Michelle Mourad, MD

Indwelling Pleural Catheters and Talc Pleurodesis Provide Similar Dyspnea Relief in Patients With Malignant Pleural Effusions

Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion. JAMA. 2012;307:23832389.

Most Dying Patients Do Not Experience Increased Respiratory Distress When Oxygen is Withdrawn

Campbell ML, Yarandi H, Dove‐Medows E. Oxygen is nonbeneficial for most patients who are near death. J Pain Symptom Manage. 2013;45(3):517523.

Sennosides Performed Similarly to Docusate Plus Sennosides in Managing Opioid‐Induced Constipation in Seriously Ill Patients

Tarumi Y, Wilson MP, Szafran O, Spooner GR. Randomized, double‐blind, placebo‐controlled trial of oral docusate in the management of constipation in hospice patients. J Pain Symptom Manage. 2013;45:213.

Sublingual Atropine Performed Similarly to Placebo in Reducing Noise Associated With Respiratory Rattle Near Death

Heisler M, Hamilton G, Abbott A, et al. Randomized double‐blind trial of sublingual atropine vs. placebo for the management of death rattle. J Pain Symptom Manage. 2012;45(1):1422.

Over Half of Older Adult Survivors of In‐Hospital Cardiopulmonary Resuscitation Were Alive At 1 Year

Chan PS, Krumholz HM, Spertus JA, et al. Long‐term outcomes in elderly survivors of in‐hospital cardiac arrest. N Engl J Med. 2013;368:10191026.

Families Who Were Present During CPR Had Decreased Post‐traumatic Stress Symptoms

Jabre P, Belpomme V, Azoulay E, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med. 2013;368:10081018.

Surrogate Decision Makers Interpreted Prognostic Information Optimistically

Zier LS, Sottile PD, Hong SY, et al. Surrogate decision makers' interpretation of prognostic information: a mixed‐methods study. Ann Intern Med. 2012;156:360366.

A Majority of Patients With Metastatic Cancer Felt That Chemotherapy Might Cure Their Disease

Weeks JC, Catalano PJ, Chronin A, et al. Patients' expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:16161625.

Older Patients Who Viewed a Goals‐of‐Care Video at Admission to a Skilled Nursing Facility Were More Likely to Prefer Comfort Care

Volandes AE, Brandeis GH, Davis AD, et al. A randomized controlled trial of a goals‐of‐care video for elderly patients admitted to skilled nursing facilities. J Palliat Med. 2012;15:805811.

Indwelling Pleural Catheters and Talc Pleurodesis Provide Similar Dyspnea Relief in Patients With Malignant Pleural Effusions

Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion. JAMA. 2012;307:23832389.

Most Dying Patients Do Not Experience Increased Respiratory Distress When Oxygen is Withdrawn

Campbell ML, Yarandi H, Dove‐Medows E. Oxygen is nonbeneficial for most patients who are near death. J Pain Symptom Manage. 2013;45(3):517523.

Sennosides Performed Similarly to Docusate Plus Sennosides in Managing Opioid‐Induced Constipation in Seriously Ill Patients

Tarumi Y, Wilson MP, Szafran O, Spooner GR. Randomized, double‐blind, placebo‐controlled trial of oral docusate in the management of constipation in hospice patients. J Pain Symptom Manage. 2013;45:213.

Sublingual Atropine Performed Similarly to Placebo in Reducing Noise Associated With Respiratory Rattle Near Death

Heisler M, Hamilton G, Abbott A, et al. Randomized double‐blind trial of sublingual atropine vs. placebo for the management of death rattle. J Pain Symptom Manage. 2012;45(1):1422.

Over Half of Older Adult Survivors of In‐Hospital Cardiopulmonary Resuscitation Were Alive At 1 Year

Chan PS, Krumholz HM, Spertus JA, et al. Long‐term outcomes in elderly survivors of in‐hospital cardiac arrest. N Engl J Med. 2013;368:10191026.

Families Who Were Present During CPR Had Decreased Post‐traumatic Stress Symptoms

Jabre P, Belpomme V, Azoulay E, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med. 2013;368:10081018.

Surrogate Decision Makers Interpreted Prognostic Information Optimistically

Zier LS, Sottile PD, Hong SY, et al. Surrogate decision makers' interpretation of prognostic information: a mixed‐methods study. Ann Intern Med. 2012;156:360366.

A Majority of Patients With Metastatic Cancer Felt That Chemotherapy Might Cure Their Disease

Weeks JC, Catalano PJ, Chronin A, et al. Patients' expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:16161625.

Older Patients Who Viewed a Goals‐of‐Care Video at Admission to a Skilled Nursing Facility Were More Likely to Prefer Comfort Care

Volandes AE, Brandeis GH, Davis AD, et al. A randomized controlled trial of a goals‐of‐care video for elderly patients admitted to skilled nursing facilities. J Palliat Med. 2012;15:805811.

Indwelling Pleural Catheters and Talc Pleurodesis Provide Similar Dyspnea Relief in Patients With Malignant Pleural Effusions

Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion. JAMA. 2012;307:23832389.

Most Dying Patients Do Not Experience Increased Respiratory Distress When Oxygen is Withdrawn

Campbell ML, Yarandi H, Dove‐Medows E. Oxygen is nonbeneficial for most patients who are near death. J Pain Symptom Manage. 2013;45(3):517523.

Sennosides Performed Similarly to Docusate Plus Sennosides in Managing Opioid‐Induced Constipation in Seriously Ill Patients

Tarumi Y, Wilson MP, Szafran O, Spooner GR. Randomized, double‐blind, placebo‐controlled trial of oral docusate in the management of constipation in hospice patients. J Pain Symptom Manage. 2013;45:213.

Sublingual Atropine Performed Similarly to Placebo in Reducing Noise Associated With Respiratory Rattle Near Death

Heisler M, Hamilton G, Abbott A, et al. Randomized double‐blind trial of sublingual atropine vs. placebo for the management of death rattle. J Pain Symptom Manage. 2012;45(1):1422.

Over Half of Older Adult Survivors of In‐Hospital Cardiopulmonary Resuscitation Were Alive At 1 Year

Chan PS, Krumholz HM, Spertus JA, et al. Long‐term outcomes in elderly survivors of in‐hospital cardiac arrest. N Engl J Med. 2013;368:10191026.

Families Who Were Present During CPR Had Decreased Post‐traumatic Stress Symptoms

Jabre P, Belpomme V, Azoulay E, et al. Family presence during cardiopulmonary resuscitation. N Engl J Med. 2013;368:10081018.

Surrogate Decision Makers Interpreted Prognostic Information Optimistically

Zier LS, Sottile PD, Hong SY, et al. Surrogate decision makers' interpretation of prognostic information: a mixed‐methods study. Ann Intern Med. 2012;156:360366.

A Majority of Patients With Metastatic Cancer Felt That Chemotherapy Might Cure Their Disease

Weeks JC, Catalano PJ, Chronin A, et al. Patients' expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367:16161625.

Older Patients Who Viewed a Goals‐of‐Care Video at Admission to a Skilled Nursing Facility Were More Likely to Prefer Comfort Care

Volandes AE, Brandeis GH, Davis AD, et al. A randomized controlled trial of a goals‐of‐care video for elderly patients admitted to skilled nursing facilities. J Palliat Med. 2012;15:805811.

Setting and Subjects

University of California, San Francisco Medical Center (UCSFMC) is a 600‐bed tertiary care academic teaching hospital. We surveyed interns, hospitalists on a teaching service, and day‐shift nurses from the inpatient medical service, based on care they provided at UCSFMC from July 2010 to February 2011. The 3 groups are the primary providers at our institution who deliver discharge education. The study was approved by our Institutional Review Board (IRB), the Committee on Human Research.

Survey Development

We developed a survey tool based on a literature review and expert input from local institutional leaders in nursing, residency training, and hospital medicine. The aims of the survey tool were to: 1) assess perceptions and practice of the nurse and physician role in patient discharge education; 2) describe the current practice of physiciannurse communication at discharge; and 3) assess openness to new communication tools.

Specific elements of discharge education assessed in the survey were established from the existing literature,10, 11 and our local best practices (see Supporting Information, Text Box, in the online version of this article). Prior to survey administration, we conducted informal focus groups of interns, hospitalists, and day‐shift nurses, and piloted the survey to assure clarity in the questions and proposed responses.

The survey asked respondents to assign responsibility for the discharge education elements to the physician, nurse, both, or neither, and then to describe their current practice in patient education and in physiciannurse communication. The frequency that respondents provide discharge education to patients and the frequency of nursephysician communication around the elements of discharge education were assessed using Likert scales (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always). Finally, the survey asked respondents about their interest in tools to improve provider communication at discharge.

Survey Administration

Surveys were administered on paper and electronically, the latter using a commercial online survey tool. Paper surveys were circulated at nurse staff meetings on the 2 units in January and February 2011, with links to an electronic survey sent by e‐mail for those unable to attend. Electronic surveys were distributed via e‐mail to all interns and hospitalists in January 2011. The mid‐year time period was selected to ensure that all interns had provided clinical care at this hospital site. Two reminder e‐mails were sent to non‐respondents.

Data Analysis

Paper‐based surveys were subsequently entered into the online survey tool. Student t tests were used to compare Likert scale means between 2 provider groups, while analysis of variance (ANOVA) was used to compare differences between nurses, interns, and hospitalists. Chi‐squared analysis was used to compare dichotomous variables of agreement and disagreement.

Likert scales of education to patients were dichotomized into frequent education (that provided often or always) versus infrequent education (that provided never, rarely, or sometimes). Likert scales of communication between nurses were similarly dichotomized. Correlation between frequent education to patients (often or always) and the frequency of communication between nurses and physicians (often or always) was assessed using Pearson's r.

Perceived Responsibility for Discharge Education

Providers felt that most elements of discharge education were a shared responsibility, accounting for 58% of the responses to all the questions. Nurses, however, were the most likely to respond that the elements of discharge education were a shared responsibility, with 64% of all nursing responses indicating that the discharge education elements were a shared responsibility, compared to 54% of intern's responses and 55% of hospitalist's responses (P < 0.005). Correspondingly, nurses also responded least often that items were primarily a nursing responsibility (10% of all responses), compared to interns (12% of all responses) and hospitalists (18% of all responses) (nurses vs hospitalists, P < 0.001). No single elements were responsible for these differences, instead Table 1 demonstrates this trend across most elements. Hospitalists, despite their increased experience in discharging patients, were less likely than interns to respond that elements of discharge education were a physician's responsibility (21% vs 32% of all responses, P < 0.001).

The majority of providers were in agreement that 9 of the 13 elements were a shared nursephysician responsibility, with varying degrees of consensus. All groups also agreed that 2 of the elements, summary of hospital findings and pending results from studies during hospitalization, should be primarily the physician's responsibility. However, there was disagreement on the remaining 2 items. The majority of interns viewed the explanation of the diagnosis in lay terms as a physician responsibility (55%), compared to a minority of nurses (31%) and hospitalists (36%) (P < 0.05). Interns were also more likely than others to view providing contact information for questions after discharge as a uniquely nursing responsibility (45%), compared to nurses (28%) and hospitalists (33%) who viewed this as shared responsibility; this difference was not statistically significant.

