Extra Discussion

· Review the above articles and write your thought on the affect of patients’ payment methods on hospital discharge process and quality of care half page APA

· Read the below discussions and make 2 respond for each one

1- Tonia Haddow

Affect of Patient Payment Methods on Hospital Discharge And Quality of Care

The articles focused on patient transitions or discharge and how it is challenging for a smooth transfer to another facility or making a patient feel comfortable when their discharge day comes. The journal from Elsevier states that, “care transitions are known to put hospitalized patients at increased risk for error as these are times when patients are between health care providers, teams and settings,” (Conn, et al., 2018). This statement explains that patients in transition are more likely to run into error with their shift because of how many parties and groups they have to go through before the transition is complete. Things like incomplete documentation and medication discrepancies are very common to have error with during transition. I think that there should be clear communication and that is key to a proper and smooth transition.

Quality of care is essential from start to finish; I don’t think that quality of care should be emphasized more during discharge or any one specific time of the patients’ stay. Even though it might not seem like it, there are consequences of patients who have poor quality of care and poor discharge performances. For example, patients may experience adverse events that require hospital re-admission (Conn, et al., 2018). This is something that we should not be running into and the discharge procedure should be thorough and complete regarding the patients’ feeling and state.

2- Isral

3- Top of Form

This article looked at the treatment that patients and their families felt during the discharge and transitioning periods from one facility to another. The experiment found that may patients thought that having things in place such as social worker conversations about discharge was very helpful. They also thought that having a positive and helpful staff was also of high importance to them; many of the staff were described as “incredible” during the transition. There were some things that needed improvement such as the emotional support that many patients felt was lacking during and after the transitioning period. There were reports of feelings of depression, shock, or fear when finding out that they were being transferred so suddenly.

Personally, I can understand the patient’s feelings of being rushed and forced to have to transition so suddenly. To counter some of those feelings, I suggest organizations maybe implementing a time frame of which a patient can chose when they want to leave. For example, if a patient is being motioned for discharged, they can be offered a period of a 2-5 day window that they can decide when to leave or not. This gives the patient a sense of some control about their decision of when to leave. Also, as it relates to cost, it may be a method that an organization may be able to budget correctly and thus will have an overall positive impact on the org. I understand that financially, getting people in and out of a facility is the most feasible way to do things, but I also think that it is equally important for an organization to recognize the impression that they are leaving on the patient and their families; and how that affects the overall reputation of the organization. Also, this reminds me of the ACHCA conference that I attended a few months back. The speaker made it a point to take into consideration how their residents feel when they have to transition to another facility. She discussed how important it is to have things in place to make the transition as smooth as possible for the resident. For example, having a person great the family upon arrival of the new facility. Or having someone check in on the family 6 months after the transition has occurred to make sure the resident feels comfortable or has any concerns. Although this may increase the costs for an organization, I feel it is worth the investment because it is important to the brand and reputation of the organization. It makes it more marketable and thus could actually increase the financials of an organization overall.

4- Bottom of Form
Injury, Int. J. Care Injured 49 (2018) 97–103

Full length article

Trauma patient discharge and care transition experiences: Identifying opportunities for quality improvement in trauma centres

Lesley Gotlib Conna,*, Ashley Zwaimana, Tracey DasGuptab, Brigette Halesb, Aaron Watamaniukb, Avery B. Nathensa,b

a Evaluative Clinical Sciences, Trauma, Emergency and Critical Care Research Program, Sunnybrook Research Institute, Toronto ON Canada b Sunnybrook Health Sciences Centre, Toronto ON Canada

A R T I C L E I N F O

Keywords: Injured patients Patient experience Discharge Care transfer Trauma centre Quality improvement Qualitative research

