Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care

[Improvement of team competence in the operating room : Training programs from aviation]

Growing attention has been drawn to patient safety during recent months due to media reports of clinical errors. To date only clinical incident reporting systems have been implemented in acute care hospitals as instruments of risk management. However, these systems only have a limited impact on human factors which account for the majority of all errors in medicine. Crew resource management (CRM) starts here. For the commissioning of a new hospital in Minden, training programs were installed in order to maintain patient safety in a new complex environment. The training was planned in three parts: All relevant processes were defined as standard operating procedures (SOP), visualized and then simulated in the new building. In addition, staff members (trainers) in leading positions were trained in CRM in order to train the complete staff. The training programs were analyzed by questionnaires. Selection of topics, relevance for practice and mode of presentation were rated as very good by 73% of the participants. The staff members ranked the topics communication in crisis situations, individual errors and compensating measures as most important followed by case studies and teamwork. Employees improved in compliance to the SOP, team competence and communication. In high technology environments with escalating workloads and interdisciplinary organization, staff members are confronted with increasing demands in knowledge and skills. To reduce errors under such working conditions relevant processes should be standardized and trained for the emergency situation. Human performance can be supported by well-trained interpersonal skills which are evolved in CRM training. In combination these training programs make a significant contribution to maintaining patient safety.

The hospitalist movement in general pediatrics

PURPOSE OF REVIEW

The present review focuses on the latest evidence from the past 18 months related to pediatric hospitalist medicine.

RECENT FINDINGS

The number of hospitalists continues to increase despite many programs not being financially self-supporting. Reports in the past have shown decreased length of stay, resource utilization, and costs with the hospitalist model. There are an increasing number of studies examining patient safety, quality initiatives, and communication issues such as 'handoffs' and family-centered rounds. The teaching role continues to broaden in scope and is highly valued by trainees. Pediatric hospitalist fellowship training programs are in an early stage of development. A list of core competencies as a framework for a pediatric hospital medicine curriculum has recently been published and should help to facilitate and standardize training. Recent publications suggest that there is still significant variation in the approach to and management of many common inpatient illnesses.

SUMMARY

In general, there continue to be reports of positive outcomes as a result of the introduction of the hospitalist model in pediatrics. Much of the current literature is geared toward reporting on alternative models of care, inpatient quality and safety initiatives, and hospitalist teaching. What is still somewhat lacking is multicenter collaborative prospective clinical trials for common inpatient general pediatric conditions. The variation reported in the management of common conditions presents an opportunity for improving the quality, safety, resource utilization, and appropriateness of care.

Discharge management for patients in Flemish psychiatric hospitals

RATIONALE AND AIMS

At the end of the 1990 s, a case management service called 'discharge management' was implemented in Belgian psychiatric hospitals. This study aimed to describe the profile of patients receiving discharge management in Flemish psychiatric hospitals as well as to analyse the discharge management indicators of these hospitals on micro and meso level.

METHODS

Ten Flemish psychiatric hospitals participated. A descriptive analysis of the profile of patients receiving discharge management (gender, age, length of stay, family situation, assistance at home, living environment and Global Assessment of Functioning) and of the indicators of discharge management (screening, interdisciplinary patient file, interdisciplinary meeting, timely announcement of discharge date, transfer of discharge documents, readmission and institutionalization) were carried out.

RESULTS

Of the 1306 patients included in the database, one-fourth received discharge management. In general, patients (54% were male) were about 45 years old, stayed for 55 days in hospital, were single and had no aid at home. Most of them came from and returned to their own home. On the micro level of discharge management, nearly all patients were screened and half of them were positively screened. Half of these patients received discharge management. Of the discharged patients who received discharge management (meso level), 13.5% were institutionalized after discharge, 37.6% had been previously admitted and 27.2% received discharge management during that previous admission. Differences between diagnostic groups occurred.

CONCLUSION

Hospitals have made efforts to support and prepare patients for discharge, although a number of improvements are suggested for different indicators.

"Just be respectful of the primary doc": teaching mutual respect as a dimension of teamwork in general pediatrics

OBJECTIVE

Although others have reported on teamwork training, little is known about what pediatric residents in inpatient settings learn implicitly about respectful working relationships with community-based general pediatricians. The purpose of this brief report is to examine how pediatric residents on an inpatient general pediatric rotation regard "the other" (community-based general pediatricians), and how academic, hospital-based general pediatric attending physicians respond.

METHODS

We conducted a case study on one general pediatrics floor, which entailed 143 hours of observation over 8 months (January to August 2006), as well as in-depth interviews with 25 residents and 14 general pediatric attending physicians whom we observed as they worked on the floor. Data were derived from >1000 pages of field notes and interview transcripts. We systematically reviewed the data and inductively derived codes related to explicit and implicit education. In this brief report, we focused our analysis on data relevant to the concept of boundary crossing: when members of the group talk about members of another group in the process of inquiring about or negotiating patient care.

RESULTS

Residents' comments tended to reveal a neutral or somewhat negative regard for their general pediatric community counterparts, whom they typically referred to as PMDs (primary medical doctors). Attending physicians' responses to these comments varied, but often explicitly taught residents about dimensions of teamwork, including mutual respect.

CONCLUSIONS

Explicit teamwork training in pediatric education should not be limited to partnering with other disciplines or other specialties, but expanded to enhance positive regard and mutual respect for general pediatricians in hospital- and community-based settings alike. Attending physicians in general pediatrics are ideally positioned to implicitly teach respectful working relationships within the specialty.

A prospective cohort study found that provider and information continuity was low after patient discharge from hospital

OBJECTIVE

Continuity of care is composed of provider and information continuity and can change value over time. Most studies that have quantitatively associated continuity of care and outcomes have ignored these characteristics. This study is a detailed examination of continuity of care in patients discharged from hospital that simultaneously measured separate components of continuity over time or determined the factors with which they are associated.

DESIGN SETTING

Multicenter, prospective cohort study of patients discharged to the community after elective or emergent hospitalization. For all physician visits during 6 months after discharge, we identified the physician and the availability of particular information (including hospital discharge summary and any information from previous physician visits). Four physician continuity scores (preadmission; hospital admitting; hospital consultant; and postdischarge) and two information continuity scores (discharge summary and postdischarge visit information) were calculated for all patients (range: 0-1, where 0 is perfect discontinuity and 1 is perfect continuity).

RESULTS

Four thousand five hundred fifty-three people were followed for a median of 175 days. Both provider (range of median values: 0-0.410) and information (range: 0.220-0.427) continuity scores were low and varied extensively over time. With a few exceptions, continuity measures were independent of each other. The influence of patient factors on continuity varied extensively between the continuity measures with the most influential factors being admission urgency, admitting service, and the number of physicians who regularly treated the patient.

