Discharge planning practices with hospital psychiatric patients

This study was done to determine what written documentation exists in the psychiatric patient's record after discharge from the University of Utah Medical Center that indicates and supports the premise that there is discharge planning of appropriate quality to withstand the scrutiny of objective review by external monitoring and regulating agencies. The purpose of this study was to determine the type of planning that took place and was documented prior to the patient being discharged, thus providing a data base for the development of criteria for a quality assurance program for psychiatric patients. Determination of the outcomes of such a program is dependent on such a data base. The survey of psychiatric patients' charts was designed to determine what specific activities occurred over a three month period, and were documented, relative to planning for a patient's discharge from the hospital. What was recoded in the patient's record that reflected and documented the University of Utah Hospital's discharge planning program? It was considered that this information would provide baseline data upon which more discriminatory studies could be designed in the future. The research design was a retrospective study in the form of survey of information in the patient's chart to identify the clinical material available for use as guidelines for discharge planning programs. The survey included admission data and discharge data. Standard hospital record forms were used to determine what information had been obtained from patients. Discharge notes of physicians, nurses, and other members of the professional team were reviewed and the information was categorized. The admission data were complete for the 79 patients with regard to demographic information of sex, age, residence, religion, and marital status, and the time of day and type of admission. A total of 29, or 36%, of 79 charts did not have educational level information and 17, or 22%, of the charts did not have present employment data. The discharge data showed 39, of 49%, of the 79 patients had one or more leaves of absence before their discharge from the hospital. Information available on follow-up referral of he 60 Salt Lake City and County patients showed 17, or 29%. Had an appointment to see a private psychiatrist; 31, or 52%, were referred to a community mental health center; 5, or 8%, to alcohol rehabilitation programs; 5, or 8%, to the Utah State Hospital; and 2, or 3%, were discharged against medical advice. Forty-seven patients, or 60%, were discharged on major or minor tranquilizing medications. Only 10, or 12%, of the 79 charts reviewed had documentation with regard to patient teaching. Examination of the discharge diagnosis of the patients revealed that 32% were diagnosed as having schizophrenia, 21% depression, 12% personality disorders, 6% drug and alcohol abuse, and 26% had not discharge diagnosis. The data are significant in that characteristics of schizophrenic patients, especially in regard to their difficulty in establishing and maintaining relationships, need to be considered for a follow-up treatment program. Implications for developing discharge planning programs for psyiatric patients were discussed and recommendations were made for future research.

DISCHARGE PLANNING PRACTICES WITH HOSPITAL PSYCHIATRIC PATIENTS by Duane D. Walker A thesis submitted to the faculty of the University of Utah in partial fulfillment of the requirements for the degree of Master of Science College of Nursing University of Utah December 1975 UNIVERSITY OF UTAH GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Duane D. Walker I have read this thrsis and have found it to be of satisfactory quality for a master's degree. " ) {/i (c; Date J ;to '/f / �)'5 t -_ Chainnan. Supervisory Committee I have read this thesis and have found it to be of satisfactory quality for a master's clu;J degree. Date ;2 � It{Zs.- ! 7lh.1�> 'd-td:! � Marie Holley Member, Supervisory Committee degree. {2U'i . 7-5/ /9 -; :3 Date Z7 7 UNIVImSl'l'Y FIN A L To the Graduate OF UTAI I GRADUATE Iz E A DIN G Council of tlie UnivClsity of SCl TOOl, AP PRO V A I J Utah: thesis of .. I'1-lLLIlC_J)_! J'JiJ,1J',gr _ _ . in its ami have found that (I) its format, citations, and bibliogr:tphic style �\n­ consistellt and acceptable; (2) its illustrative materials includillg figure-s, t:thles, and charts ;Ire ill place; and (3) the final manuscript i�; satisfactOl), to the SlljJf'r'/isory Conlllli [tee and is ready for submission to the Graduate SCh081. 1 have rc:trl the __ _ __ ____ ___ . _ ____ ____ final form Memher, Supervisory Committee Approve for the Major Department Madeleine IJcininger Chainllan/Dcan Approved for the Graduate t. . ( Council // ._, ./:>" � . /," . <:!::, " i, ') ; __ ______�-"':;(L_--L.J_f"d, < ,-1 /· Lj.-!_::: -I ,-F�,.,f.-L..i.,J.. ; ij ' Stcrlirr9' M. 1'-'1cHurrin D"an ir thl" r.raduat� Schuol / ACKNOWLEDGMENTS Sincere appreciation is extended to the members of n~ comnlittee and to the faculty of the Graduate Department of Psychiatric Nursing for their direction and support. I am especially grateful to my Chairman, Bonnie C. Clayton, and to Dr. Marie Holley for their expert guidance and supervision. lowe much to Sandi Cole for her invaluable assistance, as well as to the staff of the University of Utah Medical Center. TABLE OF CONTENTS Page ACKNOWLEDGEMENTS. iv LIST OF TABLES. vi ABSTRACT. vii CHAPTER I. INTRODUCTION I I. ~1ETHODOLOGY. III. RESULTS AND DISCUSSION. Sample . . . . . . Research Questions . . I V. SU~1MARY . 8 13 13 13 27 APPENDI X. . 32 RENCES. 34 VITA . . . . 36 LIST OF TABLES Tabl e 1. 2. 3. 4. 5. Page Means, Standard Deviations, Frequencies, and Percentage of Subjects (79) by Age Group and Sex (M 40, F 39) . . . . . . . . . . . . 14 Percentage of Subjects (79) by Marital Status and Sex (M 40, F 3 9 ) . . . . . . . . . . . . . . . 15 Percentage of Subjects (79) by Educational 40, F 39) . . Background and Sex U~ 17 Percentage of Subjects (79) by ElJlployment and Sex (M = 40, F = 39) . . . . . . . . . 