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Tung JYM, Gill SR, Sng GGR, Lim DYZ, Ke Y, Tan TF, Jin L, Elangovan K, Ong JCL, Abdullah HR, Ting DSW, Chong TW. Comparison of the Quality of Discharge Letters Written by Large Language Models and Junior Clinicians: Single-Blinded Study. J Med Internet Res 2024; 26:e57721. [PMID: 39047282 PMCID: PMC11306941 DOI: 10.2196/57721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/18/2024] [Accepted: 07/04/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Discharge letters are a critical component in the continuity of care between specialists and primary care providers. However, these letters are time-consuming to write, underprioritized in comparison to direct clinical care, and are often tasked to junior doctors. Prior studies assessing the quality of discharge summaries written for inpatient hospital admissions show inadequacies in many domains. Large language models such as GPT have the ability to summarize large volumes of unstructured free text such as electronic medical records and have the potential to automate such tasks, providing time savings and consistency in quality. OBJECTIVE The aim of this study was to assess the performance of GPT-4 in generating discharge letters written from urology specialist outpatient clinics to primary care providers and to compare their quality against letters written by junior clinicians. METHODS Fictional electronic records were written by physicians simulating 5 common urology outpatient cases with long-term follow-up. Records comprised simulated consultation notes, referral letters and replies, and relevant discharge summaries from inpatient admissions. GPT-4 was tasked to write discharge letters for these cases with a specified target audience of primary care providers who would be continuing the patient's care. Prompts were written for safety, content, and style. Concurrently, junior clinicians were provided with the same case records and instructional prompts. GPT-4 output was assessed for instances of hallucination. A blinded panel of primary care physicians then evaluated the letters using a standardized questionnaire tool. RESULTS GPT-4 outperformed human counterparts in information provision (mean 4.32, SD 0.95 vs 3.70, SD 1.27; P=.03) and had no instances of hallucination. There were no statistically significant differences in the mean clarity (4.16, SD 0.95 vs 3.68, SD 1.24; P=.12), collegiality (4.36, SD 1.00 vs 3.84, SD 1.22; P=.05), conciseness (3.60, SD 1.12 vs 3.64, SD 1.27; P=.71), follow-up recommendations (4.16, SD 1.03 vs 3.72, SD 1.13; P=.08), and overall satisfaction (3.96, SD 1.14 vs 3.62, SD 1.34; P=.36) between the letters generated by GPT-4 and humans, respectively. CONCLUSIONS Discharge letters written by GPT-4 had equivalent quality to those written by junior clinicians, without any hallucinations. This study provides a proof of concept that large language models can be useful and safe tools in clinical documentation.
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Affiliation(s)
- Joshua Yi Min Tung
- Department of Urology, Singapore General Hospital, Singapore, Singapore
- Data Science and Artificial Intelligence Laboratory, Singapore General Hospital, Singapore, Singapore
| | | | - Gerald Gui Ren Sng
- Data Science and Artificial Intelligence Laboratory, Singapore General Hospital, Singapore, Singapore
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Daniel Yan Zheng Lim
- Data Science and Artificial Intelligence Laboratory, Singapore General Hospital, Singapore, Singapore
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Yuhe Ke
- Data Science and Artificial Intelligence Laboratory, Singapore General Hospital, Singapore, Singapore
- Department of Anesthesiology, Singapore General Hospital, Singapore, Singapore
| | - Ting Fang Tan
- Singapore Eye Research Institute, Singapore National Eye Center, Singapore, Singapore
| | - Liyuan Jin
- Duke-NUS Medical School, Singapore, Singapore
| | - Kabilan Elangovan
- Artificial Intelligence Office, Singapore Health Services, Singapore, Singapore
| | | | - Hairil Rizal Abdullah
- Data Science and Artificial Intelligence Laboratory, Singapore General Hospital, Singapore, Singapore
- Department of Anesthesiology, Singapore General Hospital, Singapore, Singapore
| | - Daniel Shu Wei Ting
- Singapore Eye Research Institute, Singapore National Eye Center, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- Artificial Intelligence Office, Singapore Health Services, Singapore, Singapore
| | - Tsung Wen Chong
- Department of Urology, Singapore General Hospital, Singapore, Singapore
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Witkowski C, Kimmel L, Edwards E, Cosic F. Comparison of the quality of documentation between electronic and paper medical records in orthopaedic trauma patients. AUST HEALTH REV 2021; 46:204-209. [PMID: 34749881 DOI: 10.1071/ah21112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/15/2021] [Indexed: 11/23/2022]
Abstract
ObjectiveThe medical record is critical for documentation and communication between healthcare professionals. This study compared the completeness of orthopaedic documentation between the electronic medical record (EMR) and paper medical record (PMR).MethodsA review was undertaken of 400 medical records (200 EMR, 200 PMR) of patients with operatively managed traumatic lower limb injury. The operative report, discharge summary and first and second out-patient reviews were evaluated using criteria designed by a senior orthopaedic surgeon and senior physiotherapist. The criteria included information deemed critical to the post-operative care of the patient in the first 6 weeks post-surgery.ResultsIn all cases, an operative report was completed by a senior surgeon. Notable findings included inferior documentation of patient weight-bearing status on the operative report in the EMR than PMR group (P = 0.018). There was a significant improvement in the completion of discharge summaries in the EMR compared with PMR cohort (100% vs 82.5% respectively; P < 0.001). In the PMR group, 70.0% of discharge summaries were completed and adequately documented, compared with 91.5% of those in the EMR group (P < 0.001). At out-patient review, there was an improvement in documentation of weight-bearing instructions in the EMR compared with PMR group (81.1% vs 76.2% respectively; P = 0.032).ConclusionThe EMR is associated with an improvement in the standard of orthopaedic medical record documentation, but deficiencies remain in key components of the medical record.What is known about the topic?Medical records are an essential tool in modern medical practice and have significant implications for patient care and management, communication and medicolegal issues. Despite the importance of comprehensive documentation, numerous examples of poor documentation continue to be demonstrated. Recently, significant changes to the medical record in Australia have been implemented with the conversion of some hospitals to an EMR and the implementation of the My Health Record.What does this paper add?Standards of patient care should be monitored continuously and deficiencies identified in order to implement measures for improvement and to close the quality loop. This study has highlighted that although there has been improvement in medical record keeping with the implementation of an EMR, the standard of orthopaedic medical record keeping continues to be below what is expected, and several key areas of documentation require improvement.What are the implications for practitioners?The implications of these findings for practitioners are to highlight current deficiencies in documentation and promote change in current practice to improve the quality of medical record documentation among medical staff. Although the EMR has improved documentation, there remain areas for further improvement, and hospital administrators will find these observations useful in implementing ongoing change.
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Affiliation(s)
- Chris Witkowski
- Department of Orthopaedic Surgery, Alfred Hospital, Melbourne, Vic., Australia
| | - Lara Kimmel
- Department of Physiotherapy, Alfred Hospital, Melbourne, Vic., Australia
| | - Elton Edwards
- Department of Orthopaedic Surgery, Alfred Hospital, Melbourne, Vic., Australia
| | - Filip Cosic
- Department of Orthopaedic Surgery, Alfred Hospital, Melbourne, Vic., Australia
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Potent K, Levy B, Porritt A. Review of electronic discharge summaries from the general medicine, general surgery and mental health streams at a tertiary hospital: retrospective analysis of timeliness, brevity and completeness. AUST HEALTH REV 2021; 44:699-705. [PMID: 32962797 DOI: 10.1071/ah19057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 02/10/2020] [Indexed: 11/23/2022]
Abstract
Objective This retrospective study identified and compared the performance of electronic discharge summaries (EDSs) from three hospital in-patient streams (surgical, medical and mental health) with Australian standards. Methods An audit was performed of 120 EDSs extracted from a tertiary hospital. Auditors evaluated each EDS using an adaptation of the Australian Commission on Safety and Quality in Health Care's EDS toolkit. Results EDSs from all in-patient streams were lengthy and most did not include information regarding discharge destination, patient education or recommendations. General Medicine EDSs were most timely, averaging within 1 day of discharge. Conclusions Key areas of improvement remain for improving the timeliness, brevity and completeness of EDSs. Key areas identified for improvement include page length, discharge destination, alerts, patient education and recommendations. Variability in audit results between streams suggests the need for speciality-specific templates, standards and medical officer training. What is known about the topic? The literature suggests that an EDS is timely if it is completed within 2 days of discharge. A complete and brief EDS should also include key details of the care in two (or fewer) pages. What does this paper add? This paper evaluated 120 EDSs, compared them against a standard and stratified the EDSs according to three core clinical in-patient streams that produced them (surgical, medical and mental health). What are the implications for practitioners? Although broad guidelines for timeliness, brevity and completeness have been established for EDSs, each in-patient stream will require different standards. A hospital or health service should have established standards relevant to each in-patient stream. Before commencing a term in any of the three in-patient streams, medical officers who are to generate EDSs should be trained in the required standard. Training should highlight critical elements of a speciality stream to ensure EDS authors are aware of the nuances of the stream in which they are rotating. In addition, general practitioners should liaise with local hospitals to ensure ongoing dialogue and improvement of clinical handover documents.
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Affiliation(s)
- Keith Potent
- School of Medicine, Griffith University, Parklands Drive, Southport, Qld 4215, Australia; and Corresponding author.
| | - Benjamin Levy
- Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia.
| | - Andrew Porritt
- School of Medicine, University of Notre Dame Australia (Fremantle), 38/40 Henry Street, Fremantle, WA 6160, Australia; and Present address: Royal Perth Hospital, 197 Wellington Street, Perth, WA 6000, Australia.
