Improving Timeliness and Quality: Discharge Summaries Dictated by Internal Medicine Residents
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Transcript of Improving Timeliness and Quality: Discharge Summaries Dictated by Internal Medicine Residents
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Improving Timeliness and Quality:Improving Timeliness and Quality:Discharge Summaries Discharge Summaries Dictated by Dictated by Internal Medicine ResidentsInternal Medicine Residents
Emily A. Mallin, MDCheryl W. O’Malley, MD, FACP
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The Discharge SummaryThe Discharge SummaryHistorically served as
communication tool between physicians
“The Age of the Hospitalist”◦Vital communication tool◦Legal document◦Source for medications◦Guide for outpatient follow up
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The Current Discharge The Current Discharge SummarySummary
JC mandates discharge summary completed within 30 days of hospitalization◦Reason for hospitalization◦Significant findings◦Procedures performed and care,
treatment, and services provided◦Condition at discharge◦Information provided to patient and
familyhttp://www.jointcommission.org/NR/rdonlyres/B48B39E3-107D-495A-9032-24C3EBD96176/0/PDF32009HAPSupportingStds.pdf. Standard RC 02.04.01, EP 3, page 37. Accessed 10/6/10.
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Other Discharge Summary Other Discharge Summary GuidelinesGuidelines
JC National Patient Safety Goals◦Handoff communications◦Medication reconciliation at care
transitions National Quality ForumAgency for Healthcare Research
and QualitySociety of Hospital Medicine
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Challenges of the Discharge Challenges of the Discharge SummarySummary
UnavailableIncompleteInaccurateInexperienced authorsElectronic health record
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TimelinessTimeliness DS available for only 12.2% patients prior
to outpatient visit Trend toward decreased readmission
rates in patients whose physicians received DS prior to visit (RR 0.74, 95% CI, 0.5-1.11)
van Walraven C et al. Effect of discharge summary availability during post-discharge visits on hospital readmission. JGIM 2002;17:186-192.
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Timeliness and QualityTimeliness and Quality Delayed availability and poor quality
can contribute to adverse events after discharge
Literature Review of 73 studies◦ 14.5% reached PCP within 1 week of discharge◦ 25% never reached PCP◦ 66-88% patients contacted or were seen by PCP
before arrival of DS◦ Missing information
Hospital physician (median 25%) Main diagnosis (17.5%) Pending tests (65%)
◦ Physicians lacked awareness of pending tests in 40% of DS, 10% actionable
Kriplani S et al. Deficits in communication and information transfer between hospital-based and primary care physicians. JAMA 2007;297:831-841.
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QualityQualityEducational intervention with and
without individualized feedback improved quality of interns’ discharge summaries
Myers, JS. Are Discharge Summaries Teachable? The Effects of a Discharge Summary Curriculum on the Quality of Discharge Summaries in an Internal Medicine Residency Program. Academic Medicine 2006;81:10. pp S5-S8.
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Could we improve timeliness?Could we improve quality?
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650-bed urban, university-affiliated, quaternary care teaching hospital
100 Internal Medicine, Med-Peds, Preliminary residents
5 ward teams◦ Attending◦ 2 residents◦ 2 interns◦ Medical students
Discharge summaries◦ Dictated by upper-level residents
Study Period◦ December 2007 – February 2008 (pre-intervention)◦ December 2008 – February 2009 (post-intervention)
MethodsMethods
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STAT Discharge ProcessSTAT Discharge ProcessInstituted November 2008Hiring of transcriptionistsMandate that all hospitalists dictate
summary on day of discharge
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Educational InterventionEducational Interventionfor Internal Medicine Residentsfor Internal Medicine Residents
Noon conference◦ Reviewed the literature on discharge
summary quality◦ Reviewed the essential elements of discharge
summaries◦ Offered strategies for dictating clear, succinct,
and comprehensive summaries
Pocket cards with instructions for dictating quality discharge summary
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Timeliness ResultsTimeliness Results
Mallin E, O’Malley C, Gerkin R. Improving timeliness without compromising quality: Discharge summaries dictated by Internal Medicine residents. J Hosp Med. 2010;5(3)(suppl 2):S49.
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Quality ResultsQuality ResultsCompleteness score improved, though
not statistically significantReadability of each section and overall
readability were not affected
Limitation◦ Did not ensure residents received education
or used pocket cards
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Quality ImprovementQuality ImprovementExtension of study examines the
effect of a standardized formal educational intervention on quality of dictated discharge summaries.
Study period◦January – June 2009 (pre-intervention)◦January – June 2010 (post-intervention)
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Educational InterventionEducational Interventionfor Internal Medicine Residentsfor Internal Medicine Residents
Monthly one-hour conferences, capturing all residents rotating on ward service that month◦ Reviewed the literature on discharge summary quality◦ Reviewed the essential elements of discharge
summaries◦ Offered strategies for dictating clear, succinct, and
comprehensive summaries◦ Provided examples of poor and high quality summaries ◦ Individualized feedback session with attending using
resident’s recent discharge summary
Pocket cards with instructions for dictating quality discharge summary
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Evaluation of Discharge Evaluation of Discharge SummariesSummaries
Pre-intervention◦12 summaries – 4 each by 3 raters
Post-intervention◦5 summaries – each rated by 4 raters
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Preliminary ResultsPreliminary Results
Interrater reliability◦ Intraclass correlation coefficient (ICC)
Completeness ICC = 0.533 (p=0.138) fair Total readability ICC = 0.926 (p<0.001) excellent
Pre-intervention
Mean
Post-intervention
Mean
P value
Completeness score
0.70 0.78 0.342
Total readability score
30.3 34.6 0.172
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Limitations and Future Limitations and Future DirectionsDirections
Preliminary dataPatient charts were not reviewed for
accuracy
Analyze long-term effect of intervention
Evaluate impact of the intervention on patient outcomes and primary provider satisfaction
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Additional ReferencesAdditional Referenceswww.hospitalmedicine.org/BOOST
Moore, C., McGinn, T., and Halm, E. (2007, June). "Tying up loose ends: Discharging patients with unresolved medical issues." Archives of Internal Medicine 167, pp. 1305-1311.
Greenwald, J.L., Denham, C.R., and Jack, B.W. (2007, June). "The hospital discharge: A review of a high risk care transition with highlights of a reengineered discharge process." Journal of Patient Safety 3(2), pp. 97-106.