18 Percentage of Subjects (79) by Time of 40, F 39) . . Admission and Sex (M 20 ABSTRACT This study was done to determine what written docunlentation exists in the psychiatric patient's record after discharge from the University of Utah Medical Center that indicates and supports the premise that there is discharge planning of appropriate quality to withstand the scrutiny of objective review by external monitoring and regulating agencies. The purpose of this study was to determine the type of planning that took place and was documented prior to the patient being discharged, thus providing a data se for the development of criteria for a quality assurance program for psychiatric patien Determination of the outcomes of such a program is dependent on such a data base. The survey of psychiatric patients' charts was designed to determine what specific activities occurred over a three month period, and were documented, relative to planning for a patient's discharge from the hospital. What was recorded in the patient's record that reflected and documen the Univer'sity of Utah Hospital's discharge planning program? It was considered that this information would provide baseline data upon which more discriminatory studies could be designed in the future. The research design was a retrospective study in the form of a survey of information in the patient's chart to identify the clinical material available for use as guidelines for discharge planning programs. charge data. The survey included admission data and dis- Standard hospital record forms were used to de- termine what information had been obtained from patients. Dis- charge notes of physicians, nurses, and other members of the professional team were reviewed and the information was categorized. The admission data were complete for the 79 patients with regard to demographic information of sex, age, residence, religion, and marital status, and the time of day and type of admission. A total of 29, or ,of the 79 charts did not have educational level information and 17, or 22%, of the 79 charts did not have present employment data. The discharge data showed 39, or 49%, of the 79 patients had one or more leaves of absence before their discharge from the hospital. Information available on follow-up referral of the 60 Salt Lake City and County patients showed 17, or ,had an appointment to see a private psychiatrist; 31, or 52%, wer'e referred to a community mental health center; 5, or 8%, to alcohol rehabilitation programs; 5, or 8%, to the Utah State Hospital; and 2, or 3%, were discharged against medical advice. Forty-seven patients, or 60%, were discharged on major or minor tranquilizing medications. Only 10, or 1 ,of the 79 charts reviewed had docu mentation with regard to patient teaching. Examination of the discharge diagnosis of the patients revealed that 32% were di no as having schizophrenia, 21% depression, viii 12% personality disorders, 6% drug and alcohol abuse, and 26% had no discharge diagnosis. The data are significant in that charac- teristics of schizophrenic patients, especially in regard to their difficulty in establishing and maintaining relationships, need to be considered for a follow-up treatment program. Implications for developing discharge planning programs for psychiatric patients were discussed and recommendations were nlade for future research. ix CHAPTER I INTRODUCTION The purpose of this research was to detennine what written documentation exists in psychiatric patients' charts after discharge from the hospital to support the prenlise that there is discharge planning of appropriate quality to withstand the scrutiny of objective revie\v by external monitoring and regulating agencies. The provision of health care in the United States has become the nation's largest 'industry, with a total yearly health expenditure approaching the $104 billion mark. In 1973, Americans spent 5441 per capita or 7.7% of the gross national product on their health care needs, with the 1 t portion of this going toward hospital care (Cooper, 1974). In view of the high cost of medical care, the health care industry is currently being bombarded with demands from many sources for quality assurance of their products. Delivery of health care, whether preventive, treatment of acute or chronic illnesses, or supervision of long term health problems, should result in individuals receiving the highest quality of health care for· their dollar. The definition of quality assurance involves evaluating the degree of excellence of the resul of delivered care and taking 2 action to make improvements that in the future will result in a higher quality of care (Phaneuf, 1974). Quality is a distin- guishing characteristic that determines the value, rank, or degree of excellence. In health care, there are many views of quality such as accessibility, acceptability, adequacy, appropriateness, effectiveness, and efficiency. Zimmer (1974) stated: Assurance includes the acts of making sure and of glvlng confidence; thus quality assurance is the estimation of the degree of excellence in patient health outcomes, and the use of the results of estimation to secure improvements in order to fulfill the public trust that professionals continuously search for better means of health care. (p. 305) There are Illany conflicting points of view from various groups regarding the most effective way to assure quality care; however, the current priority for quality assurance in health care was specifically stimulated by inclusion of quality control requirement in the Social Security Amendments of 1972 (Public Law 92-603, 92nd Congress, N.R. 1, Oct. 30,1972,101-117) and by the potential for similar requirements in future federal and state health care slation. i- The Social Security Amendments of 1972 mandate the establishment of Professional Standards Review Organizations (PSRO'S) through which physicians will assume certain responsibilities for reviewing the appropriateness and quality of services provided under Medicare, Medicaid, and Maternal and Child Health Programs (Sullivan, 1974). The Social Security requirements include demands for cost analyses of health services, especially in relationship to the 3 utilization of