Discharge Education by Providers on the Care Team

Despite nurses' reluctance to claim sole responsibility for elements of discharge education, nurses on the whole reported providing discharge education more often than either interns or hospitalists (P < 0.05). Figure 1 illustrates each group's reported practice of communicating specific discharge education on a Likert scale. For the 9 elements viewed as a shared responsibility and the 2 elements where there was disagreement, nurses reported communicating most items significantly more often than both interns and hospitalists (P < 0.001 for all elements except reason for follow‐up appointments, explanation of diagnosis in lay terms, and changes to medication regimen made during hospitalization). Items that were reported to be a physician responsibility were communicated more often by interns and hospitalists than nurses (P < 0.005), but were the items least often communicated by any care provider. Hospitalists did not report communicating any items significantly more than interns.

Figure 1

Communication Between Nurses and Physicians

Overall, communication between nurses and physicians was infrequent, with the 64% of nurses, 64% of interns, and 70% of hospitalists reporting that they never or rarely communicate with the other around any discharge education elements. Hospitalists were not more likely than interns to report communicating with nurses on any items, instead reported communicating with nurses around follow‐up appointments and home health services significantly less often (P < 0.05). There was a statistically significant increase in communication by all providers around items of shared responsibility, compared to items viewed as the responsibility of the physicians (14% vs 5.0% increase in communicated often or always; P < 0.001). Elements on which nurses and physicians communicated often or always were also discharge education elements reported as more often provided to patients (r = 0.577).

Potential Solutions for Sharing Discharge Information

Overall, both nurses, interns, and hospitalists were very open to proposed methods of enhancing their communication at discharge. Compared to interns and hospitalists, nurses were more likely to support communication tools, and significantly more in favor of verbal communication, discharge summary availability at the time of discharge, and access to a physician handoff tool. Only 1 solution, a standardized checklist, was favored more by interns and hospitalists, but the difference was not statistically significant. Verbal communication with the other group on the day of discharge was supported most strongly, with 100% of nurses, and 81% of interns and hospitalists reporting being likely or very likely to use this strategy. The least supported item by all groups was using white boards to communicate discharge information (Table 2).

Setting and Subjects

University of California, San Francisco Medical Center (UCSFMC) is a 600‐bed tertiary care academic teaching hospital. We surveyed interns, hospitalists on a teaching service, and day‐shift nurses from the inpatient medical service, based on care they provided at UCSFMC from July 2010 to February 2011. The 3 groups are the primary providers at our institution who deliver discharge education. The study was approved by our Institutional Review Board (IRB), the Committee on Human Research.

Survey Development

We developed a survey tool based on a literature review and expert input from local institutional leaders in nursing, residency training, and hospital medicine. The aims of the survey tool were to: 1) assess perceptions and practice of the nurse and physician role in patient discharge education; 2) describe the current practice of physiciannurse communication at discharge; and 3) assess openness to new communication tools.

Specific elements of discharge education assessed in the survey were established from the existing literature,10, 11 and our local best practices (see Supporting Information, Text Box, in the online version of this article). Prior to survey administration, we conducted informal focus groups of interns, hospitalists, and day‐shift nurses, and piloted the survey to assure clarity in the questions and proposed responses.

The survey asked respondents to assign responsibility for the discharge education elements to the physician, nurse, both, or neither, and then to describe their current practice in patient education and in physiciannurse communication. The frequency that respondents provide discharge education to patients and the frequency of nursephysician communication around the elements of discharge education were assessed using Likert scales (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always). Finally, the survey asked respondents about their interest in tools to improve provider communication at discharge.

Survey Administration

Surveys were administered on paper and electronically, the latter using a commercial online survey tool. Paper surveys were circulated at nurse staff meetings on the 2 units in January and February 2011, with links to an electronic survey sent by e‐mail for those unable to attend. Electronic surveys were distributed via e‐mail to all interns and hospitalists in January 2011. The mid‐year time period was selected to ensure that all interns had provided clinical care at this hospital site. Two reminder e‐mails were sent to non‐respondents.

Data Analysis

Paper‐based surveys were subsequently entered into the online survey tool. Student t tests were used to compare Likert scale means between 2 provider groups, while analysis of variance (ANOVA) was used to compare differences between nurses, interns, and hospitalists. Chi‐squared analysis was used to compare dichotomous variables of agreement and disagreement.

Likert scales of education to patients were dichotomized into frequent education (that provided often or always) versus infrequent education (that provided never, rarely, or sometimes). Likert scales of communication between nurses were similarly dichotomized. Correlation between frequent education to patients (often or always) and the frequency of communication between nurses and physicians (often or always) was assessed using Pearson's r.

Perceived Responsibility for Discharge Education

Providers felt that most elements of discharge education were a shared responsibility, accounting for 58% of the responses to all the questions. Nurses, however, were the most likely to respond that the elements of discharge education were a shared responsibility, with 64% of all nursing responses indicating that the discharge education elements were a shared responsibility, compared to 54% of intern's responses and 55% of hospitalist's responses (P < 0.005). Correspondingly, nurses also responded least often that items were primarily a nursing responsibility (10% of all responses), compared to interns (12% of all responses) and hospitalists (18% of all responses) (nurses vs hospitalists, P < 0.001). No single elements were responsible for these differences, instead Table 1 demonstrates this trend across most elements. Hospitalists, despite their increased experience in discharging patients, were less likely than interns to respond that elements of discharge education were a physician's responsibility (21% vs 32% of all responses, P < 0.001).

The majority of providers were in agreement that 9 of the 13 elements were a shared nursephysician responsibility, with varying degrees of consensus. All groups also agreed that 2 of the elements, summary of hospital findings and pending results from studies during hospitalization, should be primarily the physician's responsibility. However, there was disagreement on the remaining 2 items. The majority of interns viewed the explanation of the diagnosis in lay terms as a physician responsibility (55%), compared to a minority of nurses (31%) and hospitalists (36%) (P < 0.05). Interns were also more likely than others to view providing contact information for questions after discharge as a uniquely nursing responsibility (45%), compared to nurses (28%) and hospitalists (33%) who viewed this as shared responsibility; this difference was not statistically significant.

Discharge Education by Providers on the Care Team

Despite nurses' reluctance to claim sole responsibility for elements of discharge education, nurses on the whole reported providing discharge education more often than either interns or hospitalists (P < 0.05). Figure 1 illustrates each group's reported practice of communicating specific discharge education on a Likert scale. For the 9 elements viewed as a shared responsibility and the 2 elements where there was disagreement, nurses reported communicating most items significantly more often than both interns and hospitalists (P < 0.001 for all elements except reason for follow‐up appointments, explanation of diagnosis in lay terms, and changes to medication regimen made during hospitalization). Items that were reported to be a physician responsibility were communicated more often by interns and hospitalists than nurses (P < 0.005), but were the items least often communicated by any care provider. Hospitalists did not report communicating any items significantly more than interns.

Figure 1

Communication Between Nurses and Physicians

Overall, communication between nurses and physicians was infrequent, with the 64% of nurses, 64% of interns, and 70% of hospitalists reporting that they never or rarely communicate with the other around any discharge education elements. Hospitalists were not more likely than interns to report communicating with nurses on any items, instead reported communicating with nurses around follow‐up appointments and home health services significantly less often (P < 0.05). There was a statistically significant increase in communication by all providers around items of shared responsibility, compared to items viewed as the responsibility of the physicians (14% vs 5.0% increase in communicated often or always; P < 0.001). Elements on which nurses and physicians communicated often or always were also discharge education elements reported as more often provided to patients (r = 0.577).

Potential Solutions for Sharing Discharge Information

Overall, both nurses, interns, and hospitalists were very open to proposed methods of enhancing their communication at discharge. Compared to interns and hospitalists, nurses were more likely to support communication tools, and significantly more in favor of verbal communication, discharge summary availability at the time of discharge, and access to a physician handoff tool. Only 1 solution, a standardized checklist, was favored more by interns and hospitalists, but the difference was not statistically significant. Verbal communication with the other group on the day of discharge was supported most strongly, with 100% of nurses, and 81% of interns and hospitalists reporting being likely or very likely to use this strategy. The least supported item by all groups was using white boards to communicate discharge information (Table 2).

Setting and Subjects

University of California, San Francisco Medical Center (UCSFMC) is a 600‐bed tertiary care academic teaching hospital. We surveyed interns, hospitalists on a teaching service, and day‐shift nurses from the inpatient medical service, based on care they provided at UCSFMC from July 2010 to February 2011. The 3 groups are the primary providers at our institution who deliver discharge education. The study was approved by our Institutional Review Board (IRB), the Committee on Human Research.

Survey Development

We developed a survey tool based on a literature review and expert input from local institutional leaders in nursing, residency training, and hospital medicine. The aims of the survey tool were to: 1) assess perceptions and practice of the nurse and physician role in patient discharge education; 2) describe the current practice of physiciannurse communication at discharge; and 3) assess openness to new communication tools.

Specific elements of discharge education assessed in the survey were established from the existing literature,10, 11 and our local best practices (see Supporting Information, Text Box, in the online version of this article). Prior to survey administration, we conducted informal focus groups of interns, hospitalists, and day‐shift nurses, and piloted the survey to assure clarity in the questions and proposed responses.

The survey asked respondents to assign responsibility for the discharge education elements to the physician, nurse, both, or neither, and then to describe their current practice in patient education and in physiciannurse communication. The frequency that respondents provide discharge education to patients and the frequency of nursephysician communication around the elements of discharge education were assessed using Likert scales (1 = never, 2 = rarely, 3 = sometimes, 4 = often, 5 = always). Finally, the survey asked respondents about their interest in tools to improve provider communication at discharge.

Survey Administration

Surveys were administered on paper and electronically, the latter using a commercial online survey tool. Paper surveys were circulated at nurse staff meetings on the 2 units in January and February 2011, with links to an electronic survey sent by e‐mail for those unable to attend. Electronic surveys were distributed via e‐mail to all interns and hospitalists in January 2011. The mid‐year time period was selected to ensure that all interns had provided clinical care at this hospital site. Two reminder e‐mails were sent to non‐respondents.

Data Analysis

Paper‐based surveys were subsequently entered into the online survey tool. Student t tests were used to compare Likert scale means between 2 provider groups, while analysis of variance (ANOVA) was used to compare differences between nurses, interns, and hospitalists. Chi‐squared analysis was used to compare dichotomous variables of agreement and disagreement.

Likert scales of education to patients were dichotomized into frequent education (that provided often or always) versus infrequent education (that provided never, rarely, or sometimes). Likert scales of communication between nurses were similarly dichotomized. Correlation between frequent education to patients (often or always) and the frequency of communication between nurses and physicians (often or always) was assessed using Pearson's r.

