The transition immediately following a hospitalization is a vulnerable period for patients, often resulting in adverse events and subsequent readmissions.

Risk factors for hospital readmission include but are not limited to:

• Medication errors, side effects or unavailability.
• Lack of hospital-based discharge teaching.
• Lack of post-discharge PCP follow-up.
• Lack of in-home support services.

Checklist

• Review your daily rounding checklist.
• Do you have a way to contact the patient after they leave the hospital? Is their contact information accurate?
• Is home health required? Available services include: skilled nursing needs (BP monitoring, medication education, insulin education), wound care, home safety evaluation, social services, occupational/physical therapy, rehabilitation services, speech therapy, and infusion therapy.
• Durable medical equipment: consider portable oxygen supplies and durable medical equipment such as shower chair, bedside commode, or hospital bed that patients may need on discharge. Contact your social worker or case manager to ascertain the tests or consults a patient needs to qualify for these resources (e.g., some insurance companies require an ABG for home O2, others require documented room air oxygen saturation <88%).
• Order medications early: for hospitals that provide discharge medications, preparation of these medications can delay discharges by hours. Have the medication list prepared the day prior to discharge, so small changes can easily be made on the day of discharge. If starting a new medication, confirm with the pharmacist that a prior authorization isn’t needed and confirm with the patient that they will be able to afford any out-of-pocket costs that may be associated.
• Arrange follow-up: arrange PCP follow-up within two weeks for routine hospital discharge and four weeks for SNF discharge. Obtain dates and times of all follow up appointments. Refer patients to a PCP if they do not have one. When applicable, refer patients to financial counselors to screen for MediCal/Medicaid eligibility.
• Patient education: use patient-friendly language and avoid medical jargon.
  • Use “closing the Loop” or the “teach-back” method: confirm comprehension, for example, by asking patients in a nonjudgmental way: “I want to make sure I’m being clear. Could you explain to me how you’re going to take your medications?” Invite questions from patients and their families by asking, “What questions do you have?” rather than “Do you have any questions?” which may prompt a “No” response.
  • Ask the pharmacists or nurse educators to see your patient. Many hospitals have diabetes, COPD, and CHF educators who can see the patient and discuss medication changes.
• Check on pending tests: follow up on tests ordered during the admission that may still be pending to avoid last minute surprises. Any outstanding tests should be conveyed to the PCP.
  • In general, the physician who ordered the test is legally and ethically responsible for the follow-up of test results.
  • While the attending physician assumes legal responsibility for tests ordered by trainees, the actual communication of test results to the PCP can be conducted either by the resident or the attending, and the responsibility of doing so between the two should be clearly delineated.
• Vaccinations: go to http://www.cdc.gov/vaccines/schedules/ for up to date vaccine guidelines. 
  • Pneumovax: purified polyvalent polysaccharide inactivated vaccine. Demonstrates 60-70% protective efficacy against pneumococcal bacteremia.
    • Immunocompetent patients >65 years of age should be vaccinated. If pneumovax was given previously, revaccinate only if the last dose was >5 years ago AND the patient was <65 years old at the time of previous vaccination.
    • Immunocompetent patients aged 19-64 years should get vaccinated once if they have chronic cardiovascular, pulmonary (including smokers and asthmatics), renal or liver disease, alcoholism, cochlear implants or CSF leaks/shunts, as well as if they are living in chronic care facilities.
    • Immunocompromised patients >19 years, including patients with HIV, malignancy, chronic renal disease, nephrotic syndrome, asplenia (including sickle cell disease), post-transplant patients or those on chronic immunosuppression require vaccination.
    • Contraindications: prior severe allergic reactions (anaphylaxis). Caution during moderate or severe acute illness with or without fever. Avoid vaccination during chemotherapy or radiation. Safety has not been established in pregnant women.
  • Influenza shot in appropriate season: comes in both inactivated injectable formulation and in a live intranasal formulation.
    • Recommended for: all individuals >6 months of age. Live vaccine formulation may be offered to healthy, non-pregnant persons ages 2-49 without high-risk medical conditions.
    • Contraindications: anaphylactic allergic reaction to eggs or any other vaccine components. Not contraindicated during minor URI and inactivated vaccine not contraindicated during pregnancy (all pregnant women should be vaccinated during flu season). Live vaccine contraindicated in adults >50 years old or children 6mo-23mo, pregnant women, people with chronic illnesses or otherwise immuno-compromised.
• Contact the PCP (again): phone or email the PCP about new diagnoses, medication changes, pending tests, and appointment dates.
• Transportation: ensure that the patient has a ride home whether by family, taxi, bus or ambulance. Make sure patients have keys to their living facilities when appropriate.
• Discharge summary: should be completed within 48 hours of discharge. It should include:
  • Diagnoses, concise hospital course by problem, abnormal physical findings, diet, activity level, important test results, discharge medications, follow-up arrangements and appointments that still need to be made, counseling provided to patient and family and tests still pending at discharge.
  • Highlight changes in discharge medications, which are often the main cause of adverse events following hospital discharge.

Balaban R, Williams M.  Improving Care Transitions: Hospitalists Partnering with Primary Care. J Hosp Med 2010; 5: 375-377.

Barbar S. et. al. A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: the Padua Prediction Score. J Thromb Haemost. 2010:8(11):2450-2457.

Kripalani S, Jackson A, Schnipper J, Coleman E.  Promoting Effective Transitions of Care at Hospital Discharge:  A Review of Key Issues for Hospitalists.  Journal of Hospital Medicine 2010; 2: 314-320.

Marik, Paul. Stress Ulcer Prophylaxis. Evidence-Based Critical Care. 2015, pp 513-52. Date: 15 Nov 2014

Thavendiranathan P, et. al. Do Blood Tests Cause Anemia in Hospitalized Patients? The Effect of Diagnostic Phlebotomy on Hemoglobin and Hematocrit Levels J Gen Intern Med. 2005 Jun; 20(6): 520–524.

Van Walraven C, Taljaard M, Etchells E, Bell CM, Stiell IG, Zarnke K, Forster AJ. The independent association of provider and information continuity on outcomes after hospital discharge: implications for hospitalists. J Hosp Med 2010; 7:398-405.