Rory Staunton was an active 12-year-old. He was sent to the emergency room for what doctors thought was a stomach bug after he got a cut on his arm chasing down a loose basketball. After he was given fluids and seemed to show improvement, he was released. Sadly, he died three days later from undetected sepsis shock. In hindsight, people have questioned if better information sharing could have raised a red flag with medical staff. Could his life have been spared?
To tell the story is not to shame the hospital where this happened. A doctor quoted in a 2013 New York Times article covering the story said: “I think it could have happened almost anywhere.”
After Rory’s death, when people looked into the case, they found a few places where better communication may have helped. They include information handoff from primary care physician to ED and back again along with making sure critical lab results get into the hands of doctors.
I’m sharing Rory’s story with you to resharpen the focus we bring with us to work each day. We know we’re in the lifesaving business but sometimes it is easy to just go about our daily routines or be OK doing things the way we do because they have always been done that way. With the pressures we face we often don’t pause to take stock and say “Is there a better way?” It also a good reminder of the reason behind some regulations and procedures. With constant changes to rules, regulations and procedures for emergency departments it can be overwhelming, maybe sometimes they even feel arbitrary or a lot of trouble to undertake for no good reason. Rory’s story is proof that they aren’t.
In New York State, Rory’s Law was passed in the wake of his death to try and prevent future cases like his. The new regulations call for improved communication to ensure vital health information like lab and test results are relayed to children’s parents and their primary health care providers. On the national level, Agency for Healthcare Research and Quality and Boston University Medical Center (BUMC) have released a toolkit to help you re-engineer your emergency department’s discharge process.
For some ideas on how you can measure how well your emergency department’s discharge process stacks up, I’ve pulled information directly from the Re-Engineered Discharge Toolkit to help you. It’s a free government resource you can leverage yourself. The payoff can be big.
Lower Readmission and Medical Error Rates
In addition to improved patient safety and outcomes, achieving lower readmission rates can be another benefit of re-engineering your process. See these facts from that NY Times article I mentioned earlier:
“‘Every year, between 600,000 and one million patients in the United States are sent home from emergency rooms only to return within 72 hours because of medical errors,’ according to Dr. Michael Weinstock, an associate professor in the emergency department at Ohio State University. During a career of 30 to 35 years, the average emergency doctor ‘will send home 17 patients who will die an avoidable death within seven days.’”
How to Make Evidence-Based Change
In its toolkit, AHRQ acknowledges the challenges and benefits of taking a closer look at discharge procedures. The process is complex and requires syncing communication among “inpatient care team, primary care team, community services, the patient, and the patient's caregivers. There are many opportunities for improved discharge processes at U.S. hospitals that, if accomplished, could lead to reduced rehospitalization of patients, which is currently at a rate of almost 1 in 5 for patients covered by Medicare.”
Here’s information directly from AHRQ's toolkit to get you started in the re-evaluating and reengineering your process. The excerpt below highlights four possible trouble spots to examine:
- Delayed Transfer of Discharge Summary: There is frequently a delay between the time a patient is released from the hospital and when the primary care doctor receives the discharge summary. This delay means the doctor is not immediately aware of which tests and procedures were done during the patient's hospital stay or what conditions still need attention.
- Unknown Test Results: Test results are not always complete by the time the patient leaves the hospital. This means the test results will not be included in the report the patient's primary care doctor receives.
- Lack of Follow-up: Patients themselves often do not fully understand the nature of their health problems or realize they need to make appointments for tests or procedures after leaving the hospital. They may be unable to make appointments due to lack of access to transportation or availability of appropriate doctors/specialists. Research has found that more than one-third of the patients who left the hospital in need of more care (e.g., lab tests or a referral to a specialist) failed to get that care.
- Medicine Reconciliation and Adverse Events: Confusion about which medicines to take can also lead to problems after a patient leaves the hospital. When patients are admitted to the hospital, many stop taking their regular medicines and start taking new ones. Once they leave the hospital, there is often confusion regarding which of the prehospitalization medicines should be continued. This may result in the patient failing to take needed medicine, taking duplicate medicine, or experiencing adverse drug events or natural remedy interactions.
The result of hospitals' failure to ensure an effective transition has included adverse events, high readmission rates, and high ED visit rates. Forces are, however, converging to push hospitals toward improving their discharge processes and reducing readmission rates.
For personalized help revamping your emergency department’s discharge processes to improve patient outcomes and safety and stay ahead of the HCAHPS regulations, contact me. I’m happy to help and create a customized action plan for your emergency department.
AHRQ: “Re-Engineered Discharge (RED) Toolkit.”
Boston University: “MED Prof Earns Drucker Award.”
New York Department of Health: “Rory’s Regulations.”
New York State: “Governor Cuomo Announces New York State to Lead the Nation in Fighting Sepsis the #1 Killer in Hospitals and Make Major Improvements in Pediatric Care Through "Rory's Regulations.
NY Times: “Death of a Boy Prompts New Medical Efforts Nationwide.”