Perceived Responsibility for Discharge Education

Providers felt that most elements of discharge education were a shared responsibility, accounting for 58% of the responses to all the questions. Nurses, however, were the most likely to respond that the elements of discharge education were a shared responsibility, with 64% of all nursing responses indicating that the discharge education elements were a shared responsibility, compared to 54% of intern's responses and 55% of hospitalist's responses (P < 0.005). Correspondingly, nurses also responded least often that items were primarily a nursing responsibility (10% of all responses), compared to interns (12% of all responses) and hospitalists (18% of all responses) (nurses vs hospitalists, P < 0.001). No single elements were responsible for these differences, instead Table 1 demonstrates this trend across most elements. Hospitalists, despite their increased experience in discharging patients, were less likely than interns to respond that elements of discharge education were a physician's responsibility (21% vs 32% of all responses, P < 0.001).

The majority of providers were in agreement that 9 of the 13 elements were a shared nursephysician responsibility, with varying degrees of consensus. All groups also agreed that 2 of the elements, summary of hospital findings and pending results from studies during hospitalization, should be primarily the physician's responsibility. However, there was disagreement on the remaining 2 items. The majority of interns viewed the explanation of the diagnosis in lay terms as a physician responsibility (55%), compared to a minority of nurses (31%) and hospitalists (36%) (P < 0.05). Interns were also more likely than others to view providing contact information for questions after discharge as a uniquely nursing responsibility (45%), compared to nurses (28%) and hospitalists (33%) who viewed this as shared responsibility; this difference was not statistically significant.

Discharge Education by Providers on the Care Team

Despite nurses' reluctance to claim sole responsibility for elements of discharge education, nurses on the whole reported providing discharge education more often than either interns or hospitalists (P < 0.05). Figure 1 illustrates each group's reported practice of communicating specific discharge education on a Likert scale. For the 9 elements viewed as a shared responsibility and the 2 elements where there was disagreement, nurses reported communicating most items significantly more often than both interns and hospitalists (P < 0.001 for all elements except reason for follow‐up appointments, explanation of diagnosis in lay terms, and changes to medication regimen made during hospitalization). Items that were reported to be a physician responsibility were communicated more often by interns and hospitalists than nurses (P < 0.005), but were the items least often communicated by any care provider. Hospitalists did not report communicating any items significantly more than interns.

Figure 1

Communication Between Nurses and Physicians

Overall, communication between nurses and physicians was infrequent, with the 64% of nurses, 64% of interns, and 70% of hospitalists reporting that they never or rarely communicate with the other around any discharge education elements. Hospitalists were not more likely than interns to report communicating with nurses on any items, instead reported communicating with nurses around follow‐up appointments and home health services significantly less often (P < 0.05). There was a statistically significant increase in communication by all providers around items of shared responsibility, compared to items viewed as the responsibility of the physicians (14% vs 5.0% increase in communicated often or always; P < 0.001). Elements on which nurses and physicians communicated often or always were also discharge education elements reported as more often provided to patients (r = 0.577).

Potential Solutions for Sharing Discharge Information

Overall, both nurses, interns, and hospitalists were very open to proposed methods of enhancing their communication at discharge. Compared to interns and hospitalists, nurses were more likely to support communication tools, and significantly more in favor of verbal communication, discharge summary availability at the time of discharge, and access to a physician handoff tool. Only 1 solution, a standardized checklist, was favored more by interns and hospitalists, but the difference was not statistically significant. Verbal communication with the other group on the day of discharge was supported most strongly, with 100% of nurses, and 81% of interns and hospitalists reporting being likely or very likely to use this strategy. The least supported item by all groups was using white boards to communicate discharge information (Table 2).

Site

Our survey was carried out at UCSF Moffitt‐Long Hospital, a 560‐bed university teaching hospital and the primary university hospital for the University of California San Francisco. This study was reviewed and approved by the Committee on Human Research at UCSF.

Procedure Service

The HPS is composed of two interns who rotate for 2 weeks on a mandatory rotation performing the majority of the procedures done by the service. Every procedure is supervised by an attending hospitalist who has received extended training from interventional radiologists and emergency department ultrasound faculty. Patients are referred to the service by their primary admitting team. Interns receive procedure‐specific didactics, demonstration, and practice with procedure kits, supplemental readings, computer‐based procedure modules, and evidence‐based summaries of procedure‐related considerations. All interns also attend a half‐day procedure simulation session to review procedural and ultrasound techniques.

While interns obtain informed consent and prepare the patient for the procedure, the attending and intern team communicate the following points with each patient: 1) identification as the dedicated procedure team, separate from the primary team caring for the patient; 2) attending self‐identification as the supervisor; 3) attention to stepwise communication with the patient during the procedure; 4) attention to patient comfort throughout the procedure; 5) emphasis on patient safety through the use of time‐outs, sterile technique, and ultrasound when appropriate; and 6) the intention to discuss best practice and teach during the procedure.

All paracentesis and thoracentesis sites are marked by using bedside ultrasound (S‐Cath, SonoSite, Bothell, WA) guidance prior to and, if needed, during the procedure. Ultrasound is occasionally used for marking joint aspiration and lumbar puncture.11 Interns are responsible for making an initial site marking, which is then confirmed by the attending physician. Although not systematized, our service encourages the intern and attending to communicate about proper technique during the procedure itself. For example, attendings ask questions about technique based on evidence in the literature (eg, Why do you replace the stylet in a lumbar puncture needle prior to removal?) or about trouble shooting (eg, What would you do if the flow of ascites stops during this paracentesis?) and also correct any errors in technique (Recall the angle you intended to use based on the ultrasound view).

Patients

Patients are referred to the procedure service by their primary team; referrals are accepted for patients on all services at all levels of care, including the emergency department (ED) and the intensive care unit (ICU). Participants in this study were referred for one of our target procedures (paracentesis, thoracentesis, or lumbar puncture) between November 2008 and July 2009. Patients gave written consent for the supplemental survey independent of consent for the procedure. All consents and procedures were performed in a patient's hospital room and one family member was allowed to stay in the room if desired by the patient. After the completion of the procedure, the attending on the procedure service at the time, which included study authors D.S. and M.M., approached consecutive patients who spoke and read English and were deemed to have capacity to consent for their own procedure to be surveyed. Patients were considered to have capacity to consent based on commonly accepted criteria described in the literature.12, 13 Patients were also excluded if their procedure was performed by the attending alone, if they had repeated procedures done by the service, or if they were too altered or critically ill to participate in the survey.

Survey

Our survey was developed through identification of items reported in the literature,1421 as well as items newly developed for purposes of examining our primary aims. Newly developed questions focused on patients' satisfaction with major aspects of procedure performance as well as the quality and impact of communication with the patient and between members of the team. Two open‐text questions were included to allow patients to share what went well with the procedure as well as areas for improvement. The research team developed a pool of question items for potential inclusion in a patient satisfaction questionnaire. These items were then shown to a group of research‐oriented health professionals, who meet regularly to review academic research protocols. The group provided their opinions about the content and comprehension of the questions, and the written survey employed was a result of their revisions (see Appendix in Supporting Information online).

Written surveys were distributed to patients by the hospitalist attending on service following the procedure as permitted by patients' severity of illness and availability. Surveys were anonymous and self‐administered by the patient or a family member who was in the room for the procedure; all questions were voluntary. A nurse was made responsible for collecting the survey when possible. Survey results were entered into a database without identifiers, with limited demographic information; patient gender, age, and procedure type were included by the attending hospitalist at the end of the survey. A separate and more detailed procedure database was kept of all procedures performed and was used to record patient consent or reason for not consenting as well as documented receipt of a completed survey. This non‐anonymous database contained detailed supplemental information including patient age, level of care, referring service, presence of bloody fluid at any point during the procedure, and physician‐reported immediate complications at the bedside in free text.

Analysis

Reported immediate complications were classified into major and minor based on reported definitions in the literature.2226 Similar to previous studies, major immediate complications were defined as those requiring further procedural intervention, medical therapy, or both.27 Major complications were defined as: bleeding requiring transfusion, pneumothorax requiring a chest tube, respiratory failure, bowel perforation, cerebral herniation or shock, cerebrospinal fluid (CSF) leak requiring intervention, and transfer to a higher level of care. For patients receiving a thoracentesis, chart review was performed to determine the presence of a follow‐up chest x‐ray, the presence of a pneumothorax, or clinical evidence for re‐expansion pulmonary edema. We analyzed differences between respondents and non‐respondents using Chi‐square tests for categorical variables (gender, level of care, referring service, procedure type, bloody fluid, and immediate reported complications) and independent t tests for continuous variables (age).

After review of the open‐ended fields, responses were classified into the following categories: pain control, physician skill, professionalism, communication, symptom relief, procedure duration, and miscellaneous comments. Responses regarding patient perceptions of physician communication were dichotomized into positive (1 = Strongly Agree, 2 = Agree) and negative (3 = Neutral, 4 = Disagree, and 5 = Strongly Disagree), and independent t tests were used to determine the contribution of factors, such as age, while Chi‐square tests were used for the contribution of gender and procedure type. All statistical tests were performed by using the SAS statistical application program (version 9.2).

Respondent Characteristics

Of 324 procedures performed by the HPS during the study period, 95 (29%) were eligible for consent. Of the 229 patients not eligible for consent, 32 (10%) were excluded because the procedure was performed by the attending alone, 76 (23%) lacked English proficiency or literacy, 66 (20%) had altered mental status, 32 (10%) were intubated and/or had severe illness precluding consent, and 23 (7%) were repeat procedures on patients who had previously completed the survey. Only two patients specifically requested an attending to perform the procedure after an introduction to the service. Of the 95 patients eligible for consent, 89 were consented for the survey, and 65 (68%) completed the survey. Of the six eligible, non‐consented patients, all were leaving the floor immediately following the procedure, and time did not allow for consent and survey distribution. There were no differences between eligible responders and nonresponders in age, gender, procedure, requesting service, presence of bloody fluid, or physician‐reported immediate complications (Table 1).

Complications

As complications would likely play a role in procedure satisfaction, we describe immediate complications for the study population. Of the 324 procedures performed during the study period, no patient had predefined major immediate complications. Upon further chart review of the 96 patients that had a thoracentesis performed, all had a follow‐up chest x‐ray and none suffered an iatrogenic pneumothorax or re‐expansion pulmonary edema. Minor immediate complications for the 324 procedures were reported as follows: postprocedure pain in four patients (1.2%), cough in nine patients (2.8%), five equipment malfunctions (1.5%), four ascites leaks (1.2%), and one incisional bleed requiring a suture for hemostasis (0.3%). There was no significant difference in complications between those consented for the survey and the total study population.

Procedure Satisfaction

More than 90% of patients were satisfied or very satisfied with most aspects of the procedure, including the informed consent process, pain control, expertise, and courtesy of physicians (Table 2). The percentage of patients satisfied with the duration of procedure (88%) was lower than for other measures of satisfaction. Of the 38 patients receiving therapeutic procedures, 34 (89%) were satisfied or highly satisfied with the improvement in symptoms following the procedure.

