in patient discharge planning.
I am a general internist on staff at Sarasota Memorial Hospital, Sarasota Florida. Since 2006 we have as part of our electronic medical record, the Rothman Index, RI, a powerful tool that tracks the patient's status hourly. The RI has been promoted as an early warning device for incipient deterioration in condition as well as a tool for communication between providers. However, I have been using it to good effect as a tool for communication with patient's families particularly when it comes to discharge planning and making prognoses. Families look forward to reviewing the graphs with me during rounds. They ask for copies of the graphs to share with others involved with the patient’s care. My impression is that the shared viewing of the RI allows families to take an active role in discharge. I would like to see the RI studied further as a tool to help in patient and family communication to provide better care and avoid early repeat hospitalizations.
Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Hospital-Initiated Transitional Care Interventions as a Patient Safety Strategy: A Systematic Review. Ann Intern Med. 2013;158:433-440. doi: 10.7326/0003-4819-158-5-201303051-00011
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Published: Ann Intern Med. 2013;158(5_Part_2):433-440.
Healthcare Delivery and Policy, Hospital Medicine.
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