"Out of sight, out of mind": housestaff perceptions of quality-limiting factors in discharge care at teaching hospitals

Pediatric Resident Communication of Hospital Discharge Instructions

OBJECTIVE

Suboptimal provider-parent communication contributes to poor parent comprehension of pediatric discharge instructions, which can lead to adverse outcomes. Residency is a critical window to acquire and learn to utilize key communication skills, potentially supported by formal training programs or visual reminders. Few studies have examined resident counseling practices or predictors of counseling quality. Our objectives were to (1) examine pediatric resident counseling practices and (2) determine how formal training and presence of discharge templates with domain-specific prompts are associated with counseling.

METHODS

We conducted a cross-sectional survey of a convenience sample of residents in the American Academy of Pediatrics Section on Pediatric Trainees. Outcomes included resident self-report of frequency of (1) counseling in domains of care and (2) use of health literacy-informed counseling strategies (pictures, demonstration, Teach Back, Show Back) (6-point scales; frequent = often/usually/always). Predictor variables were (1) formal discharge-related training (e.g., lectures) and (2) hospital discharge instruction template with space for individual domains. Logistic regression analyses, utilizing generalized estimating equations when appropriate to account for multiple domains (adjusting for resident gender, postgraduate year), were performed.

KEY RESULTS

Few residents (N = 317) (13.9%) reported formal training. Over 25% of residents infrequently counsel on side effects, diagnosis, and restrictions. Resident reported use of communication strategies was infrequent: drawing pictures (24.1%), demonstration (15.8%), Teach Back (36.8%), Show Back (11.4%). Designated spaces in instruction templates for individual domains were associated with frequent domain-specific counseling (adjusted odds ratio [aOR] 4.1 [95% confidence interval: 3.5-4.8]). Formal training was associated with frequent Teach Back (aOR 2.6 [1.4-5.1]) and Show Back (aOR 2.7 [1.2-6.2]).

CONCLUSIONS

Lack of formal training and designated space for domain-specific instructions are associated with suboptimal counseling at discharge by pediatric residents. Future research should focus on determining the best mechanisms for teaching trainees communication skills and optimizing written instruction templates to support verbal counseling. [HLRP: Health Literacy Research and Practice. 2023;7(4):e178-e186.].

Analysing Monday discharges to identify lost opportunities for weekend discharge

Lower rates of hospital discharge occur on weekends compared with weekdays. The authors performed a retrospective chart review of Monday discharges from the Hospital Medicine service at an academic hospital over a 3-month period to identify reasons for delayed discharge despite medical stability. Of 202 eligible patients, 81 (40%) had documentation indicating stability for earlier discharge. Common causes included bed availability or insurance authorisation at a skilled nursing facility, home care services and patient/family disagreement with discharge.

Exploring Wearables to Focus on the “Sweet Spot” of Physical Activity and Sleep After Hospitalization: Secondary Analysis

Background

Inadequate sleep and physical activity are common during and after hospitalization, but their impact on patient-reported functional outcomes after discharge is poorly understood. Wearable devices that measure sleep and activity can provide patient-generated data to explore ideal levels of sleep and activity to promote recovery after hospital discharge.

Objective

This study aimed to examine the relationship between daily sleep and physical activity with 6 patient-reported functional outcomes (symptom burden, sleep quality, physical health, life space mobility, activities of daily living, and instrumental activities of daily living) at 13 weeks after hospital discharge.

Methods

This secondary analysis sought to examine the relationship between daily sleep, physical activity, and patient-reported outcomes at 13 weeks after hospital discharge. We utilized wearable sleep and activity trackers (Withings Activité wristwatch) to collect data on sleep and activity. We performed descriptive analysis of device-recorded sleep (minutes/night) with patient-reported sleep and device-recorded activity (steps/day) for the entire sample with full data to explore trends. Based on these trends, we performed additional analyses for a subgroup of patients who slept 7-9 hours/night on average. Differences in patient-reported functional outcomes at 13 weeks following hospital discharge were examined using a multivariate linear regression model for this subgroup.

Results

For the full sample of 120 participants, we observed a “T-shaped” distribution between device-reported physical activity (steps/day) and sleep (patient-reported quality or device-recorded minutes/night) with lowest physical activity among those who slept <7 or >9 hours/night. We also performed a subgroup analysis (n=60) of participants that averaged the recommended 7-9 hours of sleep/night over the 13-week study period. Our key finding was that participants who had both adequate sleep (7-9 hours/night) and activity (>5000 steps/day) had better functional outcomes at 13 weeks after hospital discharge. Participants with adequate sleep but less activity (<5000 steps/day) had significantly worse symptom burden (z-score 0.93, 95% CI 0.3 to 1.5; P=.02), community mobility (z-score –0.77, 95% CI –1.3 to –0.15; P=.02), and perceived physical health (z-score –0.73, 95% CI –1.3 to –0.13; P=.003), compared with those who were more physically active (≥5000 steps/day).

Conclusions

Participants within the “sweet spot” that balances recommended sleep (7-9 hours/night) and physical activity (>5000 steps/day) reported better functional outcomes after 13 weeks compared with participants outside the “sweet spot.” Wearable sleep and activity trackers may provide opportunities to hone postdischarge monitoring and target a “sweet spot” of recommended levels for both sleep and activity needed for optimal recovery.

Trial Registration

ClinicalTrials.gov NCT03321279; https://clinicaltrials.gov/ct2/show/NCT03321279

The Safe Discharge Checklist: A Standardized Discharge Planning Curriculum for Medicine Trainees

OBJECTIVES

Hospital discharge is a challenging time for residents, requiring the completion of many tasks to ensure safe transitions for patients. Despite recognition of the importance of hospital discharge planning, formal curricula are lacking. We sought to improve medicine residents' comfort and skills with discharge planning and enhance the quality of care by introducing a standardized approach to discharge on the medicine wards.

METHODS

The intervention included a didactic, a bedside rounds component, and a discharge checklist. Interns were surveyed at the end of rotations to measure confidence, attitudes, and frequency of completing discharge planning tasks. Results were compared with a control group of experienced interns from the previous academic year. Clinical outcomes included hospital readmission and emergency department return rates and patient satisfaction scores in discharge-related domains.

RESULTS

Study interns reported similar confidence to control group interns with discharge planning and endorsed completing four of five discharge tasks more frequently than control interns. There were no differences in clinical outcomes.

CONCLUSIONS

We did not identify changes in clinical outcomes, although this finding likely reflects the multifactorial nature of hospital readmissions. Interns exposed to the curriculum early in the academic year had a higher reported frequency of completing key discharge tasks and similar confidence around discharge, when compared with end-of-the-year interns. These improvements suggest that the curriculum led to a change in culture surrounding discharge planning and perhaps accelerated learning of skills associated with discharge best practices.

Quality of hospital discharge letters for patients at the end of life: A retrospective medical record review

Objective

For patients who are discharged to go home after a hospitalisation, timely and adequately informing their general practitioner is important for continuity of care, especially at the end of life. We studied the quality of the hospital discharge letter for patients who were hospitalised in their last year of life.

Methods

A retrospective medical record review was performed. Included patients had been admitted to the hospital during the period 1 January to 1 July 2017 and had died within a year after discharge.

Results

Data were collected from records of 108 patients with cancer or other diseases. For 57 patients (53%), the discharge letter included information that related to their limited life expectancy (e.g., agreements about treatment limitations), whereas the patient's limited life expectancy was addressed in the medical record in 76 cases (70%). We found related information in discharge letters for 36 patients (66%) who died <3 months compared to 21 patients (40%) who died 3–12 months after hospitalisation (p < 0.01).

Conclusion

For patients with a limited life expectancy going home after a hospitalisation, one out of two hospital discharge letters lacked any information addressing their limited life expectancy. Specific guidelines for medical information exchange between care settings are needed.

