On the Med: Adjusting Hospital-to-Home Discharge Medication Strategies

The transition from hospital-to-home is one that is complex, stressful for caregivers, and puts pediatric patients at high-risk for adverse events.¹ Medication errors are a critical category of adverse outcomes associated with home-to-hospital transitions; children may be particularly prone to such errors given the variety of medication formulations and dosing strategies delivered in pediatrics.

In this month’s Hospital Pediatrics, Carroll et al sought to qualitatively explore perspectives of clinicians and caregivers surrounding medication counseling at the time of hospital discharge and develop a resultant conceptual model to inform interventions in this area (10.1542/hpeds.2022-006937). Through semi-structured interviews, 11 sub-themes were identified which were then categorized utilizing a Donabedian framework into their associated domains: healthcare infrastructure, process, or outcomes. The authors present a conceptual model identifying ideal elements for effective discharge medication counseling, including key aspects of a written discharge medication instructions, health literacy informed counseling techniques, and standardization of a team-based counseling process.

To an experienced clinician, the framework presented by Carroll et al may seem intuitive. Yet, the clinician and caregiver quotes elicited in this study reinforce what many of us experience in everyday practice: lack of standardization around this complex and critical aspect of hospital-based care. We applaud the authors for this holistic look at such an important issue. Medication reconciliation processes have become an area of focus for many hospitals as evidence for associated harm increases;² yet, proposed solutions may be oversimplified. Many institutions are hiring additional staff with a focus in this area, including pharmacists, nurses, or care managers. While such investments may translate into improved outcomes, increasing staff alone will not directly address many of the barriers identified by Carroll et al. For example, if members of these multi-disciplinary teams do not have clearly defined roles or adequate training, duplicative or inconsistent counseling from multiple team members may further complicate patient and family comprehension. Similarly, quality improvement efforts focused exclusively on written discharge instructions may fail to address the needs of many families, including those for whom translation into preferred language is unavailable or those with lower literacy levels. A “meds to beds” program cannot reach maximal efficacy if those providing counseling are unaware of a caregiver’s preferred method of learning. The findings presented by Carroll et al emphasize a need for family-centered, multi-faceted improvement efforts in this space.  

As hospitalists, we must remember that our jobs are not complete until we see the patient through the discharge process and ensure a safe transition from hospital-to-home. This article encourages introspection of one’s own habits and procedures during discharge medication counseling. To many providers, this process may be viewed as one that is reliably conducted by other team members. However, a look “under the hood” of local medication reconciliation processes may reveal that, in some settings, these assumptions are flawed. In our current healthcare environment, characterized by workforce shortages, related increases in staff to patient ratios, and reliance on staff who may be less familiar with an individual unit (i.e., travelers), maintaining consistent medication reconciliation education and practices is a difficult endeavor. Recent challenges with access to inpatient pediatric beds have also forced prioritization of efficiency in bed flow, which can challenge care quality. We must consider these current realities and test assumptions surrounding medication reconciliation processes at our own institutions. Even in systems with optimal standardized counseling delivered by multi-disciplinary teams, there remains an important, and perhaps suboptimally defined, role for primary providers. We are in a unique position to consider how a patient’s individual medical context may influence likely side effects or challenges of a medication. We can also discuss optimization of dosing strategies to improve compliance and assess medication understanding using teach back methodology.

As we continue to clarify and optimize team member roles in hospital-to-home transitions, we must also be mindful of our trainees. It is critical for us to model an intentional approach to the discharge medication process and work toward educational competencies surrounding this aspect of care for both pediatric residents and pediatric hospital medicine fellows. It is increasingly recognized that we must look beyond the walls of children’s hospitals as we seek to define and improve the quality of pediatric healthcare. Focusing on a high-quality, family-centered discharge medication process is an optimal opportunity to demonstrate how our work influences patients beyond the confines of hospitalization.

Carroll et al’s work provides new insights into the complexities of discharge medication reconciliation and counseling, emphasizing the need for broad improvement work that assesses and incorporates the needs of individual families. While the intricacies of facilitating a high-quality hospital-to-home transition that meets the unique needs of each family is certainly a challenge, this is also a space that is ripe for both innovation and knowledge sharing. A wide range of electronic tools have been utilized to augment discharge communication in the pediatric emergency department setting, with early literature suggesting favorable results.³ Research teams focused on adult care are exploring innovative use of audio and video recordings to improve family knowledge of medical visits in a variety of settings.⁴ The framework offered by Carroll et al should guide the development of novel strategies targeting the key identified elements of discharge medication counseling in inpatient pediatrics; we implore inpatient care teams to participate in the development and testing of such approaches.

Secondary Author: Samantha House, DO, MPH, Editorial Board Member, Hospital Pediatrics

References:

1. Solan LG, Beck AF, Brunswick SA, et al The Family Perspective on Hospital to Home Transitions: A Qualitative Study. Pediatrics. 2015 Dec;136(6):e1539-49
2. Neuspiel DR, Taylor MM. Reducing the Risk of Harm from Medication Errors in Children. Health Serv Insights. 2013;6:HSI.S10454
3. Wozney et al. Electronic discharge communication tools used in pediatric emergency departments: Systematic Review. JMIR Pediatr Parent. 2022; 5(2):e36878
4. Lion et al. Audio-recorded discharge instructions for limited English proficient parents: A pilot study. Jt Comm J Qual Patient Saf. 2019 Feb;45(2):98-107