Discharge Communication: A Multi-Institutional Survey of Internal Medicine Residents' Education and Practices

Teaming in Graduate Medical Education: Ward Rounds and Beyond

Teamwork in graduate medical education (GME) is often hindered in clinical learning environments where discontinuity among residents, supervisors, and other health care professionals is typical. Teaming is a conceptual approach to teamwork in dynamic environments with constantly changing team members and goals. Teaming is built on principles of project management and team leadership, which together provide an attractive strategy for addressing teamwork challenges in GME. Indeed, teaming is now a requirement of the Accreditation Council for Graduate Medical Education Clinical Learning Environment Review program. However, many clinician-educators and leaders may be unfamiliar with teaming and how to integrate it into their GME programs. In this article, the teaming framework is described with a specific example of how it can be applied to improve hospital ward rounds, a common setting of teamwork breakdown. The goal of this article is to educate and encourage GME leaders as they learn new ways to implement teaming to improve patient care and education in their programs.

Assessment of Patient Education Delivered at Time of Hospital Discharge

Importance

Patient education at time of hospital discharge is critical for smooth transitions of care; however, empirical data regarding discharge communication are limited.

Objective

To describe whether key communication domains (medication changes, follow-up appointments, disease self-management, red flags, question solicitation, and teach-back) were addressed at the bedside on the day of hospital discharge, by whom, and for how long.

Design, Setting, and Participants

This quality improvement study was conducted from September 2018 through October 2019 at inpatient medicine floors in 2 urban, tertiary-care teaching hospitals and purposefully sampled patients designated as "discharge before noon." Data analysis was performed from September 2018 to May 2020.

Exposures

A trained bedside observer documented all content and duration of staff communication with a single enrolled patient from 7 am until discharge.

Main Outcomes and Measures

Presence of the key communication domains, role of team members, and amount of time spent at the bedside.

Results

Discharge days for 33 patients were observed. Patients had a mean (SD) age of 63 (18) years; 14 (42%) identified as White, 15 (45%) were female, and 6 (18%) had a preferred language of Spanish. Thirty patients were discharged with at least 1 medication change. Of these patients, 8 (27%) received no verbal instruction on the change, while 16 of 30 (53%) were informed but not told the purpose of the changes. About half of the patients (15 of 31, 48%) were not told the reason for follow-up appointments, and 18 of 33 (55%) were not given instructions on posthospital disease self-management. Most patients (27 of 33, 81%) did not receive guidance on red-flag signs. While over half of the patients (19 of 33, 58%) were asked if they had any questions, only 1 patient was asked to teach back his understanding of the discharge plan. Median (IQR) total time spent with patients on the day of discharge by interns, senior residents, attending physicians, and nurses was 4.0 (0.75-6.0), 1.0 (0-2.0), 3.0 (0.5-7.0), and 22.5 (15.5-30.0) minutes, respectively. Most of the time was spent discussing logistics rather than discharge education.

Conclusions and Relevance

In this quality improvement study, patients infrequently received discharge education in key communication domains, potentially leaving gaps in patient knowledge. Interventions to improve the hospital discharge process should address the content, method of delivery, and transparency among team members regarding patient education.

Utilizing the "teach-back" method to improve surgical informed consent and shared decision-making: a review

The teach-back method is a valuable communication tool that can be employed to improve patient safety and shared decision-making. Its utility in patient care has been studied extensively in many areas of clinical medicine. However, the literature on the use of teach-back in surgical patient education and informed consent is limited. Additionally, there is some ambiguity about the functional definition and performance of the teach-back method in the literature, consequently rendering this valuable tool an enigma. This review examines the current standards and ethics of preoperative informed consent and provides a concise, actionable definition of teach-back. The manner in which teach-back has been implemented in medicine and surgery is then examined in detail. Studies analyzing the use of teach-back in medicine have demonstrated its effectiveness and benefit to patient care. Further study on the use of teach-back to improve preoperative informed consent is supported by the few preliminary trials showing a positive effect after implementing the teach-back method in critical patient interactions.