Case 1: Heart failure plan
A 75-year-old man is being discharged following treatment for acute decompensated heart failure. The patient and his wife are alerted to symptoms that indicate acute worsening of his heart failure and are informed of when he should seek immediate medical assistance. The discharge medication list and the side effects of these medications are reviewed, and the patient and his wife acknowledge an understanding. A nursing education visit regarding the hospital stay and evaluations is completed. A copy of the discharge summary is given to the patient, and a follow-up appointment is scheduled with his internist in 7 days.
Which of the following is also recommended to improve patient safety and reduce rehospitalization in this patient?
A. Follow-up telephone call and one home nursing visitation
B. Home telemonitoring
C. Postdischarge patient education
D. Timely discharge summary for the primary care physician
Case 2: Alcohol use disorder
A 42-year-old woman is approaching discharge from the hospital for alcohol withdrawal. She has had severe alcohol use disorder for several years but says she is willing to do whatever it takes to quit. Medical history is also significant for hypertension and chronic kidney disease. Medications are amlodipine and chlorthalidone.
Physical examination, including vital signs, is normal.
A complete blood count and comprehensive metabolic profile are normal. The estimated glomerular filtration rate is 50 mL/min/1.73 m2.
Which of the following is the most appropriate pharmacologic treatment?
Case 3: Medication discontinuation
A 62-year-old woman is admitted to the hospital for pneumonia. Her medical history is significant for stage I estrogen receptor–positive invasive breast cancer, for which she was treated with breast-conserving surgery and radiation therapy and then started on tamoxifen. During her hospital stay, antibiotic therapy is initiated, and tamoxifen is withheld. Following discharge, the patient is evaluated in the office, and it is noted that she is no longer taking tamoxifen.
Which of the following measures would have most likely prevented this medication error?
A. Computerized physician order entry
B. Electronic medication administration record use
C. Improved medication labeling
D. Medication reconciliation
Case 4: Discharge disposition
An 82-year-old man is evaluated for discharge planning. He was hospitalized with community-acquired pneumonia complicated by respiratory failure and sepsis, which required prolonged mechanical ventilation. He eventually required a tracheostomy and remains on mechanical ventilation, but his respiratory status is otherwise stable. He is severely deconditioned and has been unable to participate even minimally in physical therapy. Although he is expected to require mechanical ventilation for at least several more weeks, he is medically stable for discharge. Medical history is significant for chronic kidney disease, heart failure, hypertension, and type 2 diabetes mellitus. Medications are insulin aspart, insulin glargine, carvedilol, furosemide, and lisinopril.
On physical examination, the patient is alert and cooperative but appears frail on mechanical ventilation. Vital signs and the remainder of the examination are normal.
Which of the following is the most appropriate discharge disposition for this patient?
A. Acute rehabilitation facility
B. In-home rehabilitation services
C. Rehabilitation at a long-term acute care hospital
D. Skilled nursing facility
Case 5: Community-acquired pneumonia
A 74-year-old homeless woman is evaluated for hospital discharge. She was admitted 6 days ago with a diagnosis of community-acquired pneumonia, and empiric ceftriaxone and azithromycin were begun. Her fever resolved within 48 hours of admission; however, hospital discharge was delayed because of difficulty arranging posthospitalization placement. Medical history is otherwise noncontributory. She takes no other medications.
On physical examination, vital signs are normal. Oxygen saturation is 96% breathing ambient air. The remainder of the examination is unremarkable.
Sputum culture obtained at admission is growing Streptococcus pneumoniae sensitive to penicillin, ceftriaxone, levofloxacin, and vancomycin and resistant to erythromycin. Blood cultures obtained at admission show no growth.
The patient has been accepted into a group home and is ready for hospital discharge.
Which of the following is the most appropriate management at discharge?
A. Continue only azithromycin
B. Continue only ceftriaxone
C. Stop all antibiotics
D. Stop ceftriaxone and azithromycin and switch to amoxicillin
E. Stop ceftriaxone and azithromycin and switch to levofloxacin
Case 6: Decision-making capacity
A 70-year-old man is evaluated before discharge from the hospital after treatment for community-acquired pneumonia. Medical history is significant for mild dementia. The patient lives alone and has a daughter who lives nearby. Remaining in his home is very important to him.
The care team recommends that the patient be discharged to a short-term rehabilitation facility to gain strength and prepare him to safely return to his home. The patient refuses. Decision-making capacity is assessed; he is able to articulate the risks, benefits, and alternatives to short-term rehabilitation as well as an understanding of his current medical condition.
Which of the following is the most appropriate management?