facilities. In Utah this demand is fulfilled by the Utah Professional Review Organization (UPRO) which has developed a technique for establishing the appropriateness of adillissions, the appropriateness of the level of care, and the appropriateness of the length of stay for patients funded by government progranls, and for private health insurance companies under contractual agreements with UPRO (Utah Professional Review Organization, 1973). In addition to government intervention in quality control of health care, the Joint Commission on Accreditation of Hospitals has been a strong influence for improvement of patient care. The Joint Commission accredits hospitals on a voluntary basis and holds to the principle that voluntary care systems can best serve the public, patients, hospitals, and health care profeSsionals (PEP Primer, 1975). It has taken an active role in encouraging institutions to set up their own quality assessment mechanisms in response to public demand. Should the demand for accountability fail to achieve the required response on a voluntary basis, govey'nment -intervention is l-ikely to impose more regulations which may be less effective, more expensive, and less desirable than sel regulation of health professionals. Currently, the Joint Commission has a nursing division facilitating nursing audit of patient outcomes by conducting workshops on nursing audit including specific methods and forms which have been developed. Outcome criteria for patients with a specific disease entity are decided by staff nurses. These criteria are then used in auditing patients' charts after discharge. The results are then presented to the staff nurses who in turn plan corrective action 4 for the deficiencies in regard to the stated criteria. For example, documentation of patient teaching could represent several problems such as a problem of not recording the teaching done in the patient's chart, or a lack of knowledge in the process and content of patient teaching. Consequently, actions to correct such problems are planned and evaluated in a repeat audit. A future recommendation of the Joint Commission will be for audits of patient outcomes to be done on a joint basis between nursing and medical professionals. Some concerns about joint audits have to do with the differing primary function of each profession. Although the medical and nursing professions share concern for the patient as a unique human being, their primary concerns and functions differ. The nurse's primary concern and function is that of helping each person attain his highest possible level of functioning and general health; the physician's primary concern and function is the diagnosis and treatment of illness (Schlotfeldt, 1973). Schlotfeldt's (1973) statement identifies an aspect of difference between the professions that may explain the difficulty of assessing "quality" of nursing care. fun c t ion 0f of medicine. That is, the major concern and nur sin g i s 1e sst an g i b"I e and 1e s s con c ret e t han t hat The goals of medicine are time-limited while those of nursing are not. It can be questioned then whether the goals of nursing can be measured in terms of quality assurance. Consequently, this study was undertaken to look at discharge planning that included all health professionals. The goal was to begin to look jointly at quality assurance programs and at the contributions of 5 the various professional groups which might have been subject to written documentation in the patients l records. It was considered that determining such baseline data was preliminary to development of more discriminatory studies in the future. In September 1973, the American Academy of Nursing took the position that nurses should be included in the quality assurance review organizations and should develop outcome criteria as a next step to standards of practice. For years registered nurses have be- lieved that evaluation is an essential step in the nursing process. Nursing services and organizations have made l11any contributions to the literature on standards and evaluation programs for nurses, such as the American Nurses' Associations' delineation of the generic and specialty standards of practice and their implementation, and the emerging focus on the nature and purpose of peer rev i e~v (A NA, 1973 ) . The Medicus Corporation has developed nursing quality assurance studies in regard to the structure and process of nursing care within hospital settings. Currently, studies are being conducted relative to how the nursing process affects patient outcomes (Medicus, 1974; lHCHEN, 1975). Of particular interest is the need for quality assurance in the field of mental health. Approximately 25% of hospital beds in the United States are filled by psychiatric patients. Quality assurance programs for psychiatric patients have not been developed to the same degree as other programs of quality assurance. The Joint COI11- mission of Accreditation of Hospitals is working on methods of audit 6 for long-term psychiatric patients but has not begun to implement these programs. The American Nurses Association has developed standards of practice for psychiatric nursing; however, there is little documentation "in the literature that indicates standards of nursing care have been implemented for psychiatric tients. Quality assurance cannot be totally measured until there is a surveyed data base upon which criteria can be developed. A begin- ning data base for a quality assurance program for psychiatric patients should include evidence that appropriate planning regarding t patient's discharge from the hospital occurred before he was discharged. Comprehensive care includes having professionals in hospitals responsible for patients in regard to their going home and maintaining their health status (JGAH, 1970). important aspect of this responsibility. Discharge planning is an Discharge from a psychi atric hospital or in-patient service can be an anxiety provoking experience due to stigma toward psychiatric patients and the fear of recurrent symptoms resulting in further psychiatric hospitalization. Therefore, this research looked at a beginning quality