A B S T R A C T

Background: Challenges delivering quality care are especially salient during hospital discharge and care transitions. Severely injured patients discharged from a trauma centre will go either home, to rehabilitation or another acute care hospital with complex management needs. This purpose of this study was to explore the experiences of trauma patients and families treated in a regional academic trauma centre to better understand and improve their discharge and care transition experiences. Methods: A qualitative study using inductive thematic analysis was conducted between March and October 2016. Telephone interviews were conducted with trauma patients and/or a family member after discharge from the trauma centre. Data collection and analysis were completed inductively and iteratively consistent with a qualitative approach. Results: Twenty-four interviews included 19 patients and 7 family members. Participants’ experiences drew attention to discharge and transfer processes that either (1) Fostered quality discharge or (2) Impeded quality discharge. Fostering quality discharge was ward staff preparation efforts; establishing effective care continuity; and, adequate emotional support. Impeding discharge quality was perceived pressure to leave the hospital; imposed transfer decisions; and, sub-optimal communication and coordination around discharge. Patient-provider communication was viewed to be driven by system, rather than patient need. Inter-facility information gaps raised concern about receiving facilities’ ability to care for injured patients. Conclusions: The quality of trauma patient discharge and transition experiences is undermined by system- and ward-level processes that compete, rather than align, in producing high quality patient- centred discharge. Local improvement solutions focused on modifiable factors within the trauma centre include patient-oriented discharge education and patient navigation; however, these approaches alone may be insufficient to enhance patient experiences. Trauma patients encounter complex barriers to quality discharge that likely require a comprehensive, multimodal intervention.

© 2017 Elsevier Ltd. All rights reserved.

Contents lists available at ScienceDirect

Injury

journal homepa ge: www.elsev ier .com/locate / in jury

Background

Patient-centred care is a core dimension of healthcare quality and safety that prioritizes respect for patients’ wishes and values in clinical decision-making [1]. While globally recognized, the increasing complexity of our health care needs and their

* Corresponding author at: 2075 Bayview Avenue, K3W28, Toronto, ON M4N 3M5, Canada.

E-mail addresses: lesley.gotlibconn@sunnybrook.ca (L. Gotlib Conn), ashley.zwaiman@sunnybrook.ca (A. Zwaiman), tracey.dasgupta@sunnybrook.ca (T. DasGupta), brigette.hales@sunnybrook.ca (B. Hales), aaron.watamaniuk@sunnybrook.ca (A. Watamaniuk), avery.nathens@sunnybrook.ca (A.B. Nathens).

https://doi.org/10.1016/j.injury.2017.09.028 0020-1383/© 2017 Elsevier Ltd. All rights reserved.

coordination continually challenge local and system-wide efforts to deliver patient-centred care. The challenge is particularly salient during times when hospitalized patients move from one care context to another, for instance, leaving the hospital for home or another acute or long-term care facility. Care transitions are known to put hospitalized patients at increased risk for error as these are times when patients are between health care providers, teams and settings [2,3]. Incomplete documentation, medication discrep- ancies, sub-optimal information transfer between providers and inadequate provider-family communication are known problems [4–9]. Patients are also found to be poorly prepared to leave the hospital due to their physical, emotional and social status [10,11]. When transitions are poorly executed, patients may experience adverse events that require hospital re-admission. In light of this,

http://crossmark.crossref.org/dialog/?doi=10.1016/j.injury.2017.09.028&domain=pdf
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mailto:brigette.hales@sunnybrook.ca
mailto:aaron.watamaniuk@sunnybrook.ca
mailto:aaron.watamaniuk@sunnybrook.ca
mailto:avery.nathens@sunnybrook.ca
mailto:avery.nathens@sunnybrook.ca
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98 L. Gotlib Conn et al. / Injury, Int. J. Care Injured 49 (2018) 97–103

improved hospital discharge and care transition processes and experiences are receiving considerable attention, as evidenced by recent studies on patient understanding at discharge [12–14], and the relationship between discharge processes and patient- reported [15–17] and clinical outcomes [18–20].

Severely injured patients have complex management needs and are under-studied with respect to the quality of their discharge and transition experiences. Though trauma patient and family views on the requirements for high-quality injury care are known [21], we are only beginning to understand patient experience of trauma centre discharge and transfer [22,23], and its relationship to quality care [24]. Thisknowledgegapissurprisinggiventheprevalenceof trauma worldwide and the estimated number of people living with ongoing injury-related disability [25,26]. For instance, 20 to 50 millionpeople surviving road traffic injuries incurpermanent disability [26]. A large proportion of the injured live with life-altering physical, cognitive and social impairments such as loss of limbs, spinal cord injury, and post-traumatic stress disorder [25,26]. This may result in prolonged hospital stays, require multiple surgical and medical services for multi-system injuries, and inability to advocate for resources. These factors, along with what is at times a fragmented social support network, put trauma patients at extremely high risk during transition from a trauma centre. At present, the best way to ensure the highest quality patient-centred discharge and transition for this patient population remains unknown.

