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News & Events | Articles | April 9, 2012

Allowing a seamless transition from the hospital back into the community

Patients are particularly vulnerable to medical and follow-up errors during transitions of care, such as discharge from hospital into the community. When patients are seen by their family physician after their hospital stay, 75% of family physicians do not have a record of their patient’s hospital visit. This leads to hospital readmission rates of 23%, where 72% of these readmissions are due to adverse drug effects.

To address this problem, a team from the University of Calgary’s Ward of the 21st Century (W21C) partnered together with Alberta Health Services (AHS) to develop the Seamless Discharge Project – a web-based communications tool built to decrease the information gap concerning details of a patient’s hospital stay.

“This tool serves as a platform for communication between acute and community physicians,” says Maria Santana, PhD, project co-investigator. “By keeping the channels of communication open between the two phases of health care, this tool could improve continuity of care and increase patient safety.”
Currently, hospital discharge information is either dictated or handwritten by the physician, creating deficits with timeliness of information transfer and consistency of content. In addition to this, patients and their relatives are often responsible for relaying information back to their family physician, creating a lack of accuracy and potentially more stress on the patient and their family members. The process for sending out discharge reports to community health care providers is also not standardized.

The Seamless Discharge Tool is a structured electronic document that provides a complete summary of the patients stay in hospital that the discharging physician signs off on. A fax and e-mail notification is then delivered to the patient’s primary health care provider notifying them of their patient’s hospital discharge. Secure access to the information is immediately available to the physician through Alberta’s Netcare web platform. The patient also receives a copy of their discharge report.
“With widespread use of this tool, we could see a reduction in hospital readmission rates and also reduce stress on emergency rooms from return visits,” says Dr. William Ghali, Study Lead and one of the Scientific Leads of the W21C. “Communication failure is at the root of many health system problems; this initiative tries to fix that.”

Now, when a chronically ill patient is already managing multiple medications and is prescribed new prescriptions while in hospital, the family physician will have a record of this change and so will the patient’s family; allowing for increased accountability from the health care provider as well as the patient.
A pilot study involving patients of the W21C Medical Unit (Unit 36) of the Foothills Medical Centre and their primary and acute care physicians has been completed with positive results and physician satisfaction. Now a randomized clinical trial is underway on Unit 36 measuring the effect on deaths and readmission. Simultaneously, AHS will undertake a staged roll-out of the Seamless Discharge Tool on other medical wards in Calgary and later throughout the rest of Alberta.