as- surance program for psychiatric patients as it relates to discharge planning. Primary consideration in this study was given to the follo\'Jing questions: record? (1) What admission data are available in the in-patient (2) What constitutes discharge planning, including pro- fessional follow-up? in the chart? (3) Is there evidence of patient teaching (4) Is there doculllentation in the patient's recoy'd 7 24 hours prior to discharge about his behavior and appearance? (5) Is there evidence that the patient and his family were involved in planning for discharge? CHAPTER II METHODOLOGY The University of Utah Hospital Medical Center has a bed complement set at 305. The psychiatric nursing unit consists of 28 beds and has a projected census of 8,030 patient days for 1975-1976 (University of Utah Budget Document--approved May 1975). The University of Utah Hospital is projecting an occupancy of 84.2%, 10,783 admissions, and a length of stay of 8.71 days for 1975-1976. The patient census for 2 West (Psychiatry) for the fiscal year 1974-1975 was approximately 90% occupancy with the average length of stay 12.1 days. Psychiatric admissions to the in-patient unit consist primarily of people with problems of attempted suicide, anxiety states, drug abuse, depression, schizophrenia, psychosis, and alcoholism. The psychiatric nursing unit is managed by a head nurse whose preparation is a Master of Science degree in Psychiatric Nursing. Clinical specialty support consists of two nurse clinical specialists who are involved with the Crisis Team, in addition to providing consultation to patients, their families, and the nursing staff. involved as providers of nursing care are professional nurses, licensed practical nurses, and nursing attendants. located on the Also The unit is second floor of the hospital and has a day room, 9 occupational therapy, ward facilities. kitchenette, semi-private rooms, and some The unit is divided, with 6-8 beds being provided as a closed or locked unit, including 2 seclusion rooms. The re- mainder of the beds employ an open concept with varying levels of patient privileges. The Medical Staff consist of a Medical Director, Chief Resident, three residents, and medical students. Social workers and recre- ational therapists are also members of the team. Students from a number of colleges and departments of the University of Utah have clinical experiences on the unit at various times. Group and -individual therapy are the primary treatment modalities. The University Hospital is a component of the University of Utah Health Sciences Center which is concerned in achieving excellence in all its services and is committed in carrying out the following: (1) The patient care programs are to provide the highest quality, patient-oriented care utilizing the most advanced knowledge, methods and techniques available for the diagnosis, treatment and rehabilitation of disease or injury. Highly specialized referral or tertiary care services are available along with primary and secondary care services commensurate with the needs of the state and region and the clinical educational programs of the health sciences. (2) The Hospital's educational program is to provide a controlled clinical environment for the training of undergraduate, graduate, and post-graduate students of the Health Sciences Center iO and of other colleges and health-related programs requiring clinical education for a degree or certification. (3) University Hospital is to provide an environment for clinical research to advance the prevention and tr~eatment of disease and injury. (4) Hospital is to engage in cOllllllunity service through continuing education for health professions and community educa tion to advance and integrate contemporary health standards and health care services in the state and intermountain region (University of Utah Hospital Objectives, 1974-75). The primary objective of the University Hospital, being committed to "excellence in providing t highest quality patient- oriented care utilizing the IllOSt advanced knowledge, methods, and techniques available for treatment" is supportive of surveying patient records to summarize existing discharge planning. One of the objectives developed by the Univers'ity Hospital, Department of Nursing Services, is to design and irnplell1ent a progralll for qua'iity assurarlce in nursing care and to utilize research findings to develop the highest possible standards of care. To determine current activities which are occurring 24 hours prior to discha would be valuable in evaluating present standards of care employed in discharge planning and establishing optimal standards. Quality of care is determined by identifying characteristics that depict the desired and valued degree of excellence and the expected observable variations (Zimmer, 1974). It is necessary to determine what the present activities are before moving to establish the ted 11 level of care. The purpose of this study was to deternline the type of discharge planning for psychiatric patients which was doculnented over a period of three months at University Hospital; thus, beginning to fornlulate a base for the development of criteria for a quality assurance program for psychiatric patients. The survey of psychiatric patients l charts was designed to determine what specific activities occurred relative to planning for a patientls discharge from the hospital. What is recorded in the patientls record that reflects the University of Utah Hospital IS present discharge planning? An initial step in the research project was a meeting on May 15, 1975 with the Clinical Specialists, Head Nurse, and two staff registered nurses on the psychiatric unit to explore the development of a method for surveying available discharge infornlation. A survey tool was divided into Admission Data and Discharge Data. Standard hospital record forms were used to determine what information is obtained from patients (see Appendix A). The research design was a retrospective study in the form of a survey of information in the patientls chart. Two research associates assisted in collecting and tabulating the data. Both associates