The purpose of this study was to better understand the quality of trauma centre discharge and care transition experiences of severely injured patients. We aimed to explore how patients experience preparation to leave the trauma centre, their informa- tion and supportive care needs, and the perceived enablers and constraints to achieving these to identify modifiable factors for improvement.

Participants and methods

Study design and setting

We conducted a qualitative study using an interpretivist approach to capture the variation in patient and family experiences [27]. The study was carried out in a regional academic adult trauma centre in Toronto, Canada, where a publicly-funded healthcare system is in place. The trauma centre admits approximately 1000 injured patients annually, 90% of whom survive their injuries. In this centre, the most severely injured patients within the region will arrive direct from the scene of an injury or be transferred from one of over 80 referring non-trauma hospitals. Patients are cared for in a 35- bed trauma ward where they are visited daily by their primary surgical team (surgery trainees and staff from general surgery, orthopaedic surgery, or neurosurgery), and health care staff (nurses, therapists, etc) assigned to the ward.

Typical discharge and transfer procedures

Trauma patients discharged from our centre to home receive an information package including a discharge clinical summary listing their injuries, hospitalization course, interventions received, med- ications and follow-up procedures. Relevant written information aboutself-care, suchaswound and collarcare orsocial support isalso provided. Discharge education is delivered by the patient’s primary nurse, in conjunction with members of the health care team who review and teach the patient and/or family specific self-care needs such as weight bearing restrictions. A patient may receive in-home nursing care for wound dressing changes which would be reviewed at time of discharge.

Patients transferred to rehabilitation or another community hospital are notified by a social worker when a community bed

becomes available and discharge is possible. Transportation is arranged by the clerical staff. Medical records, a discharge summary and follow-up appointment cards are packaged and taken in-hand to the receiving centre by the patient. Discharge teaching in instances of transfer is minimal with no standard process in place. When a patient is received by a community hospital, physician-to-physician handover and nurse-to-nurse transfer of accountability are completed by telephone. A patient with a neuro-trauma injury may have a consultation with a neurosurgical outreach nurse who will follow the case through to transition. Receiving providers within the surrounding region have access to a patient’s electronic health record through a secured shared repository online. Patients and/or caregivers have access to an e-health service called MyChart in which all of their information from the hospital’s electronic patient record is stored.

Recruitment and sampling

Purposive sampling was used to recruit trauma patients or, where appropriate, a family member involved in discharge procedures [28]. Given the heterogeneity of the trauma patient population, recruit- ment was driven by efforts to capture a varied sample based on patient characteristics (age and gender), type and mechanism of injury, and discharge disposition (home, rehabilitation, or another acute care hospital). Eligible participants included English-speaking patients or the family member of a patient who was admitted to the trauma ward between March and August 2016. Individuals were approached for participation prior to hospital discharge and presented with written consent forms approved by the hospital’s research ethics board. Consented participants were contacted by telephone 30 days after discharge as this was determined to be sufficient time for the participant to experience and reflect upon the quality of the discharge or transition process. Three attempts were made to telephone consented participants who were purposively targeted to achieve a varied sample. If unreachable or unavailable after three attempts the researcher selected another consented individual for interview.

Data collection and analysis

Semi-structured interviews were conducted by telephone between April and October 2016 by the primary author, a medical anthropologist. The interview guide was informed by a literature review and research team expertise which included a senior trauma surgeon and systems researcher, an advanced practice nurse, a nurse-trained leader in interprofessional practice, and an organiza- tional leader in quality improvement and patient safety (Appendix A). All interviews were audio-recorded and transcribed, each lasting approximately 20 min. Data were analyzed iteratively and inductively consistent with thematic analysis whereby themes were derived from ongoing data collection and analysis, i.e. coding [29]. Two stages of analysis involved initial data coding completed independently by two team members using open coding procedures and discussion to reach consensus on major themes identified. Second, using the constant comparison technique, similarities and differences across and within themes were analyzed refining the themes and their content. Data collection ceased when the authors determined there to be sufficient depth, breadth and redundancy in the themes that were derived from patient experiences to offer a complete and sensible understanding of quality trauma centre discharge and transition experiences [30].

Results

Twenty-four interviews were completed with trauma patients and/or a family member (spouse, child or parent of patient); patient

Table 1 Patient Characteristics.