When asked what went well with the procedure, 59 (91%) respondents provided additional comments and feedback. Each response was classified as described in the Methods section. Of the free text responses, 8 of the 59 patients (14%) commented on the attention to pain control (eg, The caring and attention to my pain was most important to me), 5 (8%) on the skills of the operators (Great examination of the entire stomach region with the ultrasound to ensure the best position of the catheter), 6 (10%) on the courtesy and professionalism of the team (eg, Courteous, team‐feeling, addressed my concerns), 9 (15%) on their communication with the team (eg, The doctors made me feel very comfortable before the procedure by laying out the plan and explaining each part of the procedure), and 8 (14%) on relief of their symptoms (eg, There was an almost immediate and significant improvement in my breathing, bloating, and pain). Twenty‐three of the 59 comments (39%) were categorized as miscellaneous (eg, All went great. I fell asleep).

When asked areas for improvement, 55 (85%) patients responded. Thirty‐three patients (60%) reported that nothing could be improved or they instructed the team to just keep doing what you are doing, while 22 (40%) patients expressed a concern. Responses were categorized in a similar fashion to the positive responses. Five of the 22 negative comments (23%) reported that the procedure took too long (eg, Procedure could have been shorter. I got tired sitting up), 4 (18%) commented on pain control (eg, The poke for marking my skin hurt more than the anesthetic. I was surprised), 6 (27%) felt communication was a problem (eg, Discuss the steps with the patient audibly, no whispering, speak clearly), and 7 (32%) had miscellaneous concerns (eg, Try not to do this procedure right after another one).

Physician Communication

Sixty‐four patients (98%) reported that the physicians performing their procedure communicated with each other during the procedure (Table 3). Although one patient did not feel that the physicians communicated with each other, he or she still answered the follow‐up questions regarding perceptions of physician communication. We excluded this patient from our analysis as his or her answers may not be reliable. The majority of patients (84%) reported this communication as reassuring and felt it was a normal part of procedure performance (94%). Those that did not agree that physician communication was reassuring did not differ in average age (P = 0.307), gender (P = 0.511), or procedure type (P = 0.562).

Of all positive and negative comments, five specifically addressed communication between physicians. Most (four) reflected satisfaction with bedside teaching (eg, They discussed the procedure in a professional manner and eased my mind at all times) and with having an expert in the room (eg, [The team] discussed things like needle placement, which was nice because there was a second opinion right there in the room). Patients also felt that it was good to experience the teaching, with one patient reporting that the best part of the procedure was watching doctors learn from each other. Patients did not express specific reservations about bedside teaching, resident technique, or fear of complications in free text.

Site

Our survey was carried out at UCSF Moffitt‐Long Hospital, a 560‐bed university teaching hospital and the primary university hospital for the University of California San Francisco. This study was reviewed and approved by the Committee on Human Research at UCSF.

Procedure Service

The HPS is composed of two interns who rotate for 2 weeks on a mandatory rotation performing the majority of the procedures done by the service. Every procedure is supervised by an attending hospitalist who has received extended training from interventional radiologists and emergency department ultrasound faculty. Patients are referred to the service by their primary admitting team. Interns receive procedure‐specific didactics, demonstration, and practice with procedure kits, supplemental readings, computer‐based procedure modules, and evidence‐based summaries of procedure‐related considerations. All interns also attend a half‐day procedure simulation session to review procedural and ultrasound techniques.

While interns obtain informed consent and prepare the patient for the procedure, the attending and intern team communicate the following points with each patient: 1) identification as the dedicated procedure team, separate from the primary team caring for the patient; 2) attending self‐identification as the supervisor; 3) attention to stepwise communication with the patient during the procedure; 4) attention to patient comfort throughout the procedure; 5) emphasis on patient safety through the use of time‐outs, sterile technique, and ultrasound when appropriate; and 6) the intention to discuss best practice and teach during the procedure.

All paracentesis and thoracentesis sites are marked by using bedside ultrasound (S‐Cath, SonoSite, Bothell, WA) guidance prior to and, if needed, during the procedure. Ultrasound is occasionally used for marking joint aspiration and lumbar puncture.11 Interns are responsible for making an initial site marking, which is then confirmed by the attending physician. Although not systematized, our service encourages the intern and attending to communicate about proper technique during the procedure itself. For example, attendings ask questions about technique based on evidence in the literature (eg, Why do you replace the stylet in a lumbar puncture needle prior to removal?) or about trouble shooting (eg, What would you do if the flow of ascites stops during this paracentesis?) and also correct any errors in technique (Recall the angle you intended to use based on the ultrasound view).

Patients

Patients are referred to the procedure service by their primary team; referrals are accepted for patients on all services at all levels of care, including the emergency department (ED) and the intensive care unit (ICU). Participants in this study were referred for one of our target procedures (paracentesis, thoracentesis, or lumbar puncture) between November 2008 and July 2009. Patients gave written consent for the supplemental survey independent of consent for the procedure. All consents and procedures were performed in a patient's hospital room and one family member was allowed to stay in the room if desired by the patient. After the completion of the procedure, the attending on the procedure service at the time, which included study authors D.S. and M.M., approached consecutive patients who spoke and read English and were deemed to have capacity to consent for their own procedure to be surveyed. Patients were considered to have capacity to consent based on commonly accepted criteria described in the literature.12, 13 Patients were also excluded if their procedure was performed by the attending alone, if they had repeated procedures done by the service, or if they were too altered or critically ill to participate in the survey.

Survey

Our survey was developed through identification of items reported in the literature,1421 as well as items newly developed for purposes of examining our primary aims. Newly developed questions focused on patients' satisfaction with major aspects of procedure performance as well as the quality and impact of communication with the patient and between members of the team. Two open‐text questions were included to allow patients to share what went well with the procedure as well as areas for improvement. The research team developed a pool of question items for potential inclusion in a patient satisfaction questionnaire. These items were then shown to a group of research‐oriented health professionals, who meet regularly to review academic research protocols. The group provided their opinions about the content and comprehension of the questions, and the written survey employed was a result of their revisions (see Appendix in Supporting Information online).

Written surveys were distributed to patients by the hospitalist attending on service following the procedure as permitted by patients' severity of illness and availability. Surveys were anonymous and self‐administered by the patient or a family member who was in the room for the procedure; all questions were voluntary. A nurse was made responsible for collecting the survey when possible. Survey results were entered into a database without identifiers, with limited demographic information; patient gender, age, and procedure type were included by the attending hospitalist at the end of the survey. A separate and more detailed procedure database was kept of all procedures performed and was used to record patient consent or reason for not consenting as well as documented receipt of a completed survey. This non‐anonymous database contained detailed supplemental information including patient age, level of care, referring service, presence of bloody fluid at any point during the procedure, and physician‐reported immediate complications at the bedside in free text.

Analysis

Reported immediate complications were classified into major and minor based on reported definitions in the literature.2226 Similar to previous studies, major immediate complications were defined as those requiring further procedural intervention, medical therapy, or both.27 Major complications were defined as: bleeding requiring transfusion, pneumothorax requiring a chest tube, respiratory failure, bowel perforation, cerebral herniation or shock, cerebrospinal fluid (CSF) leak requiring intervention, and transfer to a higher level of care. For patients receiving a thoracentesis, chart review was performed to determine the presence of a follow‐up chest x‐ray, the presence of a pneumothorax, or clinical evidence for re‐expansion pulmonary edema. We analyzed differences between respondents and non‐respondents using Chi‐square tests for categorical variables (gender, level of care, referring service, procedure type, bloody fluid, and immediate reported complications) and independent t tests for continuous variables (age).

After review of the open‐ended fields, responses were classified into the following categories: pain control, physician skill, professionalism, communication, symptom relief, procedure duration, and miscellaneous comments. Responses regarding patient perceptions of physician communication were dichotomized into positive (1 = Strongly Agree, 2 = Agree) and negative (3 = Neutral, 4 = Disagree, and 5 = Strongly Disagree), and independent t tests were used to determine the contribution of factors, such as age, while Chi‐square tests were used for the contribution of gender and procedure type. All statistical tests were performed by using the SAS statistical application program (version 9.2).

Respondent Characteristics

Of 324 procedures performed by the HPS during the study period, 95 (29%) were eligible for consent. Of the 229 patients not eligible for consent, 32 (10%) were excluded because the procedure was performed by the attending alone, 76 (23%) lacked English proficiency or literacy, 66 (20%) had altered mental status, 32 (10%) were intubated and/or had severe illness precluding consent, and 23 (7%) were repeat procedures on patients who had previously completed the survey. Only two patients specifically requested an attending to perform the procedure after an introduction to the service. Of the 95 patients eligible for consent, 89 were consented for the survey, and 65 (68%) completed the survey. Of the six eligible, non‐consented patients, all were leaving the floor immediately following the procedure, and time did not allow for consent and survey distribution. There were no differences between eligible responders and nonresponders in age, gender, procedure, requesting service, presence of bloody fluid, or physician‐reported immediate complications (Table 1).

Complications

As complications would likely play a role in procedure satisfaction, we describe immediate complications for the study population. Of the 324 procedures performed during the study period, no patient had predefined major immediate complications. Upon further chart review of the 96 patients that had a thoracentesis performed, all had a follow‐up chest x‐ray and none suffered an iatrogenic pneumothorax or re‐expansion pulmonary edema. Minor immediate complications for the 324 procedures were reported as follows: postprocedure pain in four patients (1.2%), cough in nine patients (2.8%), five equipment malfunctions (1.5%), four ascites leaks (1.2%), and one incisional bleed requiring a suture for hemostasis (0.3%). There was no significant difference in complications between those consented for the survey and the total study population.

Procedure Satisfaction

More than 90% of patients were satisfied or very satisfied with most aspects of the procedure, including the informed consent process, pain control, expertise, and courtesy of physicians (Table 2). The percentage of patients satisfied with the duration of procedure (88%) was lower than for other measures of satisfaction. Of the 38 patients receiving therapeutic procedures, 34 (89%) were satisfied or highly satisfied with the improvement in symptoms following the procedure.

When asked what went well with the procedure, 59 (91%) respondents provided additional comments and feedback. Each response was classified as described in the Methods section. Of the free text responses, 8 of the 59 patients (14%) commented on the attention to pain control (eg, The caring and attention to my pain was most important to me), 5 (8%) on the skills of the operators (Great examination of the entire stomach region with the ultrasound to ensure the best position of the catheter), 6 (10%) on the courtesy and professionalism of the team (eg, Courteous, team‐feeling, addressed my concerns), 9 (15%) on their communication with the team (eg, The doctors made me feel very comfortable before the procedure by laying out the plan and explaining each part of the procedure), and 8 (14%) on relief of their symptoms (eg, There was an almost immediate and significant improvement in my breathing, bloating, and pain). Twenty‐three of the 59 comments (39%) were categorized as miscellaneous (eg, All went great. I fell asleep).