had Masters degrees in Nursing with one having a degree in Psychiatric Nursing. The research associates had had experience in the process of nursing audit as well as in developing standards of care. Seventy-nine consecutive charts of patients discharged during the period from March 1975 to May 1975 were obtained from the Medical Records Department on June 9, 1975. Completed charts 12 were pulled in succession by the Hedical Records staff. Data were obtained from the Admission Sheet, Progress Notes, Nurses Notes, and Discharge Summary, CHAPTER III AND DISCUSSION R SaJ.!!l?J~ The sample consisted of 79 patients who had discharged from the University of Utah Medical Center Psychiatric Unit between March 1, 1975 and May 1, 1975. male patients. There were 39 female patients and 40 The female patients were, on the average, sOlllevJhat older (mean age 41.79) than the male patients (mean age 32.95); however, the difference in a between men and women was not statis- tically significant (Table 1). Research estions are nInformation as to sex, age, Y'esidence, rel igion, and marital status was complete for each of the 79 patients (Tables Seve ntee n 0 f the 40 mal e pa tie nt s, 0 r 42%, to 4, or 10%, of the 39 female patients. \AJe res i ng1e; and 2). c 0111 par e d Planning for the social and recreational needs of the single male patients, along- with programs for the older, married female patients, should be considered in a quality care program at the University of Utah Medical Center. For example, activities on the University of Utah campus, such as movies, dances, and lectures, may be pat~t of the in-patient Table 1 Means, Standard Deviations, Frequencies, and rcentage of Subjects ( by Age Grou and Sex (M = 40, F = 39) Number Percent Men N=40 Number Percent Total Number Percent 20 2 5 4 10 6 7 21 - 30 7 18 20 50 27 34 31 - 40 13 33 9 41 - 50 6 15 2 5 8 10 51 - 60 7 18 2 5 9 11 61 - 70 4 11 3 7 7 9 Ages o- Mean Ages dard iation 28 39 40 79 4l. 32. 37.32 13.62 14.57 14.71 ...r;::. Table 2 rcenta of Subjects (79) by (~1 rv1a rri ed Single Separated N::: ~l1,- ~'1arital tus and Sex ::: 40, F ::: 3 9 ) Divorced % Widowed Informa on Not Avai a e N::: le i~a 1e Total N 79 19 49 5 14 35 17 33 43 2l 10 26 11 3 8 6 3 3 17 2 5 3 7 2 2 3 3 15 U"1 16 recreational program; thus, introducing patients to a social and recreational environment that would be productive in discharge planning. Documentation of such planning was lacking in the records reviewed. There were minimal data on level of education, current employment, and occupational background which are categories of information needed as guidelines in developing discha planning programs and for meeting quality assurance expectations. More complete data are needed. A total of 29, or 36%, of the 79 charts did not have educational level information and 17, or 22%, of the 79 charts did not have present employment data (Tables 3 and 4). luding those for whom information was not available, the high school graduate category was t highest (17, 22%, N=79) in relationship to educational background (Table 3), Ascertaining the patient's level of understanding, before giving detailed information, may have implications for patient teaching and for other aspects of discharge planning for the psychiatric team. The stress of hospital- ization emphasizes the importance of assuring that health teaching is comprehended. In referring to problems of patient teaching, Redman (1971) stated: Since teaching is goal-directed toward accomplishing particular learning, it is necessary to be able to identify goals that are appropriate to the situation and that the learner is likely to reach. (p. 573) Knowing the level of education will help the psychiatric team meillber to evaluate the patient's learning ability and to plan specific content, thus aiding in developing a teaching protocol for him. tlUnemploymcnt ll was the highest category reported--relative to Table 3 Percen of Subjects ( by Educational 8ackg , F = 39) (M and - - Less Than High School No. ~ % High hoo1 Graduate No. % 1-3 Call rs B.S. No. % No. 7 4 Female 6 16 9 24 3 1e 8 20 8 20 9 tal 14 17 17 22 12 15 5 M.S. I No. tion Not Available No. 10 2 16 41 3 3 13 31 2 29 36 6 2 'J b1e 4 Percentaqe of Subjects (79) by N (M = 40, F = 39) 39 23 MALE N oyment and Unemp 1 C1 e)~i ca 1 N N 10 fessiona N 5 5 12 12 10 I 20 40 Unskilled Skilled 3 7· 17.51 4 employed Professional Semi Professional 10 -- 16 40 co 19 type of employment (Table 4). or 40~~, Ten, or 26%, of the 39 women and 16, of the 40 Illen were unemp 1oyed. The d i ff erence between rna 1es and females is noteworthy, although approximately regarded being a housewife as a type of employment. of the females Lack of infornla- tion regarding the current employment status of 17 of the 79 patients in the sample is surprising at best. Referral for vocational training or job placement is frequently an important aspect of a quality care discharge planning program. For at least 20 years the importance of occupational rehabilitation programs for psychiatric patients has been emphasized in the literature (Greenblatt & Lidz, 1957). In an individualized psychiatric treatment program, patients Illay be assisted in obtaining employment while still hospitalized, may go to \",Iork during the day and may return to the hospital for night care. The nursing staff may than have an opportunity to help the patient in adjusting to his employment by assisting him to express his concerns about what happened during the day, and by evaluating the patient1s capacity to work outside of the hospital. The time of day and type of admission data were complete and available (Table 5). Out of 79 admissions, 37, or 47%, occurred on the evening shift and 62, or 79%, were unscheduled admissions. These findings have obvious implications for establishing optimum staffing on the psychiatric unit and for the crisis service in the emergency room Since 7 fm~ the evening shift (3:30 p.m. - 12:00 p.m.). of all admissions were not scheduled, rooms on the psychi- atric nursing unit should be kept available to accomodate the unscheduled or emergency admissions. The unit should be well staffed 20 for the evening hours in order to allow nurses to admit patients with acute problems which require intensive-care nursing. According to the current classification of patients by the nursing service of the University of Utah Medical Center, a patient with marked emotional needs, and/or who is disoriented, and/or is acutely psychotic, requires intensive nursing care which must be administered principally by a registered nurse and appropriately recorded. Table 5 Percentage of Subjects (79) by Time of Admission and Sex (M=40, 9) A.M. p~ = I~OC 0/ N= % ((l - Female N=39 10 fVia 1e N=40 16 Total N=79 26 20 51% 9 23 40!