Mortality data estimates that there are about 400,000 to 460,000 sudden cardiac deaths (SCD) in the United States.1 In resuscitated cardiac arrest patients, morbidity and mortality remains high due to cerebral ischemic anoxia. Currently it is believed that following return of spontaneous circulation (ROSC) from successful resuscitation, secondary inflammatory responses characterized by the generation of chemical mediators and free radicals, as well as increased microvascular permeability, lead to further brain injury.2 Recently, 2 randomized controlled trials (RCT) showed that induced mild hypothermia (32C‐34C) in comatose patients after out‐of‐hospital cardiac arrest leads to improved neurologic outcomes and survival.3, 4 In 2002, the International Liaison Committee on Resuscitation (ILCOR) recommended induced mild hypothermia for the management of comatose patients with ROSC after cardiac arrest.5 Despite the recommendations by ILCOR and the supporting body of evidence proving the benefit of therapeutic hypothermia after cardiac arrest, this treatment remains underused.68

We present a case series of 8 cardiac arrest survivors treated using a hypothermia protocol at a community hospital.

TREATMENT PROTOCOL

Between June 2006 and December 2006, 8 patients presented to Unity Hospital, (a 200‐bed community teaching hospital with a 20‐bed intensive care unit [ICU]) in coma following cardiac arrest with ROSC after resuscitation. All the patients were managed using therapeutic hypothermia.

The hospital protocol, developed using the ILCOR guidelines, was used on all patients. The aim was to achieve a core temperature of 32C to 34C within 6 to 8 hours and maintain this for 24 hours from the start of cooling. The inclusion criteria were as follows: (1) coma within a 6‐hour postcardiac arrest window preceded by either ventricular fibrillation (VF), pulseless ventricular tachycardia, pulseless electrical activity, or asystole; (2) ability to maintain a blood pressure with or without pressors and/or fluid volume resuscitation after cardiopulmonary resuscitation; and (3) comatose at the time of cooling. The exclusion criteria were as follows: (1) coma from drug overdose, head trauma, stroke, or overt status epilepticus; (2) pregnancy; (3) temperature of <30C; (4) recent major surgery within 14 days; (5) systemic infections; (6) patients with known terminal illness; (7) Glasgow coma scale (GCS) of 10 and above; or (8) known bleeding diathesis or ongoing bleeding.

The Advanced Cardiac Life Support (ACLS) protocol was implemented in both in‐hospital and out‐of‐hospital cardiac arrests. The decision to initiate the protocol was made by the intensivist; however, in out‐of‐hospital cardiac arrest, the decision was taken in conjunction with the emergency room physician. A bladder temperature probe was used to monitor core body temperature. Cooling was achieved using iced saline gastric lavage and ice packs to the patient's neck, axillae, and groin while a cooling blanket (Mul‐T‐Blanket; Gaymar Industries, New York) was placed over and beneath the patient. In some cases, a Blanketrol cooling machine (Blanketrol II; CSZ Products, Inc., Cincinnati, OH) was used when available. All patients were maintained at a PaO₂ above 90 mm Hg and PaCO₂ around 35 mm Hg. Cisatacurium and midazolam were used to control shivering. Regular insulin intravenous drip was used to maintain tight blood glucose control (target blood glucose level of 140 mg/dL) when necessary. Target systolic and mean arterial blood pressures were 90 mm Hg and 80 mm Hg, respectively. Potassium was replaced to 3.4 mmol/L but not within 8 hours of commencing rewarming. Rewarming was started after 24 hours at a rate of not more than 1C in 4 hours. Clinical and laboratory parameters were continuously recorded and all patients were evaluated for complications, including electrolyte imbalance, cardiac arrhythmias, and seizures.

CASES

Table 1 summarizes all the cases. There were 4 men and 4 women. The mean age was 70 14 years (range, 44‐88 years). The main comorbidities were coronary artery disease (n = 6), hypertension (n = 5), diabetes mellitus (n = 5), and chronic or recurrent cardiac arrhythmia (n = 4). Cardiac arrest occurred out‐of‐hospital in 5 of 8 patients and was witnessed in 6 of the 8 cases. Ventricular fibrillation (VF) was the initial presenting rhythm in 5 of the 8 cases. The mean time from ROSC to initiation of cooling was 3 1.6 hours. The mean time from ROSC and attaining target temperature (<34C) was 8.1 4.7 hours. The mean duration of cooling (initiation of cooling to onset of rewarming) was 23.8 0.6 hours. The mean duration at which target temperature was maintained (attainment of 32C‐34C to onset of rewarming) was 18.6 4.6 hours. The median time from onset of passive rewarming to attaining temperature of <36C was 7.25 hours. Two patients survived and were discharged to home (Patients B and C). Patient B had mild cognitive deficits on discharge.

DISCUSSION

There is substantial clinical and public health concern over increasing incidence of sudden cardiac deaths despite decreasing overall mortality from coronary heart disease.6

Supportive management has been the norm for comatose patients following cardiac arrest until recently, when induced hypothermia was shown to have favorable outcomes in 2 landmark prospective RCTs.3, 4 Supportive management often led to prolonged unconsciousness due to severe anoxic brain injury, which eventually led to high morbidity and mortality rates.9, 10 The Hypothermia after Cardiac Arrest Study Group (HACA) study4 revealed that 6 patients would need to be treated with therapeutic hypothermia to prevent an adverse neurologic outcome, while 7 patients would need to be treated to prevent 1 death. Other authors have reported improved outcomes with induced hypothermia used in patients resuscitated following cardiac arrest.1114

Despite strong and encouraging evidence, therapeutic hypothermia has not been readily accepted into daily clinical critical care practice.68 In an Internet‐based survey of physicians by Abella et al.,6 87% of respondents (comprised of emergency medicine and critical care physicians, and cardiologists) had not used this treatment modality following cardiac arrest. Reasons given by most physicians included insufficient data to support the use of therapeutic hypothermia, technical difficulties including the immense amount of resources required, as well as inadequate training. Merchant et al.,7 using an Internet‐based survey also sought to ascertain the degree of therapeutic hypothermia use from physicians in the United States, the United Kingdom, Australia, and Finland. They found that 74% of respondents in the United States and 64% of respondents outside of the United States were yet to use induced therapeutic hypothermia. Factors predicting the use of therapeutic hypothermia by physicians were found to include practice in an academic hospital with more than 250 beds, critical care specialty training, and location of the hospital outside of the United States. Similarly, the major reasons given for nonutilization of therapeutic hypothermia in this study include lack of supportive data and technical difficulties. In yet another study by Laver et al.,8 73% of respondents (ICUs in the United Kingdom) revealed that therapeutic hypothermia after cardiac arrest had not been used in their service. They also gave the same reasons for nonusage as in the aforementioned studies.

In this case series we have presented our experience with therapeutic hypothermia in comatose patients following cardiac arrest. Evaluation of our cooling process compares favorably with the findings of the HACA study4: In our study, the mean time from ROSC to cooling initiation was 180 66 minutes compared to a median of 105 minutes (interquartile range, 61192 minutes) in the HACA study; mean time between ROSC and attaining target temperature was 8.1 4.7 hours in our study compared to a median of 8 hours in the HACA study; mean duration of cooling in our study was 23.8 0.6 hours compared to a median of 24 hours in the HACA study; target temperature was maintained for a mean duration of 18.6 4.6 hours in our study compared to a median of 24 hours in the HACA study; and last, median time from passive rewarming to attainment of temperature greater than 36C in our study was 7.25 hours compared to 8 hours in the HACA study.

There were few complications observed in this case series. These include hypokalemia, mildly elevated creatinine levels, and seizures. One patient developed pneumonia. Other potential complications of therapeutic hypothermia include cardiac arrhythmias, sepsis, hyperglycemia, coagulopathy, acid‐base disturbances, and electrolyte imbalance.15 The studies by Bernard et al.3 and the HACA;4 however, revealed no clinically significant unfavorable outcomes in the patients randomized to receive hypothermia treatment.

Our experience based on this case series leads us to conclude that therapeutic hypothermia is feasible in the community hospital setting. In our 200‐bed community teaching hospital, a multidisciplinary approach involving intensivists, emergency room physicians, internists, residents, and nursing staff lessens the technical difficulties associated with implementing a seemingly cumbersome yet inexpensive and effective treatment modality. Therapeutic hypothermia should be considered in appropriate patients in coma after resuscitation from cardiac arrest.

Mortality data estimates that there are about 400,000 to 460,000 sudden cardiac deaths (SCD) in the United States.1 In resuscitated cardiac arrest patients, morbidity and mortality remains high due to cerebral ischemic anoxia. Currently it is believed that following return of spontaneous circulation (ROSC) from successful resuscitation, secondary inflammatory responses characterized by the generation of chemical mediators and free radicals, as well as increased microvascular permeability, lead to further brain injury.2 Recently, 2 randomized controlled trials (RCT) showed that induced mild hypothermia (32C‐34C) in comatose patients after out‐of‐hospital cardiac arrest leads to improved neurologic outcomes and survival.3, 4 In 2002, the International Liaison Committee on Resuscitation (ILCOR) recommended induced mild hypothermia for the management of comatose patients with ROSC after cardiac arrest.5 Despite the recommendations by ILCOR and the supporting body of evidence proving the benefit of therapeutic hypothermia after cardiac arrest, this treatment remains underused.68

We present a case series of 8 cardiac arrest survivors treated using a hypothermia protocol at a community hospital.

TREATMENT PROTOCOL

Between June 2006 and December 2006, 8 patients presented to Unity Hospital, (a 200‐bed community teaching hospital with a 20‐bed intensive care unit [ICU]) in coma following cardiac arrest with ROSC after resuscitation. All the patients were managed using therapeutic hypothermia.

The hospital protocol, developed using the ILCOR guidelines, was used on all patients. The aim was to achieve a core temperature of 32C to 34C within 6 to 8 hours and maintain this for 24 hours from the start of cooling. The inclusion criteria were as follows: (1) coma within a 6‐hour postcardiac arrest window preceded by either ventricular fibrillation (VF), pulseless ventricular tachycardia, pulseless electrical activity, or asystole; (2) ability to maintain a blood pressure with or without pressors and/or fluid volume resuscitation after cardiopulmonary resuscitation; and (3) comatose at the time of cooling. The exclusion criteria were as follows: (1) coma from drug overdose, head trauma, stroke, or overt status epilepticus; (2) pregnancy; (3) temperature of <30C; (4) recent major surgery within 14 days; (5) systemic infections; (6) patients with known terminal illness; (7) Glasgow coma scale (GCS) of 10 and above; or (8) known bleeding diathesis or ongoing bleeding.

The Advanced Cardiac Life Support (ACLS) protocol was implemented in both in‐hospital and out‐of‐hospital cardiac arrests. The decision to initiate the protocol was made by the intensivist; however, in out‐of‐hospital cardiac arrest, the decision was taken in conjunction with the emergency room physician. A bladder temperature probe was used to monitor core body temperature. Cooling was achieved using iced saline gastric lavage and ice packs to the patient's neck, axillae, and groin while a cooling blanket (Mul‐T‐Blanket; Gaymar Industries, New York) was placed over and beneath the patient. In some cases, a Blanketrol cooling machine (Blanketrol II; CSZ Products, Inc., Cincinnati, OH) was used when available. All patients were maintained at a PaO₂ above 90 mm Hg and PaCO₂ around 35 mm Hg. Cisatacurium and midazolam were used to control shivering. Regular insulin intravenous drip was used to maintain tight blood glucose control (target blood glucose level of 140 mg/dL) when necessary. Target systolic and mean arterial blood pressures were 90 mm Hg and 80 mm Hg, respectively. Potassium was replaced to 3.4 mmol/L but not within 8 hours of commencing rewarming. Rewarming was started after 24 hours at a rate of not more than 1C in 4 hours. Clinical and laboratory parameters were continuously recorded and all patients were evaluated for complications, including electrolyte imbalance, cardiac arrhythmias, and seizures.