When asked areas for improvement, 55 (85%) patients responded. Thirty‐three patients (60%) reported that nothing could be improved or they instructed the team to just keep doing what you are doing, while 22 (40%) patients expressed a concern. Responses were categorized in a similar fashion to the positive responses. Five of the 22 negative comments (23%) reported that the procedure took too long (eg, Procedure could have been shorter. I got tired sitting up), 4 (18%) commented on pain control (eg, The poke for marking my skin hurt more than the anesthetic. I was surprised), 6 (27%) felt communication was a problem (eg, Discuss the steps with the patient audibly, no whispering, speak clearly), and 7 (32%) had miscellaneous concerns (eg, Try not to do this procedure right after another one).

Physician Communication

Sixty‐four patients (98%) reported that the physicians performing their procedure communicated with each other during the procedure (Table 3). Although one patient did not feel that the physicians communicated with each other, he or she still answered the follow‐up questions regarding perceptions of physician communication. We excluded this patient from our analysis as his or her answers may not be reliable. The majority of patients (84%) reported this communication as reassuring and felt it was a normal part of procedure performance (94%). Those that did not agree that physician communication was reassuring did not differ in average age (P = 0.307), gender (P = 0.511), or procedure type (P = 0.562).

Of all positive and negative comments, five specifically addressed communication between physicians. Most (four) reflected satisfaction with bedside teaching (eg, They discussed the procedure in a professional manner and eased my mind at all times) and with having an expert in the room (eg, [The team] discussed things like needle placement, which was nice because there was a second opinion right there in the room). Patients also felt that it was good to experience the teaching, with one patient reporting that the best part of the procedure was watching doctors learn from each other. Patients did not express specific reservations about bedside teaching, resident technique, or fear of complications in free text.

Site

Our survey was carried out at UCSF Moffitt‐Long Hospital, a 560‐bed university teaching hospital and the primary university hospital for the University of California San Francisco. This study was reviewed and approved by the Committee on Human Research at UCSF.

Procedure Service

The HPS is composed of two interns who rotate for 2 weeks on a mandatory rotation performing the majority of the procedures done by the service. Every procedure is supervised by an attending hospitalist who has received extended training from interventional radiologists and emergency department ultrasound faculty. Patients are referred to the service by their primary admitting team. Interns receive procedure‐specific didactics, demonstration, and practice with procedure kits, supplemental readings, computer‐based procedure modules, and evidence‐based summaries of procedure‐related considerations. All interns also attend a half‐day procedure simulation session to review procedural and ultrasound techniques.

While interns obtain informed consent and prepare the patient for the procedure, the attending and intern team communicate the following points with each patient: 1) identification as the dedicated procedure team, separate from the primary team caring for the patient; 2) attending self‐identification as the supervisor; 3) attention to stepwise communication with the patient during the procedure; 4) attention to patient comfort throughout the procedure; 5) emphasis on patient safety through the use of time‐outs, sterile technique, and ultrasound when appropriate; and 6) the intention to discuss best practice and teach during the procedure.

All paracentesis and thoracentesis sites are marked by using bedside ultrasound (S‐Cath, SonoSite, Bothell, WA) guidance prior to and, if needed, during the procedure. Ultrasound is occasionally used for marking joint aspiration and lumbar puncture.11 Interns are responsible for making an initial site marking, which is then confirmed by the attending physician. Although not systematized, our service encourages the intern and attending to communicate about proper technique during the procedure itself. For example, attendings ask questions about technique based on evidence in the literature (eg, Why do you replace the stylet in a lumbar puncture needle prior to removal?) or about trouble shooting (eg, What would you do if the flow of ascites stops during this paracentesis?) and also correct any errors in technique (Recall the angle you intended to use based on the ultrasound view).

Patients

Patients are referred to the procedure service by their primary team; referrals are accepted for patients on all services at all levels of care, including the emergency department (ED) and the intensive care unit (ICU). Participants in this study were referred for one of our target procedures (paracentesis, thoracentesis, or lumbar puncture) between November 2008 and July 2009. Patients gave written consent for the supplemental survey independent of consent for the procedure. All consents and procedures were performed in a patient's hospital room and one family member was allowed to stay in the room if desired by the patient. After the completion of the procedure, the attending on the procedure service at the time, which included study authors D.S. and M.M., approached consecutive patients who spoke and read English and were deemed to have capacity to consent for their own procedure to be surveyed. Patients were considered to have capacity to consent based on commonly accepted criteria described in the literature.12, 13 Patients were also excluded if their procedure was performed by the attending alone, if they had repeated procedures done by the service, or if they were too altered or critically ill to participate in the survey.

Survey

Our survey was developed through identification of items reported in the literature,1421 as well as items newly developed for purposes of examining our primary aims. Newly developed questions focused on patients' satisfaction with major aspects of procedure performance as well as the quality and impact of communication with the patient and between members of the team. Two open‐text questions were included to allow patients to share what went well with the procedure as well as areas for improvement. The research team developed a pool of question items for potential inclusion in a patient satisfaction questionnaire. These items were then shown to a group of research‐oriented health professionals, who meet regularly to review academic research protocols. The group provided their opinions about the content and comprehension of the questions, and the written survey employed was a result of their revisions (see Appendix in Supporting Information online).

Written surveys were distributed to patients by the hospitalist attending on service following the procedure as permitted by patients' severity of illness and availability. Surveys were anonymous and self‐administered by the patient or a family member who was in the room for the procedure; all questions were voluntary. A nurse was made responsible for collecting the survey when possible. Survey results were entered into a database without identifiers, with limited demographic information; patient gender, age, and procedure type were included by the attending hospitalist at the end of the survey. A separate and more detailed procedure database was kept of all procedures performed and was used to record patient consent or reason for not consenting as well as documented receipt of a completed survey. This non‐anonymous database contained detailed supplemental information including patient age, level of care, referring service, presence of bloody fluid at any point during the procedure, and physician‐reported immediate complications at the bedside in free text.

Analysis

Reported immediate complications were classified into major and minor based on reported definitions in the literature.2226 Similar to previous studies, major immediate complications were defined as those requiring further procedural intervention, medical therapy, or both.27 Major complications were defined as: bleeding requiring transfusion, pneumothorax requiring a chest tube, respiratory failure, bowel perforation, cerebral herniation or shock, cerebrospinal fluid (CSF) leak requiring intervention, and transfer to a higher level of care. For patients receiving a thoracentesis, chart review was performed to determine the presence of a follow‐up chest x‐ray, the presence of a pneumothorax, or clinical evidence for re‐expansion pulmonary edema. We analyzed differences between respondents and non‐respondents using Chi‐square tests for categorical variables (gender, level of care, referring service, procedure type, bloody fluid, and immediate reported complications) and independent t tests for continuous variables (age).

After review of the open‐ended fields, responses were classified into the following categories: pain control, physician skill, professionalism, communication, symptom relief, procedure duration, and miscellaneous comments. Responses regarding patient perceptions of physician communication were dichotomized into positive (1 = Strongly Agree, 2 = Agree) and negative (3 = Neutral, 4 = Disagree, and 5 = Strongly Disagree), and independent t tests were used to determine the contribution of factors, such as age, while Chi‐square tests were used for the contribution of gender and procedure type. All statistical tests were performed by using the SAS statistical application program (version 9.2).

Respondent Characteristics

Of 324 procedures performed by the HPS during the study period, 95 (29%) were eligible for consent. Of the 229 patients not eligible for consent, 32 (10%) were excluded because the procedure was performed by the attending alone, 76 (23%) lacked English proficiency or literacy, 66 (20%) had altered mental status, 32 (10%) were intubated and/or had severe illness precluding consent, and 23 (7%) were repeat procedures on patients who had previously completed the survey. Only two patients specifically requested an attending to perform the procedure after an introduction to the service. Of the 95 patients eligible for consent, 89 were consented for the survey, and 65 (68%) completed the survey. Of the six eligible, non‐consented patients, all were leaving the floor immediately following the procedure, and time did not allow for consent and survey distribution. There were no differences between eligible responders and nonresponders in age, gender, procedure, requesting service, presence of bloody fluid, or physician‐reported immediate complications (Table 1).

Complications

As complications would likely play a role in procedure satisfaction, we describe immediate complications for the study population. Of the 324 procedures performed during the study period, no patient had predefined major immediate complications. Upon further chart review of the 96 patients that had a thoracentesis performed, all had a follow‐up chest x‐ray and none suffered an iatrogenic pneumothorax or re‐expansion pulmonary edema. Minor immediate complications for the 324 procedures were reported as follows: postprocedure pain in four patients (1.2%), cough in nine patients (2.8%), five equipment malfunctions (1.5%), four ascites leaks (1.2%), and one incisional bleed requiring a suture for hemostasis (0.3%). There was no significant difference in complications between those consented for the survey and the total study population.

Procedure Satisfaction

More than 90% of patients were satisfied or very satisfied with most aspects of the procedure, including the informed consent process, pain control, expertise, and courtesy of physicians (Table 2). The percentage of patients satisfied with the duration of procedure (88%) was lower than for other measures of satisfaction. Of the 38 patients receiving therapeutic procedures, 34 (89%) were satisfied or highly satisfied with the improvement in symptoms following the procedure.

When asked what went well with the procedure, 59 (91%) respondents provided additional comments and feedback. Each response was classified as described in the Methods section. Of the free text responses, 8 of the 59 patients (14%) commented on the attention to pain control (eg, The caring and attention to my pain was most important to me), 5 (8%) on the skills of the operators (Great examination of the entire stomach region with the ultrasound to ensure the best position of the catheter), 6 (10%) on the courtesy and professionalism of the team (eg, Courteous, team‐feeling, addressed my concerns), 9 (15%) on their communication with the team (eg, The doctors made me feel very comfortable before the procedure by laying out the plan and explaining each part of the procedure), and 8 (14%) on relief of their symptoms (eg, There was an almost immediate and significant improvement in my breathing, bloating, and pain). Twenty‐three of the 59 comments (39%) were categorized as miscellaneous (eg, All went great. I fell asleep).

When asked areas for improvement, 55 (85%) patients responded. Thirty‐three patients (60%) reported that nothing could be improved or they instructed the team to just keep doing what you are doing, while 22 (40%) patients expressed a concern. Responses were categorized in a similar fashion to the positive responses. Five of the 22 negative comments (23%) reported that the procedure took too long (eg, Procedure could have been shorter. I got tired sitting up), 4 (18%) commented on pain control (eg, The poke for marking my skin hurt more than the anesthetic. I was surprised), 6 (27%) felt communication was a problem (eg, Discuss the steps with the patient audibly, no whispering, speak clearly), and 7 (32%) had miscellaneous concerns (eg, Try not to do this procedure right after another one).