A. Administer the Mini–Mental State Examination
B. Ask the patient's daughter to make a decision on his behalf
C. Discharge the patient home with home care services
D. Obtain a court order for the patient to be discharged to a rehabilitation facility
E. Refer the patient to a psychiatrist for a capacity assessment
Case 7: Postdischarge monitoring
A 58-year-old man is assessed for discharge from the hospital. He was admitted 3 days ago with fever and chills. He has non-Hodgkin lymphoma and a tunneled subclavian venous catheter used for chemotherapy infusion. Blood cultures at admission grew vancomycin-resistant Enterococcus faecium. The patient's catheter was removed, a peripherally inserted central catheter (PICC) was placed for intravenous access, and daptomycin therapy was initiated. Blood cultures are now negative, and the patient is afebrile.
The patient is ready to be discharged to complete intravenous daptomycin therapy as an outpatient. At the time of discharge, his complete blood count and comprehensive chemistry profile are normal.
Which of the following is the most appropriate weekly monitoring of his daptomycin therapy?
A. Electrocardiography and blood glucose
B. Hemoglobin and platelet count
C. Serum amylase and triglycerides
D. Serum creatinine and creatine kinase
Answers and commentary
Correct answer: D. Timely discharge summary for the primary care physician.
Communicating with and sharing the discharge summary with the primary care physician is recommended to improve patient safety and reduce rehospitalization in this patient. The evidence to support a reduction in hospital readmissions with completion of a discharge summary is mixed, most likely because of many complex factors that are difficult to control, such as timeliness, completeness, and quality of the discharge summary. However, the Institute for Healthcare Improvement identifies the lack of a timely discharge summary as a barrier to patient safety and prevention of early hospital readmission and therefore recommends a timely discharge summary as a key element in improving the transition of care from hospital to home. A discharge summary should include the evaluations performed, medication reconciliation, pending test results, required follow-up tests, and follow-up appointments and should be shared with the follow-up clinician. Timely follow-up with the primary care clinician is also important in ensuring that the transition goes smoothly. Another approach that has been successful in reducing hospitalization is the use of multiple team members, such as a nurse and pharmacist, to provide components of care.
A systematic review found that implementation of an intensive home visitation program reduced the risk for hospital readmission for heart failure at 3 to 6 months. This intervention included a series of eight planned home visits, the first within 24 hours of discharge. A medium-intensity intervention that included one telephone call within 7 days of discharge and one planned home visit within 10 days of discharge found no statistically significant reduction in all-cause readmissions or mortality.
Home telemonitoring of patients with heart failure had no impact on hospital readmission or mortality. Postdischarge heart failure patient education programs also failed to result in reduced readmission rates or lower mortality.
- A discharge summary that includes the evaluations performed, medication reconciliation, pending test results, required follow-up tests, and follow-up appointments is an important tool in the communication between the hospital and the follow-up clinician.
Correct answer: D. Naltrexone.
The most appropriate treatment is naltrexone. Recent developments in the pharmacologic treatment of alcohol use disorder focus on modifying the reinforcing effects of alcohol use. Physicians underprescribe medications to treat alcohol use disorder and prevent relapse, despite their demonstrated efficacy. This patient, with hypertension and stage 3 chronic kidney disease, would likely benefit most from naltrexone. Available in both oral and long-acting injectable forms, naltrexone has been associated with a substantial decrease in 30-day readmission and emergency department visits when prescribed to patients with alcohol dependence at the time of hospital discharge. Multiple systematic reviews and meta-analyses of clinical trials have found naltrexone to reduce alcohol consumption compared with placebo. Naltrexone carries a risk for hepatotoxicity, for which the patient should be monitored; however, hepatotoxicity is rare with the dosages used for alcohol use disorder. Because naltrexone is an opioid receptor antagonist, opioids are contraindicated while the patient is taking naltrexone. Caution should also be used in patients with depression, due to an increased risk for suicidal ideation.
Acamprosate is FDA approved for the maintenance of abstinence in alcohol use disorder. This medication likely works through the N-methyl-D-aspartate receptor to modulate γ-aminobutyric acid and glutamate levels. The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder recommends that acamprosate not be used as first-line therapy in persons with mild to moderate kidney impairment, but if used, the dosage should be reduced. Acamprosate is contraindicated in cases of severe kidney disease (estimated glomerular filtration rate <30 mL/min/1.73 m2). Additionally, the thrice-daily dosage regimen can hinder adherence to acamprosate.
Although chlordiazepoxide can be used to treat alcohol withdrawal, it is not indicated for relapse prevention because of its addiction potential and ineffectiveness.
Disulfiram inhibits acetaldehyde dehydrogenase, causing buildup of aldehyde after alcohol consumption; the associated flushing, nausea, and vomiting act as a deterrent to further alcohol use. Unlike naltrexone and acamprosate, disulfiram does not directly diminish the motivation to drink, but it is an aversion therapy causing an unpleasant physiologic reaction when alcohol is consumed. Disulfiram is now considered second-line therapy.