~ 17 43% 7 18% 33% 37 47 20% I Thirty-two, or 41%, of the 79 patients had had previous psychiatric hospitalization. Twenty patients, or 25%, had been hospitalized before at the University of Utah Medical Center and 12 patients, or 15%, had been hospitalized at other hospitals. Surprisingly, informa- tion on hospitalizations from other hospitals was di in the patient's hospital record. icult to find This may have implications for cost and efficiency aspects of hospital utilization review, especially in 21 relationship to duplication of psychiatric tests and evaluations. The type of former psychiatric treatment experiences Illay influence the current treatment program, especially in regard to the patient's own expectations. For example, the patient may expect to have a long term hospitalization with minimal contact outsi hospital environment. of the When he is asked to participate in obtaining employment or to join in community recreational activities, the patient may be hesitant to become involved. Ruesch, Brodsky and Fischer (1964) recoillmended that from the moment the patient enters a psychiatric hospital, his expectations and those of his family should be directed toward restoration of function and that discharge from the hospital is anticipated in the foreseeable future. For the pur po s e 0f t his i nvest i gat ion, i nforma t ion 0n 1ea ve 0f absence, follow-up referral, discharge medication, and discharge diagnosis were noted. Thirty-nine, or 4 ,or the 79 patients had one or more leaves of absence before their discharge from the hospital. A leave of absence may be an important aspect of quality discharge planning in order for the patient to begin to make a transition from the hospital to his post-hospital living situation. Most authorities agree that patients in transition generally experience varying degrees of anxiety as plans for their discharge are made. These anxieties may deepened if the patient felt the community, in emphasizing responsibility and achievement, made 22 demands he was unable to meet. The patient may also be fearful of the stereotypes of the mental hospital held by others (Naboisek et al., '1957; Gralnick et al., 1961). The problems encountered by the patient while on leave of absence may provide important information for discussion and supportive assistance upon his return from the leave of absence. Thus, the patient may actively participate in the evaluation of his own ability to cope with his emotions and to evaluate his decisions away from the hospital environment. Information available on follow-up referral of the 60 Salt Lake City and County patients showed 17, or 29%, had an appointment to see a private psychiatrist; 31 patients, or 52/6, were referred to a community mental health center; 5 patients, or 8%, to alcohol rehabilitation programs; 5 patients, or 2 patients, or ,to the Utah State Hospital; and ,were discharged against medical advice. Records of the 12 patients not residing in either Salt Lake City or County showed that 8 patients, or 66%, were referred to a private psychiatrist and 4 patients, or 34%, were referred to community mental health centers. The 31, or 52%, Salt Lake City and County patients being referred to community mental health centers provide significant data for establishing discharge planning sessions involving the staff of the hospital with the local community facilities. Scheduled conferences between the professional staff may need to be arranged to exchange information about the patient and his treatment. The patient may need to participate in his discharge planning by meeting with the professional staff of the appropriate community mental health center in 23 order to understand and to agree to the type of treatment program planned for him after discharge. Ideally, the patient should have a leave of absence from the hospital to attend the community mental hea 1th center for a pre-arranged appo-j ntlllent. Forty-seven patients, or 60%, were discharged on major or minor tranquilizing medications. What the patient was taught about the medication was not documented in the chart. In view of the tendency for psychiatric patients to misuse nledication as a means to cope with problems, a lack of knowledge of the side affects of medication, as it reflects discharge planning, should provide for teaching about medications and documentation of patient's understand-ing about them. The nurse, doctor, and clinical pharmacist should develop a structured program for this function, delineating the roles and responsibility of each team member. In examining the discharge diagnoses of the 79 patients, it was found that 25, or 32%, were diagnosed as having schizophrenia; 16, or 21%, depression; 10, or 1 ,personality disorders; 5, or 6%, drug and alcohol abuse; and 20, or 26%, had no discharge diagnosis available in the record. The large number of schizophrenic patients is significant because of the characteristics of withdrawn patients, especially in regard to their difficulty in establishing and maintaining relationships (Brown & Fowler, 1971). Such factors need to be considered carefully for a follow-up treatment program. The considerable number of patients' charts without a documented discharge diagnosis should be an immediate priority for the psychiatric tealll. There are important legal and accountability implica- tions for any review of the quality of care that was given. Infor- 24 mation to referring agencies is also affected by the absence of a discharge diagnosis in the patient's record. Evidence of n There