CASES

Table 1 summarizes all the cases. There were 4 men and 4 women. The mean age was 70 14 years (range, 44‐88 years). The main comorbidities were coronary artery disease (n = 6), hypertension (n = 5), diabetes mellitus (n = 5), and chronic or recurrent cardiac arrhythmia (n = 4). Cardiac arrest occurred out‐of‐hospital in 5 of 8 patients and was witnessed in 6 of the 8 cases. Ventricular fibrillation (VF) was the initial presenting rhythm in 5 of the 8 cases. The mean time from ROSC to initiation of cooling was 3 1.6 hours. The mean time from ROSC and attaining target temperature (<34C) was 8.1 4.7 hours. The mean duration of cooling (initiation of cooling to onset of rewarming) was 23.8 0.6 hours. The mean duration at which target temperature was maintained (attainment of 32C‐34C to onset of rewarming) was 18.6 4.6 hours. The median time from onset of passive rewarming to attaining temperature of <36C was 7.25 hours. Two patients survived and were discharged to home (Patients B and C). Patient B had mild cognitive deficits on discharge.

DISCUSSION

There is substantial clinical and public health concern over increasing incidence of sudden cardiac deaths despite decreasing overall mortality from coronary heart disease.6

Supportive management has been the norm for comatose patients following cardiac arrest until recently, when induced hypothermia was shown to have favorable outcomes in 2 landmark prospective RCTs.3, 4 Supportive management often led to prolonged unconsciousness due to severe anoxic brain injury, which eventually led to high morbidity and mortality rates.9, 10 The Hypothermia after Cardiac Arrest Study Group (HACA) study4 revealed that 6 patients would need to be treated with therapeutic hypothermia to prevent an adverse neurologic outcome, while 7 patients would need to be treated to prevent 1 death. Other authors have reported improved outcomes with induced hypothermia used in patients resuscitated following cardiac arrest.1114

Despite strong and encouraging evidence, therapeutic hypothermia has not been readily accepted into daily clinical critical care practice.68 In an Internet‐based survey of physicians by Abella et al.,6 87% of respondents (comprised of emergency medicine and critical care physicians, and cardiologists) had not used this treatment modality following cardiac arrest. Reasons given by most physicians included insufficient data to support the use of therapeutic hypothermia, technical difficulties including the immense amount of resources required, as well as inadequate training. Merchant et al.,7 using an Internet‐based survey also sought to ascertain the degree of therapeutic hypothermia use from physicians in the United States, the United Kingdom, Australia, and Finland. They found that 74% of respondents in the United States and 64% of respondents outside of the United States were yet to use induced therapeutic hypothermia. Factors predicting the use of therapeutic hypothermia by physicians were found to include practice in an academic hospital with more than 250 beds, critical care specialty training, and location of the hospital outside of the United States. Similarly, the major reasons given for nonutilization of therapeutic hypothermia in this study include lack of supportive data and technical difficulties. In yet another study by Laver et al.,8 73% of respondents (ICUs in the United Kingdom) revealed that therapeutic hypothermia after cardiac arrest had not been used in their service. They also gave the same reasons for nonusage as in the aforementioned studies.

In this case series we have presented our experience with therapeutic hypothermia in comatose patients following cardiac arrest. Evaluation of our cooling process compares favorably with the findings of the HACA study4: In our study, the mean time from ROSC to cooling initiation was 180 66 minutes compared to a median of 105 minutes (interquartile range, 61192 minutes) in the HACA study; mean time between ROSC and attaining target temperature was 8.1 4.7 hours in our study compared to a median of 8 hours in the HACA study; mean duration of cooling in our study was 23.8 0.6 hours compared to a median of 24 hours in the HACA study; target temperature was maintained for a mean duration of 18.6 4.6 hours in our study compared to a median of 24 hours in the HACA study; and last, median time from passive rewarming to attainment of temperature greater than 36C in our study was 7.25 hours compared to 8 hours in the HACA study.

There were few complications observed in this case series. These include hypokalemia, mildly elevated creatinine levels, and seizures. One patient developed pneumonia. Other potential complications of therapeutic hypothermia include cardiac arrhythmias, sepsis, hyperglycemia, coagulopathy, acid‐base disturbances, and electrolyte imbalance.15 The studies by Bernard et al.3 and the HACA;4 however, revealed no clinically significant unfavorable outcomes in the patients randomized to receive hypothermia treatment.

Our experience based on this case series leads us to conclude that therapeutic hypothermia is feasible in the community hospital setting. In our 200‐bed community teaching hospital, a multidisciplinary approach involving intensivists, emergency room physicians, internists, residents, and nursing staff lessens the technical difficulties associated with implementing a seemingly cumbersome yet inexpensive and effective treatment modality. Therapeutic hypothermia should be considered in appropriate patients in coma after resuscitation from cardiac arrest.

Mortality data estimates that there are about 400,000 to 460,000 sudden cardiac deaths (SCD) in the United States.1 In resuscitated cardiac arrest patients, morbidity and mortality remains high due to cerebral ischemic anoxia. Currently it is believed that following return of spontaneous circulation (ROSC) from successful resuscitation, secondary inflammatory responses characterized by the generation of chemical mediators and free radicals, as well as increased microvascular permeability, lead to further brain injury.2 Recently, 2 randomized controlled trials (RCT) showed that induced mild hypothermia (32C‐34C) in comatose patients after out‐of‐hospital cardiac arrest leads to improved neurologic outcomes and survival.3, 4 In 2002, the International Liaison Committee on Resuscitation (ILCOR) recommended induced mild hypothermia for the management of comatose patients with ROSC after cardiac arrest.5 Despite the recommendations by ILCOR and the supporting body of evidence proving the benefit of therapeutic hypothermia after cardiac arrest, this treatment remains underused.68

We present a case series of 8 cardiac arrest survivors treated using a hypothermia protocol at a community hospital.

TREATMENT PROTOCOL

Between June 2006 and December 2006, 8 patients presented to Unity Hospital, (a 200‐bed community teaching hospital with a 20‐bed intensive care unit [ICU]) in coma following cardiac arrest with ROSC after resuscitation. All the patients were managed using therapeutic hypothermia.

The hospital protocol, developed using the ILCOR guidelines, was used on all patients. The aim was to achieve a core temperature of 32C to 34C within 6 to 8 hours and maintain this for 24 hours from the start of cooling. The inclusion criteria were as follows: (1) coma within a 6‐hour postcardiac arrest window preceded by either ventricular fibrillation (VF), pulseless ventricular tachycardia, pulseless electrical activity, or asystole; (2) ability to maintain a blood pressure with or without pressors and/or fluid volume resuscitation after cardiopulmonary resuscitation; and (3) comatose at the time of cooling. The exclusion criteria were as follows: (1) coma from drug overdose, head trauma, stroke, or overt status epilepticus; (2) pregnancy; (3) temperature of <30C; (4) recent major surgery within 14 days; (5) systemic infections; (6) patients with known terminal illness; (7) Glasgow coma scale (GCS) of 10 and above; or (8) known bleeding diathesis or ongoing bleeding.

The Advanced Cardiac Life Support (ACLS) protocol was implemented in both in‐hospital and out‐of‐hospital cardiac arrests. The decision to initiate the protocol was made by the intensivist; however, in out‐of‐hospital cardiac arrest, the decision was taken in conjunction with the emergency room physician. A bladder temperature probe was used to monitor core body temperature. Cooling was achieved using iced saline gastric lavage and ice packs to the patient's neck, axillae, and groin while a cooling blanket (Mul‐T‐Blanket; Gaymar Industries, New York) was placed over and beneath the patient. In some cases, a Blanketrol cooling machine (Blanketrol II; CSZ Products, Inc., Cincinnati, OH) was used when available. All patients were maintained at a PaO₂ above 90 mm Hg and PaCO₂ around 35 mm Hg. Cisatacurium and midazolam were used to control shivering. Regular insulin intravenous drip was used to maintain tight blood glucose control (target blood glucose level of 140 mg/dL) when necessary. Target systolic and mean arterial blood pressures were 90 mm Hg and 80 mm Hg, respectively. Potassium was replaced to 3.4 mmol/L but not within 8 hours of commencing rewarming. Rewarming was started after 24 hours at a rate of not more than 1C in 4 hours. Clinical and laboratory parameters were continuously recorded and all patients were evaluated for complications, including electrolyte imbalance, cardiac arrhythmias, and seizures.

CASES

Table 1 summarizes all the cases. There were 4 men and 4 women. The mean age was 70 14 years (range, 44‐88 years). The main comorbidities were coronary artery disease (n = 6), hypertension (n = 5), diabetes mellitus (n = 5), and chronic or recurrent cardiac arrhythmia (n = 4). Cardiac arrest occurred out‐of‐hospital in 5 of 8 patients and was witnessed in 6 of the 8 cases. Ventricular fibrillation (VF) was the initial presenting rhythm in 5 of the 8 cases. The mean time from ROSC to initiation of cooling was 3 1.6 hours. The mean time from ROSC and attaining target temperature (<34C) was 8.1 4.7 hours. The mean duration of cooling (initiation of cooling to onset of rewarming) was 23.8 0.6 hours. The mean duration at which target temperature was maintained (attainment of 32C‐34C to onset of rewarming) was 18.6 4.6 hours. The median time from onset of passive rewarming to attaining temperature of <36C was 7.25 hours. Two patients survived and were discharged to home (Patients B and C). Patient B had mild cognitive deficits on discharge.

DISCUSSION

There is substantial clinical and public health concern over increasing incidence of sudden cardiac deaths despite decreasing overall mortality from coronary heart disease.6

Supportive management has been the norm for comatose patients following cardiac arrest until recently, when induced hypothermia was shown to have favorable outcomes in 2 landmark prospective RCTs.3, 4 Supportive management often led to prolonged unconsciousness due to severe anoxic brain injury, which eventually led to high morbidity and mortality rates.9, 10 The Hypothermia after Cardiac Arrest Study Group (HACA) study4 revealed that 6 patients would need to be treated with therapeutic hypothermia to prevent an adverse neurologic outcome, while 7 patients would need to be treated to prevent 1 death. Other authors have reported improved outcomes with induced hypothermia used in patients resuscitated following cardiac arrest.1114

Despite strong and encouraging evidence, therapeutic hypothermia has not been readily accepted into daily clinical critical care practice.68 In an Internet‐based survey of physicians by Abella et al.,6 87% of respondents (comprised of emergency medicine and critical care physicians, and cardiologists) had not used this treatment modality following cardiac arrest. Reasons given by most physicians included insufficient data to support the use of therapeutic hypothermia, technical difficulties including the immense amount of resources required, as well as inadequate training. Merchant et al.,7 using an Internet‐based survey also sought to ascertain the degree of therapeutic hypothermia use from physicians in the United States, the United Kingdom, Australia, and Finland. They found that 74% of respondents in the United States and 64% of respondents outside of the United States were yet to use induced therapeutic hypothermia. Factors predicting the use of therapeutic hypothermia by physicians were found to include practice in an academic hospital with more than 250 beds, critical care specialty training, and location of the hospital outside of the United States. Similarly, the major reasons given for nonutilization of therapeutic hypothermia in this study include lack of supportive data and technical difficulties. In yet another study by Laver et al.,8 73% of respondents (ICUs in the United Kingdom) revealed that therapeutic hypothermia after cardiac arrest had not been used in their service. They also gave the same reasons for nonusage as in the aforementioned studies.

In this case series we have presented our experience with therapeutic hypothermia in comatose patients following cardiac arrest. Evaluation of our cooling process compares favorably with the findings of the HACA study4: In our study, the mean time from ROSC to cooling initiation was 180 66 minutes compared to a median of 105 minutes (interquartile range, 61192 minutes) in the HACA study; mean time between ROSC and attaining target temperature was 8.1 4.7 hours in our study compared to a median of 8 hours in the HACA study; mean duration of cooling in our study was 23.8 0.6 hours compared to a median of 24 hours in the HACA study; target temperature was maintained for a mean duration of 18.6 4.6 hours in our study compared to a median of 24 hours in the HACA study; and last, median time from passive rewarming to attainment of temperature greater than 36C in our study was 7.25 hours compared to 8 hours in the HACA study.

There were few complications observed in this case series. These include hypokalemia, mildly elevated creatinine levels, and seizures. One patient developed pneumonia. Other potential complications of therapeutic hypothermia include cardiac arrhythmias, sepsis, hyperglycemia, coagulopathy, acid‐base disturbances, and electrolyte imbalance.15 The studies by Bernard et al.3 and the HACA;4 however, revealed no clinically significant unfavorable outcomes in the patients randomized to receive hypothermia treatment.

