Publications
Audit of efficacy of patient discharge process- Are we really up to the mark?
Srinivas Rajkiran Raju ; Attibele Mahadevaiah Shubha1 ; Sumithra Selvam and Varghese, Rev. Fr. John Thekkekara The process of discharge from the hospital signifies an important transition of care from monitored in-patient care to a more physiological domiciliary care. This is a sequential, coordinated, seamless transition. Digitalization of healthcare has revolutionized the hospital records keeping, procedural billing, pharmacy indenting, and insurance systems across the world. Despite a large turnover of paediatric patients in hospitals worldwide every day, relatively scarce literature exists on formulation of framework of discharge care based on regulatory legal processes, clinical practice or research[1] Data from a reputed medical Institute in India reported significant delay in discharging paediatric patients, especially in the Credit billing (Insurance) category, occupying the private wards.[2] Delays often result from issues in processing billing requests, raising pharmacy indents, credit clearances from insurance third-party administrators, issuing discharge summary and deficient staffing. In India, the National Accreditation Board for Hospitals (NABH) has set forth a set of generalized guidelines streamlining this process of discharge from hospitals. [3] Newer Hospital Management Information systems(HMIS) have incorporated features to monitor identity based login with encryption security for accessing and performing day to day ward activities including bed status, pharmacy indents, procedural billing, discharge summaries, laboratory and imaging services and surgery scheduling.[4] There is a growing need to focus on minimizing the timeframe of these events to reduce mental anguish caused by procedural delays, enhance patient-attendant satisfaction, and optimize resource utilization for faster turnover of inpatient services. This Quality-Improvement Audit (QIA) was conducted in the 24 bedded dedicated General ward of the Department of Paediatric Surgery manned by three nurses per 8-hour shift, after a recent change in the HMIS across the hospital, aimed to note the effectiveness of the discharge process and identify potential gaps which can be rectified. MATERIALS AND METHODS This is a prospective study conducted in the Department of Paediatric Surgery to evaluate and audit stepwise, the logistics, timeframe and patient satisfaction of discharge process after recent transition from CAREWORKSTM to KRANIUM HEALTHCARETM HMIS (on 31st March 2023). Institutional Ethical Clearance was obtained prior to the study from Institutional Ethics Committee. Exclusion Criteria: Patients admitted under the Paediatric surgery department but discharged from any other ward across the hospital (including Day-care ward). Annexure-1 form (ANN-1) was prepared to capture the real-time data of different events in discharge process which was recorded by the ward clerk or staff nurse in the ward from the time logs available on the newly installed HMIS system. Annexure-2 form (ANN-2) was prepared to capture the patient attendant feedback and was made available in 6 local vernacular languages (English, Kannada, Tamil, Hindi, Telugu and Bengali) given to attendants to self-report their satisfaction with various events pertaining to discharge process. All the ward staff were trained prior to the start of this study and a Pilot study of data entry simulation was done on 30 patients to ensure proper understanding and entry of timeline events. Similarly, 30 such feedback forms were given to patient attendants at discharge, to record responses and trouble shoot difficulties in understanding or choosing the right response for the questionnaire. The responses of pilot study from both arms were validated by an independent external observer. Data from ANN-1 was collected real-time from Electronic Medical Report (EMR) on the newly installed KRANIUM HMIS system while ANN-2 was a printed paper feedback form which was filled and returned by attendants. EPICOLLECT-5 software was used for recording ANN-1 and ANN-2 data. Descriptive statistics were reported as mean with standard deviation and median with 25th and 75th percentiles. One sample t test was used to compare the mean actual time recorded against NABH standard values. Mann-Whitney U test was used to compare the mean actual time recorded between paying and insurance group. Analysis was performed using SPSS (ver 26) software RESULTS Of the 100 patients discharged, 70 were elective admissions and 30 were emergencies. 5 patients were registered as medico-legal cases and 3 patients were discharged against medical advice (DAMA). The median duration of admission was 4 days (range 0-21 days, mean 6 days). 85% were Selfpaying patients while 15% were billed under credit schemes (Institutional credit- 7, Insurance- 4 and Government backed health schemes-4). The discharge timelines were categorized into 9 events (T0 to T8) enumerated in (Table 1) for understanding the analysis of sequence of events, which provides the breakup of overall mean and standard deviation of each event in discharge process. The terminal event of Bed clearance was defined as exit of the patient from the ward, followed by housekeeping services and finally being cleared in the HMIS system for reallotment to a new patient.
