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