Physician Communication

Sixty‐four patients (98%) reported that the physicians performing their procedure communicated with each other during the procedure (Table 3). Although one patient did not feel that the physicians communicated with each other, he or she still answered the follow‐up questions regarding perceptions of physician communication. We excluded this patient from our analysis as his or her answers may not be reliable. The majority of patients (84%) reported this communication as reassuring and felt it was a normal part of procedure performance (94%). Those that did not agree that physician communication was reassuring did not differ in average age (P = 0.307), gender (P = 0.511), or procedure type (P = 0.562).

Of all positive and negative comments, five specifically addressed communication between physicians. Most (four) reflected satisfaction with bedside teaching (eg, They discussed the procedure in a professional manner and eased my mind at all times) and with having an expert in the room (eg, [The team] discussed things like needle placement, which was nice because there was a second opinion right there in the room). Patients also felt that it was good to experience the teaching, with one patient reporting that the best part of the procedure was watching doctors learn from each other. Patients did not express specific reservations about bedside teaching, resident technique, or fear of complications in free text.

Organizational Aims and Financial Impact: Determining Costs and Benefits

Organizational goals drive decision making and resource allocation at all levels. As priorities change with time, understanding which predominate in an organization will be essential to building a business case. Institutions may be more willing to adopt expensive innovations if they are justified by progress toward the qualitative organizational goals. Figure 1 demonstrates several institutional goals both qualitative (provider satisfaction, quality improvement, and institutional reputation) and quantitative (cost avoidance, cost savings, and revenue generation) that could drive the decision making for an electronic discharge summary. After examining how an initiative aligns with institutional aims, the next step is to weigh the benefits against the potential costs. Costs in our example include not only the quantitative financial investment in information technology (IT) infrastructure, personnel and maintenance, but also may include qualitative costs such as loss of staff efficiency and redundant documentation. Costs and savings will be geographically variable and depend on the institutional framework, eg, the existing system for medical records, institutional patient payer mix, type of payment structure (global vs. utilization based*), and reimbursement rates. While it may be impractical to account for every cost and savings resulting from the project implementation, every effort should be made to account for the key variables that make up the cost‐benefit calculation.

Current State of Discharge Documentation a UCSF

UCSF Medical Center is a 600‐bed quaternary care academic institution that discharges approximately 100 patients per day. Our hospital discharge summary is used to document a patient's hospital course and post discharge plan, information necessary for continued care in the outpatient setting. Literature supports the potential for timely and relevant discharge summaries to improve care transitions, clinician satisfaction, and resource use.1 In 2008, however, the majority of our discharge summaries were completed greater than 14 days post discharge, in accordance with national practice.2 Despite Centers for Medicare & Medicaid Services (CMS) and the Joint Commission discharge summary standards regarding content,3, 4 most discharge summaries are composed using freeform dictation.2 Consequently, discharge summaries often lack critical information,57 and may not reach the correct outpatient provider in a timely manner.5, 811

Our Proposed Solution: E‐Discharge

As hospitals are increasingly implementing electronic medical records (EMR),12 there is a growing opportunity to efficiently and reliably incorporate information from the medical record into electronic or database assisted discharge materials. At UCSF the need to develop a system to document and communicate tests pending at discharge fueled the development of an electronic discharge summary. UCSF's vendor‐supplied EMR lacks the ability to integrate electronic patient data into a progress note or discharge summary in a manner usable for physicians. Instead physicians are required to use a telephone voice dictation system, which is subsequently transcribed to text within 1 to 3 days. A separate software platform tracks attending signature of the transcribed text and automatically triggers dissemination through computerized fax and campus mail. The turnaround time for a discharge summary can be as long as 3 weeks. With the time involved and high cost of implementing new or more sophisticated versions of EMR, we chose to design a solution that would improve care for our patients in a more immediate and cost neutral fashion. Our goal was to create an affordable, electronic, systematized solution to produce both timely and relevant discharge summaries, in the hopes of improving communications with providers and thus patient outcomes.

In earlier work, UCSF developed UCSF Note Writer, a template‐based documentation tool that uses web service to import data from the underlying database for provider documentation.13 As a standardized template has been shown to improve quality of communication to both patients and referring providers,1, 14, 15 we developed a template in UCSF Note Writer with both free text and auto‐populated fields for a discharge summary based on current guidelines.1619 We encouraged the documentation of medication changes, changes in functional status and pending tests.

The adoption of such an electronic format has also been shown to improve the efficiency of discharge documentation over conventional dictation and transcription.1, 2022 While this change may be institution dependent, we employed strategies such as allowing the discharge summary to be initiated and updated throughout the hospital admission and unifying the discharge summary with the last day's progress note to facilitate timeliness. To promote efficiency, we allowed providers to import pertinent labs, microbiology, and in the future, the importation of pending tests. While the electronic format in itself does not promote timeliness, it incorporates the discharge summary into physician daily workflow and enables efficiency in data gathering and transfer. For outpatient providers who can access the EMR, any delay or potential fault in the delivery of the discharge materials is eliminated, while outside providers can receive copies through other rapid and reliable modes of electronic delivery (eg, EMR inbox notification) with an appropriate infrastructure.

Quality and Safety

Publically reported data are often derived from hospital chart abstraction and may impact accreditation, reputation, and pay for performance programs.18, 23, 24 The discharge summary is a readily available source of information regarding discharge medications, patient instruction, and communication regarding pending tests. As such, its quality should be a priority for hospital decision makers. Electronic discharge summaries have the potential to reduce adverse events in the high‐risk post‐hospitalization period.1, 25 As such they may improve outpatient physicians' ability to deliver relevant care, reduce preventable readmissions26 and reduce malpractice vulnerability27all key drivers in organizational decision making.

Patient Satisfaction

Patients want to feel prepared for discharge by understanding the continuity of their care from the hospital to the outpatient setting. Discharge preparedness, commonly queried and reported in national patient satisfaction surveys, is low.28 Many electronic discharge summary platforms allow for translation into tailored patient instructions available to the patient in real time, helping to ensure that patients receive quality discharge education.29

Referring Physician Satisfaction

Poor discharge communication reduces referring physicians' satisfaction, which may discourage them from referring patients to the hospital or organization, having broader financial implications.25, 30 Even for medical centers with a busy emergency department, outpatient physician referrals and recommendations make up over 50% of an institution's admissions.31 An electronic discharge summary available in the EMR at the time of discharge, electronically transmitted to referring providers can impact the referral patterns of community physicians.

Readmission

Now publicly reported, readmission rates are another benchmark by which to judge hospital care.32 Patients with discharge summaries that are unavailable to outpatient providers, a very common occurance,2 have a higher trend toward readmission.26 Improved quality of care at the time of discharge resulting in fewer readmissions will better position hospitals to contend with potential Medicare reforms.

IT Infrastructure: Transcription, Deficiency Tracking, Dissemination

Hospitals, including UCSF, use internal or external transcriptionists to transcribe dictated recordings into typed text at a substantial cost to large medical centers. Medical records staff also track both discharge summary completion and their dissemination to referring providers in compliance with regulatory mandates.4, 33 The use of electronic documentation that relies on physician‐direct entry and that automates dissemination and tracking of discharge documentation provides a potential cost savings to offset the costs of a new system. UCSF Medical Center discharges 100 patients per day and could conservatively avoid almost $500,000 in transcription costs annually (Text Box 1).34

Text Box 1

Billing

Delays in completion of discharge summaries result in billing delays when critical information required for coding is in the discharge summary. Deferred payment on long admissions can reach tens of thousands of dollars, representing a significant strain on medical center finances. Comprehensive electronic discharge materials may simplify coding through careful documentation and improve billing efficiency through rapid completion.

At our medical center, approximately 20% of billing is delayed due to incomplete discharge documentation. For a hospital that generates over $1.4 billion dollars in billing revenue per year, this can translate into significant financial losses. Hospitals may have to borrow money or draw from existing resources to cover operative deficits created by a delay in the receipt of large payment. Lenders charge approximately 1% to 2% annual interest rate, which translates into 0.2% to 0.4% in billed costs that the hospital gives away to their lenders. Hospitals would be well served by eliminating delays in billing to improve revenue flow (Text Box 2).

Text Box 2

Efficiency and Physician Time

Implementation of any new system is likely to result in initial diminished efficiency. If patient volume is stable, this may not translate into loss of revenue, but rather cause staff to change their workflow. For example, given the new inefficiency in charting, staff may spend less time on direct patient care tasks (Intravenous Catheter placement, FT placement, patient education, discharge instructions), thus increasing the qualitative costs to implementing the system.

To minimize these costs, we used a step wise phased role out starting with one pilot team, with a plan to expand to multiple teams prior to implementation on the entire medicine service. This allowed for the creation of one central and several ancillary physician champions to troubleshoot the new system to help minimize productivity losses. One of the largest concerns in the switch from voice dictation to physician‐direct entry into an electronic summary is the cost of physician time. System adjustments through several pilots helped ensure that the time investment of a novice user was not significantly greater than time previously spent dictating.

Quality of Documentation

Unanticipated consequences from a switch to an electronic platform must be considered, such as the possibility of longer more redundant discharge summaries. The amount of information available for automated import will vary by institutional preference, but the recipient's access to the EMR, primary physician preference, and technologic capabilities should be considered. At UCSF we made an effort to distill the information most important to subsequent care, disabling the importation of multiple days of radiology data and instead working to create a system for discharge medication importation. As with any electronic document, the medium also lends itself to cutting and pasting, which may lead to anachronistic information carried forward from hospital progress notes earlier in the stay.35, 36 The largest experience with this unintended consequence can be found in the Veteran's Affairs Health System EMR, which found that 9% of progress notes studied contained copied or duplicated text.37 The authors recommended that clear policies, programs to raise practitioner awareness, and the development of monitoring procedure be implemented coincident with electronic note‐writing capabilities.

Infrastructure

For most health care organizations, the transition to an EMR includes adoption of results reporting systems and computerized provider order entry; only a more select group of hospitals with a complete EMR electronically document inpatient care (eg, progress notes) through physician direct entry. While there is substantial literature regarding the benefits and pitfalls of adopting computerized order entry (CPOE),38, 39 there is less attention devoted to the costs of implementing large‐scale electronic documentation, including an electronic discharge summary, as opposed to paper notes or dictation.4042 Institutions using an EMR with electronic care documentation capability have already invested in the infrastructure to implement electronic discharge documentation, and can employ it at a modest cost. For these institutions, the infrastructure cost of the transition from paper charting or dictation to direct entry by physicians lies in ensuring sufficient computers and connectivity to handle the increased computer use. On the other hand, for those institutions where the EMR lacks this capability there are few freestanding documentation platforms available for purchase. The cost of implementing such a system is high, both for the purchase of additional software and the integration of that software in to the EMR supplied by the primary vendor. Other notable infrastructure costs to consider are ensuring sufficient network connectivity, computers and printers to accommodate increased use that will come with electronic note writing as well as server support for system backups.

