improving timeliness and quality: discharge summaries dictated by internal medicine residents

Improving Timeliness and Quality:Improving Timeliness and Quality:Discharge Summaries Discharge Summaries Dictated by Dictated by Internal Medicine ResidentsInternal Medicine Residents

Emily A. Mallin, MDCheryl W. O’Malley, MD, FACP

The Discharge SummaryThe Discharge SummaryHistorically served as

communication tool between physicians

“The Age of the Hospitalist”◦Vital communication tool◦Legal document◦Source for medications◦Guide for outpatient follow up

The Current Discharge The Current Discharge SummarySummary

JC mandates discharge summary completed within 30 days of hospitalization◦Reason for hospitalization◦Significant findings◦Procedures performed and care,

treatment, and services provided◦Condition at discharge◦Information provided to patient and

familyhttp://www.jointcommission.org/NR/rdonlyres/B48B39E3-107D-495A-9032-24C3EBD96176/0/PDF32009HAPSupportingStds.pdf. Standard RC 02.04.01, EP 3, page 37. Accessed 10/6/10.

Other Discharge Summary Other Discharge Summary GuidelinesGuidelines

JC National Patient Safety Goals◦Handoff communications◦Medication reconciliation at care

transitions National Quality ForumAgency for Healthcare Research

and QualitySociety of Hospital Medicine

Challenges of the Discharge Challenges of the Discharge SummarySummary

UnavailableIncompleteInaccurateInexperienced authorsElectronic health record

TimelinessTimeliness DS available for only 12.2% patients prior

to outpatient visit Trend toward decreased readmission

rates in patients whose physicians received DS prior to visit (RR 0.74, 95% CI, 0.5-1.11)

van Walraven C et al. Effect of discharge summary availability during post-discharge visits on hospital readmission. JGIM 2002;17:186-192.

Timeliness and QualityTimeliness and Quality Delayed availability and poor quality

can contribute to adverse events after discharge

Literature Review of 73 studies◦ 14.5% reached PCP within 1 week of discharge◦ 25% never reached PCP◦ 66-88% patients contacted or were seen by PCP

before arrival of DS◦ Missing information

Hospital physician (median 25%) Main diagnosis (17.5%) Pending tests (65%)

◦ Physicians lacked awareness of pending tests in 40% of DS, 10% actionable

Kriplani S et al. Deficits in communication and information transfer between hospital-based and primary care physicians. JAMA 2007;297:831-841.

QualityQualityEducational intervention with and

without individualized feedback improved quality of interns’ discharge summaries

Myers, JS. Are Discharge Summaries Teachable? The Effects of a Discharge Summary Curriculum on the Quality of Discharge Summaries in an Internal Medicine Residency Program. Academic Medicine 2006;81:10. pp S5-S8.

Could we improve timeliness?Could we improve quality?

650-bed urban, university-affiliated, quaternary care teaching hospital

100 Internal Medicine, Med-Peds, Preliminary residents

5 ward teams◦ Attending◦ 2 residents◦ 2 interns◦ Medical students

Discharge summaries◦ Dictated by upper-level residents

Study Period◦ December 2007 – February 2008 (pre-intervention)◦ December 2008 – February 2009 (post-intervention)

MethodsMethods

STAT Discharge ProcessSTAT Discharge ProcessInstituted November 2008Hiring of transcriptionistsMandate that all hospitalists dictate

summary on day of discharge

Educational InterventionEducational Interventionfor Internal Medicine Residentsfor Internal Medicine Residents

Noon conference◦ Reviewed the literature on discharge

summary quality◦ Reviewed the essential elements of discharge

summaries◦ Offered strategies for dictating clear, succinct,

and comprehensive summaries

Pocket cards with instructions for dictating quality discharge summary

Timeliness ResultsTimeliness Results

Mallin E, O’Malley C, Gerkin R. Improving timeliness without compromising quality: Discharge summaries dictated by Internal Medicine residents. J Hosp Med. 2010;5(3)(suppl 2):S49.

Quality ResultsQuality ResultsCompleteness score improved, though

not statistically significantReadability of each section and overall

readability were not affected

Limitation◦ Did not ensure residents received education

or used pocket cards

Quality ImprovementQuality ImprovementExtension of study examines the

effect of a standardized formal educational intervention on quality of dictated discharge summaries.

Study period◦January – June 2009 (pre-intervention)◦January – June 2010 (post-intervention)

Educational InterventionEducational Interventionfor Internal Medicine Residentsfor Internal Medicine Residents

Monthly one-hour conferences, capturing all residents rotating on ward service that month◦ Reviewed the literature on discharge summary quality◦ Reviewed the essential elements of discharge

summaries◦ Offered strategies for dictating clear, succinct, and

comprehensive summaries◦ Provided examples of poor and high quality summaries ◦ Individualized feedback session with attending using

resident’s recent discharge summary

Pocket cards with instructions for dictating quality discharge summary

Evaluation of Discharge Evaluation of Discharge SummariesSummaries

Pre-intervention◦12 summaries – 4 each by 3 raters

Post-intervention◦5 summaries – each rated by 4 raters

Preliminary ResultsPreliminary Results

Interrater reliability◦ Intraclass correlation coefficient (ICC)

Completeness ICC = 0.533 (p=0.138) fair Total readability ICC = 0.926 (p<0.001) excellent

Pre-intervention

Mean

Post-intervention

Mean

P value

Completeness score

0.70 0.78 0.342

Total readability score

30.3 34.6 0.172

Limitations and Future Limitations and Future DirectionsDirections

Preliminary dataPatient charts were not reviewed for

accuracy

Analyze long-term effect of intervention

Evaluate impact of the intervention on patient outcomes and primary provider satisfaction

Additional ReferencesAdditional Referenceswww.hospitalmedicine.org/BOOST

Moore, C., McGinn, T., and Halm, E. (2007, June). "Tying up loose ends: Discharging patients with unresolved medical issues." Archives of Internal Medicine 167, pp. 1305-1311.

Greenwald, J.L., Denham, C.R., and Jack, B.W. (2007, June). "The hospital discharge: A review of a high risk care transition with highlights of a reengineered discharge process." Journal of Patient Safety 3(2), pp. 97-106.