CONCLUSION

Both provider and information continuity was low in patients discharged from hospital. Continuity measures can change extensively over time, which are usually independent of each other, and are associated with patient and admission characteristics. Future studies should measure multiple components of provider and information continuity over time to completely capture continuity of care.

Integrating incident data from five reporting systems to assess patient safety: making sense of the elephant

BACKGROUND

A study was conducted to examine and compare information gleaned from five different reporting systems within one institution: incident reporting, patient complaints, risk management, medical malpractice claims, and executive walk rounds. These data sources vary in the timing of the reporting (retrospective or prospective), severity of the events, and profession of the reporters.

METHODS

A common methodology was developed for classifying incidents. Data specific to each incident were abstracted from each system and then categorized using the same framework into one of 23 categories.

RESULTS

Overall, there was little overlap, although each reporting system identified important safety issues. Communication problems were common among patient complaints and malpractice claims; malpractice claims' leading category was clinical judgement. Walk rounds identified issues with equipment and supplies. Adverse event reporting systems highlighted identification issues, especially mislabelled specimens. The frequency of contributions of reports by provider group varied substantially by system. Physicians accounted for 50% of risk management reports, but in adverse event reporting, where nurses were the main reporters, physicians accounted for only 2.5% of reports. Complaints and malpractice claims come primarily from patients.

CONCLUSIONS

The five reporting systems each identified different yet complementary patient safety issues. To obtain a comprehensive picture of their patient safety problems and to develop priorities for improving safety, hospitals should use a broad portfolio of approaches and then synthesize the messages from all individual approaches into a collated and cohesive whole.

Appropriate medication prescribing in elderly patients: how knowledgeable are primary care physicians? A survey study in Parma, Italy

WHAT IS KNOWN AND OBJECTIVE

Increasing attention is being paid to inappropriate medication prescribing for the elderly. A growing body of studies have detected a prevalence of inappropriate prescribing ranging from 12% to 40% worldwide, including Regione Emilia-Romagna, Italy. To improve quality of prescribing, a multi-phase pilot project in the Local Health Unit (LHU) of Parma, Regione Emilia-Romagna, was established. This phase aimed to assess primary care physicians' knowledge of appropriate prescribing in elderly patients.

METHODS

In total, 155 primary care physicians (51% of the total), convened by the LHU of Parma for an educational session, were asked to complete anonymously a 19-item paper survey. Knowledge of inappropriate medication use in the elderly was assessed using seven clinical vignettes based on the 2002 Beers Criteria. Topics tested included hypertension, osteoarthritis, arrhythmias, insomnia and depression. Data regarding physician's perceived barriers to appropriate prescribing for elderly patients were also collected. To evaluate the relationship between physician knowledge scores and physician characteristics, physicians were classified as having a 'low score' (three or below) or a 'high score' (six or more) with respect to their knowledge of prescribing for the elderly.

RESULTS AND DISCUSSION

All physicians completed the survey. Most physicians (88%) felt confident in their ability to prescribe appropriate medications for the elderly. Thirty-nine physicians (25%) received a 'high score' compared to 26 (17%) who received a 'low score'. 'Lower score' respondents had been in practice for a longer time (P < 0·05) than 'higher score' respondents. Perceived barriers to appropriate prescribing included potential drug interactions (79% of respondents) and the large number of medications a patient is already taking (75%).

WHAT IS NEW AND CONCLUSION

The study results show an unsatisfactory knowledge of appropriate prescribing among primary care physicians in the LHU of Parma, especially among older physicians. Educational strategies tailored to primary care physicians should be establish to enhance knowledge in this area and improve quality of prescribing.

The association between continuity of care and outcomes: a systematic and critical review

BACKGROUND

Numerous studies have tried to determine the association between continuity and outcomes. Studies doing so must actually measure continuity. If continuity and outcomes are measured concurrently, their association can only be determined with time-dependent methods.

OBJECTIVE

To identify and summarize all methodologically studies that measure the association between continuity of care and patient outcomes.

METHODS

We searched MEDLINE database (1950-2008) and hand-searched to identify studies that tried to associate continuity and outcomes. English studies were included if they: actually measured continuity; determined the association of continuity with patient outcomes; and properly accounted for the relative timing of continuity and outcome measures.

RESULTS

A total of 139 English language studies tried to measure the association between continuity and outcomes but only 18 studies (12.9%) met methodological criteria. All but two studies measured provider continuity and used health utilization or patient satisfaction as the outcome. Eight of nine high-quality studies found a significant association between increased continuity and decreased health utilization including hospitalization and emergency visits. Five of seven studies found improved patient satisfaction with increased continuity.

CONCLUSIONS

These studies validate the belief that increased provider continuity is associated with improved patient outcomes and satisfaction. Further research is required to determine whether information or management continuity improves outcomes.

Perspective: Whither the problem list? Organ-based documentation and deficient synthesis by medical trainees

The author argues that the well-formulated problem list is essential for both organizing and evaluating diagnostic thinking. He considers evidence of deficiencies in problem lists in the medical record. He observes a trend among medical trainees toward organizing notes in the medical record according to lists of organ systems or medical subspecialties and hypothesizes that system-based documentation may undermine the art of problem formulation and diagnostic synthesis. Citing research linking more sophisticated problem representation with diagnostic success, he suggests that documentation style and clinical reasoning are closely connected and that organ-based documentation may predispose trainees to several varieties of cognitive diagnostic error and deficient synthesis. These include framing error, premature or absent closure, failure to integrate related findings, and failure to recognize the level of diagnostic resolution attained for a given problem. He acknowledges the pitfalls of higher-order diagnostic resolution, including the application of labels unsupported by firm evidence, while maintaining that diagnostic resolution as far as evidence permits is essential to both rational care of patients and rigorous education of learners. He proposes further research, including comparison of diagnostic efficiency between organ- and problem-oriented thinkers. He hypothesizes that the subspecialty-based structure of academic medical services helps perpetuate organ-system-based thinking, and calls on clinical educators to renew their emphasis on the formulation and documentation of complete and precise problem lists and progressively refined diagnoses by trainees.

Improving the quality of discharge communication with an educational intervention

BACKGROUND

Communication between hospital providers and primary care physicians at the time of hospital discharge is necessary for optimal patient care and safety. Content of the inpatient discharge summary (DS) is not uniformly addressed by residency programs.

OBJECTIVE

To improve DSs quality through a brief educational intervention.