Ready to Go Home? Assessment of Shared Mental Models of the Patient and Discharging Team Regarding Readiness for Hospital Discharge

BACKGROUND

A critical task of the inpatient interprofessional team is readying patients for discharge. Assessment of shared mental model (SMM) convergence can determine how much team members agree about patient discharge readiness and how their mental models align with the patient's self-assessment.

OBJECTIVE

Determine the convergence of interprofessional team SMMs of hospital discharge readiness and identify factors associated with these assessments.

DESIGN

We surveyed interprofessional discharging teams and each team's patient at time of hospital discharge using validated tools to capture their SMMs.

PARTICIPANTS

Discharge events (N = 64) from a single hospital consisting of the patient and their team (nurse, coordinator, physician).

MEASURES

Clinician and patient versions of the validated Readiness for Hospital Discharge Scales/Short Form (RHDS/SF). We measured team convergence by comparing the individual clinicians' scores on the RHDS/SF, and we measured team-patient convergence as the absolute difference between the Patient-RHDS/SF score and the team average score on the Clinician-RHDS/SF.

RESULTS

Discharging teams assessed patients as having high readiness for hospital discharge (mean score, 8.5 out of 10; SD, 0.91). The majority of teams had convergent SMMs with high to very high interrater agreement on discharge readiness (mean r*wg(J), 0.90; SD, 0.10). However, team-patient SMM convergence was low: Teams overestimated the patient's self-assessment of readiness for discharge in 48.4% of events. We found that teams reporting higher-quality teamwork (P = .004) and bachelor's level-trained nurses (P < .001) had more convergent SMMs with the patient.

CONCLUSION

Measuring discharge teams' SMM of patient discharge readiness may represent an innovative assessment tool and potential lever to improve the quality of care transitions.

Who is Responsible for Discharge Education of Patients? A Multi-Institutional Survey of Internal Medicine Residents

BACKGROUND

Safely and effectively discharging a patient from the hospital requires working within a multidisciplinary team. However, little is known about how perceptions of responsibility among the team impact discharge communication practices.

OBJECTIVE

Our study attempts to understand residents' perceptions of who is primarily responsible for discharge education, how these perceptions affect their own reported communication with patients, and how residents envision improving multidisciplinary communication around discharges.

DESIGN

A multi-institutional cross-sectional survey.

PARTICIPANTS

Internal medicine (IM) residents from seven US residency programs at academic medical centers were invited to participate between March and May 2019, via email of an electronic link to the survey.

MAIN MEASURES

Data collected included resident perception of who on the multidisciplinary team is primarily responsible for discharge communication, their own reported discharge communication practices, and open-ended comments on ways discharge multidisciplinary team communication could be improved.

KEY RESULTS

Of the 613 resident responses (63% response rate), 35% reported they were unsure which member of the multidisciplinary team is primarily responsible for discharge education. Residents who believed it was either the intern's or the resident's primary responsibility had 4.28 (95% CI, 2.51-7.30) and 3.01 (95% CI, 1.66-5.71) times the odds, respectively, of reporting doing discharge communication practices frequently compared to those who were not sure who was primarily responsible. To improve multidisciplinary discharge communication, residents called for the following among team members: (1) clarifying roles and responsibilities for communication with patients, (2) setting expectations for communication among multidisciplinary team members, and (3) redefining culture around discharges.

CONCLUSIONS

Residents report a lack of understanding of who is responsible for discharge education. This diffusion of ownership impacts how much residents invest in patient education, with more perceived responsibility associated with more frequent discharge communication.

Late-afternoon communication and patient planning (CAPP) rounds: an intervention to allow early patient discharges

OBJECTIVE

Measure effect of late-afternoon communication and patient planning (CAPP) rounds to increase early electronic discharge orders (EDO).

METHODS

We enrolled 4485 patients discharged from six subspecialty medical services. We implemented late-afternoon CAPP rounds to identify patients who could have morning discharge the subsequent day. After an initial successful implementation of the intervention, we identified lack of sustainability. We made changes with sustained implementation of the intervention. This is a before-after study of a quality improvement intervention.

PROGRAM EVALUATION

Primary measures of intervention effectiveness were percentage of patients who received EDO by 11 am and patients discharged by noon. Additional measure of effectiveness were percent of patients admitted to the correct ward, emergency department (ED)-to-ward transfer time compared between intervention and nonintervention periods. We compared the overall expected LOS and the average weekly discharges to assess for comparability across the control and intervention time periods. We used the readmission rate as balancing measure to ensure that the intervention was not have unintended negative patients consequences.

RESULTS

Expected length of stay based upon discharge diagnosis/comorbidities and readmission rates were similar across the intervention and control time periods. The average weekly discharges were not statistically significant. Percentage of EDO by 11 am was higher in the first intervention period, second intervention period and combined intervention periods (28.9% vs. 21.8%, P < 0.001) compared with the respective control periods. Percent discharged before noon increased in the first intervention period, second intervention period and for the combined intervention periods (17 vs. 11.8%, P < 0.001). There was no difference in the percent admitted to the correct ward and ED-to-ward transfer time.

CONCLUSION

Afternoon CAPP rounds to identify early patient discharges the following day led to increase in EDO entered by 11 am and discharges by noon without an adverse change in readmission rates and LOS.

Quality analysis of discharge instruction among 602 hospitalized patients in China: a multicenter, cross-sectional study

BACKGROUND

The aim of this study was to understand the quality of discharge guidance for patients with chronic diseases, to clarify the gap between patient needs and the content of discharge guidance, and to provide a reference for health education and clinical path management of patients with chronic diseases in the future.

METHODS

A total of 602 inpatients with stroke, coronary heart disease, cancer, chronic obstructive pulmonary disease and diabetes from the chronic disease-related departments of 7 tertiary general hospitals in China were selected by convenience sampling. Measures included a demographic questionnaire and the Quality of Discharged Teaching Scale(QDTS). Descriptive analysis ANOVA and paired t-test were completed by SPSS 22.0 software.

RESULTS

The overall average score of QDTS in this survey was 155.79 ± 23.29. The total score of QDTS in chronic obstructive pulmonary disease was lower than coronary heart disease (P < 0.001) and cancer (P = 0.02). While coronary heart disease was higher than stroke (P = 0.01) and diabetes (P = 0.01). And the scores of patients on discharge guidance skills and effects were higher than 8.50.

CONCLUSIONS

The level of the patients' perception of quality of discharge insrtuction is middle to high. Managers should understand the characteristics of various departments, give corresponding guidance and help, and clinical nurses should understand the characteristics of ward patients and pay more attention to individual guidance.

Beyond Discharge Summaries: Communication Preferences in Care Transitions Between Hospitalists and Primary Care Providers Using Electronic Medical Records

BACKGROUND

Ineffective transitions of care continue to be a source of risk for patients. Although there has been widespread implementation of electronic medical record (EMR) systems, little is currently known about hospitalists' and primary care providers' (PCPs) direct communication preferences at discharge using messaging capabilities in a shared EMR system.

OBJECTIVE

We examined how hospitalists and PCPs with a shared EMR prefer to directly communicate at the time of hospital discharge by identifying preferred modes, information prioritization, challenges, facilitators, and proposed solutions.

DESIGN

A sequential, explanatory mixed methods study with surveys and semi-structured interviews.

PARTICIPANTS

Thirty-eight academic hospitalists and 63 PCPs working in outpatient clinics in a single safety net hospital system with a shared EMR.

MAIN APPROACH

Descriptive statistics were used to analyze survey responses. Interviews were analyzed using immersion/crystallization and a mixture of inductive and deductive thematic analysis.

