Patient discharge. It’s an everyday occurrence and, therefore, easily taken for granted. The hospitalist, who must help the patient transition back to the primary care physician, knows that this is a mistake. This transition takes an intense amount of communication among hospitalists, primary care and other physicians, nurses, case managers, social and therapy services, the patient, and the family.
Although smooth, effective patient handoffs are critical in maintaining patient safety and ensuring positive health outcomes, they are too often executed haphazardly, and the amount and precision of information as well as the means by which it is transmitted varies considerably. The journey is rife with communication landmines—communication can lapse or be absent, and when information falls through the cracks, continuity of care may be disrupted.
Considering post-discharge communication in general, “probably the most important thing is to make sure that the hospitalist conveys as much of an impression of how the patient is doing [as possible],” says Richard Frankel, PhD, professor of medicine and geriatrics at Indiana University School of Medicine, Indianapolis, “not only in terms of their medical care or their disease process, but [also] what the patient’s hospital stay has been like, what the perception of their hospital experience has been like. And to be open to additional questions from the primary care physician about issues that might arise post discharge and ambiguities that might exist in the discharge summary.”
After determining a standardized protocol for post-discharge handoffs, “then I think that the most important thing is just practicing using these various protocols,” says Dr. Frankel, who also serves as senior research scientist at the Regenstrief Institute (Indianapolis) and is a research sociologist in the Health Services Research Unit at the Roudebush Veterans Affairs Medical Center, Indianapolis. “When the astronauts train, they train for every possible contingency so that when [a problem] arises it seems like the most common thing in the world, when in fact, what they practice are very low-frequency events, very low-probability problems arising.”
The nuts and bolts of ideal practices include essentials such as dictating notes and, preferably, transcribing and transmitting them by the close of the business day on which the patient is discharged.1 If short notes are sent to the primary care physician at the time of discharge, a longer summary should arrive within a few days. Because primary care physicians disagree as to what should be included in that summary, communication among physicians becomes a key issue in the transition.
“There’s a paucity of data on the subject of how well physicians communicate with each other,” says Darrell Solet, MD, cardiology fellow at the University of Texas, Southwestern Medical Center in Dallas. “A number of organizations have jumped on the bandwagon of improving this process, especially [the] Joint Commission [on] Accreditation of Healthcare Organizations,” he says.
One of the major things the University of Texas Southwestern has emphasized in its residency program’s communication skills curriculum is not only how physicians communicate with their patients but also how well they communicate with each other. “This includes hearing a presentation on the most effective and efficient ways to perform their handoffs and also addressing the specific barriers to communication that they might face, says Dr. Solet.
These barriers to effective handoffs were identified in a study that Dr. Solet and his colleagues, including Dr. Frankel, conducted in 2005 in four hospitals in Indiana.2 At that time, Dr. Solet was the chief resident of ambulatory medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, and of medical service, Roudebush Veterans Affairs Medical Center, Indianapolis. In general, the study revealed that barriers to communication existed in four areas: physical settings, social settings, language, and communication styles.
Dr. Solet says that inconsistent information poses the biggest threat in the post-discharge communications he has seen. Another high-risk area involves documentation in which the physician writes only a line or two, such as, “This is a 50-ish-year-old man with COPD. Those one-liners are very dangerous,” he says.
In addition to the risks inherent in documentation, the biggest danger areas include pending test results, recommended follow-up studies, misunderstood medication instructions, never-purchased medications, and missed follow-up visits with the primary care physician.
Nelson and Whitcomb1 suggest that a post-discharge summary containing all essential information could overwhelm the primary care physician. They recommend standard forms with separate headings for diagnoses, medications, and hospital course, along with categories such as tests pending and evaluations needed. “Ideally, each hospitalist in a group should use the same format for these reports, so that a reader can quickly become accustomed to extracting information from them,” they write.
Tailor the Summary
Edward J. Merrens, MD, section chief of hospital medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., was one of the authors of a study investigating ways to enhance the timeliness, accuracy, and breadth of clinical information gathered at discharge.3 The improvement project was conducted in a 330-bed tertiary care teaching hospital that averages 12,800 discharges a year.
