Passing the clinical baton: 6 principles to guide the hospitalist

An Audit of Orthopaedic Discharge Summaries Comparing Electronic With Handwritten Summaries: A Quality Improvement Project

Introduction Discharge summaries (DS), which are sent from inpatient to outpatient settings, transmit critical clinical information. DS play a crucial role in the discharge process since they provide critical information about the patients that is simple to remember and help with patient follow-up in the community. This audit sought to determine if a quality improvement (QI) program may have an influence on the severity of mistakes at the moment of discharge and to assess the existing degree of inconsistencies on handwritten DS for orthopaedic patients. Methodology From the orthopaedics department at a tertiary care facility in south India, 100 handwritten DS and 100 electronic DS over six months were randomly chosen, and they were retrospectively audited against a predetermined set of criteria. The errors were compiled and compared by three reviewers. Results Some of the criteria, such as the doctor's signature, the speciality of admission, procedural therapy at the hospital, and the date of admission, were contained in all handwritten and electronic DS. Some of the metrics showed that electronic DS performed better than handwritten DS in areas such as hospital complications, which increased from 50% to 100%, contact information, which increased from 34% to 95%, and condition at discharge, which increased from 66% to 96%. Also, understandability increased from 58% to 100%, prognostic details increased from 70% to 96%, allergies increased from 66% to 100%, physical examination findings increased from 88% to 100%, admission diagnosis increased from 80% to 100%, patient/physician details increased from 92% to 100%, the information given to patient increased from 88% to 100%, problem list/issue pending increased from 35% to 92%, investigation increased from 80% to 100%, discharge medications increased from 88% to 100%, follow-up plan increased from 80% to 100%, discharge diagnosis increased from 94% to 100%, International Classification of Diseases, Tenth Revision (ICD-10) code increased from 93% to 100%, and days of admission increased from 92% to 100%. Conclusion Following the deployment of electronic DS, we were able to better care for patients and lessen their discomfort. We advise converting to electronic DS to enhance patient care and better record-keeping since this will become a significant problem if all notes are not accurately filled and are not readable.

Impact of a Longitudinal Intervention to Improve Care Coordination between a Hospital and a Hospice: A Quality Improvement Project

Objectives:

When patients with advanced cancer transition from systemic cancer treatments at MNJ Institute of Oncology to palliative and end-of-life care at a separate stand-alone non-governmental organisation-run hospice facility, there is insufficient transfer of health information, including details of cancer diagnosis and staging, past treatments, imaging reports and goals for future care. Without this information, the hospice care team is not adequately prepared to receive and deliver high-quality palliative care for these patients. This project aims to improve the care coordination between the hospital and hospice.

Materials and Methods:

The measures used are the self-reported confidence score on a scale of 0 to 10 related to knowledge about plan of care among staff who receives patients at hospice at baseline and during and after interventions. Interventions included recognizing the workplace culture and promoting ownership of the tasks, enhancing communication by creating user-friendly transfer forms and on-going assessment of the process.

Results:

Improvement in the care coordination in terms of communication of patient goals of care, from hospital to hospice.

Conclusion:

QI project and the steps involved helped the team to work towards solutions objectively. Seemingly excellent ideas may not be the most impactful and data collection demonstrates this and helps identify the most successful interventions.

Proposal for a standardized discharge letter after hospital stay for acute myocardial infarction

