NRNP 6831 Week 11 Reflection Example

The First Week After Discharge: A Reflection on a Follow-Up Visit Held Without the Discharge Summary

Student Name

College of Nursing, Walden University

NRNP 6831: Management of Specialized and Complex Populations

Instructor Name

Month Day, Year

The First Week After Discharge: A Reflection on a Follow-Up Visit Held Without the Discharge Summary

This reflection uses Schön's distinction between reflection-in-action, the thinking a practitioner does while an event is under way, and reflection-on-action, the looking back that happens afterward (Schön, 1983). The case is a composite. No patient I have seen is rebuilt in it, and no harm resulted in the version described here.

What Happened After Discharge

Leo is 4 and has chronic lung disease after a repaired congenital diaphragmatic hernia, pulmonary hypertension, and a gastrostomy. He was admitted for 6 days with a viral pneumonia. At discharge, his team made three medication changes, increasing his sildenafil, starting furosemide, and stopping his acid suppressant, and changed his feeding plan from five daytime boluses to three boluses and a continuous overnight feed.

Four days later, his father brought him to the practice for his follow-up visit. The discharge summary had not arrived. His father said the team had "changed a few medicines" and brought the bottles he had at home, which did not include the new furosemide, because it had not yet been filled. I reconciled his medicines from the old list, the bottles, and his father's account, examined him, found him well, and scheduled a weight check in 2 weeks. The summary arrived 2 days later. It showed the furosemide start, a request for electrolytes within a week, and the new overnight feed, none of which anyone at the visit knew.

In the Moment and Afterward

Reflecting in action, during the visit, I did notice that the summary was missing. I thought about calling the hospital, and decided not to. Leo looked well, his father seemed confident, and the practice had other patients waiting. My reasoning at the time was that a well child with an engaged parent and his own bottles was a reasonable basis for a follow-up visit. That judgment felt sound in the room, and I think a colleague in my place would have made it.

Reflecting on action, afterward, I can see what that judgment rested on. I assumed his father's account of the changes was complete, when he had described them as "a few." I assumed the bottles at home were the current medicines, when a new prescription is exactly the one that will not be in the bag yet. I assumed that the absence of a summary meant nothing urgent had changed, when in fact it meant only that I did not know. Each assumption was reasonable at the time and wrong in hindsight. Schön's distinction lets me say both without either excusing myself or pretending I should have known what I could not.

Readings Attached to Misses

The first miss was holding the visit without the summary. In their systematic review, Kripalani et al. (2007) found that a discharge summary was available at the first post-discharge visit in only 12% to 34% of cases, and that its absence affected the quality of care in about a quarter of follow-up visits. My visit was a textbook case of that finding, not an unusual one.

The second miss was reconciling medicines from what was in the bag. The same review found that discharge summaries themselves often left out important content, with discharge medications missing from up to 40% and follow-up plans from up to 43% (Kripalani et al., 2007). Even an arriving summary needs to be checked against the parent's account and the pharmacy's record. I had neither the summary nor the pharmacy record; I had the bottles.

The third miss was not planning around the missing information. A systematic review of pediatric discharge interventions found that the ones that reduced later readmissions and emergency visits paired inpatient education with support after discharge, and recommended naming an individual or team responsible for the move from inpatient to outpatient care (Auger et al., 2014). My visit was the outpatient half of that move, and nobody had been named to hold it.

I felt uncomfortable when the summary arrived. That discomfort was useful, because it made me look at a routine I had not questioned.

The Seam, Named Once

The seam I will watch is the first week after discharge. The practice I commit to is this: no post-discharge visit for a child with medical complexity proceeds without either the discharge summary in hand or a documented call to the discharging team before the visit starts, covering medication changes, feeding changes, and any tests requested. If neither is possible, the visit still happens, but the note says so, and a call is made the same day. A colleague could check whether I do this by opening any of my post-discharge notes and looking for one of those two things in the first line.

References

Auger, K. A., Kenyon, C. C., Feudtner, C., & Davis, M. M. (2014). Pediatric hospital discharge interventions to reduce subsequent utilization: A systematic review. Journal of Hospital Medicine, 9(4), 251-260. https://doi.org/10.1002/jhm.2134

Kripalani, S., LeFevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. JAMA, 297(8), 831-841. https://doi.org/10.1001/jama.297.8.831

Schön, D. A. (1983). The reflective practitioner: How professionals think in action. Basic Books.