Patient Characteristics N (%)

Gender Male 13 (54) Female 11 (46)

Age <25 7 (29) 26-39 5 (21) 40-54 4 (17) 55+ 8 (33)

Injury Mechanism Fall 5 (21) MVC/motorcycle 9 (38) Pedestrian 2 (8) Crush 2 (8) Other 6 (25)

Length of Stay Median 10.5 (range 3-126 days)

L. Gotlib Conn et al. / Injury, Int. J. Care Injured 49 (2018) 97–103 99

characteristics are detailed in Table 1. Interviewed participants were within 36–90 days post-discharge at the time of the interview with the average interview at 59 days post-discharge. In some instances, participants’ availability led to interview delay.

We identified two major themes that reflected participants’ accounts of the competing tensions at play in executing patient discharge: (1) Fostering quality discharge; and, (2) Impeding quality discharge. Within each of these themes we identified 3 sub- themes constituting processes that either contributed to or disrupted the extent to which participants’ perceived or experi- enced a patient-centred discharge or transfer.

Fostering quality discharge

Ward preparation Participants shared many positive accounts of ward staff efforts

to prepare them for discharge and care continuity. They reported having opportunities to discuss their discharge plan and receive some written information pertaining to their continued care. Many participants expressed a deep sense of gratitude and appreciation for the staffs’ compassion and hard work. Some ward nurses were described as “incredible” and played a key role in discharge education and preparation for self-care when transitioning home.

“The nurse told me that I would be going home and she gave me a bunch of paperwork; she put together this bag with a bunch of gauze, wrapping, bandages, non-adhesive pads, some saline solution, basically all the things I would need. She told me keep an eye on my injuries, to be aware of the possibility of infection and keep an eye out for it. She gave me the heads up on everything.” P31, patient

Extensive discussions with social workers and therapists about family support needs and optimal rehabilitation centres enabled transfer preparations. Ward staff were perceived to effectively advise patients and families on the best fit for their needs, and to act as advocates when negotiating for limited space in a preferred facility. These personalized, supportive discussions, described by many participants, were important enablers of discharge readiness and quality care.

“We did have a conversation. Originally they were thinking somewhere closer to home which is the ABC* area, that’s what they said they usually do, the clinic closest to home. But because he did have a stroke and the brain injury they suggested, that if I wanted, to send him to hospital XYZ* because they actually take care of both there. Then they gave me the entire package for that. That’s what I wanted.” P11, family member (*de-identified)

Care continuity. Primary care providers involved in patients’ post- discharge care were also perceived to play a critical role in fostering transfer quality by ensuring follow-up and care continuity. One patient described the “huge role” that her family doctor played, making a house call post-discharge and investigating a concerning incidental finding in an imaging report. The emotional support that family doctors offered patients who had suffered extremity injury or loss was particularly helpful after leaving the trauma centre.

“I have a family physician and when I first came into rehab she called me on the weekend just to say, ‘Oh my God, I’m here if you need me.’ She is wonderful.” P12, patient “When I saw my family doctor I was actually, I started crying and stuff, because I was upset every time I was seeing my hand.” P33, patient

Patients from rural areas in particular emphasized their family doctor’s crucial role in care continuity in the absence of local specialists.

Emotional support Not all participants reported being fully educated or prepared

for discharge. Some described inconsistent experiences with respect to receiving information about self-care and setting expectations for care continuity and follow up appointments. Several described a gap with respect to emotional and psychologi- cal support at the time of discharge or transfer expressing desired access to such support early on, as one patient stated,

“Certainly given the severity of my injuries � it was very traumatic to me. Whether you had financial concerns, emotional concerns, prognosis concerns, what would be permanently debilitating, what were the possible impacts, it would have been helpful.” P26, patient

Participants reported experiencing depression and anxiety that were neither identified nor addressed in the acute care period as the focus was on the patients’ physical recovery. When asked about receiving information about emotional support one patient explained,

“They could have but I honestly don’t remember it and I don’t think I’ve seen it because if I’d seen it I probably would have used it.” P6, patient

Patients also experienced barriers to mental health support after discharge including long waiting lists for insured services and no access to private services due to financial limitations.

