Abstracts

Rationale: Care transitions between inpatient and outpatient settings are complex, and can lead to adverse events. Epilepsy patients represent a vulnerable population, given the complexity of medication regimens, tapers, and safety instructions. Furthermore, a high prevalence of underlying cognitive dysfunction challenges their ability to understand complicated discharge instructions. Electronic health records (EHR) can potentially improve the quality and safety of care during this transition, but improper utilization can lead to inefficiencies and errors. Our objective was to improve the discharge process for adult patients electively admitted for video electroencephalography (VEEG) monitoring at Dartmouth-Hitchcock Epilepsy Center. We specifically aimed to 1) improve patient and provider communication, and follow-up rate; and 2) reduce medication errors, adverse events, and readmissions.Methods: Baseline data was collected on all patients admitted for VEEG monitoring over a 3 month period to identify discharge process improvement opportunities. We mapped the steps of the discharge process, and interviewed providers and patients alike to identify sources of unwanted variation. We identified key components for a successful discharge. We implemented a series of interventions: (1) a discharge process checklist; (2) documentation templates within the EHR to standardize information content communicated; (3) separate, specific templates for epilepsy and non-epileptic seizure (NES) patients for after-visit summaries in patient-friendly language, including standardized medication instructions, tapering instructions, and relevant safety instructions; (4) a patient checklist provided at admission, detailing the information the patient should expect to know prior to discharge; and (5) a revised process to communicate the discharge summary to outpatient providers. Process measures included whether key elements of information were included in the discharge paperwork and length of time to epilepsy clinic follow-up. Outcome measures included medication adverse events, emergency department (ED) visits or readmissions within four weeks of discharge. Results: Process modifications improved the percentage of patients discharged with accurate medication lists and taper instructions (94% to 100%, p<0.001) and accurate safety instructions (79.6% to 87, not significant). The number of days from hospital discharge to epilepsy follow-up decreased (37 22.3 to 27 16 days, p<0.03), and the number of patients lost to epilepsy follow-up decreased from 31% to 3% (p<0.001). There was a trend towards reduction in adverse events, ED visits, and readmissions (not significant). Conclusions: EHR optimization and checklist utilization improved care and minimized variation for patients admitted for elective VEEG monitoring. Objective data impelled urgency and motivation to change; process observation was essential to avoid incorrect assumptions. Key stakeholder involvement propelled intervention design to ultimately reduce medication errors, ED visits, and readmissions.