were minimal data on patient teaching. Only 10, or 12%, of the 79 charts reviewed had documentation with regard to patient teaching. There were 6 instances in which instruction about specific medication was given. Three patients were advised or taught the symptoms which should require further psychiatric intervention. Health knowledge is an expected outcome for hospitalized patients according to the Joint Co~nission on Accreditation of Hospitals, Nursing Audit Program (PEP Primer, 1974). Redman described patient education as a function of nursing practice and stated: Teaching is a highly versatile tool that can be used in all four modes of nursing intervention--to prevent, promote, maintain, and modify a wide variety of behavior in a receptive individual or group. (Redrnan, 1971, p. 574) Therefore, the lack of documentation of patient teaching indicates that patient teaching either should be given immediate priority by the psychiatric in-patient treatment team, or that the professional staff should record instances of patient teaching in the patient record. One nurse had recorded that she had discussed alternate means of expressing feelings with the patient, which was one of the few recorded instances of patient teaching. (~1_J._~_ t _h_~~Q~~ me!1J_a.~_i_o~0_j~ the Patient's Record 24 Hours to -hTs- Seventy-one, or 90%, of the 79 charts contained descriptive 25 statements in the nurses notes regarding the patient's behavior before discharge. A wide range of behavior was cited during the last 24 hours of hospitalization. Statements were also present as to the patient's physical appearance. Examples included comments that the patient was neatly dressed with hair combed, or in contrast, presented a disheveled appearance, unshaven, and with clothes wrinkled and dirty. Descriptions of behavior in the nurse's notes ranged from comments that the patient was smiling, talking with other patients, and attending unit activities, to recording that the patient was crying, pacing the floor, and remaining in his own room with downcast facial expression. Since 1964, behavioral methods in health care settings have been tested with a wi range of patient management problems. Documentation of the patient's behavior is obviously primary data upon which treatment and rehabilitation programs can be based. The only evidence available were statements that 31, or 41%, of the 79 patients did agree to accept the psychiatric follow-up appointment. In addition, in two patients' records it was documented that family conferences were held by members of the psychiatric team. According to the American Hospital Association (AHA) Patients' Bill of Rights (1973) the patient has a right to participate in his plan of care while in the hospital, including discharge planning. Family members should be included in planning for discharge, especially 26 when the patient is returning to a family unit. Documentation that such involvement did occur must be available for quality assurance review of the course of an individual's hospitalization and discharge planning. Since psychiatric nurses are scheduled to work in the evening when family members often visit, a nurse might be assigned to a specific patient and his family in order to explain the hospital treatment plan and discuss discharge plans; thus, providing a higher quality of psychiatric care. In summary, a retrospective study was done involving 79 psychiatric in-patients' discharge charts to see what information was available to use as guidelines for discharge planning programs. The data obtained described the current patient population, identified areas where more information is needed, and suggested the need for further study in behavioral discharge and the affects of psychiatric treatment team intervention in discharge planning. CHAPTER IV SUMMARY The provision of health care in the United States has become the nation's largest industry, with total yearly health expenditure appro a chi ng the $1 04 bill ion ma r k . I n 197 3, Am e ric an ssp e nt $441 per capita or 7.7% of the gross national product on their health care needs, with the largest portion of this going toward hospital care (Cooper, 1974). In view of the high cost of medical care, the health care industry is currently being bombarded with demands from many sources for quality assurance of their product. Delivery of health care, whether preventive, treatment of acute or chronic illnesses, or supervision of long-term health problems, should result in individuals receiving the highest quality of health care for their dollar. The purpose of this research was to determine what written documentation exists in patients' charts after discharge from the hospital to support the premise that there is discharge planning of appropriate quality to withstand the scrutiny of objective review by monitoring agencies. Quality assurance cannot be totally measured until there is a surveyed data base upon which criteria can developed. A beginning data base for a quality assurance program for psychiatric patients should include evidence that appropriate planning regarding the 28 patient's discharge from the hospital occurred he was dis- charged. Primary consideration in this study was given to the following questions: record? (1) What admission data are available in the in-patient's (2) What constitutes discharge planning, including profes- sional follow-up? chart? (3) Is there evidence of patient teaching in the (4) Is there documentation in the patient's record 24 hours prior to discharge about his havior and appearance? (5) Is there evidence that the patient and his fall1ily were involved in planning for discharge? The research design was a retrospective study in the form of a survey of information available in the patient's chart. Seventy- nine consecutive charts of psychiatric patients discharged from March 1, 1975 to May 1, 1975 were obtained from the Medical Records Department of the University of Utah Hospital on June 9, 1975. Compl charts in succession were pulled by the Medical Records staff, with two research associates assisting in collecting the tabu lating data. Data were obtained from the Admission Sheet, Progress Notes, Nu rses Note s, and Di sc ha rge SUlTlma ry. The retrospective study of the 79 psychiatric in-patients' discharge charts identified information available to use as guidelines for discharge planning programs. The data obtained described the current patient population, identified areas where Illore information is ed, and suggested the need for further study in behavioral discharge criteria, and t effects of psychiatric treatment team intervention in discharge planning. 