“In general,” says Dr. Merrens, “we’re sending people out sicker and sicker, and often [the subsequent providers] don’t need a summary of all the interventions and studies and meds and antibiotics [done during the hospitalization], but what to do with the patient next. … Hospitalizations have become less therapeutic confinements where everything gets done, but [rather] where complex interventions occur and patients go out on therapy and are still often sick.”
The discharge summary should be designed in such a way that the primary care physician can simply “pick it up and go” from there, says Dr. Merrens. “We’ve tried to think, who really reads this thing? It could be [the] primary care physician, it may be a patient, it could be a doctor taking care of a patient in a rehabilitation facility, or it may be a visiting nurse service. We try to tailor the summary to those audiences, not just summarize what we’ve done.” His team has included a section on the summary where one can write, for example, “The patient might need more diuresis for their heart failure. They’re probably going to need a follow-up with this,” and Dr. Merrens says this structure has worked well.
“As we move from the Marcus Welby model of ‘you’re always on, you’re always covering, you’re the only doc’ to shift-based care,” he says, “the core of the [provider] group itself needs to communicate well, and it needs to agree on principles.” And this, he says, is a key component of job satisfaction for hospitalists.
—Edward J. Merrens, MD
Back to Long-Term Care
The goals of transitional care include ensuring continuity, providing for safe discharge, and preventing rehospitalization.4 Hospitalists have to recognize which patients are at risk for poor outcomes and devise ways to help prevent these problems. At particularly high risk are patients with the following characteristics:
- Age 80 and older;
- A history of depression;
- Multiple chronic diseases;
- Moderate-to-severe functional impairment;
- Noncompliance with therapy;
- Inadequate social supports;
- Multiple hospitalizations in the previous six months;
- Hospitalization in the last 30 days; and
- Fair or poor self-rating of health.4
Patients who return to long-term care, therefore, need careful transfer of information.
Nursing homes tell Dr. Merrens’ team that there is not enough practical information on the discharge summary about the patient’s current functional abilities. In response, the hospitalists included a section in their discharge documentation that summarizes the patient’s status, answering questions regarding the patient’s mental capacity, her ability to feed herself, her last bowel movement, her contact at the hospital in the event of a post-discharge emergency, and her designated power of attorney (if such a form was signed at the hospital).
At and After Discharge: Communicate with Patients and Families
Communication at the time of discharge involves, again, telling patients what’s next: Clarifying the use and potential side effects of medications, explaining when the patient can resume normal activities, providing the plan for and benefits of any occupational or physical therapy, and emphasizing the importance of follow-up. But it is also a time when patients should be told that they will need to “serve as expert witnesses to their care.”5
Tom Delbanco, MD, chief of the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center, Boston, who has written extensively about communications and hospital medicine, reminds hospitalists that when it comes to getting feedback for quality improvement, it is far more helpful to gather patients’ self-reports than their ratings. Practitioners of hospital medicine, he adds, have an imperative not only to inquire into patient experiences, but also to catalog them and share findings with colleagues.
The Picker Institute (Boston), a nonprofit organization dedicated to the advancement of patient-centered healthcare, found that only one in 64 hospitals participating in its first national survey of hospitalized patients could be judged as particularly adept at preparing patients for discharge.5 What the staff were doing differently at that one hospital was very simple: They asked the patients and families to write down any questions they had before they went home; discharge occurred only after all those questions were answered.
Although post-discharge communication involves talking to and instructing patients, it also involves listening and watching for how well patients receive these communications. In the discharge conversation, patients may be groggy from too much or too little sleep, heavily medicated or coming off of major narcotics or general anesthesia, experiencing pain, suffering from anxiety or delirium, or just mentally disoriented from the stress of the hospital experience.5-8
Calkins and colleagues surveyed 99 patients to determine any difference in perceptions between patients and their attending physicians regarding the patients’ understanding of the treatment plan after hospitalization.6 Physicians reported spending more time discussing post-discharge care than did patients, and the doctors believed that 89% of patients understood the potential side effects of their medications when only 57% of the patients reported that they had.