KEY RESULTS

PCPs preferred direct communication at discharge through a message within the EMR while hospitalists preferred a message within the EMR and email. Qualitative results identified key themes related to patient care and direct communication: value of direct communication, safety, social determinants of health, and clinical judgment. Both groups prioritized direct communication for high-risk medications, pending and follow-up studies, and high-risk patients that hospitalists were concerned about. Overall, both hospitalists and PCPs reported that ensuring patient safety, flagging patients with social challenges, and expressing concerns about patients based on clinical judgment were key communication priorities.

CONCLUSIONS

Hospitalists and primary care providers report considerable overlap in preferences for direct communication at the time of hospital discharge through a shared EMR. Specifically, both groups reported similar concerns regarding patient safety and continuity during transitions. Direct messaging within the EMR could enable "closed loop" communication that helps ensure safe transitions of care for high-risk patients.

A mixed methods study examining teamwork shared mental models of interprofessional teams during hospital discharge

BACKGROUND

Little is known about how team processes impact providers' abilities to prepare patients for a safe hospital discharge. Teamwork Shared Mental Models (teamwork-SMMs) are the teams' organised understanding of individual member's roles, interactions and behaviours needed to perform a task like hospital discharge. Teamwork-SMMs are linked to team effectiveness in other fields, but have not been readily investigated in healthcare. This study examines teamwork-SMMs to understand how interprofessional teams coordinate care when discharging patients.

METHODS

This mixed methods study examined teamwork-SMMs of inpatient interprofessional discharge teams at a single hospital. For each discharge event, we collected data from the patient and their discharge team (nurse, physician and coordinator) using interviews and questionnaires. We quantitatively determined the discharge teams' teamwork-SMM components of quality and convergence using the Shared Mental Model Scale, and then explored their relationships to patient-reported preparation for posthospital care. We used qualitative thematic analysis of narrative cases to examine the contextual differences of discharge teams with higher versus lower teamwork-SMMs.

RESULTS

The sample included a total of 106 structured patient interviews, 192 provider day-of-discharge questionnaires and 430 observation hours to examine 64 discharge events. We found that inpatient teams with better teamwork-SMMs (ie, higher perceptions of teamwork quality or greater convergence) were more effective at preparing patients for post-hospital care. Additionally, teams with high and low teamwork-SMMs had different experiences with team cohesion, communication openness and alignment on the patient situation.

CONCLUSIONS

Examining the quality and agreement of teamwork-SMMs among teams provides a better understanding of how teams coordinate care and may facilitate the development of specific team-based interventions to improve patient care at hospital discharge.

Safe handovers for every patient: an interrupted time series analysis to test the effect of a structured discharge bundle in Dutch hospitals

OBJECTIVE

Patient handovers are often delayed, patients are hardly involved in their discharge process and hospital-wide standardised discharge procedures are lacking. The aim of this study was to implement a structured discharge bundle and to test the effect on timeliness of medical and nursing handovers, length of hospital stay (LOS) and unplanned readmissions.

DESIGN

Interrupted time series with six preintervention and six postintervention data collection points (September 2015 to June 2017).

SETTING

Internal medicine and surgical wards PARTICIPANTS: Patients (≥18 years) admitted for more than 48 hours to surgical or internal medicine wards.

INTERVENTION

The Transfer Intervention Procedure (TIP), containing four elements: planning the discharge date within 48 hours postadmission; arrangements for postdischarge care; preparing handovers and personalised patient discharge letter; and a discharge conversation 12-24 hours before discharge.

OUTCOME MEASURES

The number of medical and nursing handovers sent within 24 hours. Secondary outcomes were median time between discharge and medical handovers, LOS and unplanned readmissions.

RESULTS

Preintervention 1039 and postintervention 1052 patient records were reviewed. No significant change was observed in the number of medical and nursing handovers sent within 24 hours. The median (IQR) time between discharge and medical handovers decreased from 6.15 (0.96-15.96) to 4.08 (0.33-13.67) days, but no significant difference was found. No intervention effect was observed for LOS and readmission. In subgroup analyses, a reduction of 5.6 days in the median time between discharge and medical handovers was observed in hospitals with high protocol adherence and much attention for implementation.

CONCLUSION

Implementation of a structured discharge bundle did not lead to improved timeliness of patient handovers. However, large interhospital variation was observed and an intervention effect on the median time between discharge and medical handovers was seen in hospitals with high protocol adherence. Future interventions should continue to create awareness of the importance of timely handovers.

TRIAL REGISTRATION NUMBER

NTR5951; Results.

Improved Supervision and Safety of Discharges Through Formal Discharge Education

The goal of this study is to evaluate change in residents’ assessment of supervision and safety of the discharge process after formal discharge instruction education. An educational lecture and workshop addressing high-risk medications, medication reconciliation, follow-up, and handoffs were provided to internal medicine residents. Residents were given a longitudinal survey before and after the discharge education session. Significant improvement in perception was demonstrated in review of discharge instructions ( P < .001), review of new medications/side effects with patients ( P < .001), and review of discharge instructions with and receiving feedback from attending physicians ( P < .001). On review of 40 discharge instructions pre and post intervention, there was an improvement in completion of instructions for high-risk medications ( P < .05 [14 insulin, 26 anticoagulation]). This intervention was viewed positively by residents; more than two thirds of all residents favored a process of formal training over the current model of “training by doing.”

Intern Transitions of Care Curriculum Through Posthospital Home and Skilled Nursing Facility Visits

BACKGROUND

Transitions of care pose significant risks for patients with complex medical histories. There are few experiential medical education curricula targeting this important aspect of care.

OBJECTIVE

We designed and tested an internal medicine transitions of care experience integrated into interns' ambulatory curriculum.

METHODS

The program included 1-hour group didactics, a posthospitalization discharge visit in pairs with a home care nurse (cohort 1: 2011-2012; cohort 2: 2012-2013), and a half-day small-group visit to a skilled nursing facility led by a faculty member in geriatrics (cohort 2 only). Both visits had structured debriefings by faculty in geriatrics. For cohort 1, a quantitative follow-up survey was administered 18 to 20 months after the experience. For cohort 2, reflections were analyzed.

RESULTS

Thirty-three of 42 second-year residents (79%) in cohort 1 who participated in didactics and a home visit completed the survey. Seventy-six percent (25 of 33) reported increased knowledge of interprofessional team members' roles and the discharge process for patients with complex medical histories. Seventy-nine percent (26 of 33) reported continued use of medication reconciliation at discharge, and 64% (21 of 33) reported the experience enhanced their ability to identify threats to transitions. Of cohort 2 interns, 88% (42 of 48) participated in the home visit and 69% (33 of 48) in the skilled nursing facility visit. Intern reflections revealed insights gained, incomprehensive discharge plans, posthospital health care teams, and patients' postdischarge experience.

CONCLUSIONS

An experiential transitions of care curriculum is feasible and acceptable. Residents reported using the curriculum 18 to 20 months after exposure.

Hospitalist and Internal Medicine Leaders' Perspectives of Early Discharge Challenges at Academic Medical Centers

Improving early discharges may improve patient flow and increase hospital capacity. We conducted a national survey of academic medical centers addressing the prevalence, importance, and effectiveness of early-discharge initiatives. We assembled a list of hospitalist and general internal medicine leaders at 115 US-based academic medical centers. We emailed each institutional representative a 30-item online survey regarding early-discharge initiatives. The survey included questions on discharge prioritization, the prevalence and effectiveness of early-discharge initiatives, and barriers to implementation. We received 61 responses from 115 institutions (53% response rate). Forty-seven (77%) "strongly agreed" or "agreed" that early discharge was a priority. "Discharge by noon" was the most cited goal (n = 23; 38%) followed by "no set time but overall goal for improvement" (n = 13; 21%). The majority of respondents reported early discharge as more important than obtaining translators for non-English-speaking patients and equally important as reducing 30-day readmissions and improving patient satisfaction. The most commonly reported factors delaying discharge were availability of postacute care beds (n = 48; 79%) and patient-related transport complications (n = 44; 72%). The most effective early discharge initiatives reported involved changes to the rounding process, such as preemptive identification and early preparation of discharge paperwork (n = 34; 56%) and communication with patients about anticipated discharge (n = 29; 48%). There is a strong interest in increasing early discharges in an effort to improve hospital throughput and patient flow.

Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care

BACKGROUND

Despite a national focus on post-acute care brought about by recent payment reforms, relatively little is known about how hospitalized older adults and their caregivers decide whether to go to a skilled nursing facility (SNF) after hospitalization.

OBJECTIVE

We sought to understand to what extent hospitalized older adults and their caregivers are empowered to make a high-quality decision about utilizing an SNF for post-acute care and what contextual or process elements led to satisfaction with the outcome of their decision once in SNF.

DESIGN

Qualitative inquiry using the Ottawa Decision Support Framework (ODSF), a conceptual framework that describes key components of high-quality decision-making.

PARTICIPANTS

Thirty-two previously community-dwelling older adults (≥ 65 years old) and 22 caregivers interviewed at three different hospitals and three skilled nursing facilities.

MAIN MEASURES

We used key components of the ODSF to identify elements of context and process that affected decision-making and to what extent the outcome was characteristic of a high-quality decision: informed, values based, and not associated with regret or blame.

KEY RESULTS

The most important contextual themes were the presence of active medical conditions in the hospital that made decision-making difficult, prior experiences with hospital readmission or SNF, relative level of caregiver support, and pressure to make a decision quickly for which participants felt unprepared. Patients described playing a passive role in the decision-making process and largely relying on recommendations from the medical team. Patients commonly expressed resignation and a perceived lack of choice or autonomy, leading to dissatisfaction with the outcome.

CONCLUSIONS

Understanding and intervening to improve the quality of decision-making regarding post-acute care supports is essential for improving outcomes of hospitalized older adults. Our results suggest that simply providing information is not sufficient; rather, incorporating key contextual factors and improving the decision-making process for both patients and clinicians are also essential.

Bedside nurses' roles in discharge collaboration in general internal medicine: Disconnected, disempowered and devalued?

Collaboration among nurses and other healthcare professionals is needed for effective hospital discharge planning. However, interprofessional interactions and practices related to discharge vary within and across hospitals. These interactions are influenced by the ways in which healthcare professionals' roles are being shaped by hospital discharge priorities. This study explored the experience of bedside nurses' interprofessional collaboration in relation to discharge in a general medicine unit. An ethnographic approach was employed to obtain an in-depth insight into the perceptions and practices of nurses and other healthcare professionals regarding collaborative practices around discharge. Sixty-five hours of observations was undertaken, and 23 interviews were conducted with nurses and other healthcare professionals. According to our results, bedside nurses had limited engagement in interprofessional collaboration and discharge planning. This was apparent by bedside nurses' absence from morning rounds, one-way flow of information from rounds to the bedside nurses following rounds, and limited opportunities for interaction with other healthcare professionals and decision-making during the day. The disconnection, disempowerment and devaluing of bedside nurses in patient discharge planning has implications for quality of care and nursing work. Study findings are positioned within previous work on nurse-physician interactions and the current context of nursing care.

A time-motion study of residents and medical students performing patient discharges from general internal medicine wards: a disjointed, interrupted process

Patients are at high risk for adverse events after discharge from a hospital admission. As a critical and often time-consuming aspect of care for hospitalized patients, the purpose of this study was to describe the physician time, events and workflow in performing a patient discharge. On General Internal Medicine (GIM) wards at two academic medical centers in Toronto, a time-motion study was performed on 11 residents and 2 medical students performing 32 patient discharges. Using a paper data collection tool, a research associate aimed to capture the distribution of activities and the nature and frequency of workflow interruptions during patient discharges from the perspective of resident and medical student housestaff. Thirty-two GIM patient discharges by the 13 housestaff were observed over a period of 116 h. Discharges required 69.2 ± 41.2 min of housestaff-dedicated time to complete, but spanned over a mean 3.7 h from start to finish. On average, 32.8 min (47.3%) of time spent on discharges was dedicated to documentation activities; 13.5 min (19.6%) to direct patient communication; 10.8 min (15.6%) to communication with other clinicians and providers; 6.5 min (9.4%) to arranging outpatient care; 5.7 min (8.2%) to time in transit and waiting. For each discharge, housestaff were interrupted a mean of 5.5 times and switched tasks 8.7 times. During the discharge process, housestaff mainly dedicated themselves to documentation activities and focused minimally on direct patient communication. Clinicians were also found to experience several workflow inefficiencies and interruptions. The present study can be used to identify opportunities to improve and further focus efforts in characterizing this dynamic process.

It's not just what you know: junior trainees' approach to follow-up and documentation

CONTEXT

In teaching hospitals, junior trainees (first-year residents and third-year medical students) are responsible for patient follow-up and documentation under the supervision of senior team members. In order to support trainees in their role, supervisors need to understand how trainees approach these tasks and how they can be coached to develop best practices.

OBJECTIVES

The purpose of our study was to explore the range of practices used by junior trainees in clinical settings.

METHODS

Constructivist grounded theory was used to guide the collection and analysis of data on follow-up and documentation during 34 observation periods with 17 junior trainees. Data sources included field notes, field interviews and de-identified copies of patient charts. We also held two focus groups with four attending physicians in each.

RESULTS

We were able to describe three interrelated characteristics that influenced a trainee's approach to and ability to perform the tasks of patient follow-up and documentation: (i) diligence; (ii) relationship to the team (dependent, independent, collaborative), and (iii) level of performance (Data Gatherer, Sensemaker, Manager). Diligence and relationship to the team appeared to influence the quality and focus of a trainee's approach at all levels of performance. Level of performance was felt, by focus group attending physicians, to reflect a developmental progression of knowledge and skills.

CONCLUSIONS

Our findings contribute to the existing literature in three ways. Firstly, they extend our understanding of how junior trainees approach the task of in-patient follow-up and clinical documentation and the value of those activities. Secondly, they provide new insights to support formative and summative assessment. Finally, they contribute to a growing body of literature exploring the factors that impact trainees' roles and interactions with the team. Future research should focus on validating our findings and exploring their utility in the development of novel assessment strategies.

How Hospital Clinicians Select Patients for Skilled Nursing Facilities

OBJECTIVE

To understand how hospital-based clinicians evaluate older adults in the hospital and decide who will be transferred to a skilled nursing facility (SNF) for postacute care.

DESIGN

Semistructured interviews paired with a qualitative analytical approach informed by Social Constructivist theory.

SETTING

Inpatient care units in three hospitals. Purposive sampling was used to maximize variability in hospitals, units within hospitals, and staff on those units.

PARTICIPANTS

Clinicians (hospitalists, nurses, therapists, social workers, case managers) involved in evaluation and decision-making regarding postacute care (N = 25).

MEASUREMENTS

Central themes related to clinician evaluation and discharge decision-making.

RESULTS

Clinicians described pressure to expedite evaluation and discharge decisions, resulting in the use of SNFs as a "safety net" for older adults being discharged from the hospital. The lack of hospital-based clinician knowledge of SNF care practices, quality, or patient outcomes resulted in lack of a standardized evaluation process or a clear primary decision-maker.

CONCLUSION

Hospital clinician evaluation and decision-making about postacute care in SNFs may be characterized as rushed, without a clear system or framework for making decisions and uninformed by knowledge of SNF or patient outcomes in those discharged to SNFs. This leads to SNFs being used as a "safety net" for many older adults. As hospitals and SNFs are increasingly held jointly accountable for outcomes of individuals transitioning between hospitals and SNFs, novel solutions for improving evaluation and decision-making are urgently needed.