In patients admitted for acute myocardial infarction, the communication and transition from specialists to primary care physicians is often delayed, and the information imparted to subsequent healthcare providers (HCPs) may be sub-optimal. A French group of cardiologists, lipidologists and diabetologists decided to establish a consensus to optimize the discharge letter after hospitalization for acute myocardial infarction. The aim is to improve both the timeframe and the quality of the content transmitted to subsequent HCPs, including information regarding baseline assessment, procedures during hospitalization, residual risk, discharge treatments, therapeutic targets and follow-up recommendations in compliance with European Society of Cardiology guidelines. A consensus was obtained regarding a template discharge letter, to be released within two days after patient’s discharge, and containing the description of the patient’s history, risk factors, acute management, risk assessment, discharge treatments and follow-up pathway. Specifically for post acute MI patients, tailored details are necessary regarding the antithrombotic regimen, lipid-lowering and anti-diabetic treatments, including therapeutic targets. Lastly, the follow-up pathway needs to be precisely mentioned in the discharge letter. Additional information such as technical descriptions, imaging, and quality indicators may be provided separately. A template for a standardized discharge letter based on 8 major headings could be useful for implementation in routine practice and help to improve the quality and timing of information transmission between HCPs after acute MI.

An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study

BACKGROUND

Infants born prematurely or with complex medical problems are surviving to discharge in growing numbers and often require significant monitoring and coordination of care in the ambulatory setting. Using Healthcare Failure Modes and Effects Analysis (HFMEA), we identified a large number of potentially serious error points in this transition of care. PURPOSE To test whether a multifaceted intervention that included a health coach to assist families and an enhanced personal health record to improve the quality of information available to parents and community professionals would decrease adverse events and improve family assessment of the transition.

METHODS

Using a concurrent cohort design, infants in one geographic area (pod) of the intensive care nursery received the intervention; infants in two other pods received routine discharge care. Primary outcomes included deaths, sick visits, unplanned readmissions and missed appointments within 1 month of discharge. The family assessed the transition using a modified version of the Care Transitions Measure.

RESULTS

125 intervention infants (54% boys) and 104 control infants (48% boys) were enrolled over 18 months. The groups were similar in maternal education, insurance status, language spoken and number of adults in the home, birth weight and length of stay. At least one adverse outcome occurred in 63 (50.4%) intervention infants and 56 (53.8%) control infants (p=0.55). At 24–48 h post discharge, caregivers in the intervention group had significantly higher scores on the adapted care transitions measure (3.51 vs 3.27, p<0.0001); however, at 30 days, the difference was no longer significant (3.45 vs 3.40, p=0.27).

CONCLUSIONS

A multicomponent discharge intervention designed to address specific problems identified using HFMEA did not reduce certain adverse outcomes in the post-discharge period.

TRIAL REGISTRATION

NCT01088945.

Improving the reliability of verbal communication between primary care physicians and pediatric hospitalists at hospital discharge

INTRODUCTION

Timely and reliable verbal communication between hospitalists and primary care physicians (PCPs) is critical for prevention of medical adverse events but difficult in practice. Our aim was to increase the proportion of completed verbal handoffs from on-call residents or attendings to PCPs within 24 hours of patient discharge from a hospital medicine service to ≥90% within 18 months.

METHODS

A multidisciplinary team collaborated to redesign the process by which PCPs were contacted following patient discharge. Interventions focused on the key drivers of obtaining stakeholder buy-in, standardization of the communication process, including assigning primary responsibility for discharge communication to a single resident on each team and batching calls during times of maximum resident availability, reliable automated process initiation through leveraging the electronic health record (EHR), and transparency of data. A run chart assessed the impact of interventions over time.

RESULTS

The percentage of calls initiated within 24 hours of discharge improved from 52% to 97%, and the percentage of calls completed improved to 93%. Results were sustained for 18 months. Standardization of the communication process through hospital telephone operators, use of the discharge order to ensure initiation of discharge communication, and batching of phone calls were associated with improvements in our measures.

CONCLUSION

Reliable verbal discharge communication can be achieved through the use of a standardized discharge communication process coupled with the EHR.