Discharge summaries given directly to patients can help with comprehension and compliance.1 Telephone follow-up is also a valuable tool and, along with a chance to provide answers and encouragement, gives the patient a feeling of being cared for.1 Several studies have shown benefit in phone follow-up, providing a chance for hospitalists to review new test results, clarify misunderstandings, and encourage compliance, as well as to learn any unexpected outcomes, treatment failures, or side effects.9
Written instructions are imperative. One person should be assigned this duty and, on a standardized form, should provide details, not just when and how to call the primary care physician. The bare bones of a summary are not enough—especially if there was not a competent family member present at the final discharge conversation. Further, in many cases, questions arise after the patient is home, when a family member, a nurse, or the patient herself may have questions, particularly about medications.
Test Results and Follow-Up Studies
Among the factors contributing to failures at discharge is disrupted continuity of responsibility for pending test results and radiologic studies. This discontinuity may be especially operational in teaching hospitals, where physicians-in-training may frequently change services or shifts, and yet they remain responsible for all or some of the discharge communication.10 To prevent this disruption and avoid confusion, the institution or team should clarify the person responsible for follow-up on tests or studies. And they must communicate this information to the primary care physician.
Roy and colleagues looked at the prevalence, characteristics, and physician awareness of potentially actionable test results returning after hospital discharge at two major tertiary care centers.10 Of the 2,644 patients discharged from the hospitalist services, 1,095 (41%) had a total of 2,033 test results pending on the day of discharge, and 877 of these results (43%) were abnormal. Of the final 671 results included, 191 (9.4%) from 177 patients were potentially clinically actionable. Surveyed physicians were unaware of almost two-thirds of these potentially actionable results; more than a third of these results would change the patient’s diagnostic or treatment plan, and 12.6% of cases required urgent action. Other data show the unreliability of providing test results at follow-up visits; discharge summaries were available at only 12% to 33% of visits studied in one series.10
When inpatient physicians were asked how they would like electronic results-management systems that could highlight important results, filter out normal results, and help hospitalists track results returning after discharge, they were eager to adopt such systems. A future article in The Hospitalist will cover the emergence of electronic systems to better manage discharge communications.
Follow-up Contact with Patients
Van Walraven and colleagues looked at whether early post-discharge outcomes changed when patients were seen after discharge by physicians who had treated them in the hospital.11 When 938,833 adults from Ontario, Canada, were followed over five years after discharge from a medical or surgical hospitalization, 7.7% died or were readmitted. The adjusted relative risk of death or readmission decreased by 5% and 3% with each additional visit to a hospital physician—as opposed to a community physician or specialist, respectively. The effect of hospital physician visits was seen to have a dose-response effect, with the adjusted risk of 30-day death or nonelective readmission reduced to 7.3%, 7.0%, and 6.7% if patients had one, two, or three visits, respectively.
Hospital physician follow-up, say the authors of the Van Walraven, is a potentially modifiable factor that could decrease the risk of poor outcomes post discharge. Although not all providers embrace the concept, it does address the essential need of continuity of care through the potentially complicated transition from hospital to community. At the very least, the authors write, any physicians who sees the patient should have access to as much information as possible regarding the hospitalization and should be able to contact patients by phone post discharge.11-13
In a survey distributed by Steve Pantilat, MD, and colleagues, primary care physicians reported overwhelmingly that they preferred communicating with hospitalists by telephone at discharge (78%).14 While this may be unrealistic for all handoffs, says Dr. Merrens, hospitalists should make the effort for more complicated or serious cases.
Adverse Drug Events and Other Medication Issues
Although most adverse drug events (ADEs) are caused by the pharmacologic activity of the drug itself and can be predicted and mitigated, some one-third to one-half of ADEs are caused by human error or flawed systems.15
Coleman and colleagues looked at 375 patients, 65 and older, to analyze the medication problems they encountered.8 A significant percentage (14.1%) of older patients experienced one or more medication discrepancies after discharge; 50.8% were categorized as patient-associated; and 49.2% were seen as system-related. A total of 14.3% of the patients who experienced these discrepancies were rehospitalized at 30 days, compared with 6.1% of the patients who did not have any problems.
Of the contributing factors cited by patients, one-third were due to unintentional nonadherence, followed by financial barriers, intentional nonadherence, and neglect in filling a prescription.8 At the system level, incomplete, inaccurate, or illegible discharge instructions (as a result of either poor handwriting or use of Latin abbreviations) were the most commonly identified contributing factors, followed by conflicting information from different informational sources and duplicate prescribing.