METHODS

We prospectively enrolled interns (first-year pediatric residents [PL1s]) in an educational intervention that consisted of a group session in which components of a high-quality DS were taught and a subsequent brief small-group session in which key components with distribution of a reminder card were reiterated. Six key components were identified: diagnosis; timely completion; pending laboratory work/studies; medications; length ≤3 pages; and discharge weight. DSs prepared by PL1s before and after the small-group session were objectively scored by blinded reviewers on the basis of how many DS components they contained (maximum score: 6). Scores were compared with historical controls of PL1s from the previous year. Audit scores were analyzed by using a mixed-effects linear regression model.

RESULTS

Sixty-four PL1s were enrolled in the study; 477 DSs were scored. Mean score before the small-group reminder session was 3.6 in both groups. In mixed-effects models, scores in the intervention group increased by 0.56 points (P=.002) and DSs incorporating at least 5 of 6 components increased from 22% to 41% (P<.001) after the small-group session, whereas the control group's scores were unchanged.

CONCLUSION

A brief, low-intensity educational intervention can improve quality of discharge communication and be incorporated into residency training. Electronic templates should incorporate prompts for key components of a DS.

Beliefs of ambulatory care physicians about accuracy of patient medication records and technology-enhanced solutions to improve accuracy

The continuing problem of inaccurate medication records and resultant harm from medication errors has prompted the Institute of Medicine and others to encourage information technology (IT) solutions to improve medication list accuracy. There are few studies on how ambulatory care documentation contributes to medication list inaccuracies and medication reconciliation failures. To address medication reconciliation issues in ambulatory care, office-based physicians in a region with a high adoption rate for electronic medical records (EMRs) were surveyed about current reconciliation practices, the need for redesigning reconciliation processes, and acceptable IT solutions for improving availability of medication information. Physicians selected from a list of potential IT platforms that would create a single reconciled record of prescription medications, nonprescription medications, and supplements accessible wherever patients go. The two most popular platforms were either an aggregated list within existing EMRs accessible by inpatient and outpatient providers regardless of their EMR system, or a web-based repository that was not integrated into an EMR. Respondents felt that implementation of such platforms would not require major changes to clinical workflow, perhaps due to the region's existing familiarity with health IT. Leveraging community acceptance of health IT could result in rapid implementation of universally accessible medication list platforms.

Transitioning the patient with acute coronary syndrome from inpatient to primary care

Patients with acute coronary syndrome (ACS) undergo several transitions in care throughout the hospital stay, from prehospitalization to the postdischarge period when patients return to primary care. Hospitalist core competencies promote safe transitions in care for patients with ACS, including hospital discharge. These competencies also highlight the central role of the hospitalist in facilitating the continuity of care and as a key link between the patient and the primary care provider (PCP). Core competencies address key decision points and processes that occur during hospitalization for ACS including the initial evaluation and risk stratification, medication reconciliation, and discharge planning. Discharge is a crucial transition and one where hospitalists can both facilitate the transition to primary care and improve adherence to quality measures established for ACS. Poor communication during discharge reportedly results in postdischarge adverse events, most often related to medications and lack of follow-up related to pending test results. Standards for a safe discharge such as Project RED (Re-Engineered Discharge), initiatives to improve outcomes after discharge like Project BOOST (Better Outcomes for Older Adults Through Safe Transitions), and adaptive tools including the ACS Transitions Tool support timely and accurate communication of complex information between the hospitalist, the PCP, and the patient. While the role of hospitalists is evolving, it is clear that they have a central role in ensuring safe transitions in care for ACS.

Problems after discharge and understanding of communication with their primary care physicians among hospitalized seniors: a mixed methods study

BACKGROUND

Communication and coordination with primary care physicians (PCPs) is recommended to ensure safe care transitions for hospitalized older patients. Understanding patient experiences of problems after discharge can help clinical teams design more patient-centered care transitions.

OBJECTIVE

To report older patients' experiences with problems after hospital discharge and investigate whether PCPs were aware of their hospitalization.

DESIGN

Prospective mixed methods study.

SETTING

Single academic medical center.

PATIENTS

Hospitalized patients and PCPs.

MEASUREMENTS

Telephone interviews of frail, older general medical patients conducted 2 weeks after discharge to elicit patient problems after discharge, such as: (1) obtaining medications, or follow-up appointments; and (2) perceptions of hospital physician communication with their PCP. For each patient interviewed, their PCP was faxed a survey 2 weeks after discharge to assess awareness of hospitalization.

RESULTS

Forty-two percent (27) of patients reported 42 different post-discharge problems. The most frequently reported problems were difficulty with follow-up appointments or tests (12). Other reported problems included readmission and return to the Emergency Department (10), problems with medications (8), not-prepared for discharge (8), and hospital complications or questions (4). Thirty percent of PCPs were unaware of patient hospitalization. Patients were twice as likely to report a problem if their PCP was unaware of the hospitalization (31% PCP aware, vs. 67% PCP not aware; P < 0.05).

CONCLUSION

This study suggests that many frail, older patients reported problems after discharge and were twice as likely to do so when the patient's PCP was not aware of the hospitalization. Systematic interventions to improve communication with PCPs during patient hospitalization are needed.

The effect of a clinical pharmacist discharge service on medication discrepancies in patients with heart failure

OBJECTIVE

Heart failure patients are regularly admitted to hospital and frequently use multiple medication. Besides intentional changes in pharmacotherapy, unintentional changes may occur during hospitalisation. The aim of this study was to investigate the effect of a clinical pharmacist discharge service on medication discrepancies and prescription errors in patients with heart failure.

SETTING

A general teaching hospital in Tilburg, the Netherlands.

METHOD

An open randomized intervention study was performed comparing an intervention group, with a control group receiving regular care by doctors and nurses. The clinical pharmacist discharge service consisted of review of discharge medication, communicating prescribing errors with the cardiologist, giving patients information, preparation of a written overview of the discharge medication and communication to both the community pharmacist and the general practitioner about this medication. Within 6 weeks after discharge all patients were routinely scheduled to visit the outpatient clinic and medication discrepancies were measured.

MAIN OUTCOME MEASURE

The primary endpoint was the frequency of prescription errors in the discharge medication and medication discrepancies after discharge combined.

RESULTS

Forty-four patients were included in the control group and 41 in the intervention group. Sixty-eight percent of patients in the control group had at least one discrepancy or prescription error against 39% in the intervention group (RR 0.57 (95% CI 0.37-0.88)). The percentage of medications with a discrepancy or prescription error in the control group was 14.6% and in the intervention group it was 6.1% (RR 0.42 (95% CI 0.27-0.66)).