Hospital Characteristics Associated With Risk-standardized Readmission Rates

BACKGROUND

Safety-net and teaching hospitals are somewhat more likely to be penalized for excess readmissions, but the association of other hospital characteristics with readmission rates is uncertain and may have relevance for hospital-centered interventions.

OBJECTIVE

To examine the independent association of 8 hospital characteristics with hospital-wide 30-day risk-standardized readmission rate (RSRR).

DESIGN

This is a retrospective cross-sectional multivariable analysis.

SUBJECTS

US hospitals.

MEASURES

Centers for Medicare and Medicaid Services specification of hospital-wide RSRR from July 1, 2013 through June 30, 2014 with race and Medicaid dual-eligibility added.

RESULTS

We included 6,789,839 admissions to 4474 hospitals of Medicare fee-for-service beneficiaries aged over 64 years. In multivariable analyses, there was regional variation: hospitals in the mid-Atlantic region had the highest RSRRs [0.98 percentage points higher than hospitals in the Mountain region; 95% confidence interval (CI), 0.84-1.12]. For-profit hospitals had an average RSRR 0.38 percentage points (95% CI, 0.24-0.53) higher than public hospitals. Both urban and rural hospitals had higher RSRRs than those in medium metropolitan areas. Hospitals without advanced cardiac surgery capability had an average RSRR 0.27 percentage points (95% CI, 0.18-0.36) higher than those with. The ratio of registered nurses per hospital bed was not associated with RSRR. Variability in RSRRs among hospitals of similar type was much larger than aggregate differences between types of hospitals.

CONCLUSIONS

Overall, larger, urban, academic facilities had modestly higher RSRRs than smaller, suburban, community hospitals, although there was a wide range of performance. The strong regional effect suggests that local practice patterns are an important influence. Disproportionately high readmission rates at for-profit hospitals may highlight the role of financial incentives favoring utilization.

Residents' Exposure to Educational Experiences in Facilitating Hospital Discharges

BACKGROUND

There is an incomplete understanding of the most effective approaches for motivating residents to adopt guideline-recommended practices for hospital discharges.

OBJECTIVE

We evaluated internal medicine (IM) residents' exposure to educational experiences focused on facilitating hospital discharges and compared those experiences based on correlations with residents' perceived responsibility for safely transitioning patients from the hospital.

METHODS

A cross-sectional, multi-center survey of IM residents at 9 US university- and community-based training programs in 2014-2015 measured exposure to 8 transitional care experiences, their perceived impact on care transitions attitudes, and the correlation between experiences and residents' perceptions of postdischarge responsibility.

RESULTS

Of 817 residents surveyed, 469 (57%) responded. Teaching about care transitions on rounds was the most common educational experience reported by residents (74%, 327 of 439). Learning opportunities with postdischarge patient contact were less common (clinic visits: 32%, 142 of 439; telephone calls: 12%, 53 of 439; and home visits: 4%, 18 of 439). On a 1-10 scale (10 = highest impact), residents rated postdischarge clinic as having the highest impact on their motivation to ensure safe transitions of care (mean = 7.61). Prior experiences with a postdischarge clinic visit, home visit, or telephone call were each correlated with increased perceived responsibility for transitional care tasks (correlation coefficients 0.12 [P = .004], 0.1 [P = .012], and 0.13 [P =  001], respectively).

CONCLUSIONS

IM residents learn to facilitate hospital discharges most often through direct patient care. Opportunities to interact with patients across the postdischarge continuum are uncommon, despite correlating with increased perceived responsibility for ensuring safe transitions of care.

Post-acute care reform: Implications and opportunities for hospitalists

Nearly all practicing hospitalists have firsthand experience discharging patients to post-acute care (PAC), which is provided by inpatient rehabilitation facilities, skilled nursing facilities, or home healthcare providers. Many may not know that PAC is poised to undergo transformative change, spurred by recent legislation resulting in a range of reforms. These reforms have the potential to fundamentally reshape the relationship between hospitals and PAC providers. They have important implications for hospitalists and will open up opportunities for hospitalists to improve healthcare value. In this article, the authors explore the reasons for PAC reform and the scope of the reforms. Then they describe the implications for hospitalists and hospitalists' opportunities to Choose Wisely and improve healthcare value for the rapidly growing number of vulnerable older adults transitioning to PAC after hospital discharge.

A systematic review on the effect of the organisation of hospital discharge on patient health outcomes

OBJECTIVE

The transition from hospital to home represents a key step in the management of patients and several problems related to this transition may arise, with potential adverse effects on patient health after discharge. The purpose of our study was to explore the association between components of the hospital discharge process including subsequent continuity of care and patient outcomes in the post-discharge period.

DESIGN

Systematic review of observational and interventional studies.

SETTING

We conducted a combined search in the Medline and Web of Science databases. Additional studies were identified by screening the bibliographies of the included studies. The data collection process was conducted using a standardised predefined grid that included quality criteria.

PARTICIPANTS

A standard patient population returning home after hospitalisation.

PRIMARY AND SECONDARY OUTCOMES

Adverse health outcomes occurring after hospital discharge.

RESULTS

In the 20 studies fulfilling our eligibility criteria, the main discharge-process components explored were: discharge summary (n=2), discharge instructions (n=2), drug-related problems at discharge (n=4), transition from hospital to home (n=5) and continuity of care after hospital discharge (n=7). The major subsequent patient health outcomes measured were: rehospitalisations (n=18), emergency department visits (n=8) and mortality (n=5). Eight of the 18 studies exploring rehospitalisations and two of the eight studies examining emergency department visits reported at least one significant association between the discharge process and these outcomes. None of the studies investigating patient mortality reported any significant such associations between the discharge process and these outcomes.

CONCLUSIONS

Irrespective of the component of the discharge process explored, the outcome considered (composite or not), the sample size and the study design, no consistent statistical association between hospital discharge and patient health outcome was identified. This systematic review highlights a wide heterogeneity between studies, especially in terms of the component(s) of the hospital discharge process investigated, study designs, outcomes and follow-up durations.

Family caregivers as partners in care transitions: The caregiver advise record and enable act

The objective of this Perspective was to provide guidance to hospitalists and hospital clinical leadership on how to implement the Caregiver Advise Record and Enable (CARE) Act, which has been passed into law in 30 US states and territories. Specifically, the objective is 3-fold: (1) increase awareness among hospitalists and encourage them to begin to prepare for implementation, (2) explore the impetus for this legislation, and (3) provide a list of suggested resources geared to both family caregivers and healthcare professionals that may be helpful in preparation for implementing the CARE Act. Journal of Hospital Medicine 2015;11:883-885. © 2015 Society of Hospital Medicine.

Internal Medicine Residents' Perceived Responsibility for Patients at Hospital Discharge: A National Survey

BACKGROUND

Medical residents are routinely entrusted with transitions of care, yet little is known about the duration or content of their perceived responsibility for patients they discharge from the hospital.

OBJECTIVE

To examine the duration and content of internal medicine residents' perceived responsibility for patients they discharge from the hospital. The secondary objective was to determine whether specific individual experiences and characteristics correlate with perceived responsibility.

DESIGN

Multi-site, cross-sectional 24-question survey delivered via email or paper-based form.

PARTICIPANTS

Internal medicine residents (post-graduate years 1-3) at nine university and community-based internal medicine training programs in the United States.

MAIN MEASURES

Perceived responsibility for patients after discharge as measured by a previously developed single-item tool for duration of responsibility and novel domain-specific questions assessing attitudes towards specific transition of care behaviors.

KEY RESULTS

Of 817 residents surveyed, 469 responded (57.4 %). One quarter of residents (26.1 %) indicated that their responsibility for patients ended at discharge, while 19.3 % reported perceived responsibility extending beyond 2 weeks. Perceived duration of responsibility did not correlate with level of training (P = 0.57), program type (P = 0.28), career path (P = 0.12), or presence of burnout (P = 0.59). The majority of residents indicated they were responsible for six of eight transitional care tasks (85.1-99.3 % strongly agree or agree). Approximately half of residents (57 %) indicated that it was their responsibility to directly contact patients' primary care providers at discharge. and 21.6 % indicated that it was their responsibility to ensure that patients attended their follow-up appointments.