Partnering with Case Management
Variability in physicians’ rounding patterns and schedules and in nurses’ and case managers’ shifts and assignments can make it difficult to bring involved parties together. Yet hospitalists look to case managers to follow up on acute services, interact with the patient’s plan of care, communicate with families, arrange follow-up with the primary care physician, and track the patient’s condition for progress.
Cogent Healthcare (Irvine, Calif.), a leading hospitalist company, has devised a means to optimize communication between case managers and hospitalists. The effects of this partnership have been shown to shorten hospital stay and reduce costs with no adverse effect on patient outcomes or patient satisfaction.16, 17 Along with responsibilities during the hospitalization, Cogent’s clinical care coordinators (CCC) make sure the primary care physician gets correct and appropriate information as soon as possible. The CCC phones the patient at home to ensure that the discharge plan is in place, that the patient is compliant with the post–acute treatment plan, and that she or he has a plan to meet with the primary care physician.
Case managers face a good deal of daily frustration, working on the same problems for patient after patient and trying to be available to help hospitalists make clinical practice decisions at the point of care. One way to improve overall post-discharge communication would be to lobby hospitals to provide the resources to support the case managers’ workload and their accessibility to their hospitalist colleagues.16, 18
Effective post-discharge communication includes standardizing an institution’s protocol for handoffs, increasing training and practice in post-discharge communication, and keeping the lines of communication open among hospitalists, primary care physicians, patients, and families. Collecting reported feedback from patients and families shortly after patients have returned home can be used toward quality improvement. Although the effectiveness of post-discharge communication may vary from hospital to hospital and even from hospitalist to hospitalist as well as across each hospitalist-primary care physician pairing, “I think that the interest that’s been stimulated in this whole area is exciting,” says Dr. Frankel. “This is an area where everybody wins. Rather than one person or one hospital winning and another one losing, there’s a new collaborative spirit that is very heartening to see.” TH
Andrea Sattinger writes regularly for The Hospitalist.
- Nelson JR, Whitcomb WF. Organizing a hospitalist program: an overview of fundamental concepts. Med Clin North Am. 2002 Jul 8;86(4):887-909.
- Solet DJ, Norvell JM, Rutan GH, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005 Dec;80(12):1094-1099.
- Lurie JD, Merrens EJ, Lee J, et al. An approach to hospital quality improvement. Med Clin North Am. 2002 Jul;86(4):825-845.
- Callahan EH, Thomas DC, Goldhirsch SL, et al. Geriatric hospital medicine. Med Clin North Am. 2002 Jul;86(4):707-729.
- Delbanco T. Hospital medicine: understanding and drawing on the patient's perspective. Am J Med. 2001;111(Suppl 9B):2S-4S. 6. Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients' understanding of the postdischarge treatment plan. Arch Intern Med. 1997 May 12;157(9):1026-1030.
- Makaryus AN, Friedman EA. Patients' understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005 Aug;80(8):991-994.
- Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005 Sep;165(16):1842-1847.
- Nelson JR. The importance of postdischarge telephone follow-up for hospitalists: a view from the trenches. Am J Med. 2001 Dec 21;111(9B):43S-44S.
- Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005 Jul 19;143(2):121-128.
- van Walraven C, Mamdani M, Fang J, et al. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004 Jun;19(6):624-631.
- Wachter RM, Pantilat SZ. The "continuity visit" and the hospitalist model of care. Am J Med. 2001;111(Suppl 9B):40S-42S.
- Goldman L, Pantilat SZ, Whitcomb WF. Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(Suppl 9B):36S-39S.
- Pantilat SZ, Lindenauer PK, Katz PP, et al. Primary care physician attitudes regarding communication with hospitalists. Am J Med. 2001;111(Suppl 9B):15S-20S.
- Forster AJ. Can you prevent adverse drug events after hospital discharge? CMAJ. 2006 Mar 28;174(7):921-922.
- Ramey MM, Daniels S. Hospitalists and case managers: the perfect partnership. Lippincotts Case Manag. 2004 Nov-Dec;9(6):280-286.
- Ettner SL, Kotlerman J, Afifi A, et al. An alternative approach to reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model. Med Decis Making. 2006 Jan-Feb;26(1):9-17.
- Palmer HC, Armistead NS, Elnicki DM, et al. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001 Dec 1;111(8):627-632.