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Wiebe N, Otero Varela L, Niven DJ, Ronksley PE, Iragorri N, Quan H. Evaluation of interventions to improve inpatient hospital documentation within electronic health records: a systematic review. J Am Med Inform Assoc 2021; 26:1389-1400. [PMID: 31365092 DOI: 10.1093/jamia/ocz081] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 04/14/2019] [Accepted: 05/04/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Despite the widespread and increasing use of electronic health records (EHRs), the quality of EHRs is problematic. Efforts have been made to address reasons for poor EHR documentation quality. Previous systematic reviews have assessed intervention effectiveness within the outpatient setting or paper documentation. The purpose of this systematic review was to assess the effectiveness of interventions seeking to improve EHR documentation within an inpatient setting. MATERIALS AND METHODS A search strategy was developed based on elaborated inclusion/exclusion criteria. Four databases, gray literature, and reference lists were searched. A REDCap data capture form was used for data extraction, and study quality was assessed using a customized tool. Data were analyzed and synthesized in a narrative, semiquantitative manner. RESULTS Twenty-four studies were included in this systematic review. Owing to high heterogeneity, quantitative comparison was not possible. However, statistically significant results in interventions and affected outcomes were analyzed and discussed. Education and implementation of a new EHR reporting system were the most successful interventions, as evidenced by significantly improved EHR documentation. DISCUSSION Heterogeneity of interventions, outcomes, document type, EHR user, and other variables led to difficulty in measuring EHR documentation quality and effectiveness of interventions. However, the use of education as a primary intervention aligned closely with existing literature in similar fields. CONCLUSIONS Interventions implemented to enhance EHR documentation are highly variable and require standardization. Emphasis should be placed on this novel area of research to improve communication between healthcare providers and facilitate data sharing between centers and countries. PROSPERO Registration Number: CRD42017083494.
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Affiliation(s)
- Natalie Wiebe
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lucia Otero Varela
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel J Niven
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nicolas Iragorri
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hude Quan
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Omar A, Rees P, Cooper A, Evans H, Williams H, Hibbert P, Makeham M, Parry G, Donaldson L, Edwards A, Carson-Stevens A. Health and social care-associated harm amongst vulnerable children in primary care: mixed methods analysis of national safety reports. Arch Dis Child 2020; 105:731-737. [PMID: 32144091 DOI: 10.1136/archdischild-2019-318406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/24/2020] [Accepted: 02/07/2020] [Indexed: 11/03/2022]
Abstract
PURPOSE Patient safety failures are recognised as a global threat to public health, yet remain a leading cause of death internationally. Vulnerable children are inversely more in need of high-quality primary health and social-care but little is known about the quality of care received. Using national patient safety data, this study aimed to characterise primary care-related safety incidents among vulnerable children. METHODS This was a cross-sectional mixed methods study of a national database of patient safety incident reports occurring in primary care settings. Free-text incident reports were coded to describe incident types, contributory factors, harm severity and incident outcomes. Subsequent thematic analyses of a purposive sample of reports was undertaken to understand factors underpinning problem areas. RESULTS Of 1183 reports identified, 572 (48%) described harm to vulnerable children. Sociodemographic analysis showed that included children had child protection-related (517, 44%); social (353, 30%); psychological (189, 16%) or physical (124, 11%) vulnerabilities. Priority safety issues included: poor recognition of needs and subsequent provision of adequate care; insufficient provider access to accurate information about vulnerable children, and delayed referrals between providers. CONCLUSION This is the first national study using incident report data to explore unsafe care amongst vulnerable children. Several system failures affecting vulnerable children are highlighted, many of which pose internationally recognised challenges to providers aiming to deliver safe care to this at-risk cohort. We encourage healthcare organisations globally to build on our findings and explore the safety and reliability of their healthcare systems, in order to sustainably mitigate harm to vulnerable children.
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Affiliation(s)
- Adhnan Omar
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Philippa Rees
- Division of Population Medicine, Cardiff University, Cardiff, UK.,Population Policy and Practice, University College London Institute of Child Health, London, UK
| | - Alison Cooper
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Huw Evans
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Huw Williams
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University Faculty of Medicine and Health Sciences, Sydney, New South Wales, Australia.,Division of Health Sciences, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Meredith Makeham
- Department on Clinical Medicine, Macquarie University Faculty of Medicine and Health Sciences, Sydney, New South Wales, Australia
| | - Gareth Parry
- Institute for Healthcare Improvement, Cambridge, Massachusetts, USA.,Harvard Medical School, Harvard University, Cambridge, Massachusetts, USA
| | - Liam Donaldson
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, Cardiff University, Cardiff, UK .,Australian Institute of Health Innovation, Macquarie University Faculty of Medicine and Health Sciences, Sydney, New South Wales, Australia
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Williams H, Donaldson SL, Noble S, Hibbert P, Watson R, Kenkre J, Edwards A, Carson-Stevens A. Quality improvement priorities for safer out-of-hours palliative care: Lessons from a mixed-methods analysis of a national incident-reporting database. Palliat Med 2019; 33:346-356. [PMID: 30537893 PMCID: PMC6376594 DOI: 10.1177/0269216318817692] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Patients receiving palliative care are often at increased risk of unsafe care with the out-of-hours setting presenting particular challenges. The identification of improved ways of delivering palliative care outside working hours is a priority area for policymakers. Aim: To explore the nature and causes of unsafe care delivered to patients receiving palliative care from primary-care services outside normal working hours. Design: A mixed-methods cross-sectional analysis of patient safety incident reports from the National Reporting and Learning System. We characterised reports, identified by keyword searches, using codes to describe what happened, underlying causes, harm outcome, and severity. Exploratory descriptive and thematic analyses identified factors underpinning unsafe care. Setting/participants: A total of 1072 patient safety incident reports involving patients receiving sub-optimal palliative care via the out-of-hours primary-care services. Results: Incidents included issues with: medications (n = 613); access to timely care (n = 123); information transfer (n = 102), and/or non-medication-related treatment such as pressure ulcer relief or catheter care (n = 102). Almost two-thirds of reports (n = 695) described harm with outcomes such as increased pain, emotional, and psychological distress featuring highly. Commonly identified contributory factors to these incidents were a failure to follow protocol (n = 282), lack of skills/confidence of staff (n = 156), and patients requiring medication delivered via a syringe driver (n = 80). Conclusion: Healthcare systems with primary-care-led models of delivery must examine their practices to determine the prevalence of such safety issues (communication between providers; knowledge of commonly used, and access to, medications and equipment) and utilise improvement methods to achieve improvements in care.
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Affiliation(s)
- Huw Williams
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Simon Noble
- Marie Curie Research Centre, Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Peter Hibbert
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW, Australia
| | - Rhiannon Watson
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, North Ryde, NSW, Australia
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
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Caleres G, Bondesson Å, Midlöv P, Modig S. Elderly at risk in care transitions When discharge summaries are poorly transferred and used -a descriptive study. BMC Health Serv Res 2018; 18:770. [PMID: 30305104 PMCID: PMC6180642 DOI: 10.1186/s12913-018-3581-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 09/28/2018] [Indexed: 11/10/2022] Open
Abstract
Background Discharge summary with medication report effectively counteracts drug-related problems among elderly patients due to insufficient information transfer in care transitions. However, this requires optimal transfer and use of the discharge summaries. This study aimed to examine information transfer with discharge summaries from hospital to primary care. Methods A descriptive study with data consisting of discharge summaries of 115 patients, 75 years or older, using five or more drugs, collected during one week from 28 different hospital wards in Skåne county, Sweden. Two weeks after discharge, information transfer was examined via review of primary care medical records. It was noted whether the discharge summary was received (i.e. scanned to the primary care medical records), if the medication list was updated with drug changes and if a patient chart entry regarding medication or its follow-up was made in the primary care medical records. An electronic survey, which was sent to 151 primary care units in Skåne county, was used to examine experiences of the information transfer. Results Out of 115 discharge summaries, 47 (41%) were found in the primary care medical records. Patient chart entries regarding medication or its follow-up were seen in 53 (46%) cases. Drug changes during hospitalisation were seen in 51 out of 76 patients without multidose drug dispensing. In 16 (31%) out of these cases, medication lists were updated in primary care medical records. In the electronic survey, 22 (21%) out of the 107 responding primary care units reported the discharge summary was often received on the day of discharge, while 71 (66%) respondents indicated the discharge summary was always/often received but later. Medication list updates and patient chart entries in the primary care medical records were always/often done upon receipt of the discharge summary according to 61 (57%) respondents. Conclusion The transfer of information was often deficient and the discharge summaries were insufficiently used. Many discharge summaries were lost, an insufficient proportion of medication lists were updated and patient chart entries were often lacking. These findings may increase the risk of medication errors and drug-related problems for elderly in care transitions.
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Affiliation(s)
- Gabriella Caleres
- Department of Clinical Sciences in Malmö/Family Medicine, Center for Primary Health Care Research, Lund University, Box 50332, SE-20213, Malmö, Sweden.
| | - Åsa Bondesson
- Department of Clinical Sciences in Malmö/Family Medicine, Center for Primary Health Care Research, Lund University, Box 50332, SE-20213, Malmö, Sweden.,Department of Medicines Management and Informatics in Skåne County, Malmö, Sweden
| | - Patrik Midlöv
- Department of Clinical Sciences in Malmö/Family Medicine, Center for Primary Health Care Research, Lund University, Box 50332, SE-20213, Malmö, Sweden
| | - Sara Modig
- Department of Clinical Sciences in Malmö/Family Medicine, Center for Primary Health Care Research, Lund University, Box 50332, SE-20213, Malmö, Sweden.,Department of Medicines Management and Informatics in Skåne County, Malmö, Sweden
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Blassmann U, Morath B, Fischer A, Knoth H, Hoppe-Tichy T. [Medication safety in hospitals : Integration of clinical pharmacists to reduce drug-related problems in the inpatient setting]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:1103-1110. [PMID: 30022237 DOI: 10.1007/s00103-018-2788-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Drug-related problems (DRPs) are a significant and often preventable cause for morbidity and mortality. Hospitalization is associated with a high risk for DRPs, especially due to a lack of information transfer at transitions of care. At the same time, interventions during inpatient treatment usually require a change in drug therapy and additionally increase the risk of DRPs. Thereby, DRPs can occur at all levels of the medication process and can be caused by different groups of professionals. One way to improve medication safety in hospitals is to integrate clinical pharmacists into the medication process.According to available data, the integration of a clinical pharmacist in multi-professional teams during admission, hospitalization and discharge can significantly reduce DRPs, costs and increases efficacy of drug therapy. In addition, drug supply with unit-dose systems in combination with digitalization of the medication process can achieve an improvement in medication safety. Improvement in continuity of medical care through a structured medication review and seamless transmission of medically relevant information upon discharge contribute to a significant reduction of hospital readmissions and emergency admissions due to ABPs, as well as health costs. With a university education, the hospital pharmacist specialized in clinical pharmacy is the only professional group that can comprehensively support the physician in the field of drug therapy.