CONCLUSIONS

Internal medicine residents demonstrate variability in perceived duration of responsibility for recently discharged patients. Neither the duration nor the content of residents' perceived responsibility was consistently associated with level of training, program type, career path, or burnout, suggesting there may be unmeasured factors such as professional role modeling that shape these perceptions.

A sociological exploration of the tensions related to interprofessional collaboration in acute-care discharge planning

Patient discharge is a key concern in hospitals, particularly in acute care, given the multifaceted and challenging nature of patients' healthcare needs. Policies on discharge have identified the importance of interprofessional collaboration, yet research has described its limitations in this clinical context. This study aimed to extend our understanding of interprofessional interactions related to discharge in a general internal medicine setting by using sociological theories to illuminate the existence of, and interplay between, structural factors and microlevel practices. An ethnographic approach was employed to obtain an in-depth insight into healthcare providers' perspectives, behaviours, and interactions regarding discharge. Data collection involved observations, interviews, and document analysis. Approximately 65 hours of observations were undertaken, 23 interviews were conducted with healthcare providers, and government and hospital discharge documents were collected. Data were analysed using a directed content approach. The findings indicate the existence of a medically dominated division of healthcare labour in patient discharge with opportunities for some interprofessional negotiations; the role of organizational routines in facilitating and challenging interprofessional negotiations in patient discharge; and tensions in organizational priorities that impact an interprofessional approach to discharge. The findings provide insight into the various levels at which interventions can be targeted to improve interprofessional collaboration in discharge while recognizing the organizational tensions that challenge an interprofessional approach.

Assessing Origins of Quality Gaps in Discharge Summaries: A Survey of Resident Physician Attitudes

Because little is known about attitudes of primary authors of discharge summaries in academic institutions, namely trainees and physician assistants (PAs), we sought to explore values, possible areas for improvement, and interest in formal discharge summary education. A survey composed of Likert scale analyses, dichotomous relationships, and open-ended questions was designed using focus groups and validated via expert committee review. Of 135 total residents (PGY 1-3), 79 residents and 10 PAs in a large academic hospital in New York City completed it. Of surveyed trainees, 77.2% reported that quality discharge summaries are useful in primary care. Interns had less outpatient experience with discharge summaries compared to PGY 2&3s (23.7% vs. 63.4%, p< 0.001) and were less comfortable authoring discharge summaries for patients who were not as familiar to them (47.4% vs. 24.4%, p=0.04). The majority (54.8%) of interns as well as all PAs reported never receiving feedback on discharge summaries. Finally, 63.2% of interns and 90% of PAs responded that formal teaching would be helpful. Interns' greater discomfort may speak to their poor understanding of core components of a useful discharge summary, which teaching sessions may improve. Alternatively, shifting the authorship responsibility from interns to seniors could be explored as a quality improvement initiative.

Medical Residents and Interprofessional Interactions in Discharge: An Ethnographic Exploration of Factors That Affect Negotiation

BACKGROUND

Interprofessional collaboration is an important aspect of patient discharge from a general internal medicine (GIM) unit. However, there has been minimal empirical or theoretical research that has examined interactions that occur between medical residents and other healthcare professionals in the discharge process. This study provides insight into the social processes that shape and characterize such interactions.

OBJECTIVE

To explore factors that shape interactions between medical residents and other healthcare professionals in relation to patient discharge, and to examine the opportunities for negotiations about discharge between these professional groups.

DESIGN

A qualitative ethnographic approach using observations, interviews and documentary analysis.

PARTICIPANTS AND SETTING

Healthcare professionals working in a GIM unit in Canada.

APPROACH

Sixty-five hours of observations were undertaken in a range of settings (e.g. interprofessional rounds, medical and nursing rounds, nursing station) in the unit over a 17-month period. A maximum variation sampling approach was used to identify healthcare professionals working in the unit. Twenty-three interviews were completed, recorded and transcribed verbatim. A directed content approach using theories of medical dominance and negotiated order was used to analyze the data.

KEY RESULTS

The organization of clinical work in combination with clinical teaching influenced interprofessional interactions and the quality of discharge in this GIM unit. While organizational activities (orientation and rounds) and individual activities (e.g. role modeling, teaching) supported negotiations between medical residents and other healthcare professionals around discharge, participants had varied perspectives about their effectiveness.

CONCLUSIONS

This study illuminates social factors and processes that require attention in order to address challenges with interprofessional collaboration and discharge in GIM. These findings have implications for medical education, workplace learning, patient safety and quality improvement.

Solving the puzzle of posthospital recovery: What is the role of the individual physician?

Improving transitions of care from the acute care setting has been an important focus of health policy in the United States and Canada. Over the past decade, hospital performance metrics related to successful recovery have been used in the United States to implement incentives for reform. This focus has led to a laudable number of interventions to reduce readmissions--a proxy for failed recovery--but most of these have focused on the hospital or system level rather than the individual physician level. Individual physicians in both the inpatient and outpatient setting have important roles to play, but little guidance or structured support is available to them to enable successful engagement in postdischarge management of patient transitions. We describe several tensions of physician engagement in this process from the perspective of front-line providers and highlight several possible approaches to improve physician engagement in transitions.

Hospital variation in quality of discharge summaries for patients hospitalized with heart failure exacerbation

BACKGROUND

Single-site studies have demonstrated inadequate quality of discharge summaries in timeliness, transmission, and content, potentially contributing to adverse outcomes. However, degree of hospital-level variation in discharge summary quality for patients hospitalized with heart failure (HF) is uncertain.

METHODS AND RESULTS

We analyzed discharge summaries of patients enrolled in the Telemonitoring to Improve Heart Failure Outcomes (Tele-HF) study. We assessed hospital-level performance on timeliness (fraction of summaries completed on the day of discharge), documented transmission to the follow-up physician, and content (presence of components suggested by the Transitions of Care Consensus Conference). We obtained 1501 discharge summaries from 1640 (91.5%) patients discharged alive from 46 hospitals. Among hospitals contributing ≥ 10 summaries, the median hospital dictated 69.2% of discharge summaries on the day of discharge (range, 0.0%-98.0%; P<0.001); documented transmission of 33.3% of summaries to the follow-up physician (range, 0.0%-75.7%; P<0.001); and included 3.6 of 7 Transitions of Care Consensus Conference elements (range, 2.9-4.5; P<0.001). Hospital course was typically included (97.2%), but summaries were less likely to include discharge condition (30.7%), discharge volume status (16.0%), or discharge weight (15.7%). No discharge summary included all 7 Transitions of Care Consensus Conference-endorsed content elements, was dictated on the day of discharge, and was sent to a follow-up physician.

CONCLUSIONS

Even at the highest performing hospital, discharge summary quality is insufficient in terms of timeliness, transmission, and content. Improvements in all aspects of discharge summary quality are necessary to enable the discharge summary to serve as an effective transitional care tool.