CONCLUSION

This clinical pharmacist discharge service significantly reduces the risk of discrepancies and prescription errors in medication of patients with heart failure in the 1st month after discharge.

The independent association of provider and information continuity on outcomes after hospital discharge: implications for hospitalists

BACKGROUND

Since hospitalist physicians do not frequently see patients in follow-up after discharge from the hospital, patient continuity of care will decrease. To determine how this influenced patient outcomes, we examined the independent association of several physician continuity and information continuity measures on death or urgent readmission after discharge from hospital.

DESIGN

Multicenter, prospective cohort study of patients discharged to the community after elective or emergency hospitalization. We measured three physician continuity scores (preadmission; hospital; and postdischarge) and two information continuity scores (discharge summary; postdischarge visit information) as time-dependent covariates. Continuity scores ranged from 0 (perfect discontinuity) to 1 (perfect continuity). The primary outcomes were time to all-cause death or urgent readmission.

RESULTS

A total of 3876 people were followed for a median of 175 days. Death rate was 2.6 events per 100 patient-years observation (pys) (95% confidence interval [CI], 2.0-3.4) and urgent readmission rate was 19.6 events per 100 pys (95% CI, 15.9-24.3). After adjusting for important covariates and other continuity scores, increased preadmission physician continuity was independently associated with a decreased risk of urgent readmission (adjusted hazard ratio 0.94 [95% CI, 0.91-0.98] for each absolute increase in continuity of 0.1). Other continuity measures-including hospital physician continuity-were not associated with either outcome.

CONCLUSIONS

After discharge from the hospital, increased continuity with physicians who routinely treated the patient prior to the admission was significantly and independently associated with a decreased risk of urgent readmission. These data suggest that continuity with the hospital physician after discharge did not independently influence the risk of patient death or urgent readmission.

Discharge documentation of patients discharged to subacute facilities: a three-year quality improvement process across an integrated health care system

BACKGROUND

Effective communication among physicians during hospital discharge is critical to patient care. Partners Healthcare (Boston) has been engaged in a multi-year process to measure and improve the quality of documentation of all patients discharged from its five acute care hospitals to subacute facilities.

METHODS

Partners first engaged stakeholders to develop a consensus set of 12 required data elements for all discharges to subacute facilities. A measurement process was established and later refined. Quality improvement interventions were then initiated to address measured deficiencies and included education of physicians and nurses, improvements in information technology, creation of or improvements in discharge documentation templates, training of hospitalists to serve as role models, feedback to physicians and their service chiefs regarding reviewed cases, and case manager review of documentation before discharge. To measure improvement in quality as a result of these efforts, rates of simultaneous inclusion of all 12 applicable data elements ("defect-free rate") were analyzed over time.

RESULTS

Some 3,101 discharge documentation packets of patients discharged to subacute facilities from January 1, 2006, through September 2008 were retrospectively studied. During the 11 monitored quarters, the defect-free rate increased from 65% to 96% (p < .001 for trend). The largest improvements were seen in documentation of preadmission medication lists, allergies, follow-up, and warfarin information.

CONCLUSIONS

Institution of rigorous measurement, feedback, and multidisciplinary, multimodal quality improvement processes improved the inclusion of data elements in discharge documentation required for safe hospital discharge across a large integrated health care system.

Toward safe hospital discharge: a transitions in care curriculum for medical students

BACKGROUND

Medical errors often occur when patients move between care settings. Physicians generally receive little formal education on improving patient care transitions.

OBJECTIVE

To develop a sustainable and effective Transition in Care Curriculum (TICC). Specific goals were to increase student confidence in and knowledge of skills necessary during care transitions at the time of hospital discharge, and to quantify the frequency of student-identified medication discrepancies during a post-discharge home visit.

DESIGN

TICC was delivered to 136 3rd-year medical students during their required inpatient medicine clerkship at six urban Denver hospitals. TICC consists of small and large group interactive sessions and self-directed learning exercises to provide foundational knowledge of care transitions. Experiential learning occurs through direct patient care at the time of discharge and during a follow-up home, hospice, or skilled nursing visit. Students completed a pre-post confidence measure, short answer and multiple choice questions, a post-clerkship satisfaction survey, and a standardized medication discrepancy tool.

MAIN RESULTS

Overall combined confidence in transitional care skills improved following the TICC from an average score of 2.7 (SD 0.9) to 4.0 (SD 0.8) (p < 0.01) on a 5-point confidence scale. They scored an average of 77% on the written discharge plan portion of the final exam. Students rated the usefulness of TICC at a mean of 3.1 (SD 0.7), above the combined mean of 2.7 for project work in all required clerkships. Students identified medication discrepancies during 43% of post-discharge visits (58 of 136). The most common reasons for discrepancies were patient lack of understanding of instructions and intentional non-adherence to medication plan.

CONCLUSION

TICC represents a feasible and effective program to teach evidence-based transitional care.

Improving transitions of care at hospital discharge--implications for pediatric hospitalists and primary care providers

Delays, omissions, and inaccuracy of discharge information are common at hospital discharge and put patients at risk for adverse outcomes. We assembled an interdisciplinary team of stakeholders to evaluate our current discharge process between hospitalists and primary care providers (PCPs). We used a fishbone diagram to identify potential causes of suboptimal discharge communication to PCPs. Opportunities for improvement (leverage points) to achieve optimal transfer of discharge information were identified using tally sheets and Pareto charts. Quality improvement strategies consisted of training and implementation of a new discharge process including: (1) enhanced PCP identification at discharge, (2) use of an electronic discharge order and instruction system, and (3) autofaxing discharge information to PCPs. The new discharge process's impact was evaluated on 2,530 hospitalist patient discharges over a 34-week period by measuring: (1) successful transfer of discharge information (proportion of discharge information sheets successfully faxed to PCPs), (2) timeliness (proportion of sheets faxed within 2 days of discharge), and (3) content (presence of key clinical elements in discharge sheets). Postintervention, success, and timeliness of discharge information transfer between pediatric hospitalists and PCPs significantly improved while content remained high.

Relational and management continuity survey in patients with multiple long-term conditions

OBJECTIVE

To quantify problems of relational and management continuity of care in patients with multiple long-term conditions.

METHODS

A mailed questionnaire survey was conducted among people aged 60 years and older from 15 general practices. The questionnaire included 16 items concerning relational and management continuity of care. The number of long-term conditions was measured using the Self-Administered Comorbidity Questionnaire.

