Expert consensus for discharge referral decisions using online delphi.

Expert Consensus for Discharge Referral Decisions Using Online Delphi Kathy H. Bowles, PhD, RN1 , John H. Holmes, PhD 2 , Mary D. Naylor, PhD, FAAN 1 , Matthew Liberatore, PhD 3 , Robert Nydick, PhD 3 1 University of Pennsylvania School of Nursing, Philadelphia, PA, USA 2 University of Pennsylvania School of Medicine, Philadelphia, PA, USA 3 Villanova University Department of Decision and Information Technologies, Villanova, PA, USA ABSTRACT This paper describes the results of using a modified Delphi approach designed to achieve consensus from eight discharge planning experts regarding the decision to refer hospitalized older adults for postdischarge follow-up. Experts reviewed 150 cases using an online website designed to facilitate their interaction and efforts to reach agreement on the need for a referral for post-discharge care and the appropriate site for such care. In contrast to an average of eight weeks to complete just 50 cases using the traditional mail method, the first online Delphi round for 150 cases were completed in six weeks. Data provided by experts suggest that online Delphi is a time efficient and acceptable methodology for reaching group consensus. Other benefits include instant access to Delphi decision results, live knowledge of the time requirements and progress of each expert, and cost savings in postage, paper, copying, and storage of paper documents. This online Delphi methodology is highly recommended. INTRODUCTION Hospital discharge referral decision-making is a complex, multidisciplinary process with many barriers, challenges, and shortfalls. Shortened lengths of hospital stay, inconsistent assessment criteria, and varying levels of expertise and risk tolerance in clinical decision making are among the barriers that impede the ability to make accurate referral decisions 1, 2, 3 Older adults with multiple co-morbid conditions and complex treatment regimes add to the challenge. Inadequate discharge planning and referral decisionmaking can result in elders being discharged before the full effect of treatment is evident, the patient and family fully understand the illness or the treatment plan, and the patient can assume self-care. 2, 3, 4 Some believe the problem is so widespread that virtually all patients older than 60 leave the hospital with unmet needs.3 The care of these older adults is rapidly transferred from formal hospital care to the informal care of unskilled family caregivers. When referrals for follow-up professional care are missed, older adults with unmet needs suffer costly rehospitalizations, emergency room use, difficulties with activities of daily living, and declines in selfreported health.5, 6, 7, 8, 9 These adverse outcomes are very costly to the older adults, their families, and society, therefore it is critically important to understand and improve the process by which referral decisions are made. To address these issues, our team is in year two of a National Institute of Nursing Research funded study to develop an expert system to support discharge referral decision-making. The system will assist multidisciplinary clinicians to collect and synthesize key information to support accurate decision making when referring patients for services in home care, inpatient and outpatient settings, and nursing homes. National and local experts in discharge planning are identifying the factors that drive post discharge referrals. We are using these factors to develop a rule-based decision support system. In order to ensure that the knowledge base is as robust as possible and that it represents the array of best practices proposed by the experts, we developed a modified online Delphi technique to reach consensus. Consensus means that all eight experts agree on the referral decision and site of care for each case. The purpose of this paper is to share our online Delphi methodology and to discuss the results and benefits we realized by using this approach to support the goals of the parent study. METHODS Expert profiles The goal of the parent study is to develop a validated knowledge base for discharge planning decision support. In order to meet this goal, we included representatives from all of the clinical domains involved in discharge planning, including nursing, physical therapy, social work, and medicine. These individuals include four nationally known scholars and four local clinical discharge-planning experts. Their charge is to make referral decisions and AMIA 2003 Symposium Proceedings − Page 106 identify the factors that drive discharge referral decisions for a series of case studies, described below. Each of the experts was required to have at least five years of clinical or research experience in discharge planning or decision making for older adults. Experts were chosen to ensure diverse viewpoints with national, scholarly, local, and clinical perspectives. The national and scholarly perspectives came from four experts from different areas of the country including the Northeast, Midwest, and West. The four local experts provided the clinical perspective with their knowledge about the day-to-day operations, workflow, and issues about discharge decision-making. Case studies We generated a series of 200 case studies from the clinical and research files of adults aged (65 – 90) who were hospitalized for a variety of medical and surgical diagnoses. These diagnoses included congestive heart failure, respiratory tract infection, coronary bypass surgery, cardiac valve replacement, major small and large bowel procedures, angina/myocardial infarction, and orthopedic procedure of the lower extremities. Cases were generated from three previous clinical trials that evaluated transitional care. Data collected on each subject in these studies included medical and surgical history, medication and other therapies, adverse events, self-rated health, functional status, depression, health care utilization, and social support. These data were summarized to create individual case studies, which were presented in a standardized structured format. The case studies were mailed to each expert for discharge assessment. This assessment was limited to four possible discharge dispositions: home care, inpatient facility, outpatient care, or nursing home. This initial assessment indicated that there was considerable lack of agreement among the experts with regard to discharge disposition. At this point, we decided to employ a Delphi approach to facilitate consensus building. The Delphi technique The Delphi methodology is a predominantly qualitative approach in which expert opinion is determined through iterative rounds where respondents individually receive feedback about group opinions. Since information is shared confidentially and without personal contact between respondents, the biasing effects of peer pressure, seniority, or personality are minimized. 10 This technique is typically implemented asynchronously using mail or other media. For the (...truncated)