Impeding quality discharge

Pressure to leave Participants perceived discharge and transfer procedures to be

largely influenced by organizational pressures to move patients out. As such, they experienced subtle and explicit pressures to leave the hospital which they expressed as feeling rushed, shocked and scared at discharge. Several patients felt hurried out of the hospital with short notice and insufficient time to cope with what had happened to them. One patient, a pedestrian who had been dragged by a moving vehicle, was completely surprised at the news that she was ready for rehabilitation despite undergoing leg amputation just 6-days prior.

“The day I got the information that I was going to XYZ* was the first day I had been up and in the chair and in the TV room. So they’d just got me out of bed and into a chair and they said, “Oh congratulations, you’re going out tomorrow,” and it’s like ‘Hello?!”' P12, patient

Several patients felt discarded by the discharge process. Despite having received specific discharge education patients recounted upsetting experiences.

100 L. Gotlib Conn et al. / Injury, Int. J. Care Injured 49 (2018) 97–103

“They told me in the last two days, ‘Oh you might be able to get discharged tomorrow’, but then the day of they told me, ‘Okay you’re going to be discharged today,’ and then they just gave me the envelope and then that’s it. So I didn’t really know about the other appointments or anything. They were just, ‘Here’s your discharge papers, bye’.” P6, patient

Some patients attributed the unexpected speed of discharge to organizational demands to make beds available for patients who were more seriously injured than they were. One patient who had suffered a crush injury to the chest explained,

“They said they needed the bed. They confirmed it for another patient that was coming from another hospital, so they didn't give me any time. They actually wanted me to wait in the waiting room for my family to come.” P23, patient

Others perceived transfer destination and timing decisions were governed by patient volume or the availability of beds in receiving facilities, not by patient stated preference.

“The staff was talking about next steps and how I would probably want to go home and that most people would want to go home in my situation. But I didn't feel like that was an appropriate next step. They spoke about how some people do physio, but you know, ‘You might want to just go home and do private physio there’. So it was more than just about being a little bit persistent. I don't feel like I had to wage a war or anything, but I could tell, the good option was to go home. Probably because there's not any beds and things I'm sure.” P16, patient

Imposed transfer decisions For some patients, transfer to a community hospital once their

acute injury care was completed was mandated by a repatriation policy established by the provincial government. Participants perceived repatriation decisions to be imposed both subtly and explicitly. Most explicitly, as one family member explained, the patient’s transfer to a hospital that was not preferred by the family was presented as non-negotiable.

“He was sent to DEF*, not by choice and not for rehab, it was strictly we were told to repatriate. It was, ‘You've used our services here, we can't help you anymore, you're going to DEF* until you get in to rehab somewhere.’ It was just a state of fact There's a new policy about repatriation and that's it. I mean, they said it nicely, but it wasn't like there was anything open for discussion.” P3, family member

More subtly imposed, others accepted repatriation but did not know where exactly they were being transferred to, for how long, or who would be responsible for their care. For instance, one participant who was happy to be transferred closer to home did not know which of the 6 hospitals in her region she was being sent to. She was initially sent to one site, and then transferred to another.

“I wasn't very clear as to which hospital I was going to and how long I'd be there. Like I was transferred to the MNO Hospital* but I wasn't sure which one it would be until it was pretty late into � well just about being transferred. Because there's lots of hospitals down here. Now I'm in the PQR Hospital*.” P51, patient

Sub-optimal communication and coordination A major barrier to participants’ quality experiences was timely

communication. Communication problems were varied and complex. By and large, participants perceived communication processes to centre on providers’, rather than patients’ needs. Participants described absent and poorly coordinated discharge communication on the ward that suggested, “The left hand doesn’t know what the right hand is doing.” (P10, family member) Missing

and inconsistent information at discharge about their injuries led to perceptions of disorganized care and lack of oversight.

“I had various broken bones and we had to find out, when we were in rehab, which ones were broken because we were told different things from different people about what had happened to me. So for instance, one nurse said that my pelvis was broken when it is not. They also hadn't told us that my lungs had collapsed a small amount � a very small amount but we didn't even know that until we got to rehab.” P43, patient

Such concerns about missing injury information at discharge contributed to emotional distress that participants experienced after leaving the trauma centre. One patient learned about the severity of his injuries in his second follow-up appointment post- discharge with the surgeon, after which he explained, “That was a shock to me; I was getting nightmares after that.” (P23, patient) While some staff surgeons communicated directly with patients and families, many participants had no communication with staff surgeons, describing their discussions with surgical trainees as contradictory and generic. A family member who had not communicated with the surgical team slept on the ward for three nights, “just so I can catch them” on morning rounds. When unsuccessful, she explained, “I kept telling the nurses that I wanted to speak to the doctor. And, you know, they’re like, ‘Yeah, yeah, he’s coming, he’s coming,’ but he never came.” (P7, family member) Participants attributed surgeons’ unavailability to competing demands in the operating room and they described heightened anxiety as a result.