RESULTS

Data were analysed for 1,125 participants, a response rate of 37%. There were 123 (11%) with no long-term conditions, 225 (20%) with one, 284 (25%) with two, 218 (19%) with three and 275 (24%) with four or more. Factor analysis confirmed two factors with seven items for management continuity (alpha 0.88) and nine items for relational continuity (alpha 0.83). Experiences of difficulties with management continuity were higher in participants with three long-term conditions or more (adjusted odds ratio 2.01, 95% confidence interval 1.09 to 3.73), with 'poor' self-rated health (2.21, 1.21 to 4.02), or at least three hospital outpatient attendances each year (2.60, 1.32 to 5.12). The number of long-term conditions was not consistently associated with relational continuity. Difficulties of relational continuity were experienced by participants with 'poor' self-rated health (2.11, 1.16 to 3.85). Patients with more frequent general practice consultations experienced fewer difficulties of relational continuity (0.63, 0.42 to 0.92).

CONCLUSION

People with many long-term conditions are at increased risk of inadequate management continuity with potential negative impacts on their care. Experiences of relational continuity, with potential buffering effects, are not associated with the number of long-term conditions.

An intervention to improve nurse-physician communication in depression care

OBJECTIVES

Depression in older adult home care recipients is frequently undetected and inadequately treated. Failed communication between home healthcare personnel and the patient's physician has been identified as a barrier for depression care. The purpose of this pilot intervention study was to improve nurse competency for communicating depression-related information to the physician.

DESIGN

A single group pre-post experimental design.

SETTING

Two Medicare-certified home healthcare agencies serving an urban and suburban area in New York.

PARTICIPANTS

Twenty-eight home care nurses, all female Registered Nurses.

INTERVENTION

Two-hour skills training workshop.

MEASUREMENTS

To evaluate the intervention, pre-post changes in effective nurse communication using Objective Structured Clinical Examinations and nurse survey reports.

RESULTS

The intervention significantly improved the ability of the home care nurse to perform a case presentation in a complete and standard organized format pre versus postintervention. The intervention also increased nurse-reported certainty to communicate depression-related information to the physician.

CONCLUSIONS

Our findings provide support for the ability of a brief, depression-focused communication skills training intervention to improve home care nurse competency for effectively communicating depression-related information to the physician.

Non-adherence to recommendations for further testing after outpatient CT and MRI

BACKGROUND

Nearly 1 in every 5 outpatient visits ends with a request for a diagnostic imaging test, and imaging reports often contain recommendations for further testing. Little is known about adherence to recommendations for further testing after outpatient computed tomography (CT) and magnetic resonance imaging (MRI).

METHODS

We performed a retrospective cohort study linking provincial administrative data to a cross-sectional audit of 23,691 outpatient CT and MRI scans performed in 2005 in Ontario, Canada. After excluding patients who died (n=1031), were hospitalized (n=3030), or visited an emergency department (n=3660) within 180 days of the index CT/MRI scan, 15,970 CT/MRI scans were included. The primary outcome was adherence to recommendations for further testing within 180 days of an index CT/MRI scan.

RESULTS

Further testing was recommended in 2027 of 15,970 (12.7%) index CT/MRI scan reports and was recommended most frequently after CT chest scans (593 of 2276 [26.1%]). From the 2027 scans in which further testing was recommended, we identified 2102 individual recommendations for a specific type of follow-up test and found that just over one third (37.6%) of these recommendations were followed at 180 days. Adherence was lower (32.3%) when patients had a visit to the referring physician within 180 days of the index CT/MRI scan, compared with when they had no such visit (50.5%; P <.001).

CONCLUSIONS

Radiologists commonly recommend further testing after outpatient CT and MRI scanning. However, nearly two thirds of these recommendations are not followed. This suggests that substantial opportunities exist to improve the exchange of information between clinicians and radiologists and to advance the quality of outpatient care.

Clinician-patient discord: exploring differences in perspectives for discontinuing clopidogrel

BACKGROUND

Premature stopping of anti-platelet therapy has potentially fatal consequences for myocardial infarction (MI) patients who have received a drug-eluting stent (DES). Exploring multiple perspectives to identify contributing factors to the problem is essential.

AIM

We gained patient and clinician perspectives as to why MI patients prematurely stop anti-platelet therapy (clopidogrel) after DES implantation.

METHODS

This qualitative, descriptive study of DES-treated MI patients (n=22) and of clinicians (physicians and nurse practitioners; n=17) from multiple U.S. cities used content analysis of interview data. Findings across patients and clinicians were then compared to examine congruent and contrasting reasons for premature clopidogrel discontinuance.

FINDINGS

Patients frequently identified communication and education (e.g. unaware they should be taking clopidogrel, unaware of intended duration of therapy) as the primary reasons for having stopped. Patients rarely cited cost, while clinicians most commonly cited cost as a reason for premature stopping.

CONCLUSIONS

The discrepancy in perceptions of patients and clinicians as to the primary reason for early discontinuance suggests an important opportunity for improving persistence. Rather than focusing on the high costs of medications, something outside of their control, physicians should consider communicating more effectively the importance and intended duration of clopidogrel to their patients.

Health literacy and the quality of physician-patient communication during hospitalization

BACKGROUND

Overall, poor physician-patient communication is related to post-discharge adverse events and readmission. We analyzed patients' ratings of the quality of physician-patient communication during hospitalization and how this varies by health literacy.

METHODS

Medical patients were interviewed during their hospitalization to assess personal characteristics and health literacy. After discharge, patients completed by telephone the 27-item Interpersonal Processes of Care in Diverse Populations Questionnaire (IPC). Using the IPC, patients rated the clarity and quality of physicians' communication during the hospitalization along the following 8 domains: General clarity, Responsiveness to patient concerns, Explanation of patients' problems, Explanation of processes of care, Explanation of self-care after discharge, Empowerment, Decision making, and Consideration of patients' desire and ability to comply with recommendations.

RESULTS

A total of 84 patients completed both the in-hospital and telephone interviews. Subjects had a mean age of 55, and 44% had inadequate health literacy. Overall, patients gave the poorest ratings to communication that related to Consideration of patients' desire and ability to comply with recommendations. Patients with inadequate health literacy gave significantly worse ratings on the domains of General clarity, Responsiveness to patient concerns, and Explanation of processes of care (P < 0.05 for each). In multivariable analyses, the relationship with General clarity did not persist.

CONCLUSIONS

Physicians received relatively poor ratings on their Consideration of patients' desire and ability to comply with recommendations. Patients with inadequate health literacy experienced lower quality and clarity of hospital communication along multiple domains. More attention to effective health communication is warranted in the hospital setting.

