For some patients, the healthcare journey occurs in chapters, different parts happening at different places. Reassurance about next steps is crucial, particularly for those being treated for mental health.
The Psychiatric Emergency Services Unit (PESU) at Toronto Western Hospital (TW) provides care to people experiencing a mental health crisis. The clinical team wanted to improve the discharge process for patients, who often come directly to the unit from the Emergency Department for mental health and addictions treatment before moving to ongoing support at other TW clinics or elsewhere.
"When patients are stabilized and we can consider discharging them, what comes next can make them nervous," says Mohammed Oruvampurath, Manager, PESU. "We wanted to provide a structure for the discharge conversation that both involved our patients and provided documentation they could use."
Patient Oriented Discharge Summary (PODS) a standardized but adaptable tool developed by UHN OpenLab, a design and innovation group dedicated to finding creative healthcare solutions.
Designed for patients with limited health literacy, language barriers or who are hard to reach after they leave the hospital due to homelessness or other social issues, PODS uses plain language, large fonts, and pictures to create a discharge summary patients can easily understand.
PODS resources and support centralized through UHN OpenLab
"Research shows that these particular patients are at greater risk of an adverse event due to lack of information when leaving the hospital," explains Shoshana Hahn-Goldberg, scientist and PODS project co-lead with OpenLab's Creative Director, Tai Huynh.
"When you design something to help your most vulnerable patients, it's more likely to benefit all patients than if you had designed it for the average patient."
In 2015, with support from the Toronto-Central Local Health Integration Network (TC-LHIN), OpenLab developed and successfully piloted a PODS template and practice guidelines at eight TC-LHIN hospitals, including Toronto Rehab, Lyndhurst Centre.
"Data from the pilot program was encouraging," says Shoshana. "When patients have a better understanding of their discharge instructions, it not only improves the patient experience but also that of the healthcare provider."
Based on those results, and with the help of Health Quality Ontario and the Council of Academic Hospital of Ontario's Adopting Research to Improve Care (ARTIC) grant, PODS was rolled out in 2017 at 27 hospitals, including TW's general internal medicine in-patient units.
PODS resources and support are centralized through UHN's OpenLab, which also tracks the different templates adapted from the original, and collects research data of the tool's use through surveys.
In mid-2018, TW's former Senior Clinical Director for Mental Health, Jan Lackstrom, suggested the PESU team look into PODS after hearing they were being used at psychiatric programs in other hospitals.
At the time, PESU's discharge practice involved giving patients three different documents – a discharge care plan completed by the physician, an empowerment card, and contact information for UHN Patient Relations. That was challenging for staff to keep track of.
Along with Advance Practice Nurse Educator for Mental Health, Aideen Carroll, Mohammed concluded PODS had the patient-clinician discharge conversation structure they were looking for and the "one-stop shop" of information patients could easily reference, and the unit could easily document.
Quickly became a regular practice
Through quick teamwork, it was launched in October. Patients ready for discharge sit down with a clinician to fill out the PODS. The PESU team adapted the tool to include a section where patients summarize why they were admitted to the unit.
"Using a patient's own words gives us a lot of insight into their experience and mental state in PESU," explains Mohammed. "It helps us base the prescribed next steps on the patient's understanding and assumptions rather than the clinician's.
"The tool has really helped our patients better understand where they are in their journey."
The PODS includes details on any prescribed medications and when to take them, follow-up appointments and a list of crisis resources. Any belongings are returned and the patient signs the last section to confirm receipt. The patient get a copy, with a duplicate kept in the hospital chart.
PODS integrated easily into PESU's work flow, but to ensure they became a standard part of the team's discharge practice, Mohammed and Aideen conducted daily audits. They also became a quality metric for the team's daily Safety Huddle, creating an opportunity for discussion and real-time feedback.
Only 14 per cent of PESU patients were discharged with PODS in its first month of use. But it quickly became regular practice, rising to 82 per cent the following month and 92 per cent in December.
PESU is the first emergency psychiatric program in Ontario to implement PODS successfully.
"There has been a lot of great work done by the point of care staff and the rotating residents to make PODS a success," says Aideen. "Everyone adapted to the change quite well and immersed themselves in the importance of the tool – making it more than just a nursing document but one used by all disciplines which is unique from other hospitals."