Discharge communication from inpatient care: an audit of written medical discharge summary procedure against the new National Health Service Standard for clinical handover

Objective To audit written medical discharge summary procedure and practice against Standard Six (clinical handover) of the Australian National Safety and Quality Health Service Standards at a major regional Victorian health service. Methods Department heads were invited to complete a questionnaire about departmental discharge summary practices. Results Twenty-seven (82%) department heads completed the questionnaire. Seven (26%) departments had a documented discharge summary procedure. Fourteen (52%) departments monitored discharge summary completion and 13 (48%) departments monitored the timeliness of completion. Seven (26%) departments informed the patient of the content of the discharge summary and six (22%) departments provided the patient with a copy. Seven (26%) departments provided training for staff members on how to complete discharge summaries. Completing discharge summaries was usually delegated to the medical intern. Conclusions The introduction of the National Service Standards prompted an organisation-wide audit of discharge summary practices against the external criterion. There was substantial variation in the organisation’s practices. The Standards and the current audit results highlight an opportunity for the organisation to enhance and standardise discharge summary practices and improve communication with general practice. What is known about the topic? The Australian National Safety and Quality Health Service Standards (Standard 6) require health service organisations to implement documented systems that support structured and effective clinical handover. Discharge summaries are an important and often the only form of communication during a patient’s transition from hospital to the community. Incomplete, inaccurate and unavailable discharge summaries are common and expose patients to greater health risks. Junior staff members find completing discharge summaries difficult and fail to receive appropriate education or support. There is little published evidence regarding the discharge summary practices of inpatient health services. What does this paper add? The paper demonstrates that there is substantial variation in practice regarding discharge summaries in a large regional health service. Departments have different processes and vary in the degree of attention and quality assurance provided to discharge summaries. Variable organisation procedures make completing discharge summaries more difficult for junior doctors, who regularly move between departments. Variable practice is likely to increase the risk of absent, untimely, incomplete or incorrect communication between acute and community services, thereby reducing the quality of patient care. It is likely that similar findings would be found in other hospitals. What are the implications for practitioners? To be accredited under the National Safety and Quality Health Service Standards, health organisations must ensure that adequate processes are in place for safe and effective clinical handover. Organisations should reduce the practice variability by standardising processes, monitoring compliance with processes, and training and supporting junior doctors.

Using a resident discharge clinic for resident education and patient care: a feasibility study

BACKGROUND

Many patients in internal medicine resident continuity clinics experience difficulty accessing care, making posthospitalization ambulatory follow-up challenging. Experiential learning in care transitions is also lacking for residents.

OBJECTIVE

We sought to assess the feasibility and impact of a weekly Resident Discharge Clinic (RDC) in increasing access to early posthospitalization follow-up and providing learning opportunities for residents.

METHODS

We staffed the RDC with an ambulatory block resident, an internal medicine preceptor, and a clinical pharmacist. We assessed time to posthospitalization follow-up, readmission rates, and resident perceptions of postdischarge care for resident-clinic patients, comparing data before and after RDC implementation.

RESULTS

There were 636 discharges in the baseline group, 662 during the intervention period, and 56 in the RDC group. Six months after RDC implementation, the percentage of discharged resident-clinic patients with follow-up within 7 days improved from 6.6% at baseline to 9.7% (P  =  .04). The mean interval to the posthospitalization follow-up appointment in the RDC group was 7.4 days compared with 33.9 days in the baseline group (P < .001). The percentage of surveyed residents (n  =  72) who agreed that early follow-up was easy to arrange increased from 21% to 77% (P < .001). There was no significant decrease in the 30-day readmission rate for patients in the RDC group (18.1% versus 12.5%, P  =  .29).

CONCLUSIONS

The RDC was easily implemented, increased access to timely posthospitalization follow-up, and provided a platform for resident learning about care transitions.

Confounding factors in using upward feedback to assess the quality of medical training: a systematic review

PURPOSE

Upward feedback is becoming more widely used in medical training as a means of quality control. Multiple biases exist, thus the accuracy of upward feedback is debatable. This study aims to identify factors that could influence upward feedback, especially in medical training.

METHODS

A systematic review using a structured search strategy was performed. Thirty-five databases were searched. Results were reviewed and relevant abstracts were shortlisted. All studies in English, both medical and non-medical literature, were included. A simple pro-forma was used initially to identify the pertinent areas of upward feedback, so that a focused pro-forma could be designed for data extraction.

RESULTS

A total of 204 articles were reviewed. Most studies on upward feedback bias were evaluative studies and only covered Kirkpatrick level 1-reaction. Most studies evaluated trainers or training, were used for formative purposes and presented quantitative data. Accountability and confidentiality were the most common overt biases, whereas method of feedback was the most commonly implied bias within articles.

CONCLUSION

Although different types of bias do exist, upward feedback does have a role in evaluating medical training. Accountability and confidentiality were the most common biases. Further research is required to evaluate which types of bias are associated with specific survey characteristics and which are potentially modifiable.

Written medical discharge communication from an acute stroke service: a project to improve content through development of a structured stroke-specific template

Specific guidelines for the content of discharge summaries from acute stroke services do not currently exist. The aims of this project were to assess the strengths and weaknesses of stroke discharge communication from Imperial College Healthcare NHS Trust, to develop a structured template to guide completion, and to re-audit discharge communication following its implementation. The audit compared local performance against record standards from the Academy of Medical Royal Colleges (1), which was augmented by criteria generated from the British Association of Stroke Physicians (BASP) Stroke Service Standards (2). Discharge information was examined within the Trust's Electronic Discharge Communication (EDC) system to determine the recording of selected items for consecutively discharged patients from the hyperacute and acute stroke units. The audit was repeated following implementation of a newly developed stroke-specific discharge summary template. Fifty-one EDC summaries were examined at baseline (July 2012) and 30 summaries at re-audit (January 2013). The criteria which showed low adherence initially and which showed the most significant improvement following the introduction of the template were the guidance on blood pressure and lipids targets (increased from 2% and 0% respectively at baseline, to 93% post intervention), and the driving and flying advice (from 3% to 79%). Documentation was also seen to improve for measures of physical and cognitive function, discharge arrangements, and follow up plans. This audit cycle has demonstrated improvement in the consistency of content within written discharge communication following the introduction of a structured stroke-specific template adhering to combined criteria from identified standards.

Electronic discharge summary driving advice: Current practice and future directions

BACKGROUND

Driving is a complex task. Many older drivers are unaware of their obligation to inform authorities of conditions which may impact upon their driving safety.

AIMS

This study sought to establish the adequacy of driving advice in electronic discharge summaries from an Australian stroke unit.

METHOD

One month of in-patient electronic discharge summaries were reviewed. A predetermined list of items was used to assess each electronic discharge summary: age; gender; diagnosis; relevant co-morbidities; deficit at time of discharge; driving advice; length of stay; and discharge destination.

RESULTS

Of 41 participants, the mean age was 72 years. Twenty patients had a discharge diagnosis of stroke, nine of transient ischaemic attack, four of seizure and one of encephalitis. Of these, only eight discharge summaries included driving advice.

CONCLUSION

The documentation of driving advice in electronic discharge summaries is poor. This has important public health, ethical and medico-legal implications. Avenues for future research are explored.

Comprehensive quality of discharge summaries at an academic medical center

BACKGROUND

Discharge summaries are essential for safe transitions from hospital to home.

OBJECTIVE

To conduct a comprehensive quality assessment of discharge summaries.

DESIGN

Prospective cohort study.

SUBJECTS

Three hundred seventy-seven patients discharged home after hospitalization for acute coronary syndrome, heart failure, or pneumonia.

MEASURES

Discharge summaries were assessed for timeliness of dictation, transmission of the summary to appropriate outpatient clinicians, and presence of key content including elements required by The Joint Commission and elements endorsed by 6 medical societies in the Transitions of Care Consensus Conference (TOCCC).

RESULTS

A total of 376 of 377 patients had completed discharge summaries. A total of 174 (46.3%) summaries were dictated on the day of discharge; 93 (24.7%) were completed more than a week after discharge. A total of 144 (38.3%) discharge summaries were not sent to any outpatient physician. On average, summaries included 5.6 of 6 The Joint Commission elements and 4.0 of 7 TOCCC elements. Summaries dictated by hospitalists were more likely to be timely and to include key content than summaries dictated by housestaff or advanced practice nurses. Summaries dictated on the day of discharge were more likely to be sent to outside physicians and to include key content. No summary met all 3 quality criteria of timeliness, transmission, and content.