Psychiatric hospitalists and continuity of care: a comparison of two models

The Michael E. DeBakey Veterans Affairs (VA) Medical Center inpatient psychiatry program underwent a series of substantial changes that led to a shift from a continuity of care (COC) model to a hospitalist environment in 2007. Although similar changes in other fields of medicine (general medicine, pediatrics, surgery, cardiology, and neurology) have been associated with several care benefits, no studies to date have evaluated the potential effects of such a change in models in psychiatry. The shift at the Michael E. DeBakey VA Medical Center thus provided a unique opportunity to compare these two models of care and gather evidence about which model may be more beneficial to patients. Data were derived retrospectively from two separate periods of time, one representative of the COC model (July-December 2006) and one representative of the hospitalist model (July-December 2008). The total number of discharges increased significantly from the first to the second period. Although the average length of stay remained similar, the number of readmissions occurring within 30 days of discharge was much lower during the hospitalist period. In addition, patients discharged in the hospitalist period were more likely to attend their outpatient mental health appointments. Findings suggest a preference for the hospitalist model over a COC model.

U.S. trends in hospitalization and generalist physician workforce and the emergence of hospitalists

BACKGROUND

General internists and other generalist physicians have traditionally cared for their patients during both ambulatory visits and hospitalizations. It has been suggested that the expansion of hospitalists since the mid-1990s has "crowded out" generalists from inpatient care. However, it is also possible that declining hospital utilization relative to the size of the generalist workforce reduced the incentives for generalists to continue providing hospital care.

OBJECTIVE

To examine trends in hospital utilization and the generalist workforce before and after the emergence of hospitalists in the U.S. and to investigate factors contributing to these trends.

DESIGN

Using data from 1980-2005 on inpatient visits from the National Hospital Discharge Survey, and physician manpower data from the American Medical Association, we identified national trends before and after the emergence of hospitalists in the annual number of inpatient encounters relative to the number of generalists.

RESULTS

Inpatient encounters relative to the number of generalists declined steadily before the emergence of hospitalists. Declines in inpatient encounters relative to the number of generalists were driven primarily by reduced hospital length of stay and increased numbers of generalists.

CONCLUSIONS

Hospital utilization relative to generalist workforce declined before the emergence of hospitalists, largely due to declining length of stay and rising generalist workforce. This likely weakened generalist incentives to provide hospital care. Models of care that seek to preserve dual-setting generalist care spanning ambulatory and inpatient settings are most likely to be viable if they focus on patients at high risk of hospitalization.

Electronic exchange of discharge summaries between hospital and municipal care from health personnel's perspectives

Introduction

Information and communication technologies (ICT) are seen as potentially powerful tools that may promote integration of care across organisational boundaries. Here, we present findings from a study of a Norwegian project where an electronic interdisciplinary discharge summary was implemented to improve communication and information exchange between the municipal care service and the associated hospital.

Objective

To investigate the implications of introduction and use of the electronic discharge summary for health staff, and relate it to the potential for promoting integration of care across the hospital-municipality boundary.

Methods

We conducted semi-structured interviews with 49 health care providers. The material was analysed using a three-step process to identify the main themes and categories.

Findings

The study showed that the electronic discharge summary contributed to changes in health staff's work processes as well as increased legibility of summaries, and enabled municipal care staff to be better prepared for receiving patients, even though the information content mostly remained unaltered and was not always accurate.

Conclusion

Introduction of electronic discharge summaries did not result in a significant increase in integration of care. However, the project was a catalyst for the collaborating participants to address their interaction from new perspectives.

Role understanding and effective communication as core competencies for collaborative practice

The ability to work with professionals from other disciplines to deliver collaborative, patient-centred care is considered a critical element of professional practice requiring a specific set of competencies. However, a generally accepted framework for collaborative competencies is missing, which makes consistent preparation of students and staff challenging. Some authors have argued that there is a lack of conceptual clarity of the "active ingredients" of collaboration relating to quality of care and patient outcomes, which may be at the root of the competencies issue. As part of a large Health Canada funded study focused on interprofessional education and collaborative practice, our goal was to understand the competencies for collaborative practice that are considered most relevant by health professionals working at the front line. Interview participants comprised 60 health care providers from various disciplines. Understanding and appreciating professional roles and responsibilities and communicating effectively emerged as the two perceived core competencies for patient-centred collaborative practice. For both competencies there is evidence of a link to positive patient and provider outcomes. We suggest that these two competencies should be the primary focus of student and staff education aimed at increasing collaborative practice skills.

The ethics of the hospitalist model

The hospitalist model was founded on the premise that it could improve the quality and reduce the cost of hospital care. Many randomized studies have all but definitively proven this original assertion. Nevertheless, the hospitalist specialty raises lingering classical ethical issues: protecting the patient-physician relationship in an environment of increasing specialization and discontinuity of care, preserving patient autonomy and choice when structural changes are made in the provision of care, and ensuring that a model founded on efficiency and cost-effectiveness does not erode the public trust in hospitalists to always serve their patients' best interests. This work aims to serve as an update of these initial criticisms, showing how some questions have been answered, while some have not.

Critical elements of clinical follow-up after hospital discharge for heart failure: insights from the EVEREST trial

AIMS

Hospitalized heart failure (HF) patients are at high risk for death and readmission. We examined the incremental value of data obtained 1 week after HF hospital discharge in predicting mortality and readmission.

METHODS AND RESULTS

In the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with tolvaptan, 1528 hospitalized patients (ejection fraction < or =40%) with a physical examination, laboratories, and health status [Kansas City Cardiomyopathy Questionnaire (KCCQ)] assessments 1 week after discharge were included. The ability to predict 1 year cardiovascular rehospitalization and mortality was assessed with Cox models, c-statistics, and the integrated discrimination improvement (IDI). Not using a beta-blocker, rales, pedal oedema, hyponatraemia, lower creatinine clearance, higher brain natriuretic peptide, and worse health status were independent risk factors for rehospitalization and death. The c-statistic for the base model (history and medications) was 0.657. The model improved with physical examination, laboratory, and KCCQ results, with IDI increases of 4.9, 7.0, and 3.2%, respectively (P < 0.001 each). The combination of all three offered the greatest incremental gain (c-statistic 0.749; IDI increase 10.8%).

CONCLUSION

Physical examination, laboratories, and KCCQ assessed 1 week after discharge offer important prognostic information, suggesting that all are critical components of outpatient evaluation after HF hospitalization.

Are electronic medical records helpful for care coordination? Experiences of physician practices

BACKGROUND

Policies promoting widespread adoption of electronic medical records (EMRs) are premised on the hope that they can improve the coordination of care. Yet little is known about whether and how physician practices use current EMRs to facilitate coordination.