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Affiliation(s)
- Ute Blassmann
- Krankenhausapotheke, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - Benedict Morath
- Krankenhausapotheke, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.,Abteilung Klinische Pharmakologie und Pharmakoepidemiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.,Kooperationseinheit Klinische Pharmazie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Andreas Fischer
- Klinik-Apotheke, Universitätsklinikum Carl Gustav Carus Dresden, Dresden, Deutschland
| | - Holger Knoth
- Klinik-Apotheke, Universitätsklinikum Carl Gustav Carus Dresden, Dresden, Deutschland
| | - Torsten Hoppe-Tichy
- Krankenhausapotheke, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.,Kooperationseinheit Klinische Pharmazie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Newnham H, Barker A, Ritchie E, Hitchcock K, Gibbs H, Holton S. Discharge communication practices and healthcare provider and patient preferences, satisfaction and comprehension: A systematic review. Int J Qual Health Care 2018; 29:752-768. [PMID: 29025093 DOI: 10.1093/intqhc/mzx121] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 08/22/2017] [Indexed: 11/13/2022] Open
Abstract
Purpose To systematically review the available evidence about hospital discharge communication practices and identify which practices were preferred by patients and healthcare providers, improved patient and provider satisfaction, and increased patients' understanding of their medical condition. Data sources OVID Medline, Web of Science, ProQuest, PubMed and CINAHL plus. Study selection Databases were searched for peer-reviewed, English-language papers, published to August 2016, of empirical research using quantitative or qualitative methods. Reference lists in the papers meeting inclusion criteria were searched to identify further papers. Data extraction Of the 3489 articles identified, 30 met inclusion criteria and were reviewed. Results of data synthesis Much research to date has focused on the use of printed material and person-based discharge communication methods including verbal instructions (either in person or via telephone calls). Several studies have examined the use of information technology (IT) such as computer-generated and video-based discharge communication practices. Utilizing technology to deliver discharge information is preferred by healthcare providers and patients, and improves patients' understanding of their medical condition and discharge instructions. Conclusion Well-designed IT solutions may improve communication, coordination and retention of information, and lead to improved outcomes for patients, their families, caregivers and primary healthcare providers as well as expediting the task for hospital staff.
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Affiliation(s)
- Harvey Newnham
- Department of Medicine, Monash University, Level 5, 99 Commercial Road, Melbourne, Victoria 3004, Australia.,General Medicine, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Anna Barker
- School of Public Health and Preventive Medicine, Monash University, Level 4, 553 St. Kilda Road, Melbourne, Victoria 3004, Australia
| | - Edward Ritchie
- General Medicine, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Karen Hitchcock
- General Medicine, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Harry Gibbs
- Department of Medicine, Monash University, Level 5, 99 Commercial Road, Melbourne, Victoria 3004, Australia.,General Medicine, Alfred Health, 55 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Sara Holton
- School of Public Health and Preventive Medicine, Monash University, Level 4, 553 St. Kilda Road, Melbourne, Victoria 3004, Australia
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Watbled L, Marcilly R, Guerlinger S, Bastien JMC, Beuscart-Zéphir MC, Beuscart R. Combining usability evaluations to highlight the chain that leads from usability flaws to usage problems and then negative outcomes. J Biomed Inform 2018; 78:12-23. [DOI: 10.1016/j.jbi.2017.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 12/13/2017] [Accepted: 12/27/2017] [Indexed: 10/18/2022]
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Mehta RL, Baxendale B, Roth K, Caswell V, Le Jeune I, Hawkins J, Zedan H, Avery AJ. Assessing the impact of the introduction of an electronic hospital discharge system on the completeness and timeliness of discharge communication: a before and after study. BMC Health Serv Res 2017; 17:624. [PMID: 28870188 PMCID: PMC5584340 DOI: 10.1186/s12913-017-2579-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 08/29/2017] [Indexed: 12/02/2022] Open
Abstract
Background Hospital discharge summaries are a key communication tool ensuring continuity of care between primary and secondary care. Incomplete or untimely communication of information increases risk of hospital readmission and associated complications. The aim of this study was to evaluate whether the introduction of a new electronic discharge system (NewEDS) was associated with improvements in the completeness and timeliness of discharge information, in Nottingham University Hospitals NHS Trust, England. Methods A before and after longitudinal study design was used. Data were collected using the gold standard auditing tool from the Royal College of Physicians (RCP). This tool contains a checklist of 57 items grouped into seven categories, 28 of which are classified as mandatory by RCP. Percentage completeness (out of the 28 mandatory items) was considered to be the primary outcome measure. Data from 773 patients discharged directly from the acute medical unit over eight-week long time periods (four before and four after the change to the NewEDS) from August 2010 to May 2012 were extracted and evaluated. Results were summarised by effect size on completeness before and after changeover to NewEDS respectively. The primary outcome variable was represented with percentage of completeness score and a non-parametric technique was used to compare pre-NewEDS and post-NewEDS scores. Results The changeover to the NewEDS resulted in an increased completeness of discharge summaries from 60.7% to 75.0% (p < 0.001) and the proportion of summaries created under 24 h from discharge increased significantly from 78.0% to 93.0% (p < 0.001). Furthermore, five of the seven grouped checklist categories also showed significant improvements in levels of completeness (p < 0.001), although there were reduced levels of completeness for three items (p < 0.001). Conclusion The introduction of a NewEDS was associated with a significant improvement in the completeness and timeliness of hospital discharge communication.
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Affiliation(s)
- Rajnikant L Mehta
- School of Medicine, University of Nottingham, Queens Medical Centre, Nottingham, NG7 2UH, England.
| | - Bryn Baxendale
- Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, NG7 2UH, England
| | - Katie Roth
- School of Medicine, University of Nottingham, Queens Medical Centre, Nottingham, NG7 2UH, England
| | - Victoria Caswell
- School of Medicine, University of Nottingham, Queens Medical Centre, Nottingham, NG7 2UH, England
| | - Ivan Le Jeune
- Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, NG7 2UH, England
| | - Jack Hawkins
- University Hospitals Leicester, Emergency Care Intensive Support Team, Leicester, England
| | - Haya Zedan
- Department of Health Informatics, College of Health Sciences, Saudi Electronic University, Riyadh, Saudi Arabia
| | - Anthony J Avery
- School of Medicine, University of Nottingham, Queens Medical Centre, Nottingham, NG7 2UH, England
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Gilliam M, Krein SL, Belanger K, Fowler KE, Dimcheff DE, Solomon G. Novel combined patient instruction and discharge summary tool improves timeliness of documentation and outpatient provider satisfaction. SAGE Open Med 2017; 5:2050312117701053. [PMID: 28491308 PMCID: PMC5406115 DOI: 10.1177/2050312117701053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 02/28/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Incomplete or delayed access to discharge information by outpatient providers and patients contributes to discontinuity of care and poor outcomes. OBJECTIVE To evaluate the effect of a new electronic discharge summary tool on the timeliness of documentation and communication with outpatient providers. METHODS In June 2012, we implemented an electronic discharge summary tool at our 145-bed university-affiliated Veterans Affairs hospital. The tool facilitates completion of a comprehensive discharge summary note that is available for patients and outpatient medical providers at the time of hospital discharge. Discharge summary note availability, outpatient provider satisfaction, and time between the decision to discharge a patient and discharge note completion were all evaluated before and after implementation of the tool. RESULTS The percentage of discharge summary notes completed by the time of first post-discharge clinical contact improved from 43% in February 2012 to 100% in September 2012 and was maintained at 100% in 2014. A survey of 22 outpatient providers showed that 90% preferred the new summary and 86% found it comprehensive. Despite increasing required documentation, the time required to discharge a patient, from physician decision to discharge note completion, improved from 5.6 h in 2010 to 4.1 h in 2012 (p = 0.04), and to 2.8 h in 2015 (p < 0.001). CONCLUSION The implementation of a novel discharge summary tool improved the timeliness and comprehensiveness of discharge information as needed for the delivery of appropriate, high-quality follow-up care, without adversely affecting the efficiency of the discharge process.
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Affiliation(s)
- Meredith Gilliam
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sarah L Krein
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | - Derek E Dimcheff
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Gabriel Solomon
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
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Improving communication of medication changes using a pharmacist-prepared discharge medication management summary. Int J Clin Pharm 2017; 39:394-402. [PMID: 28285390 DOI: 10.1007/s11096-017-0435-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 01/31/2017] [Indexed: 10/20/2022]
Abstract
Background Discontinuity of care between hospital and primary care is often due to poor information transfer. Medication information in medical discharge summaries (DS) is often incomplete or incorrect. The effectiveness and feasibility of hospital pharmacists communicating medication information, including changes made in the hospital, is not clearly defined. Objective To explore the impact of a pharmacist-prepared Discharge Medication Management Summary (DMMS) on the accuracy of information about medication changes provided to patients' general practitioners (GPs). Setting Two medical wards at a major metropolitan hospital in Australia. Method An intervention was developed in which ward pharmacists communicated medication change information to GPs using the DMMS. Retrospective audits were conducted at baseline and after implementation of the DMMS to compare the accuracy of information provided by doctors and pharmacists. GPs' satisfaction with the DMMS was assessed through a faxed survey. Main outcome measure Accuracy of medication change information communicated to GPs; GP satisfaction and feasibility of a pharmacist-prepared DMMS. Results At baseline, 263/573 (45.9%) medication changes were documented by doctors in the DS. In the post-intervention audit, more medication changes were documented in the pharmacist-prepared DMMS compared to the doctor-prepared DS (72.8% vs. 31.5%; p < 0.001). Most GPs (73.3%) were satisfied with the information provided and wanted to receive the DMMS in the future. Completing the DMMS took pharmacists an average of 11.7 minutes. Conclusion The accuracy of medication information transferred upon discharge can be improved by expanding the role of hospital pharmacists to include documenting medication changes.