“From our point of view, a lot of the frustration came from really not understanding the full scale of her injury and it just seemed that � and I believe it's true, the surgeons and that whole neuro team did not have time to spend with us. And I get it, they're supposed to be in the OR, but that just left us really not knowing and the anxiety that comes from that is just unbearable.” P43, family member

Communication challenges also impeded the quality of inter- facility transfer experiences. Many transferred participants strug- gled with unpredictable transfer times which were felt to be poorly coordinated. One family member described a two week transfer delay to another hospital, followed by a sudden cancellation that was attributed to poor inter-facility communication, explaining “It was a huge communication problem � twice.” (P3) Another gently recounted an inappropriate rehabilitation disposition which he characterized “from a system point of view” as “a slippage.”

“I think it's possible to know whether he qualifies for this program or not. So the XYZ* people clearly were not impressed; they said he doesn't belong here. And they were very nice about it. I'm not complaining in any way. You know, it all worked out. It's just an unnecessary run-around for everybody involved.” P10, family member

Poor information exchange between facilities and providers upon transfer was common. Patients discharged home reported inconsistent information transfer from the trauma centre to their family doctors. Descriptions ranged from “having all of the reports” (P28, patient) to “he had nothing, zero.” (P30, patient) Family members noted significant information gaps that raised concern about the receiving facilities’ preparation to care for their loved ones. One participant was asked by the receiving rehabilitation physician to describe what happened to her husband because “he wasn’t clear with what he received from the trauma centre and exactly the extent of his injuries.” (P11, family member) Another expressed frustration at the lack of preparedness in a community hospital to manage his wife’s medications when she arrived upon transfer of care.

L. Gotlib Conn et al. / Injury, Int. J. Care Injured 49 (2018) 97–103 101

“When she was transferred to DEF Hospital* the first question the nurses asked her is what medications are you on? I don’t know if it was the nurses not reading what was sent or it didn’t come at the same time that my wife was transferred, but it just seemed ridiculous that she’s being asked when she’s heavily medicated, what medications are you on and what dosages.” P46, family member

Discussion

Through qualitative interviews with trauma patients and family members we have found processes that both enabled and constrained the quality of their hospital discharge and care transitions. Most trauma patients and family members perceived providers’ efforts to be purposeful and supportive, and aimed primarily at meeting their needs. To this end, patients and family members praised the surgical and ward care they received and rarely ascribed provider blame for the challenges they encoun- tered. Yet perceived prioritization of the organization’s and system’s needs undermined their sense of discharge readiness and subsequently the quality of their experiences. Unclear communication processes that were felt to be driven by system demands, rather than patients’ preferences, were largely experi- enced as detrimental to discharge and transfer quality, contribut- ing to participants’ feelings of vulnerability and distrust within the system.

These findings have highlighted several modifiable components of trauma patient discharge and transfer procedures to target for improvement. First, when participants recalled patient-oriented discharge conversations they were more likely to feel prepared to leave the acute care setting. Achieving patient understanding and activating patient self-efficacy at discharge can be complex while being critical aspects of the discharge process [31]. Several factors are known to impede patients’ understanding of their hospital care including clinicians’ unintentional use of medical jargon, as well as patient factors such as cognitive impairment, stress and low health literacy [31,32]. Even when discharge education is consistent and standardized, surgical and medical patients are found to have a poor understanding of their diagnosis, discharge instructions and required follow-up care [12,13]. After discharge, trauma patients in particular are found to have poor recall of their injuries and operations, and are unable to name the physicians who treated them [32]. In this context where multiple injuries and physicians are involved, targeted and iterative communication with patients and their families is needed. Patient-oriented discharge processes that include a patient-oriented care summary (rather than strictly a clinical summary) show promise for improving patient experiences by incrementally building a better understanding and capacity for self-care after discharge [13,33]. Designed in collaboration with patients, patient-oriented discharge tools act as working documents that are co-produced through iterative structured discussions between care providers and patients or family members during which principles of adult learning guide information transfer [33]. Using the teach-back method, whereby providers confirm patient understanding by having them explain information back to them, patient knowledge may be increased and gaps or errors more readily identified. In this way, patient knowledge and preparation for discharge are a focus of several clinician-patient interactions before the day or moment of discharge arrives, with joint documentation during these con- versations. This approach may potentially avoid the omission of or discrepancy in information about injuries and confusion about interventions or follow up that may contribute to patients’ experiences of being poorly prepared for discharge. This approach may also mitigate patient experiences of being rushed out of the