Our experience based on this case series leads us to conclude that therapeutic hypothermia is feasible in the community hospital setting. In our 200‐bed community teaching hospital, a multidisciplinary approach involving intensivists, emergency room physicians, internists, residents, and nursing staff lessens the technical difficulties associated with implementing a seemingly cumbersome yet inexpensive and effective treatment modality. Therapeutic hypothermia should be considered in appropriate patients in coma after resuscitation from cardiac arrest.

I first met G.M. (a pseudonym) a year ago during a hospitalization for a flare of his Crohn's disease. At the age of 26, he had accrued nearly 400 hospital days in more than 10 institutionsranging from academic to community medical centers from the East Coast to the West Coast. He had been admitted and discharged more than 25 times and endured several surgeries, intermittent struggles with chronic pain and depression, and mishaps due to poor discharge planning. He referred to discharge as the most chaotic time of hospitalization, a comment that prompted a memorable discussion.

He began by describing the emotions he felt when first told about being discharged, using words such as fear and helplessness. He repeatedly talked about the lack of planning and anticipation of discharge as well as the frustration of watching a system that required fixing. Speaking with tremendous emotion and insight, he also pointed out the discharge experiences that maintained his trust and faith in the system. The conversation then shifted to his mother, who pointed out that her experiences as the caretaker were quite different than her son's. She was equally passionate and genuine in trying to characterize the hospital discharge process.

The conversation was so moving that I asked G.M. and his mother to jot down their thoughts on discharge as well as participate in a multidisciplinary patient safety conference. The following are excerpts from our conversation, their letters, and the conference.

THE PATIENT'S VIEW

You never go into the hospital wanting to stay there, but you also worry tremendously about adjusting back to home life. In my case, I was often on heavy pain medications with a PCA (patient‐controlled analgesia), so the transition to orals always created a source of stress, particularly when the transition happened right at discharge. I've had a number of experiences when they told me I was going home, stopped the PCA, and then simply sent me on my way. Nothing is worse than being discharged from the hospital, spending the car ride home doubled over in pain, and then not being able to get pain meds from the pharmacy until the next day. On the other hand, I've had discharges that were better anticipated, so I could participate in the process. This made all the difference in the world. I don't think people realize that when you're on a PCA right up to discharge, you're not really in a state to receive counseling, education, or instructions about follow‐up plansI was just trying to get better.

Many times, I knew I was getting close to discharge, but I often didn't see anyone owning the process. Information would be fragmented or inconsistent, and while I may have been ready for discharge, I wasn't prepared for discharge. This was a combination of paperwork being incomplete or being left to arrange my own follow‐up appointments after getting home. When you're sick and depressed, you fall through the cracks of the system. You just don't have the resolve to make things happen.

Ultimately, a well orchestrated discharge prepared me to be independent on some level. I felt comfortable and ready for life outside the hospital. I didn't feel helpless because I was only responsible for getting wellnot for arranging my follow‐up appointments, ensuring the home care nurse was coming by, and confirming that my primary doctor knew what was going on. In these situations, there was always a discharge planner serving as a patient advocate of sorts. I also can't imagine what I would have done if I didn't have my mom with me all the time. She's my mom, my advocate, and my caretaker and I don't know how patients survive without someone like that.

HIS MOTHER'S VIEW

I wasn't the sick and helpless one but rather the one who was expected to make it all happen: keep tabs on the medications, understand the details of the discharge plan, and ultimately manage the execution of care postdischarge. In the majority of cases when we had a bad discharge experience, it was because the goals were confused. It became about the bed that was needed for the person still sitting in the emergency department. They may not have realized it, but we fully understood the tension, and we very much felt it during the spotty discharge communications. Safety for the patient being discharged seemed to fall off the radar.

The goals of the process must be clear. In good discharges, caregivers clearly outline the transition plan, transfer records to the outpatient physicians, and arrange referrals to specialists as needed. Perhaps equally important is addressing the patient's emotional state for discharge. This isn't about convincing us that he's safe to go home, but a simple acknowledgement of the difficult transitionparticularly after a long hospitalizationgoes a far way in providing reassurance and decreasing fear and anxiety. If the issue is always one about beds and cost, I would think someone would figure out that a good discharge prevents readmissions, which would have to be a cost‐effective investment.

DISCUSSION

The voice of the patient (or family member) is incredibly powerful. Rather than having a trainee present a case history to illustrate teaching points, it is sometimes more meaningful and instructive to let patients tell their own stories. We invited G.M. and his mother to discuss their discharge experiences at a multidisciplinary patient safety conference. There, representative members of the discharge team (eg, house staff, attending, bedside nurse, pharmacist, and discharge planner) responded to their comments and discussed their roles in the discharge process. Ultimately, the patient and his mother taught us the most about what we can do to improve a process fraught with complexity and the potential for errors: communicate and work better as a team.

G.M. and his mother listened to each of the experts discuss the tasks they must complete to ensure a smooth discharge. Each provider expressed how committed they were to safe discharges, yet all of them shared how easy it is for one to go awry. They knew their individual roles, but all relied on each other to make the process completehighlighting that communication failures frequently lead to poor discharge experiences for patients. Engaging patients in the process should not transfer ownership of discharge to them (ie, making them responsible to ensure we do our jobs), though our patient and his mother presented several examples of how they owned the process because it was clear no one else did.

Evaluating our hospital discharge systems must include identifying methods to improve communication with outpatient providers, ensuring medications are available to patients on discharge, and providing written instructions (including follow‐up appointments) to patients before they leave the hospital. G.M. and his mother remind us that the best systems still need to engage patients, make them an active part of the discharge process (rather than an outcome of it), and never underestimate what patients suffer through emotionally prior to discharge.

Providers often feel uneasy when having to explain to patients that they no longer require hospitalization and perhaps avoid emotional engagement in those discussions because of the fear that some patients may become upset about a planned discharge. Communicating with patients about discharge plans should be handled with the same compassion, patience, and skill as delivering bad news. Patients entrust their lives to our clinical decision making, and abandoning this trust just as they leave the hospital is an unintended message that our patient and his mother perceived during their poor discharge experiences.

In my practice, I frequently include trainees in bedside discussions with patients and families, both to illustrate how important these conversations are and to model skills I was taught during my training. I now use discussions about discharge as a specific bedside teaching moment as well, hoping to impress on trainees the overriding message shared by G.M. and his mother: do not forget to engage patients in a process that is designed for them rather than to them.

Many physicians remain dedicated to improving hospital systems, but perhaps we should all be including our patients more in quality improvement activities and hospital committee work, as they provide perspectives not easily captured by administrative data and run charts.

I first met G.M. (a pseudonym) a year ago during a hospitalization for a flare of his Crohn's disease. At the age of 26, he had accrued nearly 400 hospital days in more than 10 institutionsranging from academic to community medical centers from the East Coast to the West Coast. He had been admitted and discharged more than 25 times and endured several surgeries, intermittent struggles with chronic pain and depression, and mishaps due to poor discharge planning. He referred to discharge as the most chaotic time of hospitalization, a comment that prompted a memorable discussion.

He began by describing the emotions he felt when first told about being discharged, using words such as fear and helplessness. He repeatedly talked about the lack of planning and anticipation of discharge as well as the frustration of watching a system that required fixing. Speaking with tremendous emotion and insight, he also pointed out the discharge experiences that maintained his trust and faith in the system. The conversation then shifted to his mother, who pointed out that her experiences as the caretaker were quite different than her son's. She was equally passionate and genuine in trying to characterize the hospital discharge process.

The conversation was so moving that I asked G.M. and his mother to jot down their thoughts on discharge as well as participate in a multidisciplinary patient safety conference. The following are excerpts from our conversation, their letters, and the conference.

THE PATIENT'S VIEW

You never go into the hospital wanting to stay there, but you also worry tremendously about adjusting back to home life. In my case, I was often on heavy pain medications with a PCA (patient‐controlled analgesia), so the transition to orals always created a source of stress, particularly when the transition happened right at discharge. I've had a number of experiences when they told me I was going home, stopped the PCA, and then simply sent me on my way. Nothing is worse than being discharged from the hospital, spending the car ride home doubled over in pain, and then not being able to get pain meds from the pharmacy until the next day. On the other hand, I've had discharges that were better anticipated, so I could participate in the process. This made all the difference in the world. I don't think people realize that when you're on a PCA right up to discharge, you're not really in a state to receive counseling, education, or instructions about follow‐up plansI was just trying to get better.

Many times, I knew I was getting close to discharge, but I often didn't see anyone owning the process. Information would be fragmented or inconsistent, and while I may have been ready for discharge, I wasn't prepared for discharge. This was a combination of paperwork being incomplete or being left to arrange my own follow‐up appointments after getting home. When you're sick and depressed, you fall through the cracks of the system. You just don't have the resolve to make things happen.

Ultimately, a well orchestrated discharge prepared me to be independent on some level. I felt comfortable and ready for life outside the hospital. I didn't feel helpless because I was only responsible for getting wellnot for arranging my follow‐up appointments, ensuring the home care nurse was coming by, and confirming that my primary doctor knew what was going on. In these situations, there was always a discharge planner serving as a patient advocate of sorts. I also can't imagine what I would have done if I didn't have my mom with me all the time. She's my mom, my advocate, and my caretaker and I don't know how patients survive without someone like that.

HIS MOTHER'S VIEW

I wasn't the sick and helpless one but rather the one who was expected to make it all happen: keep tabs on the medications, understand the details of the discharge plan, and ultimately manage the execution of care postdischarge. In the majority of cases when we had a bad discharge experience, it was because the goals were confused. It became about the bed that was needed for the person still sitting in the emergency department. They may not have realized it, but we fully understood the tension, and we very much felt it during the spotty discharge communications. Safety for the patient being discharged seemed to fall off the radar.

The goals of the process must be clear. In good discharges, caregivers clearly outline the transition plan, transfer records to the outpatient physicians, and arrange referrals to specialists as needed. Perhaps equally important is addressing the patient's emotional state for discharge. This isn't about convincing us that he's safe to go home, but a simple acknowledgement of the difficult transitionparticularly after a long hospitalizationgoes a far way in providing reassurance and decreasing fear and anxiety. If the issue is always one about beds and cost, I would think someone would figure out that a good discharge prevents readmissions, which would have to be a cost‐effective investment.

DISCUSSION

The voice of the patient (or family member) is incredibly powerful. Rather than having a trainee present a case history to illustrate teaching points, it is sometimes more meaningful and instructive to let patients tell their own stories. We invited G.M. and his mother to discuss their discharge experiences at a multidisciplinary patient safety conference. There, representative members of the discharge team (eg, house staff, attending, bedside nurse, pharmacist, and discharge planner) responded to their comments and discussed their roles in the discharge process. Ultimately, the patient and his mother taught us the most about what we can do to improve a process fraught with complexity and the potential for errors: communicate and work better as a team.

G.M. and his mother listened to each of the experts discuss the tasks they must complete to ensure a smooth discharge. Each provider expressed how committed they were to safe discharges, yet all of them shared how easy it is for one to go awry. They knew their individual roles, but all relied on each other to make the process completehighlighting that communication failures frequently lead to poor discharge experiences for patients. Engaging patients in the process should not transfer ownership of discharge to them (ie, making them responsible to ensure we do our jobs), though our patient and his mother presented several examples of how they owned the process because it was clear no one else did.

Evaluating our hospital discharge systems must include identifying methods to improve communication with outpatient providers, ensuring medications are available to patients on discharge, and providing written instructions (including follow‐up appointments) to patients before they leave the hospital. G.M. and his mother remind us that the best systems still need to engage patients, make them an active part of the discharge process (rather than an outcome of it), and never underestimate what patients suffer through emotionally prior to discharge.

Providers often feel uneasy when having to explain to patients that they no longer require hospitalization and perhaps avoid emotional engagement in those discussions because of the fear that some patients may become upset about a planned discharge. Communicating with patients about discharge plans should be handled with the same compassion, patience, and skill as delivering bad news. Patients entrust their lives to our clinical decision making, and abandoning this trust just as they leave the hospital is an unintended message that our patient and his mother perceived during their poor discharge experiences.