Automated Communication Tools and Computer-Based Medication Reconciliation to Decrease Hospital Discharge Medication Errors

This study sought to determine the effects of automated primary care physician (PCP) communication and patient safety tools, including computerized discharge medication reconciliation, on discharge medication errors and posthospitalization patient outcomes, using a pre-post quasi-experimental study design, in hospitalized medical patients with ≥2 comorbidities and ≥5 chronic medications, at a single center. The primary outcome was discharge medication errors, compared before and after rollout of these tools. Secondary outcomes were 30-day rehospitalization, emergency department visit, and PCP follow-up visit rates. This study found that discharge medication errors were lower post intervention (odds ratio = 0.57; 95% confidence interval = 0.44-0.74; P < .001). Clinically important errors, with the potential for serious or life-threatening harm, and 30-day patient outcomes were not significantly different between study periods. Thus, automated health system-based communication and patient safety tools, including computerized discharge medication reconciliation, decreased hospital discharge medication errors in medically complex patients.

Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge

BACKGROUND

Achieving safe transitions of care at hospital discharge requires accurate and timely communication. Both the presence of and follow-up plan for diagnostic studies that are pending at hospital discharge are expected to be accurately conveyed during these transitions, but this remains a challenge.

OBJECTIVE

To determine the prevalence, characteristics, and communication of studies pending at hospital discharge before and after the implementation of an electronic medical record (EMR) tool that automatically generates a list of pending studies.

DESIGN

Pre-post analysis.

PATIENTS

260 consecutive patients discharged from inpatient general medicine services from July to August 2013.

INTERVENTION

Development of an EMR-based tool that automatically generates a list of studies pending at discharge.

MAIN MEASURES

The main outcomes were prevalence and characteristics of pending studies and communication of studies pending at hospital discharge. We also surveyed internal medicine house staff on their attitudes about communication of pending studies.

KEY RESULTS

Pre-intervention, 70% of patients had at least one pending study at discharge, but only 18% of these were communicated in the discharge summary. Most studies were microbiology cultures (68%), laboratory studies (16%), or microbiology serologies (10%). The majority of study results were ultimately normal (83%), but 9% were newly abnormal. Post-intervention, communication of studies pending increased to 43% (p < 0.001).

CONCLUSIONS

Most patients are discharged from the hospital with pending studies, but in usual practice, the presence of these studies has rarely been communicated to outpatient providers in the discharge summary. Communication significantly increased with the implementation of an EMR-based tool that automatically generated a list of pending studies from the EMR and allowed users to import this list into the discharge summary. This is the first study to our knowledge to introduce an automated EMR-based tool to communicate pending studies.

Cancer survivorship care plans: what can be learned from hospital discharge summaries?

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.

Improving follow-up of high-risk psychiatry outpatients at resident year-end transfer

BACKGROUND

Few studies have examined the safety risks of the annual outpatient clinic handoffthat occurs when residents either advance to a higher level of training or graduate ("year-end transfer"). A multifaceted intervention was designed and implemented to identify and improve followup of high-risk patients during academic year-end outpatient transfers in a psychiatry resident continuity clinic.

METHODS

Departing residents identified "acute" patients, who were scheduled on a priority basis for longer appointments during the first month after the transfer. In addition, standardized written and face-to-face sign-outs occurred, incoming clinicians contacted every patient in the first week, and specialized didactics were provided.

RESULTS

For the three intervention years combined, the odds ratio of hospitalization for acute patients compared to nonacute patients was 9.2 (95% confidence interval [CI]: 2.43, 34.7; p = .001). Compared to Year 1, the proportion of acute patients seen within 31 days in Years 2 and 3 increased by 32.2% (from 64.3% to 85.0%, p < .0001). The median time-to-first visit for acute patients decreased by 42% (from 24 days in Year 1 to 14 days in Year 3, p = .001). Finally, resident perception of the quality of the handoffim-proved in all areas compared to baseline, including resident-to-resident communication (2.8 to 3.0, p = .03), accuracy of caseload lists (2.8 to 4.1,p = .003), identification of high-risk patients (2.1 to 3.7, p < .0001), and usefulness of supervision during the transition (2.7 to 4.3, p < .0001).

CONCLUSIONS

Categorical designation by the outgoing clinicians effectively identified patients at higher risk for hospitalization during the transition. Relatively low-cost interventions may significantly improve patient safety and resident training in not only psychiatry, but also other disciplines and specialties.