OBJECTIVES

We examine whether and how practices use commercial EMRs to support coordination tasks and identify work-around practices have created to address new coordination challenges.

DESIGN, SETTING

Semi-structured telephone interviews in 12 randomly selected communities.

PARTICIPANTS

Sixty respondents, including 52 physicians or staff from 26 practices with commercial ambulatory care EMRs in place for at least 2 years, chief medical officers at four EMR vendors, and four national thought leaders.

RESULTS

Six major themes emerged: (1) EMRs facilitate within-office care coordination, chiefly by providing access to data during patient encounters and through electronic messaging; (2) EMRs are less able to support coordination between clinicians and settings, in part due to their design and a lack of standardization of key data elements required for information exchange; (3) managing information overflow from EMRs is a challenge for clinicians; (4) clinicians believe current EMRs cannot adequately capture the medical decision-making process and future care plans to support coordination; (5) realizing EMRs' potential for facilitating coordination requires evolution of practice operational processes; (6) current fee-for-service reimbursement encourages EMR use for documentation of billable events (office visits, procedures) and not of care coordination (which is not a billable activity).

CONCLUSIONS

There is a gap between policy-makers' expectation of, and clinical practitioners' experience with, current electronic medical records' ability to support coordination of care. Policymakers could expand current health information technology policies to support assessment of how well the technology facilitates tasks necessary for coordination. By reforming payment policy to include care coordination, policymakers could encourage the evolution of EMR technology to include capabilities that support coordination, for example, allowing for inter-practice data exchange and multi-provider clinical decision support.

Cultural diversity between hospital and community nurses: implications for continuity of care

Introduction

Health care systems and nurses need to take into account the increasing number of people who need post-hospital nursing care in their homes. Nurses have taken a pivotal role in discharge planning for frail patients. Despite considerable effort and focus on how to undertake hospital discharge successfully, the problem of ensuring continuity of care remains.

Challenges

In this paper, we highlight and discuss three challenges that seem to be insufficiently articulated when hospital and community nurses interact during discharge planning. These three challenges are: how local practices circumvent formal structures, how nurses' different perspectives influence their assessment of patients' need for post-hospital care, and how nurses have different understanding of what it means to be ‘ready to be discharged’.

Discussion

We propose that nurses need to discuss these challenges and their implications for nursing care so as to be ready to face changing demands for health care in future.

The effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in a multicultural population of internal medicine patients

Background

Medication errors occur frequently at points of transition in care. The key problems causing these medication errors are: incomplete and inappropriate medication reconciliation at hospital discharge (partly arising from inadequate medication reconciliation at admission), insufficient patient information (especially within a multicultural patient population) and insufficient communication to the next health care provider. Whether interventions aimed at the combination of these aspects indeed result in less discontinuity and associated harm is uncertain. Therefore the main objective of this study is to determine the effect of the COACH program (Continuity Of Appropriate pharmacotherapy, patient Counselling and information transfer in Healthcare) on readmission rates in patients discharged from the internal medicine department.

Methods/Design

An experimental study is performed at the internal medicine ward of a general teaching hospital in Amsterdam, which serves a multicultural population. In this study the effects of the COACH program is compared with usual care using a pre-post study design. All patients being admitted with at least one prescribed drug intended for chronic use are included in the study unless they meet one of the following exclusion criteria: no informed consent, no medication intended for chronic use prescribed at discharge, death, transfer to another ward or hospital, discharge within 24 hours or out of office hours, discharge to a nursing home and no possibility to counsel the patient.

The intervention consists of medication reconciliation, patient counselling and communication between the hospital and primary care healthcare providers.

The following outcomes are measured: the primary outcome readmissions within six months after discharge and the secondary outcomes number of interventions, adherence, patient's attitude towards medicines, patient's satisfaction with medication information, costs, quality of life and finally satisfaction of general practitioners and community pharmacists.

Interrupted time series analysis is used for data-analysis of the primary outcome. Descriptive statistics is performed for the secondary outcomes. An economic evaluation is performed according to the intention-to-treat principle.

Discussion

This study will be able to evaluate the clinical and cost impact of a comprehensive program on continuity of care and associated patient safety.

Trial registration

Dutch trial register: NTR1519

Primary care physicians and hospitalists: two branches of the same tree

The success of the evolving filed of pediatric hospitalist medicine should be judged on the health outcomes achieved for the more than 6 million children who are hospitalized annually. The focused approach hospitalists bring to defining the best knowledge that their role is important but is limited in the overall health of most children. In order to achieve the best health outcomes, hospitalists must fully partner with the child's primary care provider. By consistently communicating well during pre-admission, hospitalization, and discharge intervals, hospitalists and primary care pediatricians can enhance learning, as well as maximize outcomes for shared patients.

GPs' perceptions of multiple-medicine use in older patients

RATIONALE, AIM AND OBJECTIVE

Multiple-medicine use (polypharmacy) is a growing problem for older patients, prescribers and health policy makers. The general practitioner (GP) is most often the main professional care provider; hence, improvements of treatment can only be carried out in concordance with GPs. The aim of this study was, therefore, to explore GPs' perspectives of treating older users of multiple medicines, using a qualitative approach.

METHOD

Six focus groups, with four private GPs and 27 county-employed GPs, were analysed by using the framework method.

RESULTS

In contrast to definitions in most epidemiologic studies, the GPs gave a spontaneous definition of polypharmacy as 'the administration of more medicines than are clinically indicated'. They had problems stating both a cut-off number and which medicines should be included. Clinical practice guidelines were thought of as 'medicine generators', having an ambiguous effect on the GPs, who both trust them and find them difficult to apply. There was a perceived lack of communication between GPs and hospital specialists concerning their patients' medicines, which was further perceived to reduce treatment quality. The influence of patient pressure was acknowledged by the GPs as a factor contributing to the development of multiple-medicine use.

CONCLUSIONS

The GPs felt insecure although surrounded by clinical practice guidelines. There is a need for policy makers to appreciate this paradox, as the problem is likely to grow in size and proportion. GPs must be empowered to handle the increasing proportion of older users of multiple medicines with individual agendas, receiving care from multiple specialists.

Improving inpatients' identification of their doctors: use of FACE cards

BACKGROUND

Improving patients' ability to identify their inpatient physicians and understand their roles is vital to safe patient care. Picture cards were designed to facilitate physician introductions. The effect of Feedback Care and Evaluation (FACE) cards on patients' ability to correctly identify their inpatient physicians and on patients understanding of physicians roles was assessed.

