Figure 1
Overview of events included in audits.
Table 1
The audit form questions.
| QUESTIONS TO BE ANSWERED BEFORE THE DAY OF THE AUDIT BY HOSPITAL-BASED PHYSICIANS, NURSES AND PHARMACISTS REGARDING THE HOSPITALIZATION IMMEDIATELY BEFORE THE PATIENT’S FIRST CONTACT WITH THE WARD ROUND TEAM |
|---|
| Was a referral sent by the physician under whose order the patient was hospitalized? If yes, describe the quality of the referral. (only to be answered by physicians and pharmacists) |
| Was a manually updated admission report sent from the municipality? If yes, when was the report received at the hospital? Describe the quality of the admission report. |
| Which diagnoses, symptoms and problems were addressed during the hospitalization? |
| What is your assessment of the investigation conducted during the hospitalization? Could the patient have benefitted from further investigation during the hospitalization? (only to be answered by physicians) |
| What is your assessment of the treatment initiated during the hospitalization? Could the patient profitably have been treated further or differently during the hospitalization? (only to be answered by physicians) |
| In your judgment, was it relevant to hospitalize the patient? (only to be answered by physicians) |
| In your judgment, were there any inappropriate patient medications before and during the hospitalization? (only to be answered by physicians and pharmacists) |
| Were any medication changes made during the hospitalization? (only to be answered by physicians and pharmacists) |
| In your judgment, was the patient appropriately medicated by the time of discharge? (only to be answered by physicians and pharmacists) |
| In your judgment, was there any risk of impending readmission by the time of discharge? |
| If yes, could anything have been done to reduce the risk of readmission? |
| What information was sent electronically from the hospital to general practice and the municipality? Was any information delivered only in paper form? In your judgment, was the information adequate for the general practitioner and municipality to handle further care? |
| Which conditions of the patient’s situation made it relevant to refer the patient to a TTA? |
| QUESTIONS TO BE ANSWERED BEFORE THE DAY OF THE AUDIT BY THE NURSES AT THE TTAS REGARDING THE CARE PATHWAY AT THE TTA |
| When did the patient stay at the TTA (times and dates for arrival and departure)? |
| What information was received in the municipality from the hospital by the time of the patient’s arrival at the TTA? In your judgment, was the information adequate for the municipality to handle further care? |
| Was the nursing assessment prepared and, if yes, when? Was the information from the hospital considered in the nursing assessment? |
| Which vital parameters were assessed at the reception of the patient at the TTA? Could other parameters profitably have been assessed? |
| How much time passed from discharge until the ward round team attended to the patient for the first time? |
| Why did the staff at the TTA contact the ward round team? |
| How often were vital parameters measured before the ward round team was contacted? Could other parameters profitably have been measured or with another frequency? |
| In your judgment, could the staff at the TTA have prevented deterioration of the patient’s health status before the ward round team attended to the patient? |
| In your judgment, could any contact with a general practitioner at an earlier stage have prevented deterioration of the patient’s health status? |
| Have any changes in medication been made or have any concerns about inappropriate medication been documented during the patient’s stay at the TTA? |
| QUESTIONS TO BE ANSWERED JOINTLY DURING THE AUDIT REGARDING THE EFFORT OF THE WARD ROUND TEAM |
| Describe the content of the effort of the ward round team |
| In your judgment, did the effort of the ward round team improve the patient’s state of health? |
| In your judgment, did the effort of the ward round team prevent an admission within eight days following the patient’s last contact with the team? |
| In your judgment, did the ward round team contribute to creating an overview of the patient’s immediate situation? In your judgment, did the effort of the ward round team improve the succeeding care pathway? |
| In your judgment, did the effort of the ward round team optimize the patient’s medication? |
| Are there any other elements of the care pathway that the effort of the ward round team affected? |
| In your judgment, did it make a difference that the ward round team had easy access to information in the hospital’s electronic patient records? |
| Could parts of the effort of the ward round team profitably have been performed during the hospitalization? |
| Is it likely that a general practitioner could have made a similar effort? |
| Overall assessment of the effort of the ward round team? |
| QUESTIONS TO BE ANSWERED JOINTLY DURING THE AUDIT REGARDING THE TOTAL CARE PATHWAY ACROSS SECTORS |
| Which elements of the care pathway worked particularly well across sectors? |
| What were the challenges in the care pathway across sectors? |
| In an ideal healthcare system, what could have been done better? |