Incidence and risk factors for 30-day postdischarge mortality in patients with vascular disease undergoing major lower extremity amputation

BACKGROUND

Our goal was to analyze the incidence and risk factors for 30-day postdischarge mortality in patients with vascular disease undergoing major lower extremity amputation.

METHODS

We queried the American College of Surgeons National Surgery Quality Improvement Program data set from the years 2005 to 2009 for amputations with vascular disease diagnosis codes. We analyzed in-hospital mortality and postdischarge mortality by year of the study and relative to length of hospital stay. Patients with American Society of Anesthesiologists physical status classification level 5, do-not-resuscitate status, disseminated cancer, and emergent operations were excluded to highlight risk among patients more likely to survive. We compared risk factors for each mortality group using separate multivariate logistic regressions.

RESULTS

Our query resulted in 6,188 patients with mean age of 67 ± 14 years; of these, 39.1% were female. Thirty-day mortality was 7.6%; 4.2% in-hospital mortality and 3.4% postdischarge mortality. After postoperative day 14, the majority of deaths were after discharge and the daily death risk was almost constant until postoperative day 30 at around 2.1 per 1000 survivors. The postdischarge death rates were consistent across the 5 years of the study (χ(2): p = 0.59), despite the fact that median hospital length of stay decreased from 12 to 9 days (Kruskal-Wallis: p < 0.001). Preoperative risk factors for postdischarge death included age, functional status, lower serum albumin, serum creatinine level of >1.2 mg/dL, dialysis, serum bilirubin level of >1.0 mg/dL, black race (protective), systemic inflammatory response syndrome, steroid use for chronic condition, impaired sensorium, alcohol abuse, recent weight loss, and dyspnea.

CONCLUSIONS

Patients with vascular disease undergoing major amputation are at high risk for postdischarge mortality. This risk is not associated with recent decrease in hospital stay. Systemic comorbid risk factors were identified, thus highlighting the need for adequate medical management of these patients in the 30 days after the operation. Coordination of postdischarge care to ensure management of systemic illness could potentially improve outcomes.

A systematic review of curricular interventions teaching transitional care to physicians-in-training and physicians

PURPOSE

To systematically review and describe published interventions about teaching continuity-of-care best practices, embodied by transitional care, to physician-trainees and physicians.

METHOD

The authors performed a systematic review of interventions indexed in PubMed, ISI Web of Science, Educational Resources Information Center, professional society Web sites, education databases, and hand-selected references. English-language articles published between 1973 and 2010 that demonstrated purposeful, directed education of physician-trainees and physicians on topics consistent with the contemporary definition of transitional care were included. Abstracted data included intended audience, duration/intensity, objectives, resources used, learner assessment, and curricular evaluation method.

RESULTS

A dramatic increase in the number of published interventions teaching transitional care was noted in the last 10 years. Learners included preclinical medical students through attending physicians and also included allied health professionals. Brief, self-limited interactions in large groups were the most frequent mode of interaction. A wide array of objectives and resources used were represented. Most interventions provided a method for assessing knowledge acquisition by the learner; however, few interventions provided a mechanism for eliciting feedback from learners.

CONCLUSIONS

Proficiency in providing transitional care is an essential skill for medical practitioners. Historically, there have been few curricular interventions teaching this topic; however, recently a dramatic increase in the number of interventions has occurred. A diverse range of learners, modes of delivery, and intended objectives are represented. In establishing a pooled description of published interventions, this review provides a comprehensive and novel resource for educators charged with designing curricula for all medical professionals.

Incidence and predictors of microbiology results returning postdischarge and requiring follow-up

BACKGROUND

Failure to follow up microbiology results pending at discharge can delay appropriate treatment, increasing the risk of patient harm and litigation. Limited data describe the frequency of postdischarge microbiology results requiring a treatment change.

OBJECTIVE

To determine the incidence and predictors of postdischarge microbiology results requiring follow-up.