- Naltrexone, which is available in both oral and long-acting injectable forms, is associated with a substantial decrease in 30-day readmission and emergency department visits when prescribed to patients with alcohol dependence at the time of hospital discharge.
Correct answer: D. Medication reconciliation.
Medication reconciliation would have most likely prevented this medication error. Medication reconciliation is the process of creating an accurate, comprehensive list of the patient's prescription and nonprescription medications (including the dose, frequency, and route of administration) and comparing the list to medication orders (at admission, transfer, or discharge) to resolve inconsistencies. Completion of medication reconciliation decreases adverse drug events, and although the effect on hospital readmissions, morbidity, and mortality is less clear, medication reconciliation should occur at all care transitions to prevent medication errors. In this case, tamoxifen was withheld upon admission but should have been restarted at the time of the patient's discharge from the hospital. Medication reconciliation at the time of discharge would have prevented this error, which resulted in a lapse in the patient's breast cancer treatment.
Computerized physician order entry (CPOE) systems are designed to improve the medication ordering process and prevent medication errors and medication adverse events. Some CPOE systems are integrated with decision support systems. CPOE has resulted in many practice improvements, including standardization of care, improved legibility of orders, and implementation of medication alerts (such as allergy and drug interaction alerts). However, CPOE cannot replace medication reconciliation and would not have prevented this medication error at a transition of care.
Manually transcribing physician medication orders into a paper-based medication administration record, even if originated by using the CPOE process, can lead to medication administration errors and adverse events. However, using a system that features a direct electronic interface between CPOE and the electronic medication administration record can eliminate transcription errors and errors in reading and interpreting hand-written, paper-based medication administration records. Such a system does not replace medication reconciliation and would not have prevented this medication error at the time of discharge.
Improved medication labeling, including the use of “tall man” lettering (for example, DOBUTamine versus DOPamine), helps minimize confusion surrounding look-alike and sound-alike medications, thereby reducing medication errors. However, improved medication labeling would not have prevented this medication error resulting from a transition of care.
- Medication reconciliation should occur at all transitions of care to prevent medication errors.
Correct answer: C. Rehabilitation at a long-term acute care hospital.
The most appropriate discharge plan for this patient is rehabilitation at a long-term acute care hospital (LTACH). The patient requires continued mechanical ventilation but otherwise no longer requires hospitalization. LTACHs provide longer-term, higher-intensity medical treatment, such as complex wound care, mechanical ventilation weaning, and treatment with intravenous medications. Patients can also receive physical rehabilitation at such facilities.
Acute rehabilitation in a specialized rehabilitation facility is an appropriate choice for patients who require short-term rehabilitation (typically <4 weeks). To ensure reimbursement of services, such facilities require that a patient be able to participate in therapy at least 3 hours per day, 5 days per week. This patient clearly does not meet these criteria.
In-home rehabilitation services are useful for patients who may safely return home but still require physical or occupational therapy to continue optimizing return to their previous level of functioning. In-home rehabilitation services would not be a safe option for this patient who still requires mechanical ventilation and has significant physical deconditioning.
Subacute rehabilitation at a skilled nursing facility is a good option for patients who are not physically ready to return to their previous living situation but cannot tolerate at least 3 hours of therapy per day, 5 days per week. Skilled nursing facilities have physician directors but do not have the physician or staff resources to provide the complex medical care this patient requires.
- Long-term acute care hospitals provide longer-term, higher-intensity medical treatment, such as complex wound care, mechanical ventilation weaning, and treatment with intravenous medications; such facilities also provide physical rehabilitation services.
Correct answer: C. Stop all antibiotics.
The most appropriate management for this patient at discharge is to discontinue her antibiotics. She had pneumococcal pneumonia requiring hospitalization for treatment and stabilization. Her clinical status rapidly improved with appropriate empiric therapy. The Infectious Diseases Society of America/American Thoracic Society guidelines recommend an antibiotic treatment duration for uncomplicated community-acquired pneumonia of 5 to 7 days. A recent randomized trial found no difference in clinical response between patients treated for 5 days compared with control patients who received a median of 10 days of antibiotic therapy. This study was limited to immunocompetent patients who did not require admission to the ICU and who defervesced at least 48 hours before antibiotic discontinuation; short-course therapy has not been validated in patients with complicated infection, including those at risk for Staphylococcus aureus or Pseudomonas infection. Short-course therapy offers the advantages of minimizing the risk of adverse effects, lowering cost, and potentially decreasing length of hospital stay. Because this patient completed more than 5 days of therapy during hospitalization, no further antibiotics are indicated at discharge.