Personnel

Engaging the right personnel will smooth the implementation of an electronic discharge summary. In addition to dedicated user training sessions, a physician champion who can promote and monitor user training on the new platform will facilitate prompt implementation. An IT support programmer should work with the physician champion to address concerns and troubleshoot problems. Additional personnel may also be needed to track progress in discharge summary adoption, quality and efficiency. Ideally these personnel can be funneled from those who work transcribing, disseminating and tracking completion of discharge summaries, positions that will be needed in a reduced capacity.

Maintenance

Increased IT infrastructure also means increased IT maintenance and upgrades of servers, network connectivity, computers and printers. Discussions with vendors regarding costs of maintenance, upgrades and add‐on features should be considered when adopting an electronic discharge summary platform.

Organizational Aims and Financial Impact: Determining Costs and Benefits

Organizational goals drive decision making and resource allocation at all levels. As priorities change with time, understanding which predominate in an organization will be essential to building a business case. Institutions may be more willing to adopt expensive innovations if they are justified by progress toward the qualitative organizational goals. Figure 1 demonstrates several institutional goals both qualitative (provider satisfaction, quality improvement, and institutional reputation) and quantitative (cost avoidance, cost savings, and revenue generation) that could drive the decision making for an electronic discharge summary. After examining how an initiative aligns with institutional aims, the next step is to weigh the benefits against the potential costs. Costs in our example include not only the quantitative financial investment in information technology (IT) infrastructure, personnel and maintenance, but also may include qualitative costs such as loss of staff efficiency and redundant documentation. Costs and savings will be geographically variable and depend on the institutional framework, eg, the existing system for medical records, institutional patient payer mix, type of payment structure (global vs. utilization based*), and reimbursement rates. While it may be impractical to account for every cost and savings resulting from the project implementation, every effort should be made to account for the key variables that make up the cost‐benefit calculation.

Current State of Discharge Documentation a UCSF

UCSF Medical Center is a 600‐bed quaternary care academic institution that discharges approximately 100 patients per day. Our hospital discharge summary is used to document a patient's hospital course and post discharge plan, information necessary for continued care in the outpatient setting. Literature supports the potential for timely and relevant discharge summaries to improve care transitions, clinician satisfaction, and resource use.1 In 2008, however, the majority of our discharge summaries were completed greater than 14 days post discharge, in accordance with national practice.2 Despite Centers for Medicare & Medicaid Services (CMS) and the Joint Commission discharge summary standards regarding content,3, 4 most discharge summaries are composed using freeform dictation.2 Consequently, discharge summaries often lack critical information,57 and may not reach the correct outpatient provider in a timely manner.5, 811

Our Proposed Solution: E‐Discharge

As hospitals are increasingly implementing electronic medical records (EMR),12 there is a growing opportunity to efficiently and reliably incorporate information from the medical record into electronic or database assisted discharge materials. At UCSF the need to develop a system to document and communicate tests pending at discharge fueled the development of an electronic discharge summary. UCSF's vendor‐supplied EMR lacks the ability to integrate electronic patient data into a progress note or discharge summary in a manner usable for physicians. Instead physicians are required to use a telephone voice dictation system, which is subsequently transcribed to text within 1 to 3 days. A separate software platform tracks attending signature of the transcribed text and automatically triggers dissemination through computerized fax and campus mail. The turnaround time for a discharge summary can be as long as 3 weeks. With the time involved and high cost of implementing new or more sophisticated versions of EMR, we chose to design a solution that would improve care for our patients in a more immediate and cost neutral fashion. Our goal was to create an affordable, electronic, systematized solution to produce both timely and relevant discharge summaries, in the hopes of improving communications with providers and thus patient outcomes.

In earlier work, UCSF developed UCSF Note Writer, a template‐based documentation tool that uses web service to import data from the underlying database for provider documentation.13 As a standardized template has been shown to improve quality of communication to both patients and referring providers,1, 14, 15 we developed a template in UCSF Note Writer with both free text and auto‐populated fields for a discharge summary based on current guidelines.1619 We encouraged the documentation of medication changes, changes in functional status and pending tests.

The adoption of such an electronic format has also been shown to improve the efficiency of discharge documentation over conventional dictation and transcription.1, 2022 While this change may be institution dependent, we employed strategies such as allowing the discharge summary to be initiated and updated throughout the hospital admission and unifying the discharge summary with the last day's progress note to facilitate timeliness. To promote efficiency, we allowed providers to import pertinent labs, microbiology, and in the future, the importation of pending tests. While the electronic format in itself does not promote timeliness, it incorporates the discharge summary into physician daily workflow and enables efficiency in data gathering and transfer. For outpatient providers who can access the EMR, any delay or potential fault in the delivery of the discharge materials is eliminated, while outside providers can receive copies through other rapid and reliable modes of electronic delivery (eg, EMR inbox notification) with an appropriate infrastructure.

Quality and Safety

Publically reported data are often derived from hospital chart abstraction and may impact accreditation, reputation, and pay for performance programs.18, 23, 24 The discharge summary is a readily available source of information regarding discharge medications, patient instruction, and communication regarding pending tests. As such, its quality should be a priority for hospital decision makers. Electronic discharge summaries have the potential to reduce adverse events in the high‐risk post‐hospitalization period.1, 25 As such they may improve outpatient physicians' ability to deliver relevant care, reduce preventable readmissions26 and reduce malpractice vulnerability27all key drivers in organizational decision making.

Patient Satisfaction

Patients want to feel prepared for discharge by understanding the continuity of their care from the hospital to the outpatient setting. Discharge preparedness, commonly queried and reported in national patient satisfaction surveys, is low.28 Many electronic discharge summary platforms allow for translation into tailored patient instructions available to the patient in real time, helping to ensure that patients receive quality discharge education.29

Referring Physician Satisfaction

Poor discharge communication reduces referring physicians' satisfaction, which may discourage them from referring patients to the hospital or organization, having broader financial implications.25, 30 Even for medical centers with a busy emergency department, outpatient physician referrals and recommendations make up over 50% of an institution's admissions.31 An electronic discharge summary available in the EMR at the time of discharge, electronically transmitted to referring providers can impact the referral patterns of community physicians.

Readmission

Now publicly reported, readmission rates are another benchmark by which to judge hospital care.32 Patients with discharge summaries that are unavailable to outpatient providers, a very common occurance,2 have a higher trend toward readmission.26 Improved quality of care at the time of discharge resulting in fewer readmissions will better position hospitals to contend with potential Medicare reforms.

IT Infrastructure: Transcription, Deficiency Tracking, Dissemination

Hospitals, including UCSF, use internal or external transcriptionists to transcribe dictated recordings into typed text at a substantial cost to large medical centers. Medical records staff also track both discharge summary completion and their dissemination to referring providers in compliance with regulatory mandates.4, 33 The use of electronic documentation that relies on physician‐direct entry and that automates dissemination and tracking of discharge documentation provides a potential cost savings to offset the costs of a new system. UCSF Medical Center discharges 100 patients per day and could conservatively avoid almost $500,000 in transcription costs annually (Text Box 1).34

Text Box 1

Billing

Delays in completion of discharge summaries result in billing delays when critical information required for coding is in the discharge summary. Deferred payment on long admissions can reach tens of thousands of dollars, representing a significant strain on medical center finances. Comprehensive electronic discharge materials may simplify coding through careful documentation and improve billing efficiency through rapid completion.

At our medical center, approximately 20% of billing is delayed due to incomplete discharge documentation. For a hospital that generates over $1.4 billion dollars in billing revenue per year, this can translate into significant financial losses. Hospitals may have to borrow money or draw from existing resources to cover operative deficits created by a delay in the receipt of large payment. Lenders charge approximately 1% to 2% annual interest rate, which translates into 0.2% to 0.4% in billed costs that the hospital gives away to their lenders. Hospitals would be well served by eliminating delays in billing to improve revenue flow (Text Box 2).

Text Box 2

Efficiency and Physician Time

Implementation of any new system is likely to result in initial diminished efficiency. If patient volume is stable, this may not translate into loss of revenue, but rather cause staff to change their workflow. For example, given the new inefficiency in charting, staff may spend less time on direct patient care tasks (Intravenous Catheter placement, FT placement, patient education, discharge instructions), thus increasing the qualitative costs to implementing the system.

To minimize these costs, we used a step wise phased role out starting with one pilot team, with a plan to expand to multiple teams prior to implementation on the entire medicine service. This allowed for the creation of one central and several ancillary physician champions to troubleshoot the new system to help minimize productivity losses. One of the largest concerns in the switch from voice dictation to physician‐direct entry into an electronic summary is the cost of physician time. System adjustments through several pilots helped ensure that the time investment of a novice user was not significantly greater than time previously spent dictating.

Quality of Documentation

Unanticipated consequences from a switch to an electronic platform must be considered, such as the possibility of longer more redundant discharge summaries. The amount of information available for automated import will vary by institutional preference, but the recipient's access to the EMR, primary physician preference, and technologic capabilities should be considered. At UCSF we made an effort to distill the information most important to subsequent care, disabling the importation of multiple days of radiology data and instead working to create a system for discharge medication importation. As with any electronic document, the medium also lends itself to cutting and pasting, which may lead to anachronistic information carried forward from hospital progress notes earlier in the stay.35, 36 The largest experience with this unintended consequence can be found in the Veteran's Affairs Health System EMR, which found that 9% of progress notes studied contained copied or duplicated text.37 The authors recommended that clear policies, programs to raise practitioner awareness, and the development of monitoring procedure be implemented coincident with electronic note‐writing capabilities.

Infrastructure

For most health care organizations, the transition to an EMR includes adoption of results reporting systems and computerized provider order entry; only a more select group of hospitals with a complete EMR electronically document inpatient care (eg, progress notes) through physician direct entry. While there is substantial literature regarding the benefits and pitfalls of adopting computerized order entry (CPOE),38, 39 there is less attention devoted to the costs of implementing large‐scale electronic documentation, including an electronic discharge summary, as opposed to paper notes or dictation.4042 Institutions using an EMR with electronic care documentation capability have already invested in the infrastructure to implement electronic discharge documentation, and can employ it at a modest cost. For these institutions, the infrastructure cost of the transition from paper charting or dictation to direct entry by physicians lies in ensuring sufficient computers and connectivity to handle the increased computer use. On the other hand, for those institutions where the EMR lacks this capability there are few freestanding documentation platforms available for purchase. The cost of implementing such a system is high, both for the purchase of additional software and the integration of that software in to the EMR supplied by the primary vendor. Other notable infrastructure costs to consider are ensuring sufficient network connectivity, computers and printers to accommodate increased use that will come with electronic note writing as well as server support for system backups.

Personnel

Engaging the right personnel will smooth the implementation of an electronic discharge summary. In addition to dedicated user training sessions, a physician champion who can promote and monitor user training on the new platform will facilitate prompt implementation. An IT support programmer should work with the physician champion to address concerns and troubleshoot problems. Additional personnel may also be needed to track progress in discharge summary adoption, quality and efficiency. Ideally these personnel can be funneled from those who work transcribing, disseminating and tracking completion of discharge summaries, positions that will be needed in a reduced capacity.