DESIGN

Cross-sectional.

SETTING

Large academic hospital during 2007.

MEASUREMENTS

We evaluated blood, urine, sputum, and cerebrospinal fluid (CSF) cultures ordered for hospitalized patients. We identified cultures that returned postdischarge and determined which were clinically important and not treated by an antibiotic to which they were susceptible. We reviewed a random subset to assess the potential need for antibiotic change. Using logistic regression, we identified significant predictors of results requiring follow-up.

RESULTS

Of 77,349 inpatient culture results, 8668 (11%) returned postdischarge. Of these, 385 (4%) were clinically important and untreated at discharge. Among 94 manually reviewed cases, 53% potentially required a change in therapy. Urine cultures were more likely to potentially require therapy change than non-urine cultures (OR 2.8, 95% CI 1.1-7.2; P = 0.03). Also, 76% of 25 results from surgical services potentially required a therapy change, compared with 59% of 29 results from general medicine, 38% of 16 results from oncology, and 33% of 24 results from medical subspecialties. Overall, 2.4% of postdischarge cultures potentially necessitated an antibiotic change.

CONCLUSIONS

Many microbiology results return postdischarge and some necessitate a change in treatment. These results arise from many specialties, suggesting the need for a hospital-wide system to ensure effective communication of these results.

Lessons learned from implementation of a computerized application for pending tests at hospital discharge

BACKGROUND

Patients are often discharged from the hospital before test results are finalized. Awareness of these results is poor and therefore an important patient safety concern. Few computerized systems have been deployed at care transitions to address this problem. We describe an attempt to implement a computerized application to help inpatient physicians manage these test results.

METHODS

We modified an ambulatory electronic medical record (EMR)-based results management application to track pending tests at hospital discharge (Hospitalist Results Manager, HRM). We trained inpatient physicians at 2 academic medical centers to track these tests using this application. We surveyed inpatient physicians regarding usage of and satisfaction with the application, barriers to use, and the characteristics of an ideal system to track pending tests at discharge.

RESULTS

Of 29 survey respondents, 14 (48%) reported never using HRM, and 13 (45%) used it 1 to 2 times per week. A total of 23 (79%) reported barriers prohibiting use, including being inundated with clinically "irrelevant" results, not having sufficient time, and a lack of integration of post-discharge test result management into usual workflow. Twenty-one (72%) wanted to receive notification of abnormal and clinician-designated pending test results. Twenty-seven physicians (93%) agreed that an ideally designed computerized application would be valuable for managing pending tests at discharge.

CONCLUSIONS

Although inpatient physicians would highly value a computerized application to manage pending tests at discharge, the characteristics of an ideal system are unclear and there are important barriers prohibiting adoption and optimal usage of such systems. We outline suggestions for future electronic systems to manage pending tests at discharge.

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

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

Residents' and attending physicians' handoffs: a systematic review of the literature

PURPOSE

Effective communication is central to patient safety. There is abundant evidence of negative consequences of poor communication and inadequate handoffs. The purpose of the current study was to conduct a systematic review of articles focused on physicians' handoffs, conduct a qualitative review of barriers and strategies, and identify features of structured handoffs that have been effective.

METHOD

The authors conducted a thorough, systematic review of English-language articles, indexed in PubMed, published between 1987 and June 2008, and focused on physicians' handoffs in the United States. The search strategy yielded 2,590 articles. After title review, 401 were obtained for further review by trained abstractors.

RESULTS

Forty-six articles met inclusion criteria, 33 (71.7%) of which were published between 2005 and 2008. Content analysis yielded 91 handoffs barriers in eight major categories and 140 handoffs strategies in seven major categories. Eighteen articles involved research on handoffs. Quality assessment scores for research studies ranged from 1 to 13 (possible range 1-16). One third of the reviewed research studies obtained quality scores at or below 8, and only one achieved a score of 13. Only six studies included any measure of handoff effectiveness.