In my practice, I frequently include trainees in bedside discussions with patients and families, both to illustrate how important these conversations are and to model skills I was taught during my training. I now use discussions about discharge as a specific bedside teaching moment as well, hoping to impress on trainees the overriding message shared by G.M. and his mother: do not forget to engage patients in a process that is designed for them rather than to them.

Many physicians remain dedicated to improving hospital systems, but perhaps we should all be including our patients more in quality improvement activities and hospital committee work, as they provide perspectives not easily captured by administrative data and run charts.

I first met G.M. (a pseudonym) a year ago during a hospitalization for a flare of his Crohn's disease. At the age of 26, he had accrued nearly 400 hospital days in more than 10 institutionsranging from academic to community medical centers from the East Coast to the West Coast. He had been admitted and discharged more than 25 times and endured several surgeries, intermittent struggles with chronic pain and depression, and mishaps due to poor discharge planning. He referred to discharge as the most chaotic time of hospitalization, a comment that prompted a memorable discussion.

He began by describing the emotions he felt when first told about being discharged, using words such as fear and helplessness. He repeatedly talked about the lack of planning and anticipation of discharge as well as the frustration of watching a system that required fixing. Speaking with tremendous emotion and insight, he also pointed out the discharge experiences that maintained his trust and faith in the system. The conversation then shifted to his mother, who pointed out that her experiences as the caretaker were quite different than her son's. She was equally passionate and genuine in trying to characterize the hospital discharge process.

The conversation was so moving that I asked G.M. and his mother to jot down their thoughts on discharge as well as participate in a multidisciplinary patient safety conference. The following are excerpts from our conversation, their letters, and the conference.

THE PATIENT'S VIEW

You never go into the hospital wanting to stay there, but you also worry tremendously about adjusting back to home life. In my case, I was often on heavy pain medications with a PCA (patient‐controlled analgesia), so the transition to orals always created a source of stress, particularly when the transition happened right at discharge. I've had a number of experiences when they told me I was going home, stopped the PCA, and then simply sent me on my way. Nothing is worse than being discharged from the hospital, spending the car ride home doubled over in pain, and then not being able to get pain meds from the pharmacy until the next day. On the other hand, I've had discharges that were better anticipated, so I could participate in the process. This made all the difference in the world. I don't think people realize that when you're on a PCA right up to discharge, you're not really in a state to receive counseling, education, or instructions about follow‐up plansI was just trying to get better.

Many times, I knew I was getting close to discharge, but I often didn't see anyone owning the process. Information would be fragmented or inconsistent, and while I may have been ready for discharge, I wasn't prepared for discharge. This was a combination of paperwork being incomplete or being left to arrange my own follow‐up appointments after getting home. When you're sick and depressed, you fall through the cracks of the system. You just don't have the resolve to make things happen.

Ultimately, a well orchestrated discharge prepared me to be independent on some level. I felt comfortable and ready for life outside the hospital. I didn't feel helpless because I was only responsible for getting wellnot for arranging my follow‐up appointments, ensuring the home care nurse was coming by, and confirming that my primary doctor knew what was going on. In these situations, there was always a discharge planner serving as a patient advocate of sorts. I also can't imagine what I would have done if I didn't have my mom with me all the time. She's my mom, my advocate, and my caretaker and I don't know how patients survive without someone like that.

HIS MOTHER'S VIEW

I wasn't the sick and helpless one but rather the one who was expected to make it all happen: keep tabs on the medications, understand the details of the discharge plan, and ultimately manage the execution of care postdischarge. In the majority of cases when we had a bad discharge experience, it was because the goals were confused. It became about the bed that was needed for the person still sitting in the emergency department. They may not have realized it, but we fully understood the tension, and we very much felt it during the spotty discharge communications. Safety for the patient being discharged seemed to fall off the radar.

The goals of the process must be clear. In good discharges, caregivers clearly outline the transition plan, transfer records to the outpatient physicians, and arrange referrals to specialists as needed. Perhaps equally important is addressing the patient's emotional state for discharge. This isn't about convincing us that he's safe to go home, but a simple acknowledgement of the difficult transitionparticularly after a long hospitalizationgoes a far way in providing reassurance and decreasing fear and anxiety. If the issue is always one about beds and cost, I would think someone would figure out that a good discharge prevents readmissions, which would have to be a cost‐effective investment.

DISCUSSION

The voice of the patient (or family member) is incredibly powerful. Rather than having a trainee present a case history to illustrate teaching points, it is sometimes more meaningful and instructive to let patients tell their own stories. We invited G.M. and his mother to discuss their discharge experiences at a multidisciplinary patient safety conference. There, representative members of the discharge team (eg, house staff, attending, bedside nurse, pharmacist, and discharge planner) responded to their comments and discussed their roles in the discharge process. Ultimately, the patient and his mother taught us the most about what we can do to improve a process fraught with complexity and the potential for errors: communicate and work better as a team.

G.M. and his mother listened to each of the experts discuss the tasks they must complete to ensure a smooth discharge. Each provider expressed how committed they were to safe discharges, yet all of them shared how easy it is for one to go awry. They knew their individual roles, but all relied on each other to make the process completehighlighting that communication failures frequently lead to poor discharge experiences for patients. Engaging patients in the process should not transfer ownership of discharge to them (ie, making them responsible to ensure we do our jobs), though our patient and his mother presented several examples of how they owned the process because it was clear no one else did.

Evaluating our hospital discharge systems must include identifying methods to improve communication with outpatient providers, ensuring medications are available to patients on discharge, and providing written instructions (including follow‐up appointments) to patients before they leave the hospital. G.M. and his mother remind us that the best systems still need to engage patients, make them an active part of the discharge process (rather than an outcome of it), and never underestimate what patients suffer through emotionally prior to discharge.

Providers often feel uneasy when having to explain to patients that they no longer require hospitalization and perhaps avoid emotional engagement in those discussions because of the fear that some patients may become upset about a planned discharge. Communicating with patients about discharge plans should be handled with the same compassion, patience, and skill as delivering bad news. Patients entrust their lives to our clinical decision making, and abandoning this trust just as they leave the hospital is an unintended message that our patient and his mother perceived during their poor discharge experiences.

In my practice, I frequently include trainees in bedside discussions with patients and families, both to illustrate how important these conversations are and to model skills I was taught during my training. I now use discussions about discharge as a specific bedside teaching moment as well, hoping to impress on trainees the overriding message shared by G.M. and his mother: do not forget to engage patients in a process that is designed for them rather than to them.

Many physicians remain dedicated to improving hospital systems, but perhaps we should all be including our patients more in quality improvement activities and hospital committee work, as they provide perspectives not easily captured by administrative data and run charts.

Patients are vulnerable to adverse events when they transition from the hospital to outpatient care.13 Approximately 19%‐23% of patients experience adverse events within 4 weeks after acute care hospitalization.3, 4 One cause of postdischarge adverse events is ineffective discharge planning1, 2, 5, 6 Efforts to study and improve the hospital discharge‐planning processes require appropriate and valid measurement instruments. These instruments must assess the discharge process from multiple perspectives. One of the important perspectives is the patient's.7, 8

The PREPARED Patient Questionnaire is a comprehensive quality improvement tool to assess hospital discharge‐planning processes and outcomes from the patient's perspective.9, 10 The PREPARED acronym describes the content of this tool used to investigate the following phenomena: 1) prescriptions, 2) ready to reenter community, 3) education, 4) placement, 5) assurance of safety, 6) realistic expectations, 7) empowerment, and 8) directed to appropriate services.9 The PREPARED questionnaire was developed for, modified for, and validated with patients at least 65 years old. When administered to elderly patients 1 week after hospital discharge, the PREPARED has face, content, and construct validity.9

We considered the PREPARED questionnaire when we designed a clinical trial to assess the value of a discharge intervention. We sought a survey questionnaire to assess the patients' perceptions after the discharge intervention. In 2004, we found noother validated questionnaires except the PREPARED. We also noted some limitations of the PREPARED. The validated population for the PREPARED was patients older than 65 years. In our clinical trial, we planned to enroll adults of all ages. Another limitation was the PREPARED response scoring system that assigned missing data values to patients who took no medicines, needed no services, or needed no equipment.10 We were concerned about the potential for unacceptably large numbers of patients with nonignorable missing data. We decided to address the above limitations with a validation study in our patient population and with a revised response scoring system.

In the present article, we describe item reduction and validation for the Brief PREPARED (B‐PREPARED) scale to measure patients' perceptions of their preparedness for hospital discharge. When we designed B‐PREPARED, we asked the following question: Does a subset of PREPARED items with a revised scoring system have internal consistency, construct validity, and predictive validity in a population of adult patients with broad age range? We also wanted a brief scale with acceptable, defined statistical properties for multiple users. One user class included clinicians who guide and assess discharge‐planning processes. Other users would be researchers like us who measure differences between treatment groups after discharge process interventions.

METHODS

The Peoria Institutional Review Board approved the protocol for human research. The patient sample for scale analysis was a prospective cohort. Follow‐up was 1 month after patient's discharge from a 730‐bed acute‐care teaching hospital in central Illinois. The patients were enrolled in an ongoing cluster randomized clinical trial with blinded outcome assessment. Willing patients or their proxies provided written consent for study participation. Enrollment occurred between December 2004 and July 2006.

RESULTS

DISCUSSION

The B‐PREPARED scale measures patients' perceptions of their preparedness for hospital discharge home. Scale items came from the PREPARED, a survey with validated psychometric properties in elderly patients. We assessed the B‐PREPARED in a cohort of young and elderly adult patients. We examined the B‐PREPARED instrument for internal consistency, construct validity, and predictive validity. In comparison with the domains identified in the full PREPARED instrument,9 the abbreviated B‐PREPARED scale identified similar domains. Some differences were anticipated because we limited items to those the respondents would be able to perceive before leaving the hospital.

The results of our study should be interpreted in the context of strengths and limitations. One of the strengths was the validity of the PREPARED, from which the B‐PREPARED was derived.7 The conceptually rigorous process used to develop the PREPARED questionnaire allowed us to draw from a bank of concise, well‐worded items.9 The B‐PREPARED extends validity to a population of adults of all ages with high risk for readmission. The other strength of the B‐PREPARED was the association with the clinically relevant constructs worry and satisfaction with medication information. The B‐PREPARED also discriminated between patients who did and those who did not return to emergency departments after discharge. Although the patient population for the B‐PREPARED validation was one of the strengths of this study, it is also a limitation. Our cohort lacked diversity with respect to readmission risk. The results of our study may not generalize to patients with low risk for repeated admission. Furthermore, all our patients were discharged home. The exclusion of other discharge destinations helped us to enroll a cohort with homogenous risk for readmission. However, our exclusion criteria did not allow us to validate the B‐PREPARED in patients discharged to nursing homes, inpatient rehabilitation units, or other acute care facilities.

Another limitation related to outpatient visits after discharge. We did not analyze outpatient sites other than emergency departments. For all of our study patients, the discharging hospitalist scheduled at least 1 outpatient visit with the primary care practitioner. For some patients, the hospitalist also scheduled postdischarge visits for diagnostic evaluations like cardiac stress tests, endoscopies, radiographs, or other laboratory tests. When these visits occurred, they represented successful execution of the discharge plan. Sometimes patients arrived for planned or unplanned outpatient visits with exacerbated symptoms or adverse events. These latter visits might represent failures of the discharge plan. Our data collection did not allow us to distinguish outpatient visits as successes or failures of the discharge plan. When we counted only emergency department visits, we may have underestimated the number of patients with adverse events who sought and received successful treatment in outpatient clinics. Future studies should consider ascertainment of planned and unplanned outpatient visits for exacerbated symptoms and adverse events.

After our study began enrollment, other investigators published the Readiness for Hospital Discharge Scale14 and Care Transitions Measure.15 The design and validation of these sampling instruments differed with each other and with the B‐PREPARED. The differences made the 3 scales complementary but not interchangeable. For example, investigators administered the 21‐item Readiness for Hospital Discharge Scale on the day of discharge to adult medical‐surgical patients, postpartum mothers, and parents of hospitalized children. In contrast, we administered the B‐PREPARED 1 week after discharge to adult internal medicine patients or their proxies. The Readiness for Hospital Discharge subscales were personal status, knowledge, coping ability, and expected support. These subscales were similar to the components of the B‐PREPARED. The Readiness for Hospital Discharge Scale demonstrated internal consistency and construct validity but did not predict patients who returned to emergency departments after hospital discharge.14 Future users of the Readiness for Hospital Discharge Scale or the B‐PREPARED should consider their patient populations and the date of administration when selecting 1 scale versus another. If brevity is important to a clinician or researcher, then the 11‐item B‐PREPARED scale may be considered.