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Abstract
Background Discharge from hospital presents significant risks to patient safety, with up to one in five patients experiencing adverse events within 3 weeks of leaving hospital. Aim To describe the frequency and types of patient safety incidents associated with discharge from secondary to primary care, and commonly described contributory factors to identify recommendations for practice. Design and setting A mixed methods analysis of 598 patient safety incident reports in England and Wales related to ‘Discharge’ from the National Reporting and Learning System. Method Detailed data coding (with 20% double-coding), data summaries generated using descriptive statistical analysis, and thematic analysis of special-case sample of reports. Incident type, contributory factors, type, and level of harm were described, informing recommendations for future practice. Results A total of 598 eligible reports were analysed. The four main themes were: errors in discharge communication (n = 151; 54% causing harm); errors in referrals to community care (n = 136; 73% causing harm); errors in medication (n = 97; 87% causing harm); and lack of provision of care adjuncts such as dressings (n = 62; 94% causing harm). Common contributory factors were staff factors (not following referral protocols); and organisational factors (lack of clear guidelines or inefficient processes). Improvement opportunities include developing and testing electronic discharge methods with agreed minimum information requirements and unified referrals systems to community care providers; and promoting a safety culture with ‘safe discharge’ checklists, discharge coordinators, and family involvement. Conclusion Significant harm was evident due to deficits in the discharge process. Interventions in this area need to be evaluated and learning shared widely.
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Dean SM, Gilmore-Bykovskyi A, Buchanan J, Ehlenfeldt B, Kind AJH. Design and Hospitalwide Implementation of a Standardized Discharge Summary in an Electronic Health Record. Jt Comm J Qual Patient Saf 2016; 42:555-AP11. [PMID: 28334559 DOI: 10.1016/s1553-7250(16)30107-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The hospital discharge summary is the primary method used to communicate a patient's plan of care to the next provider(s). Despite the existence of regulations and guidelines outlining the optimal content for the discharge summary and its importance in facilitating an effective transition to posthospital care, incomplete discharge summaries remain a common problem that may contribute to poor posthospital outcomes. Electronic health records (EHRs) are regularly used as a platform on which standardization of content and format can be implemented. The feasibility of designing and implementing a standardized discharge summary hospitalwide using an EHR was examined-to the authors' knowledge, for the first time. METHODS This large-scale project at the University of Wisconsin Hospital and Clinics was led by a task force that had been assembled to develop best practices for EHR notes. The evidence-based Replicating Effective Programs (REP) model was employed to guide the development and implementation during the project. REP outlines four stages in clinical health service intervention implementation: preconditions, preimplementation, implementation, and maintenance. RESULTS At 18 months postimplementation, 90% of all hospital discharge summaries were written using the standardized format. Hospital providers found the template helpful and easy to use, and recipient providers perceived an improvement in the quality of discharge summaries compared to those previously sent from the hospital. CONCLUSION Discharge summaries can be standardized and implemented hospitalwide with both author and recipient provider satisfaction, particularly if evidence-based implementation strategies are employed. The use of EHR tools to guide clinicians in writing comprehensive discharge summaries holds promise in improving the existing deficits in communication at transitions of care.
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Affiliation(s)
- Shannon M Dean
- Associate Professor of Pediatrics, Division of Hospital Medicine, University of Wisconsin School of Medicine and Public Health; Chief Medical Information Officer for UW Health, Madison.
| | - Andrea Gilmore-Bykovskyi
- Formerly Advanced Fellow, William S. Middleton Memorial Veterans Affairs Hospital, Madison; Assistant Professor, University of Wisconsin-Madison School of Nursing
| | - Joel Buchanan
- Professor of Medicine, Division of General Internal Medicine; Medical Director, Information Technology Services Strategic Projects, University of Wisconsin School of Medicine and Public Health
| | | | - Amy J H Kind
- Associate Professor of Medicine, Division of Geriatrics, University of Wisconsin School of Medicine and Public Health; Associate Director-Clinical, Geriatrics Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital
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Soong C, Kurabi B, Exconde K, Tajammal F, Bell CM. Design of an orthopaedic-specific discharge summary. BMC Health Serv Res 2016; 16:545. [PMID: 27716194 PMCID: PMC5050605 DOI: 10.1186/s12913-016-1783-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 09/22/2016] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Patients undergoing orthopaedic procedures experience major changes in function and daily routines upon their return home. Discharge summaries are an important communication tool that may play a role in optimizing a safe transition from hospital. Current care gaps and key elements of an ideal discharge summary specific for orthopaedic population are unknown. We sought to identify the challenges of current orthopaedic discharge summaries and to determine key elements of an ideal document. METHODS Qualitative study survey using semi-structured interviews with a sample of 17 patients and clinicians representing diverse professions, backgrounds, and practice settings. We used the constant comparative method of qualitative analysis to define the experiences and perceptions of quality gaps and strategies to improve orthopaedic-specific discharge summaries. RESULTS We identified 3 major themes describing factors perceived to be limiting the quality of current discharge summaries: 1) physician-centric documentation and the absence of a comprehensive, inter-professional perspective; 2) access to resources and health informatics; and 3) process variations in document creation and dissemination. CONCLUSIONS Clinicians and patients identified several factors limiting the quality of discharge summaries among orthopaedic inpatients. Incorporating these elements could improve hospital transitions.
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Affiliation(s)
- Christine Soong
- Division of General Internal Medicine, Mount Sinai Hospital, 600 University Avenue, Room 428, Toronto, ON M5G 1X5 Canada
- Institute of Health Policy, Management and Evaluation, Toronto, ON Canada
| | - Bochra Kurabi
- Department of Medicine, University of Toronto, Toronto, ON Canada
| | - Kathleen Exconde
- Inter-department Division of Critical Care Medicine, University Health Network, Toronto, ON Canada
| | - Faiqa Tajammal
- Division of General Internal Medicine, Mount Sinai Hospital, 600 University Avenue, Room 428, Toronto, ON M5G 1X5 Canada
| | - Chaim M. Bell
- Division of General Internal Medicine, Mount Sinai Hospital, 600 University Avenue, Room 428, Toronto, ON M5G 1X5 Canada
- Institute of Health Policy, Management and Evaluation, Toronto, ON Canada
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Carson-Stevens A, Hibbert P, Williams H, Evans HP, Cooper A, Rees P, Deakin A, Shiels E, Gibson R, Butlin A, Carter B, Luff D, Parry G, Makeham M, McEnhill P, Ward HO, Samuriwo R, Avery A, Chuter A, Donaldson L, Mayor S, Panesar S, Sheikh A, Wood F, Edwards A. Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04270] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundThere is an emerging interest in the inadvertent harm caused to patients by the provision of primary health-care services. To date (up to 2015), there has been limited research interest and few policy directives focused on patient safety in primary care. In 2003, a major investment was made in the National Reporting and Learning System to better understand patient safety incidents occurring in England and Wales. This is now the largest repository of patient safety incidents in the world. Over 40,000 safety incident reports have arisen from general practice. These have never been systematically analysed, and a key challenge to exploiting these data has been the largely unstructured, free-text data.AimsTo characterise the nature and range of incidents reported from general practice in England and Wales (2005–13) in order to identify the most frequent and most harmful patient safety incidents, and relevant contributory issues, to inform recommendations for improving the safety of primary care provision in key strategic areas.MethodsWe undertook a cross-sectional mixed-methods evaluation of general practice patient safety incident reports. We developed our own classification (coding) system using an iterative approach to describe the incident, contributory factors and incident outcomes. Exploratory data analysis methods with subsequent thematic analysis was undertaken to identify the most harmful and most frequent incident types, and the underlying contributory themes. The study team discussed quantitative and qualitative analyses, and vignette examples, to propose recommendations for practice.Main findingsWe have identified considerable variation in reporting culture across England and Wales between organisations. Two-thirds of all reports did not describe explicit reasons about why an incident occurred. Diagnosis- and assessment-related incidents described the highest proportion of harm to patients; over three-quarters of these reports (79%) described a harmful outcome, and half of the total reports described serious harm or death (n = 366, 50%). Nine hundred and ninety-six reports described serious harm or death of a patient. Four main contributory themes underpinned serious harm- and death-related incidents: (1) communication errors in the referral and discharge of patients; (2) physician decision-making; (3) unfamiliar symptom presentation and inadequate administration delaying cancer diagnoses; and (4) delayed management or mismanagement following failures to recognise signs of clinical (medical, surgical and mental health) deterioration.ConclusionsAlthough there are recognised limitations of safety-reporting system data, this study has generated hypotheses, through an inductive process, that now require development and testing through future research and improvement efforts in clinical practice. Cross-cutting priority recommendations include maximising opportunities to learn from patient safety incidents; building information technology infrastructure to enable details of all health-care encounters to be recorded in one system; developing and testing methods to identify and manage vulnerable patients at risk of deterioration, unscheduled hospital admission or readmission following discharge from hospital; and identifying ways patients, parents and carers can help prevent safety incidents. Further work must now involve a wider characterisation of reports contributed by the rest of the primary care disciplines (pharmacy, midwifery, health visiting, nursing and dentistry), include scoping reviews to identify interventions and improvement initiatives that address priority recommendations, and continue to advance the methods used to generate learning from safety reports.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Andrew Carson-Stevens
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
- Wales Primary and Emergency Care (PRIME) Research Centre, Cardiff University, Cardiff, UK
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Peter Hibbert
- Australian Institute for Health Innovation (AIHI), Macquarie University, Sydney, NSW, Australia
| | - Huw Williams
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Huw Prosser Evans
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Alison Cooper
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Philippa Rees
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Anita Deakin
- Australian Patient Safety Foundation, University of South Australia, Adelaide, SA, Australia
| | - Emma Shiels
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Russell Gibson
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Amy Butlin
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Ben Carter
- Centre for Medical Education, Cardiff University, Cardiff, UK
| | - Donna Luff
- Harvard Medical School, Harvard University, Boston, MA, USA
| | - Gareth Parry
- Harvard Medical School, Harvard University, Boston, MA, USA
- Institute for Healthcare Improvement (IHI), Cambridge, MA, USA
| | - Meredith Makeham
- Australian Institute for Health Innovation (AIHI), Macquarie University, Sydney, NSW, Australia
| | - Paul McEnhill
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Hope Olivia Ward
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Raymond Samuriwo
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Anthony Avery
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | | | - Liam Donaldson
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sharon Mayor
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Sukhmeet Panesar
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Aziz Sheikh
- Harvard Medical School, Harvard University, Boston, MA, USA
- Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
| | - Fiona Wood
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Adrian Edwards
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
- Wales Primary and Emergency Care (PRIME) Research Centre, Cardiff University, Cardiff, UK
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Uppal NK, Eisen D, Weissberger J, Wyman RJ, Urbach DR, Bell CM. Transfer of care of postsurgical patients from hospital to the community setting: cross-sectional survey of primary care physicians. Am J Surg 2015; 210:778-82. [DOI: 10.1016/j.amjsurg.2015.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 01/29/2015] [Accepted: 03/03/2015] [Indexed: 11/16/2022]
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Unnewehr M, Schaaf B, Marev R, Fitch J, Friederichs H. Optimizing the quality of hospital discharge summaries--a systematic review and practical tools. Postgrad Med 2015; 127:630-9. [PMID: 26074128 DOI: 10.1080/00325481.2015.1054256] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Although doctors' discharge summaries (DS) are important forms of communication between the physicians in patient care, deficits in the quality of DS are common. This review aims to answer the following question: according to the literature, how can the quality of DS be improved by (1) interventions; (2) reviews and guidelines of regulatory bodies; and (3) other practical recommendations? METHODS Systematic review of the literature. RESULTS The scientific papers on optimizing the quality of DS (n = 234) are heterogeneous and do not allow any meta-analysis. The interventional studies revealed that a structured approach of writing, educational training including feedback and the use of a checklist are effective methods. Guidelines are helpful for outlining the key characteristics of DS. Additionally, the articles in the literature provided practical proposals on improving form, structure, clinical content, treatment recommendations, follow-up plan, medications and changes, addressees, patient data, length, language, dictation, electronic processing and timeliness of DS. CONCLUSION The literature review revealed various possibilities for improving the quality of DS.
