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      Goals of care or goals of life? A qualitative study of clinicians’ and patients’ experiences of hospital discharge using Patient-Oriented Discharge Summaries (PODS)

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          Abstract

          Background

          Recognizing the need for improved communication with patients at the point of hospital discharge, a group of clinicians, patients, and designers in Toronto, Canada collaborated to develop a standardized tool known as the Patient-Oriented Discharge Summary (PODS). Although quantitative results suggest PODS helps mitigate gaps in knowledge, a qualitative inquiry from the clinician and patient perspective of psychiatric hospital discharge using PODS has not been widely explored. Our aim was to explore clinicians’ and patients’ experiences with PODS.

          Methods

          We used a qualitative thematic analysis to explore clinicians’ ( n = 10) and patients’ ( n = 6) experiences with PODS. We used convenience sampling to identify and invite potential participants at the Center for Addiction and Mental Health in Toronto, Canada to participate in semi-structured interviews between February 2019 and September 2019. Data were analyzed using a thematic analysis approach to develop descriptive themes.

          Results

          Emerging themes from the data between clinicians and patients were both different and complementary. Clinicians described PODS using the concept of “goals of care.” They relayed their experiences with PODS as a discrete event and emphasized its role in meeting their “goals of care” for discharge planning. Patients provided more of a “goals of life” perspective on recovery. They characterized PODS as only one facet of their recovery journey and not necessarily as a discrete or memorable event. Patients focused on their outcomes post-discharge and situated their experiences with PODS through its relation to their overall recovery.

          Conclusions

          PODS was experienced differently by clinicians and patients. Clinicians experienced PODS as helpful in orienting them to the fulfillment of goals of care. Patients did not experience PODS as a particularly memorable intervention. Due to the information advantage that clinicians have about PODS, it is not surprising that clinicians and patients experienced the PODS differently. This study expanded our understanding of hospital discharge from clinicians and patients perspectives, and suggests that there are additional areas that need improvement.

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          Most cited references22

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          Adverse events among medical patients after discharge from hospital.

          Adverse events (AEs) are adverse outcomes caused by medical care. Several studies have indicated that a substantial number of patients experience AEs before or during hospitalization. However, few data describe AEs after hospital discharge. We determined the incidence, severity, preventability and ameliorability of AEs in patients discharged from the general internal medicine service of a Canadian hospital. At a multisite Canadian teaching hospital, we prospectively studied patients who were consecutively discharged home or to a seniors' residence from the general internal medicine service during a 14-week interval in 2002. We used telephone interview and chart review to identify outcomes after discharge. Two physicians independently reviewed each outcome to determine if the patient experienced an AE. The severity, preventability and ameliorability of all AEs were classified. During the study period, outcomes were determined for 328 of the 361 eligible patients, who averaged 71 years of age (interquartile range 54-81 years). After discharge, 76 of the 328 patients experienced at least 1 AE (overall incidence 23%, 95% confidence interval [CI] 19%-28%). The AE severity ranged from symptoms only (68% of the AEs) or symptoms associated with a nonpermanent disability (25%) to permanent disability (3%) or death (3%). The most common AEs were adverse drug events (72%), therapeutic errors (16%) and nosocomial infections (11%). Of the 76 patients, 38 had an AE that was either preventable or ameliorable (overall incidence 12%, 95% CI 9%-16%). Approximately one-quarter of patients in our study had an AE after hospital discharge, and half of the AEs were preventable or ameliorable.
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            User Experience and Care Integration in Transitional Care for Older People From Hospital to Home: A Meta-Synthesis.

            This meta-synthesis aimed to improve understanding of user experience of older people, carers, and health providers; and care integration in the care of older people transitioning from hospital to home. Following our systematic search, we identified and synthesized 20 studies, and constructed a comprehensive framework. We derived four themes: (1) 'Who is taking care of what? Trying to work together"; (2) 'Falling short of the mark'; (3) 'A proper discharge'; and (4) 'You adjust somehow.' The themes that emerged from the studies reflected users' experience of discharge and transitional care as a social process of 'negotiation and navigation of independence (older people/carers), or dependence (health providers).' Users engaged in negotiation and navigation through the interrogative strategies of questioning, discussion, information provision, information seeking, assessment, and translation. The derived themes reflected care integration that facilitated, or a lack of care integration that constrained, users' experiences of negotiation and navigation of independence/dependence.
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              "Sign right here and you're good to go": a content analysis of audiotaped emergency department discharge instructions.

              The goal of this study is to quantitatively and qualitatively assess the quality and content of verbal discharge instructions at 2 emergency departments (EDs). This was a secondary data analysis of 844 ED audiotapes collected during a study of patient-emergency provider communication at 1 urban and 1 suburban ED. ED visits of nonemergency adult female patients were recorded with a digital audiotape. Of 844 recorded ED visits, 477 (57%) audiotapes captured audible discharge instructions suitable for analysis. Audiotapes were double coded for the following discharge content: (1) explanation of illness, (2) expected course, (3) self-care, (4) medication instructions, (5) symptoms prompting return to the ED, (6) time-specified for follow-up visit, (7) follow-up care instructions, (8) opportunities for questions, and (9) patient confirmation of understanding. Analysis included descriptive statistics, χ(2) tests, 2-sample t tests, and logistic regression models. Four hundred seventy-seven of 871 (55%) patient tapes contained audible discharge instructions. The majority of discharges were conducted by the primary provider (emergency physician or nurse practitioner). Ninety-one percent of discharges included some opportunity to ask questions, although most of these were minimal. Only 22% of providers confirmed patients' understanding of instructions. Verbal ED discharge instructions are often incomplete, and most patients are given only minimal opportunities to ask questions or confirm understanding. Copyright © 2010 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.
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                Author and article information

                Contributors
                sophie.soklaridis@camh.ca
                Journal
                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central (London )
                1472-6963
                24 July 2020
                24 July 2020
                2020
                : 20
                : 687
                Affiliations
                [1 ]GRID grid.155956.b, ISNI 0000 0000 8793 5925, Center for Addiction and Mental Health, ; 33 Russell Street, 2nd floor, room 2059, Toronto, ON Canada
                [2 ]GRID grid.42327.30, ISNI 0000 0004 0473 9646, The Hospital for Sick Children, ; Toronto, ON M5S 1S2 Canada
                Author information
                http://orcid.org/0000-0001-5119-8473
                Article
                5541
                10.1186/s12913-020-05541-7
                7379793
                32709233
                d61b7e4d-f74c-4c4b-b6d9-1ac00cc4926e
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 5 February 2020
                : 14 July 2020
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2020

                Health & Social care
                quality improvement,mental health,discharge planning,patient experience,provider experience,qualitative research

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