The Care Transitions Measure also differed from the B‐PREPARED. The 15‐item Care Transitions Measure evaluated an adult population with a broad age range and with chronic obstructive pulmonary disease, heart failure, stroke, or hip fracture.15 The diseases represented in the population for the Care Transitions Measure were similar to those in the B‐PREPARED cohort, although the distribution of the diseases differed. When validating the Care Transitions Measure, investigators administered questionnaires 6 to 12 weeks after discharge. The Care Transitions Measure had 4 factors: critical understanding, preferences important, management preparation, and care plan. The factors of the Care Transitions Measure were comparable to the components of the B‐PREPARED, and both scales assessed medication self‐management. However, the Care Transitions Measure addressed patient preferences with specific items, whereas the B‐PREPARED used the scoring system to quantify patient preferences. Both the Care Transitions Measure and the B‐PREPARED demonstrated internal consistency and discriminated between patients who did and those who did not return to emergency departments after hospital discharge.15 When selecting a scale, future users should consider the B‐PREPARED only for assessments 1 week post discharge and should consider the Care Transitions Measure for later assessments.

There are applications of the B‐PREPARED scale in hospital quality improvement efforts. Hospitals have multiple motivations to pursue quality improvement projects related to discharge processes: satisfaction of patients, reduction in adverse events, relation with referring physicians, and accreditation by regulators.6, 16 When hospital‐based clinicians survey patients, they may wish to use a brief, reliable, and validated instrument like the B‐PREPARED questionnaire.

CONCLUSIONS

The B‐PREPARED provided a reliable and valid measure of patients' perceptions of their preparedness for hospital discharge home. Clinicians and researchers may find the B‐PREPARED useful to guide, assess, and compare discharge‐planning interventions.

Patients are vulnerable to adverse events when they transition from the hospital to outpatient care.13 Approximately 19%‐23% of patients experience adverse events within 4 weeks after acute care hospitalization.3, 4 One cause of postdischarge adverse events is ineffective discharge planning1, 2, 5, 6 Efforts to study and improve the hospital discharge‐planning processes require appropriate and valid measurement instruments. These instruments must assess the discharge process from multiple perspectives. One of the important perspectives is the patient's.7, 8

The PREPARED Patient Questionnaire is a comprehensive quality improvement tool to assess hospital discharge‐planning processes and outcomes from the patient's perspective.9, 10 The PREPARED acronym describes the content of this tool used to investigate the following phenomena: 1) prescriptions, 2) ready to reenter community, 3) education, 4) placement, 5) assurance of safety, 6) realistic expectations, 7) empowerment, and 8) directed to appropriate services.9 The PREPARED questionnaire was developed for, modified for, and validated with patients at least 65 years old. When administered to elderly patients 1 week after hospital discharge, the PREPARED has face, content, and construct validity.9

We considered the PREPARED questionnaire when we designed a clinical trial to assess the value of a discharge intervention. We sought a survey questionnaire to assess the patients' perceptions after the discharge intervention. In 2004, we found noother validated questionnaires except the PREPARED. We also noted some limitations of the PREPARED. The validated population for the PREPARED was patients older than 65 years. In our clinical trial, we planned to enroll adults of all ages. Another limitation was the PREPARED response scoring system that assigned missing data values to patients who took no medicines, needed no services, or needed no equipment.10 We were concerned about the potential for unacceptably large numbers of patients with nonignorable missing data. We decided to address the above limitations with a validation study in our patient population and with a revised response scoring system.

In the present article, we describe item reduction and validation for the Brief PREPARED (B‐PREPARED) scale to measure patients' perceptions of their preparedness for hospital discharge. When we designed B‐PREPARED, we asked the following question: Does a subset of PREPARED items with a revised scoring system have internal consistency, construct validity, and predictive validity in a population of adult patients with broad age range? We also wanted a brief scale with acceptable, defined statistical properties for multiple users. One user class included clinicians who guide and assess discharge‐planning processes. Other users would be researchers like us who measure differences between treatment groups after discharge process interventions.

METHODS

The Peoria Institutional Review Board approved the protocol for human research. The patient sample for scale analysis was a prospective cohort. Follow‐up was 1 month after patient's discharge from a 730‐bed acute‐care teaching hospital in central Illinois. The patients were enrolled in an ongoing cluster randomized clinical trial with blinded outcome assessment. Willing patients or their proxies provided written consent for study participation. Enrollment occurred between December 2004 and July 2006.

RESULTS

DISCUSSION

The B‐PREPARED scale measures patients' perceptions of their preparedness for hospital discharge home. Scale items came from the PREPARED, a survey with validated psychometric properties in elderly patients. We assessed the B‐PREPARED in a cohort of young and elderly adult patients. We examined the B‐PREPARED instrument for internal consistency, construct validity, and predictive validity. In comparison with the domains identified in the full PREPARED instrument,9 the abbreviated B‐PREPARED scale identified similar domains. Some differences were anticipated because we limited items to those the respondents would be able to perceive before leaving the hospital.

The results of our study should be interpreted in the context of strengths and limitations. One of the strengths was the validity of the PREPARED, from which the B‐PREPARED was derived.7 The conceptually rigorous process used to develop the PREPARED questionnaire allowed us to draw from a bank of concise, well‐worded items.9 The B‐PREPARED extends validity to a population of adults of all ages with high risk for readmission. The other strength of the B‐PREPARED was the association with the clinically relevant constructs worry and satisfaction with medication information. The B‐PREPARED also discriminated between patients who did and those who did not return to emergency departments after discharge. Although the patient population for the B‐PREPARED validation was one of the strengths of this study, it is also a limitation. Our cohort lacked diversity with respect to readmission risk. The results of our study may not generalize to patients with low risk for repeated admission. Furthermore, all our patients were discharged home. The exclusion of other discharge destinations helped us to enroll a cohort with homogenous risk for readmission. However, our exclusion criteria did not allow us to validate the B‐PREPARED in patients discharged to nursing homes, inpatient rehabilitation units, or other acute care facilities.

Another limitation related to outpatient visits after discharge. We did not analyze outpatient sites other than emergency departments. For all of our study patients, the discharging hospitalist scheduled at least 1 outpatient visit with the primary care practitioner. For some patients, the hospitalist also scheduled postdischarge visits for diagnostic evaluations like cardiac stress tests, endoscopies, radiographs, or other laboratory tests. When these visits occurred, they represented successful execution of the discharge plan. Sometimes patients arrived for planned or unplanned outpatient visits with exacerbated symptoms or adverse events. These latter visits might represent failures of the discharge plan. Our data collection did not allow us to distinguish outpatient visits as successes or failures of the discharge plan. When we counted only emergency department visits, we may have underestimated the number of patients with adverse events who sought and received successful treatment in outpatient clinics. Future studies should consider ascertainment of planned and unplanned outpatient visits for exacerbated symptoms and adverse events.

After our study began enrollment, other investigators published the Readiness for Hospital Discharge Scale14 and Care Transitions Measure.15 The design and validation of these sampling instruments differed with each other and with the B‐PREPARED. The differences made the 3 scales complementary but not interchangeable. For example, investigators administered the 21‐item Readiness for Hospital Discharge Scale on the day of discharge to adult medical‐surgical patients, postpartum mothers, and parents of hospitalized children. In contrast, we administered the B‐PREPARED 1 week after discharge to adult internal medicine patients or their proxies. The Readiness for Hospital Discharge subscales were personal status, knowledge, coping ability, and expected support. These subscales were similar to the components of the B‐PREPARED. The Readiness for Hospital Discharge Scale demonstrated internal consistency and construct validity but did not predict patients who returned to emergency departments after hospital discharge.14 Future users of the Readiness for Hospital Discharge Scale or the B‐PREPARED should consider their patient populations and the date of administration when selecting 1 scale versus another. If brevity is important to a clinician or researcher, then the 11‐item B‐PREPARED scale may be considered.

The Care Transitions Measure also differed from the B‐PREPARED. The 15‐item Care Transitions Measure evaluated an adult population with a broad age range and with chronic obstructive pulmonary disease, heart failure, stroke, or hip fracture.15 The diseases represented in the population for the Care Transitions Measure were similar to those in the B‐PREPARED cohort, although the distribution of the diseases differed. When validating the Care Transitions Measure, investigators administered questionnaires 6 to 12 weeks after discharge. The Care Transitions Measure had 4 factors: critical understanding, preferences important, management preparation, and care plan. The factors of the Care Transitions Measure were comparable to the components of the B‐PREPARED, and both scales assessed medication self‐management. However, the Care Transitions Measure addressed patient preferences with specific items, whereas the B‐PREPARED used the scoring system to quantify patient preferences. Both the Care Transitions Measure and the B‐PREPARED demonstrated internal consistency and discriminated between patients who did and those who did not return to emergency departments after hospital discharge.15 When selecting a scale, future users should consider the B‐PREPARED only for assessments 1 week post discharge and should consider the Care Transitions Measure for later assessments.

There are applications of the B‐PREPARED scale in hospital quality improvement efforts. Hospitals have multiple motivations to pursue quality improvement projects related to discharge processes: satisfaction of patients, reduction in adverse events, relation with referring physicians, and accreditation by regulators.6, 16 When hospital‐based clinicians survey patients, they may wish to use a brief, reliable, and validated instrument like the B‐PREPARED questionnaire.

CONCLUSIONS

The B‐PREPARED provided a reliable and valid measure of patients' perceptions of their preparedness for hospital discharge home. Clinicians and researchers may find the B‐PREPARED useful to guide, assess, and compare discharge‐planning interventions.

Patients are vulnerable to adverse events when they transition from the hospital to outpatient care.13 Approximately 19%‐23% of patients experience adverse events within 4 weeks after acute care hospitalization.3, 4 One cause of postdischarge adverse events is ineffective discharge planning1, 2, 5, 6 Efforts to study and improve the hospital discharge‐planning processes require appropriate and valid measurement instruments. These instruments must assess the discharge process from multiple perspectives. One of the important perspectives is the patient's.7, 8

The PREPARED Patient Questionnaire is a comprehensive quality improvement tool to assess hospital discharge‐planning processes and outcomes from the patient's perspective.9, 10 The PREPARED acronym describes the content of this tool used to investigate the following phenomena: 1) prescriptions, 2) ready to reenter community, 3) education, 4) placement, 5) assurance of safety, 6) realistic expectations, 7) empowerment, and 8) directed to appropriate services.9 The PREPARED questionnaire was developed for, modified for, and validated with patients at least 65 years old. When administered to elderly patients 1 week after hospital discharge, the PREPARED has face, content, and construct validity.9

We considered the PREPARED questionnaire when we designed a clinical trial to assess the value of a discharge intervention. We sought a survey questionnaire to assess the patients' perceptions after the discharge intervention. In 2004, we found noother validated questionnaires except the PREPARED. We also noted some limitations of the PREPARED. The validated population for the PREPARED was patients older than 65 years. In our clinical trial, we planned to enroll adults of all ages. Another limitation was the PREPARED response scoring system that assigned missing data values to patients who took no medicines, needed no services, or needed no equipment.10 We were concerned about the potential for unacceptably large numbers of patients with nonignorable missing data. We decided to address the above limitations with a validation study in our patient population and with a revised response scoring system.

In the present article, we describe item reduction and validation for the Brief PREPARED (B‐PREPARED) scale to measure patients' perceptions of their preparedness for hospital discharge. When we designed B‐PREPARED, we asked the following question: Does a subset of PREPARED items with a revised scoring system have internal consistency, construct validity, and predictive validity in a population of adult patients with broad age range? We also wanted a brief scale with acceptable, defined statistical properties for multiple users. One user class included clinicians who guide and assess discharge‐planning processes. Other users would be researchers like us who measure differences between treatment groups after discharge process interventions.