CONCLUSIONS

Despite the negative consequences of inadequate physicians' handoffs, very little research has been done to identify best practices. Many of the existing peer-reviewed studies had design or reporting flaws. There is remarkable consistency in the anecdotally suggested strategies; however, there remains a paucity of evidence to support these strategies. Overall, there is a great need for high-quality handoff outcomes studies focused on systems factors, human performance, and the effectiveness of structured protocols and interventions.

Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record

BACKGROUND

The nationwide expansion of the hospitalist movement brings rapid change in communication and work processes in many hospitals. While our fast-growing hospitalist program has greatly improved length of stay and quality measures, it has also faced complex operational challenges affecting the whole organization rather than just our division: assigning and tracking hospitalist coverage of admitted patients was one of these challenges.

METHODS

We integrated a system of algorithms and interface solutions into our hospital's preexisting electronic health records (EHR) program to act as a decision support tool and computerized safety net during admission and patient distribution. Its main structural elements include: (1) algorithms that identify patients for hospitalist coverage and monitor coverage during transitions of care; (2) EHR data fields that enable hospitalists to assign and update each patient's coverage information in real time; and (3) a combination of display solutions to inform users of coverage arrangements and alert for potentially misassigned patients. Our system assists with correct attending selection on admission. It also assures continuity of coverage during transitions within the hospitalist program and across care settings.

RESULTS

Our enhancements to the EHR received unanimously positive assessment by users and added an important layer of patient safety and organizational efficiency for our hospitalist program.

DISCUSSION

Adaptations of our tools may provide similar opportunities for improvements in a variety of hospitalist settings; an integrated computerized physician order entry (CPOE) system is not a prerequisite. We demonstrate how the presented innovations can be used to enhance other EHR functions as well.

Association of communication between hospital-based physicians and primary care providers with patient outcomes

BACKGROUND

Patients admitted to general medicine inpatient services are increasingly cared for by hospital-based physicians rather than their primary care providers (PCPs). This separation of hospital and ambulatory care may result in important care discontinuities after discharge. We sought to determine whether communication between hospital-based physicians and PCPs influences patient outcomes.

METHODS

We approached consecutive patients admitted to general medicine services at six US academic centers from July 2001 to June 2003. A random sample of the PCPs for consented patients was contacted 2 weeks after patient discharge and surveyed about communication with the hospital medical team. Responses were linked with the 30-day composite patient outcomes of mortality, hospital readmission, and emergency department (ED) visits obtained through follow-up telephone survey and National Death Index search. We used hierarchical multi-variable logistic regression to model whether communication with the patient's PCP was associated with the 30-day composite outcome.

RESULTS

A total of 1,772 PCPs for 2,336 patients were surveyed with 908 PCPs responses and complete patient follow-up available for 1,078 patients. The PCPs for 834 patients (77%) were aware that their patient had been admitted to the hospital. Of these, direct communication between PCPs and inpatient physicians took place for 194 patients (23%), and a discharge summary was available within 2 weeks of discharge for 347 patients (42%). Within 30 days of discharge, 233 (22%) patients died, were readmitted to the hospital, or visited an ED. In adjusted analyses, no relationship was seen between the composite outcome and direct physician communication (adjusted odds ratio 0.87, 95% confidence interval 0.56 - 1.34), the presence of a discharge summary (0.84, 95% CI 0.57-1.22), or PCP awareness of the index hospitalization (1.08, 95% CI 0.73-1.59).

CONCLUSION

Analysis of communication between PCPs and inpatient medical teams revealed much room for improvement. Although communication during handoffs of care is important, we were not able to find a relationship between several aspects of communication and associated adverse clinical outcomes in this multi-center patient sample.

Economic and healthcare forces of hospitalist movement

The field of hospital medicine has become a widely accepted model for inpatient care and has grown rapidly in the past ten years. The impetus for growth has largely been pressure to contain costs for inpatient care and improve efficiency in the hospital. Studies have shown that care by hospitalists is generally more cost-effective than care by faculty or private practice physicians without affecting quality. The field faces challenges in continuity of patient care and retention of physicians in the workforce.