Under the same circumstances, azithromycin would be contraindicated because the isolate was resistant to erythromycin, indicating a class effect of macrolide resistance.
Continuing ceftriaxone would necessitate either continued inpatient intravenous treatment or placement of an indwelling intravenous line for outpatient therapy, both unnecessary interventions.
The management of patients who have clinically responded before completing 5 days of inpatient therapy can be challenging, especially if cultures are negative. Antibiotic de-escalation from parenteral to oral formulations is appropriate when patients have clinically improved. If this patient had been ready for discharge before completing 5 days of therapy, transition to oral amoxicillin would have been appropriate for completing the antibiotic course.
Although levofloxacin is active against this patient's infection, it is overly broad therapy for a penicillin-sensitive strain of Streptococcus pneumoniae.
- In patients with uncomplicated community-acquired pneumonia not requiring ICU admission, a short course of antibiotic therapy (5-7 days) is sufficient.
Correct answer: C. Discharge the patient home with home care services.
The most appropriate management is to discharge this patient home with home care services. Patients should be presumed legally competent to make medical decisions unless found otherwise by judicial determination. However, in the clinical setting, physicians must frequently determine a patient's decision-making capacity by assessing the patient's ability to understand the relevant information, appreciate the medical consequences of the situation, consider various treatment options, and communicate a choice. Decision-making capacity should be evaluated for each decision to be made, and frequent reassessment is necessary to confirm prior determinations of capacity. Patients with depression or mild dementia may retain decision-making capacity; however, in such circumstances, the capacity assessment should be performed more cautiously, particularly when a decision may result in serious consequences. Validated tools, such as the Aid to Capacity Evaluation, may be useful for capacity assessment in the clinical setting. In this situation, the assessment reveals that the patient demonstrates sufficient capacity to make decisions; thus, he should be discharged home with appropriate services to ensure his safety. This patient's choice is also consistent with his previously expressed wishes, which lends validity to his decision.
Cognitive evaluations, such as the Mini–Mental State Examination, do not assess capacity; rather, they are used to detect cognitive impairment.
This competent and autonomous patient is able to make his own choices; therefore, the patient's daughter should not be asked to make a decision on his behalf.
Formal assessments of competence require judicial determination, although a competency hearing is not usually required for clinical decision making. In this case, a court order for the patient to be discharged to a rehabilitation facility is not required because he demonstrates decision-making capacity.
A psychiatric consultation is unnecessary to determine a patient's decision-making capacity; any physician can perform this assessment. However, some hospitals may suggest a psychiatric evaluation in high-stakes situations, such as when a patient requests to leave against medical advice.
- In the clinical setting, physicians must determine a patient's decision-making capacity by assessing the patient's ability to understand the relevant information, appreciate the medical consequences of the situation, consider various treatment options, and communicate a choice.
Correct answer: D. Serum creatinine and creatine kinase.
Patients receiving outpatient daptomycin therapy should undergo baseline measurement of kidney function and creatine kinase (CK) followed by weekly monitoring. Patients should also be screened for symptoms of myopathy. Daptomycin is commonly used for outpatient parenteral antibiotic therapy (OPAT) because of its safety profile, ease of administration (once daily), and good activity against gram-positive bacteria, including vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus. However, daptomycin is known to cause elevated levels of CK and can contribute to the development of myopathy during therapy. Daptomycin should be discontinued in asymptomatic patients if CK levels increase to greater than 10 times the upper limit of normal or the CK level is greater than 5 times the upper limit of normal with symptoms of myopathy. Concomitant treatment with statins (particularly simvastatin and atorvastatin) may increase the chance of developing an elevated CK level; it is suggested that statins be discontinued if possible during daptomycin treatment. If statins cannot be discontinued, or if kidney dysfunction is evident, the CK level should be monitored more frequently than once weekly. Likewise, the creatinine level should also be monitored because daptomycin dosing may require adjustment (lower dose or dosing interval of every other day), and CK may require more frequent monitoring if the creatinine level increases.
Daptomycin use does not require electrocardiographic monitoring, and it has no effect on the bone marrow (for example, erythrocyte or platelet suppression), pancreas, lipid levels, or blood glucose level; so weekly amylase, triglyceride, glucose, and hemoglobin measurements and platelet count monitoring are unnecessary (although periodic leukocyte counts may be necessary in some patients for monitoring of the primary infection). It is important for patients undergoing OPAT to have close follow-up to monitor for any adverse effects from antibiotic therapy (including development of vascular access infections) as well as resolution of the infection being treated.
- Patients receiving daptomycin therapy should undergo baseline measurement of kidney function and creatine kinase level followed by weekly monitoring.