Timely Delivery of Discharge Medications to Patients’ Bedsides: A Patient-centered Quality Improvement Project

Patients who are unable to fill prescriptions after discharge are at risk of hospital readmission. Ensuring that patientshave prescriptions in hand at the time of discharge is a critical component of a safe and effective discharge process. Using a “Medsto Beds” program, we aimed to increase the percentage of patients discharged from Holtz Children’s Hospital with medications inhand from 49% to 80%, reduce turnaround time (TAT) from electronic prescription signature to bedside delivery from 4.9 hours (±2.6hours) to 2 hours, and increase caregiver satisfaction. Methods: We formed a multidisciplinary team and implemented 4 patient-centeredinterventions through iterative plan-do-study-act cycles. Statistical process control charts were used to understand the impactof the interventions over 10 months. Hospital length of stay and discharges before 2:00 pm were used as balancing measures. Wemeasured caregiver satisfaction using a telephone survey administered by pediatric residents within 7 days after discharge. Results:The mean percentage of patients discharged with medications in hand increased to 76%. TAT decreased to 3.5 hours (±1.8 hours).Length of stay did not significantly increase, whereas the percentage of patients discharged before 2:00 pm did. Caregivers of patientswho had prescriptions delivered to their bedside reported high levels of satisfaction. Conclusions: Using a “Meds to Beds” program,we increased the percentage of patients discharged with medications in hand, decreased TAT with reduced variability, and achievedhigh levels of caregiver satisfaction. Importantly, there was a shift in the culture of the institution toward improved medication accessfor patients. (Pediatr Qual Saf 2020;3:e297; doi: 10.1097/pq9.0000000000000297</p

Effect of Lowering Dialysate Sodium Concentration on Interdialytic Weight Gain and Blood Pressure in Patients Undergoing Thrice-Weekly In-center Nocturnal Hemodialysis: A Quality Improvement Study

BACKGROUND: Patients on in-center nocturnal hemodialysis therapy typically experience higher interdialytic weight gain (IDWG) than patients on conventional hemodialysis therapy. We determined the safety and effects of decreasing dialysate sodium concentration on IDWG and blood pressure in patients on thrice-weekly in-center nocturnal hemodialysis therapy. STUDY DESIGN: Quality improvement, pre-post intervention. SETTINGS & PARTICIPANTS: 15 participants in a single facility. QUALITY IMPROVEMENT PLAN: Participants underwent three 12-week treatment phases, each with different dialysate sodium concentrations, as follows: phase A, 140 mEq/L; phase B, 136 or 134 mEq/L; and phase A(+), 140 mEq/L. Participants were blinded to the exact timing of the intervention. OUTCOMES: IDWG, IDWG/dry weight (IDWG%), and blood pressure. MEASUREMENTS: Outcome data were obtained during the last 2 weeks of each phase and compared with mixed models. The fraction of sessions with adverse events (eg, cramping and hypotension) also was reported. RESULTS: IDWG, IDWG%, and predialysis systolic blood pressure decreased significantly by 0.6 ± 0.6 kg, 0.6% ± 0.8%, and 8.3 ± 14.9 mm Hg, respectively, in phase B compared with phase A (P < 0.05 for all comparisons). No differences in predialysis diastolic and mean arterial or postdialysis blood pressures were found (P > 0.05 for all comparisons). The proportion of treatments with intradialytic hypotension was low and similar in each phase (P = 0.9). In phase B compared with phase A, predialysis plasma sodium concentration was unchanged (P > 0.05), whereas postdialysis plasma sodium concentration decreased by 3.7 ± 1.9 mEq/L (P < 0.05). LIMITATIONS: Modest sample size. CONCLUSION: Decreasing dialysate sodium concentrations in patients undergoing thrice-weekly in-center nocturnal hemodialysis resulted in a clinical and statistically significant decrease in IDWG, IDWG%, postdialysis plasma sodium concentration, and predialysis systolic blood pressure without increasing adverse events. Prolonged exposure to higher than required dialysate sodium concentrations may drive IDWG and counteract some of the purported benefits of “go-slow” (longer session length) hemodialysis