Preliminary development of the physician documentation quality instrument

OBJECTIVES

This study sought to design and validate a reliable instrument to assess the quality of physician documentation.

DESIGN

Adjectives describing clinician attitudes about high-quality clinical documentation were gathered through literature review, assessed by clinical experts, and transformed into a semantic differential scale. Using the scale, physicians and nurse practitioners scored the importance of the adjectives for describing quality in three note types: admission, progress, and discharge notes. Psychometric methods including exploratory factor analysis were applied to provide preliminary evidence for the construct validity and internal consistency reliability.

RESULTS

A 22-item Physician Documentation Quality Instrument (PDQI) was developed. Exploratory factor analysis (n = 67 clinician respondents) on three note types resulted in solutions ranging from four (discharge) to six (admission and progress) factors, and explained 65.8% (discharge) to 73% (admission and progress) of the variance. Each factor solution was unique. However, four sets of items consistently factored together across all note types: (1) up-to-date and current; (2) brief, concise, succinct; (3) organized and structured; and (4) correct, comprehensible, consistent. Internal consistency reliabilities were: admission note (factor scales = 0.52-88, overall = 0.86), progress note (factor scales = 0.59-0.84, overall = 0.87), and discharge summary (factor scales = 0.76-0.85, overall = 0.88).

CONCLUSION

The exploratory factor analyses and reliability analyses provide preliminary evidence for the construct validity and internal consistency reliability of the PDQI. Two novel dimensions of the construct for document quality were developed related to form (Well-formed, Compact). Additional work is needed to assess intrarater and interrater reliability of applying of the proposed instrument and to examine the reproducibility of the factors in other samples.

Care transitions for hospitalized patients

Ensuring safe care transitions is a core part of hospital medicine. These transitions include inpatient-outpatient transitions and in-hospital transitions. To ensure safe care during these transitions, clinicians should be aware of the types of transitions and the way in which these transitions can impede safe patient care. With this knowledge, strategies to ensure patient safety during care transitions can be adopted and training directed at teaching physicians safe hands-off practices could be developed and supported.

Outcomes of care by hospitalists, general internists, and family physicians

BACKGROUND

The hospitalist model is rapidly altering the landscape for inpatient care in the United States, yet evidence about the clinical and economic outcomes of care by hospitalists is derived from a small number of single-hospital studies examining the practices of a few physicians.

METHODS

We conducted a retrospective cohort study of 76,926 patients 18 years of age or older who were hospitalized between September 2002 and June 2005 for pneumonia, heart failure, chest pain, ischemic stroke, urinary tract infection, acute exacerbation of chronic obstructive pulmonary disease, or acute myocardial infarction at 45 hospitals throughout the United States. We used multivariable models to compare the outcomes of care by 284 hospitalists, 993 general internists, and 971 family physicians.

RESULTS

As compared with patients cared for by general internists, patients cared for by hospitalists had a modestly shorter hospital stay (adjusted difference, 0.4 day; P<0.001) and lower costs (adjusted difference, $268; P=0.02) but a similar inpatient rate of death (odds ratio, 0.95; 95% confidence interval [CI], 0.85 to 1.05) and 14-day readmission rate (odds ratio, 0.98; 95% CI, 0.91 to 1.05). As compared with patients cared for by family physicians, patients cared for by hospitalists had a shorter length of stay (adjusted difference, 0.4 day; P<0.001), and the costs (adjusted difference, $125; P=0.33), rate of death (odds ratio, 0.95; 95% CI, 0.83 to 1.07), and 14-day readmission rate (odds ratio, 0.95; 95% CI, 0.87 to 1.04) were similar.