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Affiliation(s)
- Markus Unnewehr
- Klinikum Dortmund gGmbH, Respiratory Medicine, Infectious Diseases, Intensive Care Medicine , Dortmund , Germany
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Garg T, Lee JY, Evans KH, Chen J, Shieh L. Development and Evaluation of an Electronic Health Record–Based Best-Practice Discharge Checklist for Hospital Patients. Jt Comm J Qual Patient Saf 2015; 41:126-31. [DOI: 10.1016/s1553-7250(15)41017-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Quality of psychiatric discharge summaries: a service evaluation following the introduction of an electronic discharge summary system. Ir J Psychol Med 2015; 32:327-330. [DOI: 10.1017/ipm.2014.95] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BackgroundThere has been a recent move in psychiatry towards the use of electronic discharge (e-discharge) summaries in an effort to improve the efficiency of communication between primary and secondary care, but there are little data on how this affects the quality of information exchanged.ObjectiveTo evaluate the quality of psychiatric discharge summaries before and after the introduction of the e-discharge summary system.MethodsA retrospective analysis of 50 dictated discharge summaries from 1 January to 1 July 2010 and of 50 e-discharge summaries from 1 January to 1 July 2012, evaluating for the inclusion of 15 key items of clinical information.ResultsThe average total score of the dictated summaries (mean=9.5, s.d.=2.0) was significantly higher (p<0.001) than the e-discharge summaries (mean=6.7, s.d.=1.8). There were statistically significant differences in five of the standards: findings of physical examination (p<0.001), ICD-10 code (p<0.001), forensic history (p<0.001), alcohol history (p<0.001) and drug history (p<0.001).ConclusionOur results revealed a decline in the quality of discharge summaries following the introduction of an electronic system. The reasons for this are unclear and require further analysis. Specific suggestions will depend on the local need, but include improvements in software design and layout as well as better education and training.
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Al-Damluji MS, Dzara K, Hodshon B, Punnanithinont N, Krumholz HM, Chaudhry SI, Horwitz LI. Hospital variation in quality of discharge summaries for patients hospitalized with heart failure exacerbation. Circ Cardiovasc Qual Outcomes 2015; 8:77-86. [PMID: 25587091 DOI: 10.1161/circoutcomes.114.001227] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Mohammed Salim Al-Damluji
- From the Section of General Internal Medicine, Department of Medicine (M.S.A.-D., K.D., S.I.C.), Section of Cardiovascular Medicine, Department of Internal Medicine (B.H., H.M.K.), and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT; Department of Medicine, Erie County Medical Center, Buffalo, NY (N.P.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K., S.I.C.); Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT (H.M.K.); Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center (L.I.H.); and Division of Healthcare Delivery Science, Department of Population Health and Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine (L.I.H.)
| | - Kristina Dzara
- From the Section of General Internal Medicine, Department of Medicine (M.S.A.-D., K.D., S.I.C.), Section of Cardiovascular Medicine, Department of Internal Medicine (B.H., H.M.K.), and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT; Department of Medicine, Erie County Medical Center, Buffalo, NY (N.P.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K., S.I.C.); Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT (H.M.K.); Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center (L.I.H.); and Division of Healthcare Delivery Science, Department of Population Health and Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine (L.I.H.)
| | - Beth Hodshon
- From the Section of General Internal Medicine, Department of Medicine (M.S.A.-D., K.D., S.I.C.), Section of Cardiovascular Medicine, Department of Internal Medicine (B.H., H.M.K.), and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT; Department of Medicine, Erie County Medical Center, Buffalo, NY (N.P.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K., S.I.C.); Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT (H.M.K.); Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center (L.I.H.); and Division of Healthcare Delivery Science, Department of Population Health and Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine (L.I.H.)
| | - Natdanai Punnanithinont
- From the Section of General Internal Medicine, Department of Medicine (M.S.A.-D., K.D., S.I.C.), Section of Cardiovascular Medicine, Department of Internal Medicine (B.H., H.M.K.), and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT; Department of Medicine, Erie County Medical Center, Buffalo, NY (N.P.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K., S.I.C.); Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT (H.M.K.); Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center (L.I.H.); and Division of Healthcare Delivery Science, Department of Population Health and Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine (L.I.H.)
| | - Harlan M Krumholz
- From the Section of General Internal Medicine, Department of Medicine (M.S.A.-D., K.D., S.I.C.), Section of Cardiovascular Medicine, Department of Internal Medicine (B.H., H.M.K.), and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT; Department of Medicine, Erie County Medical Center, Buffalo, NY (N.P.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K., S.I.C.); Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT (H.M.K.); Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center (L.I.H.); and Division of Healthcare Delivery Science, Department of Population Health and Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine (L.I.H.)
| | - Sarwat I Chaudhry
- From the Section of General Internal Medicine, Department of Medicine (M.S.A.-D., K.D., S.I.C.), Section of Cardiovascular Medicine, Department of Internal Medicine (B.H., H.M.K.), and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT; Department of Medicine, Erie County Medical Center, Buffalo, NY (N.P.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K., S.I.C.); Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT (H.M.K.); Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center (L.I.H.); and Division of Healthcare Delivery Science, Department of Population Health and Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine (L.I.H.)
| | - Leora I Horwitz
- From the Section of General Internal Medicine, Department of Medicine (M.S.A.-D., K.D., S.I.C.), Section of Cardiovascular Medicine, Department of Internal Medicine (B.H., H.M.K.), and Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine (H.M.K.), Yale School of Medicine, New Haven, CT; Department of Medicine, Erie County Medical Center, Buffalo, NY (N.P.); Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K., S.I.C.); Department of Health Policy and Management, School of Public Health, Yale University, New Haven, CT (H.M.K.); Center for Healthcare Innovation and Delivery Science, New York University Langone Medical Center (L.I.H.); and Division of Healthcare Delivery Science, Department of Population Health and Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine (L.I.H.).
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Leyenaar JK, Bergert L, Mallory LA, Engel R, Rassbach C, Shen M, Woehrlen T, Cooperberg D, Coghlin D. Pediatric primary care providers' perspectives regarding hospital discharge communication: a mixed methods analysis. Acad Pediatr 2015; 15:61-8. [PMID: 25444655 PMCID: PMC4371737 DOI: 10.1016/j.acap.2014.07.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 07/18/2014] [Accepted: 07/19/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Effective communication between inpatient and outpatient providers may mitigate risks of adverse events associated with hospital discharge. However, there is an absence of pediatric literature defining effective discharge communication strategies at both freestanding children's hospitals and general hospitals. The objectives of this study were to assess associations between pediatric primary care providers' (PCPs) reported receipt of discharge communication and referral hospital type, and to describe PCPs' perspectives regarding effective discharge communication and areas for improvement. METHODS We administered a questionnaire to PCPs referring to 16 pediatric hospital medicine programs nationally. Multivariable models were developed to assess associations between referral hospital type and receipt and completeness of discharge communication. Open-ended questions asked respondents to describe effective strategies and areas requiring improvement regarding discharge communication. Conventional qualitative content analysis was performed to identify emergent themes. RESULTS Responses were received from 201 PCPs, for a response rate of 63%. Although there were no differences between referral hospital type and PCP-reported receipt of discharge communication (relative risk 1.61, 95% confidence interval 0.97-2.67), PCPs referring to general hospitals more frequently reported completeness of discharge communication relative to those referring to freestanding children's hospitals (relative risk 1.78, 95% confidence interval 1.26-2.51). Analysis of free text responses yielded 4 major themes: 1) structured discharge communication, 2) direct personal communication, 3) reliability and timeliness of communication, and 4) communication for effective postdischarge care. CONCLUSIONS This study highlights potential differences in the experiences of PCPs referring to general hospitals and freestanding children's hospitals, and presents valuable contextual data for future quality improvement initiatives.