Maintenance

Increased IT infrastructure also means increased IT maintenance and upgrades of servers, network connectivity, computers and printers. Discussions with vendors regarding costs of maintenance, upgrades and add‐on features should be considered when adopting an electronic discharge summary platform.

Organizational Aims and Financial Impact: Determining Costs and Benefits

Organizational goals drive decision making and resource allocation at all levels. As priorities change with time, understanding which predominate in an organization will be essential to building a business case. Institutions may be more willing to adopt expensive innovations if they are justified by progress toward the qualitative organizational goals. Figure 1 demonstrates several institutional goals both qualitative (provider satisfaction, quality improvement, and institutional reputation) and quantitative (cost avoidance, cost savings, and revenue generation) that could drive the decision making for an electronic discharge summary. After examining how an initiative aligns with institutional aims, the next step is to weigh the benefits against the potential costs. Costs in our example include not only the quantitative financial investment in information technology (IT) infrastructure, personnel and maintenance, but also may include qualitative costs such as loss of staff efficiency and redundant documentation. Costs and savings will be geographically variable and depend on the institutional framework, eg, the existing system for medical records, institutional patient payer mix, type of payment structure (global vs. utilization based*), and reimbursement rates. While it may be impractical to account for every cost and savings resulting from the project implementation, every effort should be made to account for the key variables that make up the cost‐benefit calculation.

Current State of Discharge Documentation a UCSF

UCSF Medical Center is a 600‐bed quaternary care academic institution that discharges approximately 100 patients per day. Our hospital discharge summary is used to document a patient's hospital course and post discharge plan, information necessary for continued care in the outpatient setting. Literature supports the potential for timely and relevant discharge summaries to improve care transitions, clinician satisfaction, and resource use.1 In 2008, however, the majority of our discharge summaries were completed greater than 14 days post discharge, in accordance with national practice.2 Despite Centers for Medicare & Medicaid Services (CMS) and the Joint Commission discharge summary standards regarding content,3, 4 most discharge summaries are composed using freeform dictation.2 Consequently, discharge summaries often lack critical information,57 and may not reach the correct outpatient provider in a timely manner.5, 811

Our Proposed Solution: E‐Discharge

As hospitals are increasingly implementing electronic medical records (EMR),12 there is a growing opportunity to efficiently and reliably incorporate information from the medical record into electronic or database assisted discharge materials. At UCSF the need to develop a system to document and communicate tests pending at discharge fueled the development of an electronic discharge summary. UCSF's vendor‐supplied EMR lacks the ability to integrate electronic patient data into a progress note or discharge summary in a manner usable for physicians. Instead physicians are required to use a telephone voice dictation system, which is subsequently transcribed to text within 1 to 3 days. A separate software platform tracks attending signature of the transcribed text and automatically triggers dissemination through computerized fax and campus mail. The turnaround time for a discharge summary can be as long as 3 weeks. With the time involved and high cost of implementing new or more sophisticated versions of EMR, we chose to design a solution that would improve care for our patients in a more immediate and cost neutral fashion. Our goal was to create an affordable, electronic, systematized solution to produce both timely and relevant discharge summaries, in the hopes of improving communications with providers and thus patient outcomes.

In earlier work, UCSF developed UCSF Note Writer, a template‐based documentation tool that uses web service to import data from the underlying database for provider documentation.13 As a standardized template has been shown to improve quality of communication to both patients and referring providers,1, 14, 15 we developed a template in UCSF Note Writer with both free text and auto‐populated fields for a discharge summary based on current guidelines.1619 We encouraged the documentation of medication changes, changes in functional status and pending tests.

The adoption of such an electronic format has also been shown to improve the efficiency of discharge documentation over conventional dictation and transcription.1, 2022 While this change may be institution dependent, we employed strategies such as allowing the discharge summary to be initiated and updated throughout the hospital admission and unifying the discharge summary with the last day's progress note to facilitate timeliness. To promote efficiency, we allowed providers to import pertinent labs, microbiology, and in the future, the importation of pending tests. While the electronic format in itself does not promote timeliness, it incorporates the discharge summary into physician daily workflow and enables efficiency in data gathering and transfer. For outpatient providers who can access the EMR, any delay or potential fault in the delivery of the discharge materials is eliminated, while outside providers can receive copies through other rapid and reliable modes of electronic delivery (eg, EMR inbox notification) with an appropriate infrastructure.

Quality and Safety

Publically reported data are often derived from hospital chart abstraction and may impact accreditation, reputation, and pay for performance programs.18, 23, 24 The discharge summary is a readily available source of information regarding discharge medications, patient instruction, and communication regarding pending tests. As such, its quality should be a priority for hospital decision makers. Electronic discharge summaries have the potential to reduce adverse events in the high‐risk post‐hospitalization period.1, 25 As such they may improve outpatient physicians' ability to deliver relevant care, reduce preventable readmissions26 and reduce malpractice vulnerability27all key drivers in organizational decision making.

Patient Satisfaction

Patients want to feel prepared for discharge by understanding the continuity of their care from the hospital to the outpatient setting. Discharge preparedness, commonly queried and reported in national patient satisfaction surveys, is low.28 Many electronic discharge summary platforms allow for translation into tailored patient instructions available to the patient in real time, helping to ensure that patients receive quality discharge education.29

Referring Physician Satisfaction

Poor discharge communication reduces referring physicians' satisfaction, which may discourage them from referring patients to the hospital or organization, having broader financial implications.25, 30 Even for medical centers with a busy emergency department, outpatient physician referrals and recommendations make up over 50% of an institution's admissions.31 An electronic discharge summary available in the EMR at the time of discharge, electronically transmitted to referring providers can impact the referral patterns of community physicians.

Readmission

Now publicly reported, readmission rates are another benchmark by which to judge hospital care.32 Patients with discharge summaries that are unavailable to outpatient providers, a very common occurance,2 have a higher trend toward readmission.26 Improved quality of care at the time of discharge resulting in fewer readmissions will better position hospitals to contend with potential Medicare reforms.

IT Infrastructure: Transcription, Deficiency Tracking, Dissemination

Hospitals, including UCSF, use internal or external transcriptionists to transcribe dictated recordings into typed text at a substantial cost to large medical centers. Medical records staff also track both discharge summary completion and their dissemination to referring providers in compliance with regulatory mandates.4, 33 The use of electronic documentation that relies on physician‐direct entry and that automates dissemination and tracking of discharge documentation provides a potential cost savings to offset the costs of a new system. UCSF Medical Center discharges 100 patients per day and could conservatively avoid almost $500,000 in transcription costs annually (Text Box 1).34

Text Box 1

Billing

Delays in completion of discharge summaries result in billing delays when critical information required for coding is in the discharge summary. Deferred payment on long admissions can reach tens of thousands of dollars, representing a significant strain on medical center finances. Comprehensive electronic discharge materials may simplify coding through careful documentation and improve billing efficiency through rapid completion.

At our medical center, approximately 20% of billing is delayed due to incomplete discharge documentation. For a hospital that generates over $1.4 billion dollars in billing revenue per year, this can translate into significant financial losses. Hospitals may have to borrow money or draw from existing resources to cover operative deficits created by a delay in the receipt of large payment. Lenders charge approximately 1% to 2% annual interest rate, which translates into 0.2% to 0.4% in billed costs that the hospital gives away to their lenders. Hospitals would be well served by eliminating delays in billing to improve revenue flow (Text Box 2).

Text Box 2

Efficiency and Physician Time

Implementation of any new system is likely to result in initial diminished efficiency. If patient volume is stable, this may not translate into loss of revenue, but rather cause staff to change their workflow. For example, given the new inefficiency in charting, staff may spend less time on direct patient care tasks (Intravenous Catheter placement, FT placement, patient education, discharge instructions), thus increasing the qualitative costs to implementing the system.

To minimize these costs, we used a step wise phased role out starting with one pilot team, with a plan to expand to multiple teams prior to implementation on the entire medicine service. This allowed for the creation of one central and several ancillary physician champions to troubleshoot the new system to help minimize productivity losses. One of the largest concerns in the switch from voice dictation to physician‐direct entry into an electronic summary is the cost of physician time. System adjustments through several pilots helped ensure that the time investment of a novice user was not significantly greater than time previously spent dictating.

Quality of Documentation

Unanticipated consequences from a switch to an electronic platform must be considered, such as the possibility of longer more redundant discharge summaries. The amount of information available for automated import will vary by institutional preference, but the recipient's access to the EMR, primary physician preference, and technologic capabilities should be considered. At UCSF we made an effort to distill the information most important to subsequent care, disabling the importation of multiple days of radiology data and instead working to create a system for discharge medication importation. As with any electronic document, the medium also lends itself to cutting and pasting, which may lead to anachronistic information carried forward from hospital progress notes earlier in the stay.35, 36 The largest experience with this unintended consequence can be found in the Veteran's Affairs Health System EMR, which found that 9% of progress notes studied contained copied or duplicated text.37 The authors recommended that clear policies, programs to raise practitioner awareness, and the development of monitoring procedure be implemented coincident with electronic note‐writing capabilities.

Infrastructure

For most health care organizations, the transition to an EMR includes adoption of results reporting systems and computerized provider order entry; only a more select group of hospitals with a complete EMR electronically document inpatient care (eg, progress notes) through physician direct entry. While there is substantial literature regarding the benefits and pitfalls of adopting computerized order entry (CPOE),38, 39 there is less attention devoted to the costs of implementing large‐scale electronic documentation, including an electronic discharge summary, as opposed to paper notes or dictation.4042 Institutions using an EMR with electronic care documentation capability have already invested in the infrastructure to implement electronic discharge documentation, and can employ it at a modest cost. For these institutions, the infrastructure cost of the transition from paper charting or dictation to direct entry by physicians lies in ensuring sufficient computers and connectivity to handle the increased computer use. On the other hand, for those institutions where the EMR lacks this capability there are few freestanding documentation platforms available for purchase. The cost of implementing such a system is high, both for the purchase of additional software and the integration of that software in to the EMR supplied by the primary vendor. Other notable infrastructure costs to consider are ensuring sufficient network connectivity, computers and printers to accommodate increased use that will come with electronic note writing as well as server support for system backups.

Personnel

Engaging the right personnel will smooth the implementation of an electronic discharge summary. In addition to dedicated user training sessions, a physician champion who can promote and monitor user training on the new platform will facilitate prompt implementation. An IT support programmer should work with the physician champion to address concerns and troubleshoot problems. Additional personnel may also be needed to track progress in discharge summary adoption, quality and efficiency. Ideally these personnel can be funneled from those who work transcribing, disseminating and tracking completion of discharge summaries, positions that will be needed in a reduced capacity.

Maintenance

Increased IT infrastructure also means increased IT maintenance and upgrades of servers, network connectivity, computers and printers. Discussions with vendors regarding costs of maintenance, upgrades and add‐on features should be considered when adopting an electronic discharge summary platform.