CONCLUSIONS

For common inpatient diagnoses, the hospitalist model is associated with a small reduction in the length of stay without an adverse effect on rates of death or readmission. Hospitalist care appears to be modestly less expensive than that provided by general internists, but it offers no significant savings as compared with the care provided by family physicians.

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

CONTEXT

Delayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events.

OBJECTIVES

To characterize the prevalence of deficits in communication and information transfer at hospital discharge and to identify interventions to improve this process.

DATA SOURCES

MEDLINE (through November 2006), Cochrane Database of Systematic Reviews, and hand search of article bibliographies.

STUDY SELECTION

Observational studies investigating communication and information transfer at hospital discharge (n = 55) and controlled studies evaluating the efficacy of interventions to improve information transfer (n = 18).

DATA EXTRACTION

Data from observational studies were extracted on the availability, timeliness, content, and format of discharge communications, as well as primary care physician satisfaction. Results of interventions were summarized by their effect on timeliness, accuracy, completeness, and overall quality of the information transfer.

DATA SYNTHESIS

Direct communication between hospital physicians and primary care physicians occurred infrequently (3%-20%). The availability of a discharge summary at the first postdischarge visit was low (12%-34%) and remained poor at 4 weeks (51%-77%), affecting the quality of care in approximately 25% of follow-up visits and contributing to primary care physician dissatisfaction. Discharge summaries often lacked important information such as diagnostic test results (missing from 33%-63%), treatment or hospital course (7%-22%), discharge medications (2%-40%), test results pending at discharge (65%), patient or family counseling (90%-92%), and follow-up plans (2%-43%). Several interventions, including computer-generated discharge summaries and using patients as couriers, shortened the delivery time of discharge communications. Use of standardized formats to highlight the most pertinent information improved the perceived quality of documents.

CONCLUSIONS

Deficits in communication and information transfer at hospital discharge are common and may adversely affect patient care. Interventions such as computer-generated summaries and standardized formats may facilitate more timely transfer of pertinent patient information to primary care physicians and make discharge summaries more consistently available during follow-up care.

Organizing the transfer of patient care information: the development of a computerized resident sign-out system

BACKGROUND

The problem of safe and efficient transfer of care has increased over the years as new and complex diagnostic tools and more complex treatment options became available. Traditionally, residents ensured continuity of care by working long hours and minimizing the transfer of significant diagnostic or therapeutic responsibilities to other providers. The new 80-hour workweek has curtailed that practice and increased the pressure on trainees for workflow efficiency. We report on a study of information-handling routines among residents for the separate tasks of transfer of care ("sign-out") and daily patient care work (ward work). Using these results, an institution-wide computerized system was developed to centralize information-handling tasks and facilitate the management and transfer of patient care information.

STUDY DESIGN

House staff from 31 resident-run inpatient and consult services at 2 teaching hospitals described current methods of maintaining patient information used during ward rounds and during sign-out. A subgroup of 28 residents then participated in the design of a computerized resident sign-out system to centralize patient information and produce lists for rounding and transferring care duties. Accuracy, flexibility, and portability were identified as key elements by the design team.

RESULTS

Analysis of the type of information handled by residents caring for inpatients at our institution demonstrated common elements across many services. Most services used a paper patient list to manage both nightly sign-out and daily ward work, which required repeated recopying of patient data during the day. Utilizing medical information systems tools and rapid application development concepts, we constructed a computerized resident sign-out system ("UWCores"). This system combines the patient sign-out and daily ward work information in one central location. We believed this would improve the quality of information transferred during sign-out and enhance resident efficiency. During the design process, we identified rules that govern the type of clinical information that should be automatically versus manually updated. We observed an immediate acceptance by all residents and services that tried the system.

CONCLUSIONS

This study shows that by combining downloaded patient data from hospital systems with resident-entered patient details, a computerized resident sign-out system can be a feasible, powerful, and popular tool. While its effect on patient safety and resident efficiency await the results of further studies, our study shows that this tool rapidly captured the attention of resident physicians and became widely used as a valuable means to centralize and organize sign-out and daily ward work information.