acute care environment, having had multiple opportunities to express concerns and ask questions of providers on a more frequent basis during hospitalization.

Patients’ transition experiences are challenged by many communication problems that can be characterized as system deficiencies, such as delayed or incomplete information transfer between trauma centre and community providers, whether by direct handover or exchange of the medical record. Participants in our study described inconsistent and sometimes completely absent information transfer, which left them worrying whether the person assuming responsibility for their care was actually informed and/or able to provide it. This was surprising to some extent given the electronic information systems in place in our centre that readily connect providers across the region to patient information and make health records available to patients themselves through the internet. Yet primary care physicians in Ontario have previously reported poor information transfer with respect to post-surgical patients’ care with 36% reporting no communication at all with the patient’s hospital team [7]. Uncertainty about physician responsibility for post-surgical care is also reported with a belief that these poorly defined processes may contribute to adverse events [7]. In trauma specifically, general practitioners have described feeling ill-equipped in this capacity because they lack access to resources to optimally manage injured patients [34].

These findings indicate a clear gap in the system between tertiary and primary care providers that is not easily solved by implementing information systems or commonly used discharge improvement interventions such as post-discharge phone calls to patients, or pre-discharge planning tools [35]. These popular interventions do not address the complex systems-level challenges that transferred patients and their families encounter that primarily include consolidating a mass of new and complicated medical information and accessing care. Patient Navigation (PN), however, offers a patient-centred but system-oriented solution that may help trauma patients and providers overcome identified barriers to an optimal discharge experience [36]. PN is an approach used predominantly in cancer care to guide and support patients and families though their illness journey. Navigators are trained health care providers within a hospital program or ward who integrate patient information, facilitate access to system-wide services, and offer therapeutic care continuity where fragmenta- tion exists. Patient-reported experiences and outcomes with cancer care navigation include improved efficiency with in- hospital communication and care coordination, access to and knowledge of care, enhanced care continuity, and patient satisfaction [37,38]. Findings from our interviews with trauma patients and families indicate an opportunity to develop a model for trauma care navigation that mitigates system-level deficiencies to improve the experiences of injured patients. Such a model for post-acute care may help address the challenges that trauma patients and providers face in managing and transferring information related to their hospitalization, and accessing resources to optimize both their physical and emotional recovery. Moreover, navigators may be well positioned to offer routine screening for depression and anxiety, such as described by participants in our study and elsewhere, to ensure emotional well-being after physical injury is adequately addressed [39]. Navigators may also contribute to improved documentation and discharge planning processes required for consistent pain man- agement after injury [40]. Brief reports suggest that navigation is an emerging consideration in trauma patient care [41,42], with previous research identifying the role of the trauma case manager through which improved patient outcomes are demonstrated [43]. To our knowledge, a comprehensive model for trauma care

102 L. Gotlib Conn et al. / Injury, Int. J. Care Injured 49 (2018) 97–103

navigation during and after hospital discharge does not currently exist in the published literature.

Finally, participants’ reports of feeling pressured to leave the trauma centre reflect a more widespread and systemic problem of having to balance the quality of patient discharge experience with the need to achieve organizational and system-level efficiency. Such findings highlight the complexity involved in executing quality discharge more broadly whereby individual, organization and system needs are actively negotiated and the ability to achieve true discharge readiness is challenged [44,45]. Discharge readiness requires synchronicity between the patient’s physical, psychologi- cal and social states, with system resources and community and family ability to provide ongoing care and support [46]. When out of synch, patients may not only feel ill-prepared and pressured to leave the acute care hospital, they may also feel unsafe and lack confidence in their ability to recover [46]. While difficult to modify at a systems-level, it may be possible to minimize the negative effects of this complexity on patient discharge experience, for example, by sensitizing healthcare staff to patients’ feelings or fears and raising these in targeted discharge discussions. Acknowledging and normalizing this emotional aspect of hospital discharge and transfer may provide point-of-care support for patients that they currently perceive to be absent. Navigation may also provide support in these circumstances.