METHODS

The Peoria Institutional Review Board approved the protocol for human research. The patient sample for scale analysis was a prospective cohort. Follow‐up was 1 month after patient's discharge from a 730‐bed acute‐care teaching hospital in central Illinois. The patients were enrolled in an ongoing cluster randomized clinical trial with blinded outcome assessment. Willing patients or their proxies provided written consent for study participation. Enrollment occurred between December 2004 and July 2006.

RESULTS

DISCUSSION

The B‐PREPARED scale measures patients' perceptions of their preparedness for hospital discharge home. Scale items came from the PREPARED, a survey with validated psychometric properties in elderly patients. We assessed the B‐PREPARED in a cohort of young and elderly adult patients. We examined the B‐PREPARED instrument for internal consistency, construct validity, and predictive validity. In comparison with the domains identified in the full PREPARED instrument,9 the abbreviated B‐PREPARED scale identified similar domains. Some differences were anticipated because we limited items to those the respondents would be able to perceive before leaving the hospital.

The results of our study should be interpreted in the context of strengths and limitations. One of the strengths was the validity of the PREPARED, from which the B‐PREPARED was derived.7 The conceptually rigorous process used to develop the PREPARED questionnaire allowed us to draw from a bank of concise, well‐worded items.9 The B‐PREPARED extends validity to a population of adults of all ages with high risk for readmission. The other strength of the B‐PREPARED was the association with the clinically relevant constructs worry and satisfaction with medication information. The B‐PREPARED also discriminated between patients who did and those who did not return to emergency departments after discharge. Although the patient population for the B‐PREPARED validation was one of the strengths of this study, it is also a limitation. Our cohort lacked diversity with respect to readmission risk. The results of our study may not generalize to patients with low risk for repeated admission. Furthermore, all our patients were discharged home. The exclusion of other discharge destinations helped us to enroll a cohort with homogenous risk for readmission. However, our exclusion criteria did not allow us to validate the B‐PREPARED in patients discharged to nursing homes, inpatient rehabilitation units, or other acute care facilities.

Another limitation related to outpatient visits after discharge. We did not analyze outpatient sites other than emergency departments. For all of our study patients, the discharging hospitalist scheduled at least 1 outpatient visit with the primary care practitioner. For some patients, the hospitalist also scheduled postdischarge visits for diagnostic evaluations like cardiac stress tests, endoscopies, radiographs, or other laboratory tests. When these visits occurred, they represented successful execution of the discharge plan. Sometimes patients arrived for planned or unplanned outpatient visits with exacerbated symptoms or adverse events. These latter visits might represent failures of the discharge plan. Our data collection did not allow us to distinguish outpatient visits as successes or failures of the discharge plan. When we counted only emergency department visits, we may have underestimated the number of patients with adverse events who sought and received successful treatment in outpatient clinics. Future studies should consider ascertainment of planned and unplanned outpatient visits for exacerbated symptoms and adverse events.

After our study began enrollment, other investigators published the Readiness for Hospital Discharge Scale14 and Care Transitions Measure.15 The design and validation of these sampling instruments differed with each other and with the B‐PREPARED. The differences made the 3 scales complementary but not interchangeable. For example, investigators administered the 21‐item Readiness for Hospital Discharge Scale on the day of discharge to adult medical‐surgical patients, postpartum mothers, and parents of hospitalized children. In contrast, we administered the B‐PREPARED 1 week after discharge to adult internal medicine patients or their proxies. The Readiness for Hospital Discharge subscales were personal status, knowledge, coping ability, and expected support. These subscales were similar to the components of the B‐PREPARED. The Readiness for Hospital Discharge Scale demonstrated internal consistency and construct validity but did not predict patients who returned to emergency departments after hospital discharge.14 Future users of the Readiness for Hospital Discharge Scale or the B‐PREPARED should consider their patient populations and the date of administration when selecting 1 scale versus another. If brevity is important to a clinician or researcher, then the 11‐item B‐PREPARED scale may be considered.

The Care Transitions Measure also differed from the B‐PREPARED. The 15‐item Care Transitions Measure evaluated an adult population with a broad age range and with chronic obstructive pulmonary disease, heart failure, stroke, or hip fracture.15 The diseases represented in the population for the Care Transitions Measure were similar to those in the B‐PREPARED cohort, although the distribution of the diseases differed. When validating the Care Transitions Measure, investigators administered questionnaires 6 to 12 weeks after discharge. The Care Transitions Measure had 4 factors: critical understanding, preferences important, management preparation, and care plan. The factors of the Care Transitions Measure were comparable to the components of the B‐PREPARED, and both scales assessed medication self‐management. However, the Care Transitions Measure addressed patient preferences with specific items, whereas the B‐PREPARED used the scoring system to quantify patient preferences. Both the Care Transitions Measure and the B‐PREPARED demonstrated internal consistency and discriminated between patients who did and those who did not return to emergency departments after hospital discharge.15 When selecting a scale, future users should consider the B‐PREPARED only for assessments 1 week post discharge and should consider the Care Transitions Measure for later assessments.

There are applications of the B‐PREPARED scale in hospital quality improvement efforts. Hospitals have multiple motivations to pursue quality improvement projects related to discharge processes: satisfaction of patients, reduction in adverse events, relation with referring physicians, and accreditation by regulators.6, 16 When hospital‐based clinicians survey patients, they may wish to use a brief, reliable, and validated instrument like the B‐PREPARED questionnaire.

CONCLUSIONS

The B‐PREPARED provided a reliable and valid measure of patients' perceptions of their preparedness for hospital discharge home. Clinicians and researchers may find the B‐PREPARED useful to guide, assess, and compare discharge‐planning interventions.

A 61‐year‐old Hispanic male with chronic hepatitis C presented with a 4‐week history of a nonpruritic skin rash involving his lower extremities, hands, arms, and right ear. He also reported purple discoloration of his right foot, along with pain in the extremity that worsened with ambulation. Physical examination revealed diffuse purpura of both arms and legs (Figure 1). The right foot was cold to the touch and purple to black in color (Figure 2). There were multiple skin ulcers of various sizes covering the anterior aspect of his legs bilaterally. Pedal pulses were 2/4. Laboratory evaluation revealed positive cryoglobulins with low C₄ and CH₅₀ concentrations of 3 mg/dL (10‐40) and 2 units/mL (60‐144), respectively. Other immunological studies were negative. Lower extremity arterial Doppler studies were normal.

Figure 1

Figure 2

His clinical and laboratory findings were attributed to mixed cryoglobulinemia, and treatment, consisting of daily intravenous methylprednisolone, a single dose of intravenous cyclophosphamide, and plasmapheresis, was initiated. Despite these interventions, 5 days later, he developed severe burning pain in the right extremity with worsening discoloration and a line of demarcation at the level of his proximal midfoot. Eventually, right below the knee, amputation was performed, and histopathological examination showed soft‐tissue gangrene with avascular necrosis of the bone (Figure 3). The patient subsequently had an uneventful course. Plasmapheresis and oral prednisone were continued.

Figure 3

Cryoglobulinemia is a small‐ to medium‐vessel vasculitis due to cryoglobulin‐containing immune complexes. There are 3 types, with the classification based on an immunological analysis of the cryoglobulin composition. Hepatitis C virus infection is closely associated with type II mixed cryoglobulinemia. Cutaneous manifestations are the most common, consisting of palpable purpura, urticaria, postinflammatory hyperpigmentation, acrocyanosis, and skin ulcers. A serum cryoglobulin elevation is diagnostic and is usually accompanied by hypocomplementemia.

Treatment of the underlying disease is essential. However, aggressive therapy with plasmapheresis and immunosuppressive medications is warranted in severe cases involving limb‐ or organ‐threatening vasculitis.

A 61‐year‐old Hispanic male with chronic hepatitis C presented with a 4‐week history of a nonpruritic skin rash involving his lower extremities, hands, arms, and right ear. He also reported purple discoloration of his right foot, along with pain in the extremity that worsened with ambulation. Physical examination revealed diffuse purpura of both arms and legs (Figure 1). The right foot was cold to the touch and purple to black in color (Figure 2). There were multiple skin ulcers of various sizes covering the anterior aspect of his legs bilaterally. Pedal pulses were 2/4. Laboratory evaluation revealed positive cryoglobulins with low C₄ and CH₅₀ concentrations of 3 mg/dL (10‐40) and 2 units/mL (60‐144), respectively. Other immunological studies were negative. Lower extremity arterial Doppler studies were normal.

Figure 1

Figure 2

His clinical and laboratory findings were attributed to mixed cryoglobulinemia, and treatment, consisting of daily intravenous methylprednisolone, a single dose of intravenous cyclophosphamide, and plasmapheresis, was initiated. Despite these interventions, 5 days later, he developed severe burning pain in the right extremity with worsening discoloration and a line of demarcation at the level of his proximal midfoot. Eventually, right below the knee, amputation was performed, and histopathological examination showed soft‐tissue gangrene with avascular necrosis of the bone (Figure 3). The patient subsequently had an uneventful course. Plasmapheresis and oral prednisone were continued.

Figure 3

Cryoglobulinemia is a small‐ to medium‐vessel vasculitis due to cryoglobulin‐containing immune complexes. There are 3 types, with the classification based on an immunological analysis of the cryoglobulin composition. Hepatitis C virus infection is closely associated with type II mixed cryoglobulinemia. Cutaneous manifestations are the most common, consisting of palpable purpura, urticaria, postinflammatory hyperpigmentation, acrocyanosis, and skin ulcers. A serum cryoglobulin elevation is diagnostic and is usually accompanied by hypocomplementemia.

Treatment of the underlying disease is essential. However, aggressive therapy with plasmapheresis and immunosuppressive medications is warranted in severe cases involving limb‐ or organ‐threatening vasculitis.

A 61‐year‐old Hispanic male with chronic hepatitis C presented with a 4‐week history of a nonpruritic skin rash involving his lower extremities, hands, arms, and right ear. He also reported purple discoloration of his right foot, along with pain in the extremity that worsened with ambulation. Physical examination revealed diffuse purpura of both arms and legs (Figure 1). The right foot was cold to the touch and purple to black in color (Figure 2). There were multiple skin ulcers of various sizes covering the anterior aspect of his legs bilaterally. Pedal pulses were 2/4. Laboratory evaluation revealed positive cryoglobulins with low C₄ and CH₅₀ concentrations of 3 mg/dL (10‐40) and 2 units/mL (60‐144), respectively. Other immunological studies were negative. Lower extremity arterial Doppler studies were normal.

Figure 1

Figure 2

His clinical and laboratory findings were attributed to mixed cryoglobulinemia, and treatment, consisting of daily intravenous methylprednisolone, a single dose of intravenous cyclophosphamide, and plasmapheresis, was initiated. Despite these interventions, 5 days later, he developed severe burning pain in the right extremity with worsening discoloration and a line of demarcation at the level of his proximal midfoot. Eventually, right below the knee, amputation was performed, and histopathological examination showed soft‐tissue gangrene with avascular necrosis of the bone (Figure 3). The patient subsequently had an uneventful course. Plasmapheresis and oral prednisone were continued.

Figure 3

Cryoglobulinemia is a small‐ to medium‐vessel vasculitis due to cryoglobulin‐containing immune complexes. There are 3 types, with the classification based on an immunological analysis of the cryoglobulin composition. Hepatitis C virus infection is closely associated with type II mixed cryoglobulinemia. Cutaneous manifestations are the most common, consisting of palpable purpura, urticaria, postinflammatory hyperpigmentation, acrocyanosis, and skin ulcers. A serum cryoglobulin elevation is diagnostic and is usually accompanied by hypocomplementemia.

Treatment of the underlying disease is essential. However, aggressive therapy with plasmapheresis and immunosuppressive medications is warranted in severe cases involving limb‐ or organ‐threatening vasculitis.

The Joint Commission's (TJC) National Patient Safety Goal (NPSG) #8Accurately and completely reconcile medications across the continuum of carechallenges hospitals to design and implement new medication management processes. With medication errors contributing to patient morbidity and mortality,1 establishing a comprehensive process for reconciling a patient's medications during the hospitalization episode is an important quality improvement and patient safety goal.