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Affiliation(s)
- JoAnna K. Leyenaar
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Tufts University School of Medicine, Boston, MA
| | - Lora Bergert
- Division of Pediatric Hospital Medicine, Department of Pediatrics, The John A Burns School of Medicine, Honolulu, HI
| | - Leah A. Mallory
- Division of Pediatric Hospital Medicine, Department of Pediatrics, The Barbara Bush Children’s Hospital at Maine Medical Center, Portland, ME
| | - Richard Engel
- University of Arizona College of Medicine-Phoenix, Phoenix Children’s Hospital, Phoenix, AZ
| | - Caroline Rassbach
- Stanford University School of Medicine, Lucile Packard Children’s Hospital, Palo Alto, CA 94304
| | - Mark Shen
- Dell Children’s Medical Center of Central Texas
| | - Tess Woehrlen
- Michigan State University College of Osteopathic Medicine, East Lansing MI
| | - David Cooperberg
- Drexel University College of Medicine, St. Christopher’s Hospital for Children, Philadelphia, PA
| | - Daniel Coghlin
- The Warren Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, RI
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Soong C, Kurabi B, Wells D, Caines L, Morgan MW, Ramsden R, Bell CM. Do post discharge phone calls improve care transitions? A cluster-randomized trial. PLoS One 2014; 9:e112230. [PMID: 25386678 PMCID: PMC4227814 DOI: 10.1371/journal.pone.0112230] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 10/05/2014] [Indexed: 11/18/2022] Open
Abstract
Importance The transition from hospital to home can expose patients to adverse events during the post discharge period. Post discharge care including phone calls may provide support for patients returning home but the impact on care transitions is unknown. Objective To examine the effect of a 72-hour post discharge phone call on the patient's transition of care experience. Design Cluster-randomized control trial. Setting Urban, academic medical center. Participants General medical patients age 18 and older discharged home after hospitalization. Main Outcomes and Measures Primary outcome measure was the Care Transition Measure (CTM-3) score, a validated measure of the quality of care transitions. Secondary measures included self-reported adherence to medication and follow up plans, and 30-day composite of emergency department (ED) visits and hospital readmission. Results 328 patients were included in the study over an 6-month period. 114 (69%) received a post discharge phone call, and 214 of all patients in the study completed the follow outcome survey (65% response rate). A small difference in CTM-3 scores was observed between the intervention and control groups (1.87 points, 95% CI 0.47–3.27, p = 0.01). Self-reported adherence to treatment plans, ED visits, and emergency readmission rates were similar between the two groups (odds ratio 0.57, 95% CI 0.13–2.45, 1.20, 95% CI 0.61–2.37, and 1.18, 95% CI 0.53–2.61, respectively). Conclusions and Relevance A single post discharge phone call had a small impact on the quality of care transitions and no effect on hospital utilization. Higher intensity post discharge support may be required to improve the patient experience upon returning home. Trial Registration ClinicalTrials.gov NCT01580774
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Affiliation(s)
- Christine Soong
- Division of General Internal Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Mount Sinai Hospital, Toronto, Canada
- * E-mail:
| | - Bochra Kurabi
- Division of General Internal Medicine, University of Toronto, Toronto, Canada
| | - David Wells
- Department of Medicine, Mount Sinai Hospital, Toronto, Canada
| | - Lesley Caines
- Department of Medicine, Mount Sinai Hospital, Toronto, Canada
| | - Matthew W. Morgan
- Division of General Internal Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Mount Sinai Hospital, Toronto, Canada
| | - Rebecca Ramsden
- Department of Medicine, Mount Sinai Hospital, Toronto, Canada
| | - Chaim M. Bell
- Division of General Internal Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, Mount Sinai Hospital, Toronto, Canada
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A two-site survey of clinicians to identify practices and preferences of intensive care unit transfers to general medical wards. J Crit Care 2014; 30:358-62. [PMID: 25499415 DOI: 10.1016/j.jcrc.2014.10.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 09/22/2014] [Accepted: 10/26/2014] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The transfer of patients from the intensive care unit (ICU) to the general medical ward is high risk for adverse events and health care provider dissatisfaction. We aimed to identify perceived practices, and what information is important to communicate during an ICU transfer. METHODS This study used a self-administered questionnaire that surveyed physicians in 2 different hospitals. These physicians provide care in either the ICU or the general medical ward. Responses were evaluated with Likert scales and frequencies. RESULTS A total of 121 physicians (54% response rate) completed the survey. Current practice most often includes written chart and telephone communication. Most providers (63.3%) believed that the current process is inadequate. Surprises are common (79% of respondents); and reported adverse events include medication errors (60.4%), aspiration (49.5%), and decreased level of consciousness requiring intervention (44.6%). The use of an ICU transfer tool is one potential mechanism of improving this process of care, and providers reported several items that may be useful. CONCLUSION Providers reported the current process of transferring patients from the ICU to the general medical ward as inadequate. We highlight data that physicians feel is important to communicate at the time of transfer.
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Liu J, Griesman J, Nisenbaum R, Bell CM. Quality of care of hospitalized internal medicine patients bedspaced to non-internal medicine inpatient units. PLoS One 2014; 9:e106763. [PMID: 25184480 PMCID: PMC4153721 DOI: 10.1371/journal.pone.0106763] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 08/08/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND When the number of patients requiring hospital admission exceeds the number of available department-allotted beds, patients are often placed on a different specialty's inpatient ward, a practice known as "bedspacing". Whether bedspacing affects quality of patient care has not been previously studied. METHODS We reviewed consecutive general internal medicine (GIM) admissions for congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and pneumonia at St. Michael's Hospital in Toronto, Canada, from 2007 to 2011 and examined whether quality of care differs between bedspaced and nonbedspaced patients. We matched each bedspaced patient with a GIM ward patient admitted on the same call shift with the same diagnosis. The primary outcome was the ratio of the actual to the estimated length of stay (ELOS). General and disease specific measures for CHF, COPD, and pneumonia (e.g. fluid restriction) were evaluated, as well as 30-day Emergency Department (ED) and hospital readmissions. RESULTS Overall, 1639 consecutive admissions were reviewed, and 39 matched pairs for CHF, COPD and pneumonia were studied. Differences in both general and disease specific care measures were not detected between groups. For many disease-specific comparisons, ordering and adherence to quality of care indicators was low in both groups. CONCLUSIONS We were unable to detect differences in quality of care between bedspaced and nonbedspaced patients. As high patient volumes and hospital overcrowding remains, bedspacing will likely continue. More research is required in order to determine if quality of care is compromised by this ongoing practice.
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Affiliation(s)
- Jessica Liu
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | | | - Rosane Nisenbaum
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Chaim M. Bell
- University of Toronto, Department of Medicine, Toronto, Ontario, Canada
- Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
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Moy NY, Lee SJ, Chan T, Grovey B, Boscardin WJ, Gonzales R, Pierluissi E. Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project. Jt Comm J Qual Patient Saf 2014; 40:219-27. [PMID: 24919253 DOI: 10.1016/s1553-7250(14)40029-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND After hospital discharge, patients are at risk for medication errors, missed test results, adverse events, and readmissions. Handoff communication between the inpatient and outpatient settings is primarily accomplished with the discharge summary. However, critical information can often be missing, such as the date of the first postdischarge follow-up visit, a complete and accurate list of discharge medications, and follow-up recommendations. There have been no studies focusing on identifying and implementing a parsimonious, clinically relevant, inpatient-to-outpatient discharge handoff tool within a fully integrated electronic medical record (EMR) system. A concise, written, electronic handoff communication tool was created to address this gap. METHODS Using inpatient and outpatient provider stakeholder input, a standard, succinct, and clinically relevant handoff tool was designed and implemented within the Veterans Affairs EMR. Retrospective chart review at 3 and 15 months after the handoff tool rollout in December 2010 was conducted to monitor handoff uptake and outcomes. RESULTS At 15 months after implementation, 86% (129/150) of patients had a completed handoff at the time of discharge. More handoff notes were available in the EMR within 24 hours of discharge than discharge summaries (100% versus 77%, p < .0001). There was no difference between those patients with or without a handoff in the number of emergency department visits or readmissions. DISCUSSION A standardized clinically relevant discharge handoff tool had high user uptake and sustainability and improved timeliness of communication of information between the hospital and outpatient setting. Even within a fully integrated EMR system, simple and efficient handoffs between inpatient and outpatient providers may fulfill a communication gap at the time of discharge.
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Leppin AL, Gionfriddo MR, Kessler M, Brito JP, Mair FS, Gallacher K, Wang Z, Erwin PJ, Sylvester T, Boehmer K, Ting HH, Murad MH, Shippee ND, Montori VM. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med 2014; 174:1095-107. [PMID: 24820131 PMCID: PMC4249925 DOI: 10.1001/jamainternmed.2014.1608] [Citation(s) in RCA: 550] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Reducing early (<30 days) hospital readmissions is a policy priority aimed at improving health care quality. The cumulative complexity model conceptualizes patient context. It predicts that highly supportive discharge interventions will enhance patient capacity to enact burdensome self-care and avoid readmissions. OBJECTIVE To synthesize the evidence of the efficacy of interventions to reduce early hospital readmissions and identify intervention features--including their impact on treatment burden and on patients' capacity to enact postdischarge self-care--that might explain their varying effects. DATA SOURCES We searched PubMed, Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, and Scopus (1990 until April 1, 2013), contacted experts, and reviewed bibliographies. STUDY SELECTION Randomized trials that assessed the effect of interventions on all-cause or unplanned readmissions within 30 days of discharge in adult patients hospitalized for a medical or surgical cause for more than 24 hours and discharged to home. DATA EXTRACTION AND SYNTHESIS Reviewer pairs extracted trial characteristics and used an activity-based coding strategy to characterize the interventions; fidelity was confirmed with authors. Blinded to trial outcomes, reviewers noted the extent to which interventions placed additional work on patients after discharge or supported their capacity for self-care in accordance with the cumulative complexity model. MAIN OUTCOMES AND MEASURES Relative risk of all-cause or unplanned readmission with or without out-of-hospital deaths at 30 days postdischarge. RESULTS In 42 trials, the tested interventions prevented early readmissions (pooled random-effects relative risk, 0.82 [95% CI, 0.73-0.91]; P < .001; I² = 31%), a finding that was consistent across patient subgroups. Trials published before 2002 reported interventions that were 1.6 times more effective than those tested later (interaction P = .01). In exploratory subgroup analyses, interventions with many components (interaction P = .001), involving more individuals in care delivery (interaction P = .05), and supporting patient capacity for self-care (interaction P = .04) were 1.4, 1.3, and 1.3 times more effective than other interventions, respectively. A post hoc regression model showed incremental value in providing comprehensive, postdischarge support to patients and caregivers. CONCLUSIONS AND RELEVANCE Tested interventions are effective at reducing readmissions, but more effective interventions are complex and support patient capacity for self-care. Interventions tested more recently are less effective.