METHODS

In October 2006, team members introduced themselves with FACE cards, which included a photo and an explanation of their roles. During an inpatient interview, research assistants asked patients to name their inpatient physicians and trainees and to rate their understanding of their physicians' roles.

RESULTS

Of 2,100 eligible patients, 1,686 (80%) patients participated in the baseline period, and 857 (67%) of the 1,278 patients in the intervention period participated in the evaluation. With the FACE intervention, patients were significantly more likely to correctly identify at least one inpatient physician (attending, resident, or intern; baseline 12.5% versus intervention 21.1%; p < .001). Of the 181 patients who were able to correctly identify at least one inpatient physician in the intervention period, research assistants noted that 59% (107) had FACE cards visible in their rooms. Surprisingly, fewer patients rated their understanding of their physicians' roles as excellent or very good in the intervention period (45.6%) compared with the baseline period (55.3%; p < .001).

DISCUSSION

Although FACE cards improved patients ability to identify their inpatient physicians, many patients still could not identify their inpatient doctors. FACE cards may have served as a reminder to physicians to introduce themselves to their patients. The FACE cards also served to highlight patients' misunderstanding of their physicians' roles.

Informational needs of general practitioners regarding discharge medication: content, timing and pharmacotherapeutic advice

OBJECTIVE

To investigate the needs of Dutch general practitioners on discharge medication, both regarding content, timing and the appreciation of pharmacotherapeutic advice from clinical pharmacists.

SETTING

A general teaching hospital in Amsterdam, The Netherlands.

METHOD

A prospective observational study was performed. A questionnaire with regard to the content, optimal timing (including way of information transfer) and appreciation of pharmacotherapeutic advice was posted to 464 general practitioners. One reminder was sent.

MAIN OUTCOME MEASURE

Description of the needs of general practitioners was assessed. For each question and categories of comments frequency tables were made. The Fisher-exact test was used to study associations between the answers to the questions.

RESULTS

In total, 149 general practitioners (32%) responded. Most general practitioners (75%) experienced a delay in receiving discharge medication information and preferred to receive this on the day of discharge. GPs wished to receive this information mainly through e-mail (44%). There was a significant correlation (P = 0.002) between general practitioners who wanted to know whether and why medication had been stopped (87%) and changed (88%) during hospital admission. The general practitioners (88%) appreciated pharmacotherapeutic advice from clinical pharmacists.

CONCLUSION

This study indicates how information transfer on discharge medication to GPs can be optimised in the Netherlands. The information arrives late and GPs want to be informed on the day of discharge mainly by e-mail. GPs wish to know why medication is changed or discontinued and appreciate pharmacotherapeutic advice from clinical pharmacists.

The sustainability of Medical Morning Handover Reporting: adherence in a regional hospital

Background.The Medical Morning Handover Report is a form of clinical handover and is considered to be an essential mechanism for continuity of care and adverse event minimisation within a hospital environment. It is considered a significant Quality of Care activity recommended in Australian Medical Association clinical handover guidelines. The sustainability of such activities has not been reported. Aim.We aimed to assess the sustainability of Medical Morning Handover Reporting (MMHR) in the Department of Medicine at the Launceston General Hospital since its implementation in 2001. Methods.We conducted a quality improvement survey amongst the medical staff (pre-graduate and post graduate medical faculties) to assess its sustainability since implementation in 2001. Results.There were 30 respondents of whom 19 attended MMHR daily, four attended weekly, and only five attended less than weekly. Attendance rates at MMHR were maintained from 2001 to 2009 based on comparisons with previously conducted surveys. Conclusions.This study shows MMHR is sustainable and has evolved in format to incorporate advances in Health Information Technology. We believe adherence is dependent on providing leadership and structure to MMHR. What is known about the topic?Since the mid 2000s, the MMHR has emerged as a significant quality intervention activity in our Department of Medicine, with particular emphasis on the first 12–24 h of a patient's encounter with the hospital with conditions that are considered to be medical diagnoses. When considered relevant follow up feedback on previous admissions is covered by the meeting. What does this paper add?This paper attempts to add measurable end points for the quality of the MMHR meeting, the importance of measuring sustainability and introduce the concepts relating to the use of health information technologies as significant decision support and peer review tools within the meeting. What are the implications for practitioners?This study has several implications for clinicians in hospitals: (1) the Report is an essential component of ongoing quality of care handover to maintain the continuity of care and to apply the necessary variations in care uncovered during the handover process. (2) Strict adherence to the meeting time frame improves the MMHR efficiency. (3) Consultant staff attendance has a strong positive influence on the care and educational benefits of the meeting. (4) The integrated use of e-technologies appears to have a strong positive effect on decision making and education during MMHR.

Is organizational change associated with increased rates of readmission to general hospital in suicide attempters? A 10-year prospective catchment area study

The objective of this study was to examine predictors for readmissions in patients admitted to a general hospital emergency ward for suicide attempts before and after organizational changes potentially affecting the chain of care. Socio-demographic and clinical variables were collected by clinicians from 1997 thru 2007. Data from the periods before and after 2004--when the hospital changed its catchment area--were compared. A substantial increase in readmission rates in the period after the organizational change was observed. This increase was not associated with any of the socio-demographic or clinical patient characteristics. Although no causal connection can be inferred, the observed association between organizational change and readmission rates could indicate that established post-discharge care systems for suicide attempters may be vulnerable to such change.

[Problems and deficits in the transition from inpatient and outpatient care of cancer patients. A qualitative analysis]

INTRODUCTION

Problems and deficits in the transition between hospital-based and outpatient care of cancer patients were evaluated. The project was initiated by the Public Health Department of the City of Aachen and was carried out with cooperation from all hospitals in the urban areas.

METHOD

From September 2002 to April 2003 a total of 145 cancer patients fulfilling the inclusion criteria from 4 regional hospitals were documented at 4 time points within a period of 6-8 weeks by questionnaires, telephone and personal interviews. Aspects of interest were disease type, symptom burden, well-being, the homecare situation and medical aids required.

RESULTS

Patients and their relatives reported on inadequate pain management, insufficient preparation of transition, problems in information flow, organisational problems, lack of attention and humaneness, deficiency of care, delay of diagnosis, inadequate access to services, insufficient prescription of drugs and adjuvants, financial problems and quarrels with the health insurance company on payment of aid devices. Coping strategies were mostly non-functional and not problem-orientated.

DISCUSSION

Special attention should be paid to psychosocial and interpersonal needs of patients. Volunteers may have an important role in the care of patients and relatives. The introduction of case managers might lead to an advancement of care. Sensitisation of physicians, nurses and other caregivers for deficits in transition of patients is needed and should be covered in palliative care education and training.