CONCLUSIONS

Discharge summary quality is inadequate in many domains. This may explain why individual aspects of summary quality such as timeliness or content have not been associated with improved patient outcomes. However, improving discharge summary timeliness may also improve content and transmission.

Features of high quality discharge planning for patients following acute myocardial infarction

BACKGROUND

Hospital discharge planning is required as a Medicare Condition of Participation (CoP), and is essential to the health and safety for all patients. However, there have been no studies examining specific hospital discharge processes, such as patient education and communication with primary care providers, in relation to hospital 30-day risk standardized mortality rates (RSMRs) for patients with acute myocardial infarction (AMI).

OBJECTIVE

To identify hospital discharge processes that may be associated with better performance in hospital AMI care as measured by RSMR.

DESIGN

We conducted a qualitative study of U.S. Hospitals, which were selected based on their RSMR reported by the Centers for Medicare & Medicaid Services (CMS) Hospital Compare website for the most recent data available (January 1, 2005 - December 31, 2007). We selected hospitals that ranked in the top 5 % and the bottom 5 % of RSMR for the two consecutive years. We focused on hospitals at the extreme ends of the range in RSMR, known as deviant case sampling. We excluded hospitals that did not have the ability to perform percutaneous coronary intervention in order to decrease the heterogeneity in our sample.

PARTICIPANTS

Participants included key hospital clinical and administrative staff most involved in discharge planning for patients admitted with AMI.

METHODS

We conducted 14 site visits and 57 in-depth interviews using a standard discussion guide. We employed a grounded theory approach and used the constant comparative method to generate recurrent and unifying themes.

KEY RESULTS

We identified five broad discharge processes that distinguished higher and lower performing hospitals: 1) initiating discharge planning upon patient admission; 2) using multidisciplinary case management services; 3) ensuring that a follow-up plan is in place prior to discharge; 4) providing focused education sessions for both the patient and family; and 5) contacting the primary care physician regarding the patient's hospitalization and follow-up care plan.

CONCLUSION

Comprehensive and more intense discharge processes that start on admission continue during the patient's hospital stay, and follow up with the primary care physician within 2 days post-discharge, may be critical in reducing hospital RSMR for patients with AMI.

Moving beyond readmission penalties: creating an ideal process to improve transitional care

Hospital readmissions are common and costly; this has resulted in their emergence as a key quality indicator in the current era of renewed focus on cost containment. However, many concerns remain about the use of readmissions as a hospital quality measure and about how to reduce hospital readmissions. These concerns stem in part from deficiencies in the state of the science of transitional care. A conceptualization of the "ideal" discharge process could help address these deficiencies and move the state of the science forward. We describe an ideal transition in care, explicate the key components, discuss its implications in the context of recent efforts to reduce readmissions, and suggest next steps for policymakers, researchers, healthcare administrators, practitioners, and educators.

Communicating discharge instructions to patients: a survey of nurse, intern, and hospitalist practices

BACKGROUND

Comprehensive discharge education can improve patient understanding and may reduce unnecessary rehospitalization.

OBJECTIVES

To understand nurse and physician communication practices around patient discharge education.

SETTING

University of California, San Francisco Medical Center (UCSFMC).

PARTICIPANTS

Nurses, interns, and hospitalists caring for hospitalized medicine patients.

MEASUREMENTS

Participants were surveyed regarding discharge education practices. The survey asked respondents about 13 elements of discharge education found in the literature. For each element, participants were queried regarding: 1) the provider responsible for this element of patient education; 2) the frequency with which they communicate this teaching to patients; 3) how often they directly communicate with the nurse or physician caring for the patient about each element; and 4) tools to improve nurse-physician communication.

RESULTS

A total of 129/184 (70%) nurses, interns, and hospitalists responded to the survey. The majority of respondents in all 3 groups felt that 9 of 13 elements were a combined responsibility. Nurses reported educating patients on these 9 items significantly more often than physicians (P < 0.05). All groups also agreed that instruction on 2 of the elements, summary of hospital findings and pending results, should be primarily the physicians' responsibility; these were the elements least often discussed by any provider. Despite the majority of items being agreed upon as a shared responsibility, communication between nurses and physicians regarding discharge education was low. Standardized verbal communication on the day of discharge was supported most strongly by all providers.

CONCLUSIONS

Ambiguous responsibility for providing discharge education and poor communication between nurses and physicians offers an opportunity for improvement. Journal of Hospital Medicine 2013. © 2012 Society of Hospital Medicine.

"Learning by doing"--resident perspectives on developing competency in high-quality discharge care

BACKGROUND

Reducing readmissions and post-discharge adverse events by improving the quality of discharge care has become a national priority, yet we have limited understanding about how physicians learn to provide high-quality discharge care.

METHODS

We conducted in-depth, in-person interviews with housestaff physicians with qualitative analysis by a multi-disciplinary team using the constant comparative method to explore learning about high-quality discharge care as a systems-based practice and to identify opportunities to improve training around these concepts.

RESULTS

We analyzed interview transcripts from 29 internal medicine residents: 17 (59 %) were interns (PGY-2 or PGY-3), 12 (41 %) seniors, and 17 (59 %) were female. We identified a recurrent theme of lack of formal training about the discharge process, substantial peer-to-peer instruction, and "learning by doing" on the wards. Within this theme, we identified five specific concepts related to systems-based practice and high-quality discharge care which residents learned during residency: (1) teamwork and the interdisciplinary nature of discharge planning; (2) advanced planning strategies to anticipate challenges in the discharge process; (3) patient safety and the concept of a "safe discharge;" (4) patient continuity of care and learning from post-discharge outcomes and; (5) documentation of discharge plans as a valuable skill.

CONCLUSIONS

Discharge care is an overlooked opportunity to teach concepts of systems-based practice explicitly as learning about discharge care is unstructured and individual experiences may vary considerably. Educational interventions to standardize learning about discharge care may improve the development of systems-based practice during residency and help improve the overall quality of discharge care at teaching hospitals.

Contemporary evidence about hospital strategies for reducing 30-day readmissions: a national study

OBJECTIVES

This study sought to determine the range and prevalence of practices being implemented by hospitals to reduce 30-day readmissions of patients with heart failure or acute myocardial infarction (AMI).

BACKGROUND

Readmissions of patients with heart failure or AMI are both common and costly; however, evidence on strategies adopted by hospitals to reduce readmission rates is limited.

METHODS

We used a Web-based survey to conduct a cross-sectional study of hospitals' reported use of specific practices to reduce readmissions for patients with heart failure or AMI. We contacted all hospitals enrolled in the Hospital to Home (H2H) quality improvement initiative as of July 2010. Of 594 hospitals, 537 completed the survey (response rate of 90.4%). We used standard frequency analysis to describe the prevalence of key hospital practices in the areas of: 1) quality improvement resources and performance monitoring; 2) medication management efforts; and 3) discharge and follow-up processes.

RESULTS

Nearly 90% of hospitals agreed or strongly agreed that they had a written objective of reducing preventable readmission for patients with heart failure or AMI. More hospitals reported having quality improvement teams to reduce preventable readmissions for patients with heart failure (87%) than for patients with AMI (54%). Less than one-half (49.3%) of hospitals had partnered with community physicians and only 23.5% had partnered with local hospitals to manage patients at high risk for readmissions. Inpatient and outpatient prescription records were electronically linked usually or always in 28.9% of hospitals, and the discharge summary was always sent directly to the patient's primary medical doctor in only 25.5% of hospitals. On average, hospitals used 4.8 of 10 key practices; <3% of hospitals utilized all 10 practices.

CONCLUSIONS

Although most hospitals have a written objective of reducing preventable readmissions of patients with heart failure or AMI, the implementation of recommended practices varied widely. More evidence establishing the effectiveness of various practices is needed.