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Affiliation(s)
- Aaron L Leppin
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Michael R Gionfriddo
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota2Mayo Graduate School, Mayo Clinic, Rochester, Minnesota
| | - Maya Kessler
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota3Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Juan Pablo Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota3Department of Medicine, Mayo Clinic, Rochester, Minnesota4Mayo Clinic Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Frances S Mair
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Katie Gallacher
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Zhen Wang
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota4Mayo Clinic Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | | | - Tanya Sylvester
- medical student at St Louis University School of Medicine, St Louis, Missouri
| | - Kasey Boehmer
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota8graduate student at University of Minnesota School of Public Health, Minneapolis
| | - Henry H Ting
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - M Hassan Murad
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota4Mayo Clinic Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Nathan D Shippee
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota3Department of Medicine, Mayo Clinic, Rochester, Minnesota4Mayo Clinic Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
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Reinke CE, Kelz RR, Baillie CA, Norris A, Schmidt S, Wingate N, Myers JS. Timeliness and quality of surgical discharge summaries after the implementation of an electronic format. Am J Surg 2013; 207:7-16. [PMID: 24269034 DOI: 10.1016/j.amjsurg.2013.04.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 03/25/2013] [Accepted: 04/24/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND As electronic discharge summaries (EDS) become more prevalent and health care systems increase their focus on transitions of care, analysis of EDS quality is important. The objective of this study was to assess the timeliness and quality of EDS compared with dictated summaries for surgical patients, which has not previously been evaluated. METHODS A retrospective study was conducted of a sample of discharge summaries from surgical patients at an urban university teaching hospital before and after the implementation of an EDS program. Summaries were evaluated on several dimensions, including time to summary completion, summary length, and summary quality, which was measured on a 13-item scoring tool. RESULTS After the exclusion of 5 patients who died, 195 discharge summaries were evaluated. Discharge summaries before and after EDS implementation were similar in admission types and discharge destinations of the patients. Compared with dictated summaries, EDS had equivalent overall quality (P = .11), with higher or equivalent scores on all specific quality aspects except readability. There was a highly significant statistical and clinical improvement in timeliness for electronic summaries (P < .01). Obvious use of copying and pasting was identified in 8% of discharge summaries and was associated with decreased readability (P = .02). CONCLUSIONS The implementation of EDS can improve the timeliness of summary completion without sacrificing quality for surgical patients. Excessive copying and pasting can reduce the readability of discharge summaries, and strategies to discourage this practice without the use of appropriate editing should be used.
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Affiliation(s)
- Caroline E Reinke
- Department of Surgery, Division of Surgery Education, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 4 Maloney, Philadelphia, PA 19104, USA; Center for Healthcare Improvement and Patient Safety, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Rachel R Kelz
- Department of Surgery, Division of Surgery Education, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 4 Maloney, Philadelphia, PA 19104, USA
| | - Charles A Baillie
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Anne Norris
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sara Schmidt
- Clinical Effectiveness and Quality Improvement, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Jennifer S Myers
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Center for Healthcare Improvement and Patient Safety, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Barr R, Chin KY, Yeong K. Improving transmission rates of electronic discharge summaries to GPs. BMJ QUALITY IMPROVEMENT REPORTS 2013; 2:bmjquality_u756_w1013. [PMID: 26734187 PMCID: PMC4652718 DOI: 10.1136/bmjquality.u756.w1013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 08/08/2013] [Indexed: 11/08/2022]
Abstract
Discharge summaries are a vital tool to communicate information from Hospital to Primary Care teams; updating GPs about what happened during an admission, and handing over care detailing any follow up care required. Historically, Discharge Summaries have been posted to hospitals, increasing costs for hospitals, creating administrative work for GP practices receiving the letters, and resulting in some letters being lost or delayed in reaching the GP, with implications for patient safety if follow up requests are not received and acted upon. In an effort to improve patient care, the Clinical Commissioning Group in Surrey drew up a contract with Ashford and St Peter's Foundation Trust, aiming to increase the percentage of discharge summaries sent electronically from the rate of 9% sent within 24 hours, to over 75%. This contract set targets of 50% in May, 65% in June, and 80% in July. Financial penalties would be imposed if targets were not achieved, starting in June 2013. The Trust set up a working group comprising of doctors, IT personnel and ward PAs to devise a multi-pronged solution to achieve this target. The electronic discharge summary system was reviewed and improvements were designed and developed to make the process of signing off letters easier, and transmission of signed off letters became automated rather than requiring manual transmission by ward PAs. Presentations and leaflets to explain the importance of prompt completion and transmission of discharge summaries were given to Doctors to improve compliance using the revised IT system. Figures on transmission rates were automatically emailed to key stakeholders every day (Ward PAs, Divisional Leads) showing performance on each ward. This helped identify areas requiring more intervention. Areas (e.g. Day Surgery) that had not used electronic discharge summaries were engaged with, and persuaded to take part. As a result, transmission rates of Discharge Summaries within 24 hours of patient discharge increased from 9% on May 11th 2013, to 76% by June 29th 2013. This has improved communication with GPs, led to more reliable handover of care, and reduced costs for the Trust (both in processing and postage costs, and by avoiding fines).
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Horwitz LI, Jenq GY, Brewster UC, Chen C, Kanade S, Van Ness PH, Araujo KLB, Ziaeian B, Moriarty JP, Fogerty RL, Krumholz HM. Comprehensive quality of discharge summaries at an academic medical center. J Hosp Med 2013; 8:436-43. [PMID: 23526813 PMCID: PMC3695055 DOI: 10.1002/jhm.2021] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 01/11/2013] [Accepted: 01/16/2013] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Leora I Horwitz
- Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06520, USA.
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Soong C, Daub S, Lee J, Majewski C, Musing E, Nord P, Wyman R, Baker GR, Zacharopoulos N, Bell CM. Development of a checklist of safe discharge practices for hospital patients. J Hosp Med 2013; 8:444-9. [PMID: 23554352 DOI: 10.1002/jhm.2032] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 01/29/2013] [Accepted: 02/10/2013] [Indexed: 11/09/2022]
Abstract
BACKGROUND Discharge from hospital can be a vulnerable period for patients. Multifaceted "discharge bundles" facilitate care transitions and possibly decrease adverse outcomes. We describe a structured approach to discharge planning, starting from admission and proceeding through discharge, using a standardized checklist of tasks to be performed for each hospitalization day. OBJECTIVE To create an evidence-based checklist of safe discharge practices for hospital patients. METHODS In the province of Ontario, the Ministry of Health and Long-Term Care convened a panel of expert members from multiple disciplines and across several healthcare sectors. The panel conducted a systematic search of the literature and used a structured approach to review evidence-based practices that ensure efficient, effective, safe, and patient-centered care transitions. A discharge-checklist tool was created to facilitate safe discharge from hospital. RESULTS The final checklist describes the processes necessary for a safe and optimal discharge and recommended timeline of when to complete each step, starting from the first day of admission. The checklist domains include (1) indication for hospitalization, (2) primary care, (3) medication safety, (4) follow-up plans, (5) home-care referral, (6) communication with outpatient providers, and (7) patient education. CONCLUSIONS The Checklist of Safe Discharge Practices for Hospital Patients summarizes the sequence of events that need to be completed throughout a typical hospitalization. Standardizing discharge planning and initiating processes early on in a patient's hospital stay may ensure a safe transition home.
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Affiliation(s)
- Christine Soong
- Division of General Internal Medicine, University of Toronto, Toronto, Ontario, Canada.
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Fallis BA, Dhalla IA, Klemensberg J, Bell CM. Primary medication non-adherence after discharge from a general internal medicine service. PLoS One 2013; 8:e61735. [PMID: 23658698 PMCID: PMC3642181 DOI: 10.1371/journal.pone.0061735] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 03/14/2013] [Indexed: 11/18/2022] Open
Abstract
Background Medication non-adherence frequently leads to suboptimal patient outcomes. Primary non-adherence, which occurs when a patient does not fill an initial prescription, is particularly important at the time of hospital discharge because new medications are often being prescribed to treat an illness rather than for prevention. Methods We studied older adults consecutively discharged from a general internal medicine service at a large urban teaching hospital to determine the prevalence of primary non-adherence and identify characteristics associated with primary non-adherence. We reviewed electronic prescriptions, electronic discharge summaries and pharmacy dispensing data from April to August 2010 for drugs listed on the public formulary. Primary non-adherence was defined as failure to fill one or more new prescriptions after hospital discharge. In addition to descriptive analyses, we developed a logistical regression model to identify patient characteristics associated with primary non-adherence. Results There were 493 patients eligible for inclusion in our study, 232 of whom were prescribed new medications. In total, 66 (28%) exhibited primary non-adherence at 7 days after discharge and 55 (24%) at 30 days after discharge. Examples of medications to which patients were non-adherent included antibiotics, drugs for the management of coronary artery disease (e.g. beta-blockers, statins), heart failure (e.g. beta-blockers, angiotensin converting enzyme inhibitors, furosemide), stroke (e.g. statins, clopidogrel), diabetes (e.g. insulin), and chronic obstructive pulmonary disease (e.g. long-acting bronchodilators, prednisone). Discharge to a nursing home was associated with an increased risk of primary non-adherence (OR 2.25, 95% CI 1.01–4.95). Conclusions Primary non-adherence after medications are newly prescribed during a hospitalization is common, and was more likely to occur in patients discharged to a nursing home.
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Affiliation(s)
- Brooks A. Fallis
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Irfan A. Dhalla
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Jason Klemensberg
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Chaim M. Bell
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
- * E-mail:
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Bell CM, Brener SS, Comrie R, Anderson GM, Bronskill SE. Quality measures for medication continuity in long-term care facilities, using a structured panel process. Drugs Aging 2012; 29:319-27. [PMID: 22462630 DOI: 10.2165/11599150-000000000-00000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Patient transitions, such as transfers between acute and long-term care (LTC), aposare times when the likelihood of communication failure between healthcare providers is increased. Employing appropriate health quality indicators helps support improvement efforts. To date, few quality indicators that evaluate the continuity of medication use between acute and LTC facilities have been described. OBJECTIVE The aim of the study was to develop quality indicators signalling the potential discontinuation of previously prescribed medications for chronic diseases when residents return to LTC following an acute-care hospitalization. METHODS A literature review for the selection of potential indicators was conducted, followed by a three-step process: (i) initial screening round that rated the indicators; (ii) a 1-day in-person consensus meeting in which the panel refined the parameters regarding the proposed quality indicators; and (iii) a final anonymous survey that assessed consensus among panel members. The study setting was a survey and consensus meeting with national representation, held in Toronto, ON, Canada. A ten-member expert panel with broad geographical and clinical representation participated and was made up of registered nurses, physicians, pharmacists, policy makers and academic researchers. A 75% agreement threshold was required for consensus, as measured on a 9-point Likert-type scale. The panel evaluated quality indicators for effectiveness, relevance and feasibility, using currently available healthcare administrative data. RESULTS The panel reached consensus on four quality indicators to assess the unintentional discontinuation of medications prescribed to LTC residents for chronic diseases upon return to LTC after an acute-care admission. The selected indicators were (i) HMG-CoA reductase inhibitors (statins) for all indications; (ii) anticoagulants (e.g. warfarin) for the indication of atrial fibrillation; (iii) proton-pump inhibitors for the indication of post-gastrointestinal haemorrhage; and (iv) thyroxine for all indications. The panel identified three additional treatment groups for future consideration as quality indicators: anti-Parkinson's disease, anti-diabetes and antidepressant medications. CONCLUSION A novel set of quality indicators has been developed to evaluate medication continuity between acute and LTC facilities. The adoption and implementation of these indicators in clinical practice can help inform quality improvement efforts at various local and regional levels.