Study limitation

This study offers new insight to patient experience with discharge from a trauma centre to guide quality improvement efforts. These findings may be transferable to other trauma centres or tertiary care environments where complex or vulnerable patients are treated. While providing some depth, this qualitative analysis reflects the experiences of a relatively small sample of patients and family members who were willing to discuss them for research purposes and may therefore be limited in its generaliz- ability. Future efforts to understand healthcare provider perspec- tives on quality discharge barriers and enablers in this setting are needed.

Conclusion

The quality of trauma patient discharge and transition experiences is undermined by system- and ward-level processes that compete, rather than align, in producing high quality patient- centred discharge. Local improvement solutions focused on modifiable factors within the trauma centre include patient- oriented discharge education and patient navigation; however, these approaches alone may be insufficient to enhance quality experiences. Trauma patients encounter complex barriers to quality discharge that likely require a comprehensive, multimodal intervention. These findings will be used to identify effective and enduring ways to support trauma patients and families through discharge and care transitions, and inform further efforts to optimize care continuity for the injured patient population.

Conflict of interest

The authors declare that there are no conflicts of interest including no financial and personal relationships with other people or organisations that could inappropriately influence (bias) this work.

Acknowledgments

Study funding was received by the Canadian Medical Protective Association Research Grant 2015–2016. The funder had no

involvement in the study design; collection, analysis and interpretation of data; the writing of the manuscript; or, the decision to submit the manuscript for publication.

Appendix A. Interview topic guide

1 Thinking back to your time in the hospital, when were you first involved in discussions about your discharge plan?

� Did you have an opportunity to talk about the plan to go home/ rehab/other hospital?

� Who did you talk about this with? � Were you happy with the plan? Did you want to go somewhere else?

� Did you have any worries or concerns about going home/rehab/ other hospital? If yes, what were they? Were you able to discuss those with anyone?

2 When you left S trauma centre, did you feel prepared to go to home?

� Did you know what to expect in terms of the follow up care? � Were you given any written materials? If yes, what were you given?

� Were the materials useful? How? � Was the information shared in a way that was easy for you to understand? What made it easy or difficult to understand?

� Did you feel comfortable asking staff to clarify things about your follow up care that you might not have fully understood? If not, why did you feel uncomfortable? Language? Intrusion on time? Use of medical jargon? Other?

� Did you have a good understanding of your medications and how to take them?

� Did you know what to look for in terms of warning signs or things you should come back to the hospital or see your GP for?

� Did you get information about return to work/school or any other usual major activity?

� Did you get information about your activity levels � for example, exercise, lifting, taking stairs, etc.

� Did you get information about how to take care of your wounds? � Did you get any or adequate information about emotional distress or mental health support?

� Did you have get information to address any financial concerns related to your injuries or recovery?

3 How do you feel things have gone with your recovery at home/ time in rehab/time at other hospital?

� Have you had any follow up appointments? With who? � Have you had any specific challenges with your recovery? What have been the challenges? Examples?

� Have there been any surprises in terms of your recovery? � Are there any supports that you are not getting that you would like or feel you need?

� Do you have any outstanding concerns or worries at this time about your care?

� Do you feel prepared enough for taking care of yourself? Do you feel you know the signs and symptoms of concern? Do you know who to contact if you have concerns?

4 If you could change anything about your discharge experience at S the trauma centre or the transition to home/rehab/other hospital what would that be?

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Trauma patient discharge and care transition experiences: Identifying opportunities for quality improvement in trauma centres
Background
Participants and methods
Study design and setting
Typical discharge and transfer procedures
Recruitment and sampling
Data collection and analysis
Results
Fostering quality discharge
Ward preparation
Care continuity
Emotional support
Impeding quality discharge
Pressure to leave
Imposed transfer decisions
Sub-optimal communication and coordination
Discussion
Study limitation
Conclusion
Conflict of interest
Acknowledgments
Appendix A Interview topic guide
References