At discharge, patients typically have one thing on their mind: getting home. "At discharge, nursing is the only thing standing between the patient and the door," says Cheryl Bailey, R.N., Cullman's chief nursing officer who served as manager of the discharge summary project. "There is so much information given to the patient and the family. It can be overwhelming. Patients were not listening, did not understand or were afraid to ask questions. Patients get home and they might say to the family, 'they made some medication changes,' but they don't remember them."
Cullman's bedside patient discharge process was time-honored. Responding to the physician's discharge order, a nurse would gather up all the information a patient needed, such as a to-do list for follow-up visits, instructions for current medications and any new prescriptions that needed to be filled and would review the documents at bedside. Nurses also handed out pre-printed instructions on various mediations. The patients would listen, sign a copy and take another copy home. Even though the interaction is typically not long-three minutes on average-patients often underestimated its importance, adds Paula Burks, R.N., director of critical care. "You would be surprised at the number of patients who actually toss the instructions into the garbage when they get home," Burks says. "In the shuffle, the instructions get lost. Then all of a sudden the patients realized what was on the paper and they were left with nothing."
To tackle the problem, Cullman turned to one its long-standing software suppliers, Vocera. Cullman has been using Vocera's voice communications badge for eight years, says Burks. It relays voice messages across a wireless network, dispatching communications directly to the nurse and sidestepping overhead paging. Experia Health, a division of Vocera, contacted Burks to see if she had any interest in serving as a guinea pig for a new patient discharge communications product-which later became "Good to Go." Burks describes Cullman as a very tech-friendly environment. "We love technology at this hospital," she enthuses. "We're on the cutting edge. Experia told me about the new product and it seemed easy" so she agreed to becoming a beta site. "If there is something that could benefit us, we will try it."
That was in the summer of 2011. By October, the hospital had gone live with the unit-which the vendor modified in accordance with nurse input from Cullman. Its set-up is simple, and adds no extra time to the discharge process, Burks says. She explains how the process works: Nurses are given an iPod Touch, which resides at a charging station. When it is time to conduct a discharge meeting, the nurse gathers up the typical documents for signing and takes the device to the bedside. Using the iPod, the nurse records the interaction with the patient, including any questions from the patient and their answers. That information is automatically downloaded to a Web site hosted by the vendor and the voice file becomes part of an online package available to the patient.
The iPod Touch has been stripped down of its standard features, such as music downloads, and has no other activated features, says Bailey. "There no music on the device and it can't be used to make calls," she says. The device, however, is interfaced with the hospital's inpatient EHR, from CPSI. The iPod Touch gets an ADT feed from the EHR, and when the nurse logs on, the device will pull in a list of names admitted to the hospital, organized by floor. During the discharge, the nurse goes to her floor, clicks on the patient name and pulls up a discharge template for a given condition, such as CHF. The system will generate a PIN number for the patient to later use to access the recording, a number which the nurse writes down on a preprinted form for the patient. She then records the conversation, and upon completion, the Good to Go system securely dispatches the voice file to its Web site.
As part of the patient's take-home package, they receive the instruction sheet on how to access the Good to Go Web site, which the vendor hosts remotely and which has customized pages for each patient. Patients can also call an 800 number if they just want to listen to the conversation. The Web site-one of the modifications added during the beta development-includes related hospital-produced videos to the discharge condition, and Bailey says the hospital has "just begun to scratch the surface" of adding related content to the patient page. "Think of all the reasons you're admitted. That is a lot of templates to tailor and a lot of videos to complete." Physicians have expressed interest in adding their own video messages to patients, she notes.
During its first phase of the project, Cullman deployed the technology in Burks' "step down unit," reserved for patients who do not qualify as critical care patients, but who still need more attention than a regular unit. These are typically patients with CHF, pneumonia and acute MI, says Bailey. They're also likely candidates for 30-day readmissions. The 31-bed unit is usually full to capacity, Burks says.
Cullman currently deploys the technology in six departments, including its post-op, maternity and one-day surgery departments. The set-up is used for situations other than discharges, as well. For example, respiratory therapists use the devices to record any specialized patient care instructions the patient might need at home. Those recordings become part of the patient's online package. Bailey's next project is linking in nursing homes with the technology. A case manager planning a nursing home stay will record her dialogue with the patient. And the patient's Web site will include related links to the home itself. "The nursing home can dial in as well and hear exactly what our case manager told the patient. Our goal is to improve communications between hospital and nursing home."