However, the current state of inpatient medication management is highly fragmented. Standard documentation is lacking, as is integration of information between care settings.2 There are now reports describing implementation of various medication reconciliation processes for admissions,3 transfers,4 and discharges.5

Hospitalists are well‐positioned to contribute to the implementation of medication reconciliation. Indeed, because TJC does not explicitly specify what type of health care provider (eg, physician, nurse, etc.) should assume responsibility for this process, institutions have designed workflows to suit their own needs, while striving to comply with national standards.

Given the complexity and lack of standardization around this NPSG, a survey was distributed to attendees of a Society of Hospital Medicine (SHM) national meeting to determine the various processes implemented thus far, and to ascertain existing challenges to implementation. We report here on the results.

METHODS

A survey tool (Appendix) was designed to query demographic and institutional factors, involvement in the process, and barriers to implementation of medication reconciliation. Surveys were included in all attendees' registration materials, resulting in the distributions of approximately 800 surveys.

Responses were entered into an Excel spreadsheet. Simple descriptive statistics were used to determine proportions for providers, processes, and barriers to implementation. Where appropriate, variables were dichotomized, allowing for paired t‐test analysis. Statistical significance was defined as a P value less than .05. Subgroup analyses by hospital type, provider type, and process method were performed.

RESULTS

A total of 295 completed surveys were collected. The responses are tabulated in Table 1.

DISCUSSION

Managing medication information for inpatients is an extremely complex task. On admission, home medication lists are often inaccurate or absent,6 requiring extra time and effort to discover this information. By discharge, medication regimens have frequently been altered,7 making communication of changes to the next provider essential. One study described myriad provider, patient, and health system issues in maintaining accurate outpatient medication lists.8 These issues are further compounded by the multiple prescribers, necessary hand‐offs, and formulary differences in the inpatient setting.

Over half of the hospitalists in this survey reported hospitalist involvement in design and implementation of medication reconciliation. Given the familiarity with hospital systems and inpatient workflow, hospitalists are well‐positioned to contribute to successful implementation. Nonetheless, many were unaware of efforts to implement this NPSG.

Measurement of both process and outcome measures is important when determining value in quality improvement. Beyond process measures, outcome measures such as adverse drug events, readmission rates, mortality, patient satisfaction, and outpatient provider satisfaction may be appropriate in evaluating medication reconciliation strategies. Even measuring the accuracy of the process with respect to the admission orders written would be a valuable source of information for further improvement. Unfortunately, respondents indicated that evaluation was occurring infrequently. Potentially more problematic is the apparent lack of clarity regarding identification of healthcare provider responsibility for specific process steps. By far the least uniformity is in the acquisition and documentation of the preadmission medication list. There is variability in who is assigned to perform this task, but a substantial number of respondents indicated that their process involved a shared responsibility between physicians and nurses. It is unclear whether this phenomenon reflects the complexity of inpatient medication information management, or is simply an attempt to distribute the work among providers. Sharing the work between physicians and nurses may increase the overall likelihood for compliance and possibly improve the safety and accuracy of the process, especially if the physicians and nurses take the medication history in a redundant fashion and share their findings. Conversely, compliance may decrease if each provider merely expects the other to complete the process. Optimally, an interdisciplinary workflow for medication history taking would be in place, involving both physicians and nurses, with the availability of pharmacist consultation in complex cases. However, our survey data suggest this is infrequent; resident physicians appear to be the ones shouldering substantial responsibility for medication reconciliation in tertiary academic centers. Further research into the accuracy of medication reconciliation processes involving different strategies for medication information collection would be useful.

We documented several barriers to successful implementation of medication reconciliation. Physicians cited a lack of medication knowledge on the part of the patient and unavailable prior medication lists as substantial barriers to success. Many medication reconciliation processes are limited by issues of poor health literacy or inadequate patient knowledge about medications. This lack of medication knowledge is especially problematic for patients new to a healthcare system. It will be important to implement processes that not only reconcile medications accurately, but also make medication information available for future care episodes.

Time required to complete the process was also important. Certain elements of the medication reconciliation process are new work, and integrating the process into existing workflows is crucial. Given the significant time commitment required, the rare involvement of pharmacists at most institutions is striking. It appears that hospital pharmacists do not currently own any of the medication reconciliation process steps at most facilities, despite having formal training in medication history‐taking. In the 2006 ASHP national hospital pharmacy survey, one‐third of pharmacists stated that there were not enough pharmacy resources to meet medication reconciliation demands; only 19% of those surveyed stated pharmacists provided medication education at discharge to more than 25% of their patients.9

This report has several limitations. The survey used was not comprehensive, and only represents a convenience sample of hospitalists attending anational meeting. Nearly 300 physicians responded, representing both teaching and private hospital settings. We consider the response rate of 37% reasonable for a survey of this nature, and the variety of processes described is likely indicative of the overall status of medication reconciliation implementation. The over‐representation of certain institutions in our survey is possible, especially those with large or influential hospital medicine programs. Our survey did not ask respondents to name their home institutions. In addition, this design is open to a convenience sample bias, in that surveying only national meeting attendees (rather than the entire SHM membership) risks overinclusion of those hospitalists involved in leadership roles and quality improvement projects. Despite this, the variety of processes described is likely indicative of the overall status of medication reconciliation implementation in mid‐2006. It is possible that processes have become more uniform nationwide in the interim.

Our survey results reflect the complexity surrounding medication reconciliation. It appears that full implementation has not yet occurred everywhere, significant barriers remain, and outcome measurement is limited. Importantly, physicians, nurses, and pharmacists do not have standardized roles. Responsibility for medication reconciliation has predominantly been added to the existing duties of inpatient physicians and nurses, with limited involvement of pharmacists. Hospitalists are well‐positioned to lead the ongoing implementation of medication reconciliation processes and should take advantage of their systems knowledge to effectively partner with other physicians, nurses, and pharmacists to achieve success in medication reconciliation.

The Joint Commission's (TJC) National Patient Safety Goal (NPSG) #8Accurately and completely reconcile medications across the continuum of carechallenges hospitals to design and implement new medication management processes. With medication errors contributing to patient morbidity and mortality,1 establishing a comprehensive process for reconciling a patient's medications during the hospitalization episode is an important quality improvement and patient safety goal.

However, the current state of inpatient medication management is highly fragmented. Standard documentation is lacking, as is integration of information between care settings.2 There are now reports describing implementation of various medication reconciliation processes for admissions,3 transfers,4 and discharges.5

Hospitalists are well‐positioned to contribute to the implementation of medication reconciliation. Indeed, because TJC does not explicitly specify what type of health care provider (eg, physician, nurse, etc.) should assume responsibility for this process, institutions have designed workflows to suit their own needs, while striving to comply with national standards.

Given the complexity and lack of standardization around this NPSG, a survey was distributed to attendees of a Society of Hospital Medicine (SHM) national meeting to determine the various processes implemented thus far, and to ascertain existing challenges to implementation. We report here on the results.

METHODS

A survey tool (Appendix) was designed to query demographic and institutional factors, involvement in the process, and barriers to implementation of medication reconciliation. Surveys were included in all attendees' registration materials, resulting in the distributions of approximately 800 surveys.

Responses were entered into an Excel spreadsheet. Simple descriptive statistics were used to determine proportions for providers, processes, and barriers to implementation. Where appropriate, variables were dichotomized, allowing for paired t‐test analysis. Statistical significance was defined as a P value less than .05. Subgroup analyses by hospital type, provider type, and process method were performed.

RESULTS

A total of 295 completed surveys were collected. The responses are tabulated in Table 1.

DISCUSSION

Managing medication information for inpatients is an extremely complex task. On admission, home medication lists are often inaccurate or absent,6 requiring extra time and effort to discover this information. By discharge, medication regimens have frequently been altered,7 making communication of changes to the next provider essential. One study described myriad provider, patient, and health system issues in maintaining accurate outpatient medication lists.8 These issues are further compounded by the multiple prescribers, necessary hand‐offs, and formulary differences in the inpatient setting.

Over half of the hospitalists in this survey reported hospitalist involvement in design and implementation of medication reconciliation. Given the familiarity with hospital systems and inpatient workflow, hospitalists are well‐positioned to contribute to successful implementation. Nonetheless, many were unaware of efforts to implement this NPSG.

Measurement of both process and outcome measures is important when determining value in quality improvement. Beyond process measures, outcome measures such as adverse drug events, readmission rates, mortality, patient satisfaction, and outpatient provider satisfaction may be appropriate in evaluating medication reconciliation strategies. Even measuring the accuracy of the process with respect to the admission orders written would be a valuable source of information for further improvement. Unfortunately, respondents indicated that evaluation was occurring infrequently. Potentially more problematic is the apparent lack of clarity regarding identification of healthcare provider responsibility for specific process steps. By far the least uniformity is in the acquisition and documentation of the preadmission medication list. There is variability in who is assigned to perform this task, but a substantial number of respondents indicated that their process involved a shared responsibility between physicians and nurses. It is unclear whether this phenomenon reflects the complexity of inpatient medication information management, or is simply an attempt to distribute the work among providers. Sharing the work between physicians and nurses may increase the overall likelihood for compliance and possibly improve the safety and accuracy of the process, especially if the physicians and nurses take the medication history in a redundant fashion and share their findings. Conversely, compliance may decrease if each provider merely expects the other to complete the process. Optimally, an interdisciplinary workflow for medication history taking would be in place, involving both physicians and nurses, with the availability of pharmacist consultation in complex cases. However, our survey data suggest this is infrequent; resident physicians appear to be the ones shouldering substantial responsibility for medication reconciliation in tertiary academic centers. Further research into the accuracy of medication reconciliation processes involving different strategies for medication information collection would be useful.

We documented several barriers to successful implementation of medication reconciliation. Physicians cited a lack of medication knowledge on the part of the patient and unavailable prior medication lists as substantial barriers to success. Many medication reconciliation processes are limited by issues of poor health literacy or inadequate patient knowledge about medications. This lack of medication knowledge is especially problematic for patients new to a healthcare system. It will be important to implement processes that not only reconcile medications accurately, but also make medication information available for future care episodes.

Time required to complete the process was also important. Certain elements of the medication reconciliation process are new work, and integrating the process into existing workflows is crucial. Given the significant time commitment required, the rare involvement of pharmacists at most institutions is striking. It appears that hospital pharmacists do not currently own any of the medication reconciliation process steps at most facilities, despite having formal training in medication history‐taking. In the 2006 ASHP national hospital pharmacy survey, one‐third of pharmacists stated that there were not enough pharmacy resources to meet medication reconciliation demands; only 19% of those surveyed stated pharmacists provided medication education at discharge to more than 25% of their patients.9

This report has several limitations. The survey used was not comprehensive, and only represents a convenience sample of hospitalists attending anational meeting. Nearly 300 physicians responded, representing both teaching and private hospital settings. We consider the response rate of 37% reasonable for a survey of this nature, and the variety of processes described is likely indicative of the overall status of medication reconciliation implementation. The over‐representation of certain institutions in our survey is possible, especially those with large or influential hospital medicine programs. Our survey did not ask respondents to name their home institutions. In addition, this design is open to a convenience sample bias, in that surveying only national meeting attendees (rather than the entire SHM membership) risks overinclusion of those hospitalists involved in leadership roles and quality improvement projects. Despite this, the variety of processes described is likely indicative of the overall status of medication reconciliation implementation in mid‐2006. It is possible that processes have become more uniform nationwide in the interim.

Our survey results reflect the complexity surrounding medication reconciliation. It appears that full implementation has not yet occurred everywhere, significant barriers remain, and outcome measurement is limited. Importantly, physicians, nurses, and pharmacists do not have standardized roles. Responsibility for medication reconciliation has predominantly been added to the existing duties of inpatient physicians and nurses, with limited involvement of pharmacists. Hospitalists are well‐positioned to lead the ongoing implementation of medication reconciliation processes and should take advantage of their systems knowledge to effectively partner with other physicians, nurses, and pharmacists to achieve success in medication reconciliation.

The Joint Commission's (TJC) National Patient Safety Goal (NPSG) #8Accurately and completely reconcile medications across the continuum of carechallenges hospitals to design and implement new medication management processes. With medication errors contributing to patient morbidity and mortality,1 establishing a comprehensive process for reconciling a patient's medications during the hospitalization episode is an important quality improvement and patient safety goal.

