She’s Got a Ticket To.... Go Home

Once a hospital patient is on the mend, the most urgent question on his or her mind is apt to be, “When can I go home?” Unfortunately, the frustrating answer is apt to be, “That depends.” Elderly patients with multiple needs are apt to hear this the most. Their discharge may hinge on an assortment of medical, functional, and social factors that are difficult to keep track of, much less forecast. Too often, the result is a perceived information vacuum that satisfies neither the patient, family members, nor the care team.
 
In March 2004, the staff at Virginia Mason Medical Center (VMMC) in Seattle, Washington, decided there was a better way to keep patients and families informed and engaged with the discharge planning. Most of the 23 patients in VMMC’s Acute Care for the Elderly (ACE) unit receive a “Ticket Home” in the form of a white laminated board that’s placed in front of each patient’s bed. 
 
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In large permanent black letters, easily seen by aging eyes, the 6’-by-2.5’ boards display all the fundamental questions about an individual’s progress. At the top is a request for the projected date and time of discharge. Below are queries on specific requirements for leaving the hospital, such as whether a patient can eat and go to the bathroom on their own, walk safely, the status of pain control and lab work, and whether safety risks have been addressed.
 
As the answers become available, medical staff, patients, and families can write on the board with colored markers, creating a fuller picture of the patient’s current status than any one participant is likely to have alone. For instance, a patient can confirm that his pain has been brought under control with oral medication; a family member can announce that a ride home has been arranged; and a nurse can verify that lab tests are complete. Similar ideas were being tested in the Institute for Healthcare Improvement’s (IHI) Transforming Care at the Bedside (TCAB) project, a collaboration with the Robert Wood Johnson Foundation. At TCAB hospitals such as James A. Haley VA Medical Center in Tampa, Brigham and Women’s Hospital in Boston, and Theda Care Medical Center in Appleton, Wisconsin, white boards may record what patients would like to eat each day, who they’re expecting as visitors, and, if patients are going home, how they want that process to unfold. Diane Miller, a previous director of TCAB, says Ticket Home’s emphasis on quality and satisfaction embodies TCAB‘s four goals of improved safety/reliability, vitality, waste reduction and patient-centeredness.
 
At VMMC, Ticket Home offers a pooled information record that’s a boon to everyone. “The boards allow medical staff in different disciplines and on different shifts to get a quick, concise snapshot of a patient’s functional level without having to access the chart,” explains Debra Beauchaine, the geriatric nurse practitioner who heads the ACE unit. Meanwhile, she says, the transparency of the care plan and the constant visual cue on the patient’s progress help motivate the ailing elderly to stay engaged in their own recovery.
 
There’s room on the left side of the board to list the day’s scheduled tests and procedures and plenty of blank space for back-and-forth communication in off-hours. Families can write questions and comments or leave instructions about a patient’s preferred routines. Staff can reply in the same convenient spot and everyone is assured that their messages won’t get lost. An attached bulletin board with push pins invites visitors to post get well cards or encouraging thoughts. Many boards sport enthusiastically crayoned “We Love You, Grandpa (or Grandma)” signs.
 
Families seem to need little or no prompting to use the boards well, says Beauchaine. “Most take to it instinctively and some do an outstanding job.” Beauchaine recalls a dialysis patient transferred from another unit. “His son came ahead with his dad’s belongings. We didn’t even know he was there. By the time the patient arrived, he had filled in the entire board — he really kept up on his dad’s care. He even added a few details, like his dad’s normal blood pressure. Then he scrawled a great big ‘I love you, Dad’ across the top.” The dad loved it, says Beauchaine, “and the staff was just amazed by how powerful the boards could be.”
 
The idea for Ticket Home emerged from problem-solving workshops that are a regular part of the 336-bed VMMC’s process improvement system. The 84-year-old urban hospital, which serves the greater Seattle area and is a regional resource for patients as far away as Alaska, has no pediatrics or obstetrics departments. Its patients are mainly older adults. All the other units were already using smaller, less detailed boards, but on the ACE unit, where patients are over 65, staff thought larger boards might be more effective — especially to ease frequent delays that often accompanied discharging patients to extended care facilities. This is often the next stop for the debilitated elderly. “We found that patients and families didn’t always understand that was the plan,” says Beauchaine. “The boards make it clear what kind of needs a patient still has.” TCAB’s Diane Miller says, “It’s a simple, effective idea that takes a lot of the ‘flurry’ out of the discharge process. When everyone knows what they need to know, it’s much more likely that things will go smoothly.”
 
In 2003, nurses at Kaiser Foundation Hospital in Roseville, California, a TCAB hospital, patient’s care team on wall-mounted boards. Soon, they bought a digital camera and posted photos. Gradually, they began noting daily clinical targets such as “eat 100 percent of food” and “get up from chair three times.” The idea was such a hit with patients that more and more information was added, says Chief Operating Officer Barbara Crawford, until the project outgrew the boards. The staff now uses the adjacent walls — coated with magnetic paint — to attach photos, cards, children’s pictures, and other loose items with refrigerator magnets — saving the boards for written messages from staff, family, and patients.
 
VMMC’s Debra Beauchaine says the hospital has no plans to track whether use of the Ticket Home boards has a direct impact on length-of-stay, but, she explains, “When you have fewer surprises, that’s often the case.” Patient satisfaction will be surveyed next year and Beauchaine anticipates positive evaluations from patients and families, none of whom has raised any privacy concerns. “So far, only one patient, a gentleman with a poor prognosis, has asked us not to fill in his board.”
 
The main challenge for the health care team has been keeping the boards fully updated. “It takes time to keep writing up the latest information,” says Beauchaine, and “people are very busy.” She estimates that, at any one time, only about half the boards are fully utilized. Still, she says, “We get so much good feedback from patients and their families, that’s a pretty good incentive to increase our efforts.”
 
All TCAB hospitals explored the best ways to integrate patient information and preferences into the decisions providers make, in conjunction with patients, about their care. Eventually, tools such as white boards may help capture how patients feel about certain procedures, tests, and other clinical interventions. It’s an example of  shared decision making — writ large.
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