Standardized Communication Tool Improves Inpatient-Outpatient Care Transitions for Adults with Acute Leukemia

Background: Management of adults with acute leukemia involves frequent transitions between high acuity inpatient and intensive outpatient clinical settings. While clinical handoffs between inpatient team members are well-studied, little is known about the optimal means and clinical impact of inpatient-to-outpatient handoffs. The aim of our study was to develop a standardized discharge communication tool using the electronic medical record (EMR). We hypothesized that improvement in consistent inpatient-to-outpatient handoffs at our institution would lead to improved clinical care of adults with acute leukemia.

Methods: This project was performed as a quality improvement initiative at The Medical College of Wisconsin and its associated tertiary care hospital, Froedtert Hospital, between November 2020 and April 2022. Survey data was collected from inpatient and outpatient leukemia team members and was utilized to create a standardized communication tool and discharge process that was implemented in May 2021. Team members included physicians (attending, fellow, and resident physicians), advanced practice providers (APPs), and outpatient nursing and scheduling staff. The communication tool was sent by the inpatient team via EMR in-basket messaging approximately 48 hours prior to discharge. Included topics covered anticipated discharge date, types and timing of appointments needed, hospital complications, and results and tasks requiring follow-up. EMR data was collected for all discharged patients from the acute leukemia service including discharge date, follow-up appointments, and compliance with the communication tool. Patients were excluded if they were deceased prior to follow-up or discharged to hospice. 30-day readmission data was obtained from Vizient, and charts were reviewed to identify the primary reason for readmission. A follow-up survey was conducted 9 months after the tool was deployed to assess perceived changes in communication. Primary outcomes included rate of appointments scheduled prior to discharge, adherence with use of communication tool, and perceived success of the communication tool. Secondary outcomes included 30-day unplanned readmission rate and satisfaction with use of the communication tool. Significance testing was performed utilizing Chi-square testing for discrete variables and Mann-Whitney U-test for continuous variables.

Results: There were 755 total discharges between November 2020 and April 2022 from the acute leukemia service: 242 (32%) in the pre-intervention group and 513 (68%) in the post-intervention group (Table 1). Compliance with use of the communication tool occurred in 70% of cases. Overall, the percentage of scheduled follow-up clinic visits remained stable between groups (89% vs. 89%), but appointments scheduled prior to discharge significantly increased from 34% to 45% (p=0.007). The percentage of total infusion visits significantly decreased in the post-intervention group (81% vs 72%, p=0.004), but there was a significant increase in those scheduled before discharge (20% vs 33%, p=0.001) (Table 1). Perceptions of communication (strongly agree + somewhat agree) significantly increased regarding timely communication, outpatient staff members being informed of clinical plans, appointments scheduled prior to discharge, and correct appointment types being made (Table 2). There was a non-significant increase in in perceived sufficient communication between teams (Table 2).

The 30-day readmission rate decreased from 23% to 16% after implementation of the communication tool (p=0.017) (Table 1). The most common reasons for readmission between November 2020 and April 2022 were neutropenic fever (n=41, 29.1%) and infection not including neutropenic fever (n=21, 15%). Other reasons for readmission included respiratory complaints (n=15, 11%) gastrointestinal complaints (n=14, 10%), and neurologic complaints (n=13, 9%,). Cytopenia, oncologic reasons (treatment or transfusion reactions), and weakness/falls followed for a combined 15% (n=22).

Conclusion: Implementation of a standardized discharge communication tool was associated with increased follow-up scheduled prior to discharge, perceived communication between inpatient and outpatient teams and decreased 30-day unplanned readmission rates.