However, the current state of inpatient medication management is highly fragmented. Standard documentation is lacking, as is integration of information between care settings.2 There are now reports describing implementation of various medication reconciliation processes for admissions,3 transfers,4 and discharges.5

Hospitalists are well‐positioned to contribute to the implementation of medication reconciliation. Indeed, because TJC does not explicitly specify what type of health care provider (eg, physician, nurse, etc.) should assume responsibility for this process, institutions have designed workflows to suit their own needs, while striving to comply with national standards.

Given the complexity and lack of standardization around this NPSG, a survey was distributed to attendees of a Society of Hospital Medicine (SHM) national meeting to determine the various processes implemented thus far, and to ascertain existing challenges to implementation. We report here on the results.

METHODS

A survey tool (Appendix) was designed to query demographic and institutional factors, involvement in the process, and barriers to implementation of medication reconciliation. Surveys were included in all attendees' registration materials, resulting in the distributions of approximately 800 surveys.

Responses were entered into an Excel spreadsheet. Simple descriptive statistics were used to determine proportions for providers, processes, and barriers to implementation. Where appropriate, variables were dichotomized, allowing for paired t‐test analysis. Statistical significance was defined as a P value less than .05. Subgroup analyses by hospital type, provider type, and process method were performed.

RESULTS

A total of 295 completed surveys were collected. The responses are tabulated in Table 1.

DISCUSSION

Managing medication information for inpatients is an extremely complex task. On admission, home medication lists are often inaccurate or absent,6 requiring extra time and effort to discover this information. By discharge, medication regimens have frequently been altered,7 making communication of changes to the next provider essential. One study described myriad provider, patient, and health system issues in maintaining accurate outpatient medication lists.8 These issues are further compounded by the multiple prescribers, necessary hand‐offs, and formulary differences in the inpatient setting.

Over half of the hospitalists in this survey reported hospitalist involvement in design and implementation of medication reconciliation. Given the familiarity with hospital systems and inpatient workflow, hospitalists are well‐positioned to contribute to successful implementation. Nonetheless, many were unaware of efforts to implement this NPSG.

Measurement of both process and outcome measures is important when determining value in quality improvement. Beyond process measures, outcome measures such as adverse drug events, readmission rates, mortality, patient satisfaction, and outpatient provider satisfaction may be appropriate in evaluating medication reconciliation strategies. Even measuring the accuracy of the process with respect to the admission orders written would be a valuable source of information for further improvement. Unfortunately, respondents indicated that evaluation was occurring infrequently. Potentially more problematic is the apparent lack of clarity regarding identification of healthcare provider responsibility for specific process steps. By far the least uniformity is in the acquisition and documentation of the preadmission medication list. There is variability in who is assigned to perform this task, but a substantial number of respondents indicated that their process involved a shared responsibility between physicians and nurses. It is unclear whether this phenomenon reflects the complexity of inpatient medication information management, or is simply an attempt to distribute the work among providers. Sharing the work between physicians and nurses may increase the overall likelihood for compliance and possibly improve the safety and accuracy of the process, especially if the physicians and nurses take the medication history in a redundant fashion and share their findings. Conversely, compliance may decrease if each provider merely expects the other to complete the process. Optimally, an interdisciplinary workflow for medication history taking would be in place, involving both physicians and nurses, with the availability of pharmacist consultation in complex cases. However, our survey data suggest this is infrequent; resident physicians appear to be the ones shouldering substantial responsibility for medication reconciliation in tertiary academic centers. Further research into the accuracy of medication reconciliation processes involving different strategies for medication information collection would be useful.

We documented several barriers to successful implementation of medication reconciliation. Physicians cited a lack of medication knowledge on the part of the patient and unavailable prior medication lists as substantial barriers to success. Many medication reconciliation processes are limited by issues of poor health literacy or inadequate patient knowledge about medications. This lack of medication knowledge is especially problematic for patients new to a healthcare system. It will be important to implement processes that not only reconcile medications accurately, but also make medication information available for future care episodes.

Time required to complete the process was also important. Certain elements of the medication reconciliation process are new work, and integrating the process into existing workflows is crucial. Given the significant time commitment required, the rare involvement of pharmacists at most institutions is striking. It appears that hospital pharmacists do not currently own any of the medication reconciliation process steps at most facilities, despite having formal training in medication history‐taking. In the 2006 ASHP national hospital pharmacy survey, one‐third of pharmacists stated that there were not enough pharmacy resources to meet medication reconciliation demands; only 19% of those surveyed stated pharmacists provided medication education at discharge to more than 25% of their patients.9

This report has several limitations. The survey used was not comprehensive, and only represents a convenience sample of hospitalists attending anational meeting. Nearly 300 physicians responded, representing both teaching and private hospital settings. We consider the response rate of 37% reasonable for a survey of this nature, and the variety of processes described is likely indicative of the overall status of medication reconciliation implementation. The over‐representation of certain institutions in our survey is possible, especially those with large or influential hospital medicine programs. Our survey did not ask respondents to name their home institutions. In addition, this design is open to a convenience sample bias, in that surveying only national meeting attendees (rather than the entire SHM membership) risks overinclusion of those hospitalists involved in leadership roles and quality improvement projects. Despite this, the variety of processes described is likely indicative of the overall status of medication reconciliation implementation in mid‐2006. It is possible that processes have become more uniform nationwide in the interim.

Our survey results reflect the complexity surrounding medication reconciliation. It appears that full implementation has not yet occurred everywhere, significant barriers remain, and outcome measurement is limited. Importantly, physicians, nurses, and pharmacists do not have standardized roles. Responsibility for medication reconciliation has predominantly been added to the existing duties of inpatient physicians and nurses, with limited involvement of pharmacists. Hospitalists are well‐positioned to lead the ongoing implementation of medication reconciliation processes and should take advantage of their systems knowledge to effectively partner with other physicians, nurses, and pharmacists to achieve success in medication reconciliation.

Preventable adverse events occur when patients transition from hospital to outpatient care.1, 2 The most common cause for postdischarge adverse events is poor communication between inpatient healthcare providers and outpatient primary care physicians.1 Adverse events also occur because of inadequate processes to communicate unresolved problems, monitor drug therapies, or monitor the patient's overall condition.1 Efforts to reduce adverse events logically focus on effective discharge planning and communication.

Systematic reviews have evaluated clinical trials to improve discharge planning and communication.36 Reviewers often reported inconclusive results because of a shortage of high‐quality trials with validated outcome measures.35 Reviewers recommended future studies to develop and validate outcome measures that assessed the discharge process from various perspectives.4 One important perspective was the assessment by the outpatient, primary care physician who was responsible for patient care after discharge.79

One of the authors (K.G.S.) developed the Physician‐PREPARED questionnaire to measure perceptions of outpatient physicians about the quality of hospital discharge. Item content came from studies in Australia that investigated barriers to best practice in discharge planning for older patients.1013 Fifteen items asked community physicians about their awareness of discharge planning processes for their patients. Items also assessed the adequacy of information provided about discharge plans. The Physician‐PREPARED items underwent assessment in Australia. Evaluation revealed well‐worded text, unambiguous response options, face validity, and content validity.

We reconsidered the Physician‐PREPARED questionnaire when we designed a clinical trial to assess the value of a discharge intervention in the United States. Our goal was a comprehensive survey instrument and scale to measure the perceptions of outpatient physicians after the discharge intervention. We found no other appropriate, validated questionnaires except the Physician‐PREPARED. However, we recognized some limitations to the Physician‐PREPARED. The items were developed for Australian physicians who treated elderly patients. We wanted to assess North American physicians who cared for a broad age range of adults. The Physician‐PREPARED did not have a scale with validated, psychometric performance characteristics in our population. We decided to address the above limitations with a scale development and validation study in the United States.

In the present work, we describe item development for the Physician‐PREPARED that occurred in Australia. Then we present item reduction and validation for the Modified Physician‐PREPARED that occurred in the United States. Our primary objective was to validate a scale to measure perceptions of outpatient physicians about qualities of discharge planning and communication. The secondary objectives were to quantify the scale's internal consistency and construct validity. Our goal was a brief scale with acceptable, defined statistical properties for clinicians and researchers.

PATIENTS AND METHODS

RESULTS

DISCUSSION

The Modified Physician‐PREPARED scale measured the quality of discharge planning and communication from the perspective of the outpatient primary care physician or practitioner. We described the derivation of the scale items. We demonstrated the reliability and validity of the scale among physicians and practitioners who provided postdischarge care to patients at high risk for readmission to the hospital. The item content included timeliness, adequacy, patient health status, medication information, and reasons for medication changes.

According to expert consensus guidelines for hospital discharge care, the communication with the outpatient primary care physician should occur as soon as possible after discharge.25 Recommended data elements in the communication include condition at discharge, diagnoses, medications added, medications discontinued, and medications changed.25 We found the Modified Physician‐PREPARED scale items included content that was consistent with expert consensus guidelines. The items also assessed timeliness and adequacy, 2 domains important to outpatient physicians.14, 26

The Modified Physician‐PREPARED is one of several questionnaires developed to measure qualities of discharge processes from the perspective of outpatient physicians.8, 15, 2733 Previous questionnaires did not report psychometrics except 1 that assessed the quality of discharge summaries and measured test‐retest reliability.33 We are not aware of other physician questionnaires with reliable or valid scales besides the Modified Physician‐PREPARED.

We believe 1 application of the Modified Physician‐PREPARED questionnaire is in quality improvement efforts within hospitals. Most hospitals and inpatient physicians rely on discharge letters or summaries to communicate information about the hospitalization to outpatient practitioners.6 However, systematic problems with generation and transmission of letters and summaries make them sometimes unreliable as sources of consistent, timely, accurate, or important information.6 When patients arrive for their posthospital visits, their outpatient physicians have received no discharge letter for 16% to 53% of patients and no discharge summary for 66% to 88%.6 Among outpatient physicians, 41% attribute preventable adverse events for at least 1 of their patients to inadequate discharge communication.34 One hospital accreditation organization includes discharge communication improvement as a national patient safety goal in the United States.35 Hospitals have multiple motivations to pursue quality improvement projects related to discharge communication: reduction in adverse events, relation with referring physicians, and accreditation by regulators. When surveying physicians, hospital personnel may wish to use a reliable and validated instrument like the Modified Physician‐PREPARED questionnaire.

Another application of the Modified Physician‐PREPARED scale is in research. An example is our randomized, controlled trial to measure the value of a discharge intervention. We published the rationale and design for our intervention.36 In the future, we will analyze the results of our trial and we will need validated scales. One of the trial outcomes is the perspective of the outpatient physician. We expect to compare the scores on the Modified Physician‐PREPARED scale values from community practitioners who treated test patients versus control patients. The statistical properties of the Modified Physician‐PREPARED scale that we validated in the current work will allow us to estimate the precision of between‐group differences and to perform tests of inference.

The results of our study should be interpreted in the context of strengths and limitations. We were able to generalize the validity of the Modified Physician‐PREPARED to North American primary care physicians who treated adult outpatients with a broad age range. We minimized biases with the high survey response rate and low proportion of missing responses. During validation, we asked physicians to evaluate patient transitions from hospital to home. Consequently, the Modified Physician‐PREPARED scale may not apply when doctors follow patients after discharge to nursing homes or other acute care facilities. We excluded patients with low probability of repeat admission: hospice patients and patients with low Pra scores. The purpose of our exclusion criteria was to enrich the sample with patients likely to benefit from interventions to improve discharge processes. We recognize that the Modified Physician‐PREPARED may not generalize to physicians who treat hospice patients or patients with low probability for readmission.

Additional limitations relate to test‐retest reliability and to the clinical meaning of small changes in scale values. In our study, physician respondents returned questionnaires approximately 3 weeks after hospital discharge. We did not ask physicians to complete the questionnaire again after they returned the first questionnaire. Therefore, the test‐retest reliability for the Modified Physician‐PREPARED is unknown. Our protocol was not designed to detect the minimum important difference in the scale values. Consequently, small changes in scale values have uncertain clinical relevance. Future studies are necessary to assess the minimum important difference in the scale values.

CONCLUSION

The Modified Physician‐PREPARED scale was a reliable and valid measure of outpatient physician perceptions of quality and communication after hospital discharge. Clinicians and researchers may find the scale useful to guide, assess, and compare discharge‐planning activities.