29 In examining the discharge diagnosis of the patients, 32% were diagnosed as having schizophrenia, 21% depression, 1 disorder, 6% drug and alcohol abuse, and sis. personality had no discharge diagno- The data are significant in that characteristics of schizo- phrenic patients, especially in regard to their difficulty in establishing and maintaining relationships need to be considered for a follow-up treatment program (Brown & Fowler, 1971). The con- siderable number of patients' charts without a discharge diagnosis points to an immediate priority for the psychiatric team. There are important legal and accountability implications for any review of the quality of care. Information to referring agencies is also affected by the discharged diagnosis not being available. Documentation of the patient's participation in his discharge planning and evidence of behavioral change at the time of discharge were most often not available in the charts. These are two important aspects of discharge planning especially in considering the patient's own rights and evaluating the hospital treatment plan. Family mem- bers need to be included in planning for discharge especially when the patient is returning to a family unit. As psychiatric nurses are scheduled to work in the evening when family members often visit, a nurse could be assigned to a specific patient and his family to explain the hospital treatment plan and to discuss discharge plans to provide quality of psychiatric care. Ways to measure and compare behavior on admission and discharge, as well as methods for controlling the value system of the observer, are not available in the current psychology or psychiatric literature. 30 Some research questions are: (1) What behavioral changes aY'e predictive of adjustment of the patient post-hospitalization? (2) What behaviors are indicators of further in-patient treatment? (3) Are the behavioral changes identified for discharge valid and reliable in other psychiatric hospital settings? (4) What influence did the treatment plan have on the expected behavior changes indicating quality of care? However, further refinement of and adherence to present documentation systems in patient records are prerequisite to such research studies. The nursing audit is one such program which will be valuable for research, as well as for quality assurance reviews. A further study is suggested by the need for patient teaching and patient participation in discharge planning. The psychiatric team could establish and conduct discharge planning groups with the patient and his family during hospitalization as suggested by Almond (1974). Group discussions could focus on l"ings and prob- lems of leaving the hospital and returning to their current living situation. In such a program for discharge planning, each team member could concentrate on their own area of expertise in the group meetings. For example, the psychiatrist might discuss the need for medication and anS\'Ier questions about specific medications. Differ- ent diagnoses and the possibility of recurrent symptoms might be discussed, as well we the support systems available to individuals upon discharge. The psychiatric nurse might discuss activities of daily living, especially as they relate to physical and eillotional 31 needs and satisfactions. The social worker might discuss with the patient and his family the resources available for financial and social problems. Research into such a coordinated program of dis charge planning would provide valuable information about the effectiveness of patient and family teaching, and about the problems encountered in implementing the program. APPENDIX ADMISSION AND DISCHARGE INFORf,1ATION Code Number ------------------ Admission Data Age ---------~.--------------- Sex -------_._---Address -Salt Lake City Mariatal Status-- M Utah ( ) Out of State ( S Catholic Religion-- LOS o w Protestant Other Occupation ---_.._-----------------------_.--------_._-----------------_._ .--------------Educational Level .. __ Private Welfare Other Type of Adillission-- 1. Scheduled Emergency Room Unscheduled ( ) 2. Voluntary 3. Day ( ) Night ( ) 4. ( ) Transfer Non-Voluntary Evening Physician or Agency ) ( ) ( ) Admitting Diagnostic Impression _._------------------------_.---------------------------_. Length of Stay--Admission Date ------------------------.-------~-----------------------.- Discharge Date -------_._--------------------- 33 Di sc ha Whe re Pat i en t Di scharged--l . Home ( ) 2. Nursing Horne ( ) Relative ( ) 3. Other ( ) M.D. Appointment ( ) Corlllllu ni ty Men ta 1 Health Center Private Counseling ( ) 3. Professional Follow-up-- Activity - Data Work Community Groups Other ( ) Sc hoo 1 ( ) Other ( ) ( ) Evidence of Patient Teachi ng Documentation in Patient's Record 24 Hours Prior to Discharge Appearance Behavior Leave of Absence (LOF) Evidence of Patient Involved in Discharge Planning Prognosis Discharge Diagnosis Previous Admissions REFERENCES Accreditation Manua1 for Hospitals. oint commission 1970. Almond, R. The heal ~ ________ ~_~ _ _ _ _ _ _ . ______ r~ Ho ital accreditation ram, Jason Aronson, Inc., 1974. American Hospital Association, Patient bill of r Chicago, 1973. American Nurses Association, Commission on Nursing Services. Standards for nursi rvice. Kansas City: ANA, 1973. Brown, M., & Fow 1e r, G. .~~L~hodY~~lJ...Lc;__Q..~..:s_f!1.-9.. Sau nde rs Compa ny, 1 971 . Phi 1ade 1phi a : Cooper, 8. S., Waithington, N. L., & Piro, P.A. ~ull ~tLn_, 1974, 37 3), 20-23. Social Securi W. B. Gralnick, A., & Duncan, R. Problems of the patient in transit frolll hospital to community. 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