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Affiliation(s)
- Chaim M Bell
- St Michaels Hospital, Keenan Research Centre in the Li Ka Shing Knowledge Institute, Toronto, ON, Canada
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Cain CH, Neuwirth E, Bellows J, Zuber C, Green J. Patient experiences of transitioning from hospital to home: an ethnographic quality improvement project. J Hosp Med 2012; 7:382-7. [PMID: 22378714 DOI: 10.1002/jhm.1918] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Revised: 12/02/2011] [Accepted: 01/08/2012] [Indexed: 11/07/2022]
Abstract
BACKGROUND Little is known about patient perspectives of the transition from hospital to home. OBJECTIVE To develop a richly detailed, patient-centered view of patient and caregiver needs in the hospital-to-home transition. DESIGN An ethnographic approach including participant observation and in-depth, semi-structured video recorded interviews. SETTING Kaiser Permanente's Southern California, Colorado, and Hawaii regions. PATIENTS Twenty-four adult inpatients hospitalized for a range of acute and chronic conditions and characterized by variety in diagnoses, illness severity, planned or unplanned hospitalization, age, and ability to self manage. RESULTS During the hospital-to-home transition, patients and caregivers expressed or demonstrated experiences in 6 domains: 1) translating knowledge into safe, health-promoting actions at home; 2) inclusion of caregivers at every step of the transition process; 3) having readily available problem-solving resources; 4) feeling connected to and trusting providers; 5) transitioning from illness-defined experience to "normal" life; and 6) anticipating needs after discharge and making arrangements to meet them. The work of transitioning occurs for patients and caregivers in the hours and days after they return home and is fraught with challenges. CONCLUSIONS Reducing readmissions will remain challenging without a broadened understanding of the types of support and coaching patients need after discharge. We are piloting strategies such as risk stratification and tailoring of care, a specialized phone number for recently discharged patients, standardized same-day discharge summaries to primary care providers, medication reconciliation, follow-up phone calls, and scheduling appointments before discharge.
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Affiliation(s)
- Carol H Cain
- The Permanente Federation, Oakland, California 94612, USA.
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Harel Z, Wald R, Perl J, Schwartz D, Bell CM. Evaluation of deficiencies in current discharge summaries for dialysis patients in Canada. J Multidiscip Healthc 2012; 5:77-84. [PMID: 22536078 PMCID: PMC3333802 DOI: 10.2147/jmdh.s27572] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Deficits in the transfer of information between inpatient and outpatient physicians are common and pose a patient safety risk. This is particularly the case for vulnerable populations such as patients with end-stage renal disease requiring dialysis. These patients have unique and complex health care needs that may not be effectively communicated on standard discharge summaries, which may result in potential medical errors and adverse events. Objective To evaluate Canadian dialysis center directors’ perceptions of deficiencies in the content and quality of hospital discharge summaries for dialysis patients. Methods A web-based, cross-sectional survey of Canadian dialysis center directors was performed between September and November 2010. The survey consisted of three parts. The first part was designed to assess dialysis center directors’ attitudes on the quality of discharge summaries they receive. The second part was designed to elicit respondents’ preferences for discharge summary content, and the third part consisted of questions regarding demographic and practice information. Results Of 79 dialysis center directors, 21 (27%) completed the survey. Sixty-two percent felt that current discharge summaries inadequately communicate dialysis-specific information. Receipt of antibiotics for line sepsis or peritonitis, modifications to vascular access, and changes in target weight/dialysis prescription were rated as essential dialysis-specific information to include in discharge summaries by respondents. Conclusion Over three quarters of dialysis center directors find the current practice of transferring discharge information for hospitalized dialysis patients grossly inadequate. The inclusion of dialysis-specific information may improve the quality of discharge summaries for dialysis patients.
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Affiliation(s)
- Ziv Harel
- Division of Nephrology, St Michael's Hospital, University of Toronto, Toronto, Ontario
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Nekhlyudov L, Schnipper JL. Cancer survivorship care plans: what can be learned from hospital discharge summaries? J Oncol Pract 2012; 8:24-9. [PMID: 22548007 PMCID: PMC3266312 DOI: 10.1200/jop.2011.000273] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2011] [Indexed: 11/20/2022] Open
Abstract
The Institute of Medicine panel on cancer survivorship recommended that all patients with cancer and their primary care providers receive a written survivorship care plan that summarizes their initial treatment and provides guidance on post-treatment management. Cancer survivorship care plans aim to improve coordination of care and communication between providers as their patients transition from oncology to primary care settings. As such, survivorship care plans share similarities with hospital discharge summaries, focusing on improving the transition from inpatient to outpatient settings. In this article, we explore potential lessons that may be learned from hospital discharge summaries, which may be used to facilitate the development, implementation, and testing of survivorship care plans.
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Affiliation(s)
- Larissa Nekhlyudov
- Harvard Medical School; Harvard Vanguard Medical Associates; Brigham and Women's Hospital; and Partners HealthCare, Boston, MA
| | - Jeffrey L. Schnipper
- Harvard Medical School; Harvard Vanguard Medical Associates; Brigham and Women's Hospital; and Partners HealthCare, Boston, MA
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Stainkey L, Pain T, McNichol M, Hack J, Roberts L. Matched comparison of GP and consultant rating of electronic discharge summaries. Health Inf Manag 2011; 39:7-15. [PMID: 21041842 DOI: 10.1177/183335831003900302] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Queensland Health is implementing a state-wide system to electronically generate and distribute discharge summaries. Previously, general practitioners (GPs) have indicated that the quality of the discharge summary does not support clinical handover. While the electronic system will address some issues (e.g. legibility and timeliness), the quality of the discharge summary content is predominantly independent of method of generation. As discharge summaries are usually generated by interns, we proposed that improvement in the quality of the summary may be achieved through education. This project aimed to compare the perceptions of hospital-based consultant educators and recipient GPs regarding discharge summary content and quality. The discharge summary and audit tool were sent to the recipient GP (n=134) and a hospital consultant (n=14) for satisfaction rating, using a 5- point Likert scale for questions relating to diagnosis, the listing of clinical management, medication, pathology, investigations, and recommendations to GP. Sampling was performed by selecting up to 10 discharge summaries completed by each first-year intern (n=36) in 2009, during the second, third and fourth rotations at the Townsville Hospital until a total of 403 was reached. Matched responses were compared using the Kappa statistic. The response rate was 93% (n=375) and 63% (n=254) for consultants and GPs respectively. Results from this study demonstrated that GPs were more satisfied with discharge summaries than were consultants. An anomaly occurred in three questions where, despite the majority of GPs rating satisfied or very satisfied, a small but proportionally greater number of GPs were very dissatisfied when compared with consultants. Poor or fair agreement between GPs and consultants was demonstrated in medications, pathology results, investigations and recommendations to GP, with GPs rating higher satisfaction in all questions. Lower consultant satisfaction ratings compared with GP ratings suggest that consultants can evaluate discharge summary content to the level required by GPs for clinical handover. Therefore, consultants can appropriately educate interns on discharge summary content for GP needs.
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Affiliation(s)
- Lesley Stainkey
- Townsville General Practice Network, Garbutt, QLD, Australia
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Choudhary V, Chandrashekar G, Subaraya PK, Satheesh S, Krishna S, Rakoff M. Electronic Discharge Summary to Speed Patient Discharge. Am J Med Qual 2011; 26:241-2. [DOI: 10.1177/1062860610391647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Voleti Choudhary
- Sri Sathya Institute for Higher Medical Sciences, Bangalore, India
| | - G. Chandrashekar
- Sri Sathya Institute for Higher Medical Sciences, Bangalore, India
| | | | - S.V. Satheesh
- Sri Sathya Institute for Higher Medical Sciences, Bangalore, India
| | - Sri Krishna
- Sri Sathya Institute for Higher Medical Sciences, Bangalore, India
| | - Michael Rakoff
- Sri Sathya Institute for Higher Medical Sciences, Bangalore, India, Sri Sathya Institute for Higher Medical Sciences, Sharspburg, MD,
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Coiera E. Do we need a national electronic summary care record? Med J Aust 2011; 194:90-2. [PMID: 21241224 DOI: 10.5694/j.1326-5377.2011.tb04176.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 10/12/2010] [Indexed: 11/17/2022]
Abstract
Electronic referrals and discharge summaries can improve the quality and timeliness of clinical communication. The electronic summary care record (SCR) extends the concept of digital health summaries to create a perpetually updated and centrally stored summary of care, extracting key data from local systems after each encounter. The only major SCR evaluation to date, in England, found that rates of usage were low, and any impact on care was difficult to quantify. The SCR is seen by some as a first step to building a national distributed shared electronic health record (SEHR). However, the SCR may be a problematic diversion, creating a need for centralised databases, while the SEHR can function by sharing locally stored records, letters and discharge summaries. Uncertainty about the quality and provenance of SCR data raises concerns about patient safety, as key data may be absent and old data may persist, partly because of a lack of ownership of the summary. A national e-health strategy should emphasise the true stepping stones to a distributed and shared electronic record, including encouraging the uptake and meaningful use of electronic clinical records, clinical messaging, electronic discharge summaries and letters, and services such as decision support and e-prescribing, all of which have good evidence to support them.
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Affiliation(s)
- Enrico Coiera
- Centre for Health Informatics, Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW, Australia.
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Harlan GA, Nkoy FL, Srivastava R, Lattin G, Wolfe D, Mundorff MB, Colling D, Valdez A, Lange S, Atkinson SD, Cook LJ, Maloney CG. Improving transitions of care at hospital discharge--implications for pediatric hospitalists and primary care providers. J Healthc Qual 2010; 32:51-60. [PMID: 20854359 DOI: 10.1111/j.1945-1474.2010.00105.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Gregory A Harlan
- Medical Affairs, IPC-The Hospitalist Company, North Hollywood, CA, USA
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