• Like
Improving Timeliness and Quality: Discharge Summaries Dictated by Internal Medicine Residents
Upcoming SlideShare
Loading in...5
×

Improving Timeliness and Quality: Discharge Summaries Dictated by Internal Medicine Residents

  • 2,209 views
Uploaded on

 

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads

Views

Total Views
2,209
On Slideshare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
15
Comments
0
Likes
2

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide
  • We wanted to address some of these problems with discharge summaries and used a system process as a starting point.

Transcript

  • 1. Improving Timeliness and Quality: Discharge Summaries Dictated by Internal Medicine Residents Emily A. Mallin, MD Cheryl W. O’Malley, MD, FACP
  • 2. The Discharge Summary
    • Historically served as communication tool between physicians
    • “The Age of the Hospitalist”
      • Vital communication tool
      • Legal document
      • Source for medications
      • Guide for outpatient follow up
  • 3. The Current Discharge Summary
    • 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 family
    http://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.
  • 4. Other Discharge Summary Guidelines
    • JC National Patient Safety Goals
      • Handoff communications
      • Medication reconciliation at care transitions
    • National Quality Forum
    • Agency for Healthcare Research and Quality
    • Society of Hospital Medicine
  • 5. Challenges of the Discharge Summary
    • Unavailable
    • Incomplete
    • Inaccurate
    • Inexperienced authors
    • Electronic health record
  • 6. Timeliness
    • 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.
  • 7. Timeliness 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.
  • 8. Quality
    • Educational 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.
  • 9.  
  • 10.
    • Could we improve timeliness?
    • Could we improve quality?
  • 11.
    • 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)
    Methods
  • 12. STAT Discharge Process
    • Instituted November 2008
    • Hiring of transcriptionists
    • Mandate that all hospitalists dictate summary on day of discharge
  • 13. Educational Intervention for 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
  • 14. Timeliness 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.
  • 15. Quality Results
    • Completeness score improved, though not statistically significant
    • Readability of each section and overall readability were not affected
    • Limitation
      • Did not ensure residents received education or used pocket cards
  • 16. Quality Improvement
    • Extension 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)
  • 17. Educational Intervention for 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
  • 18. Evaluation of Discharge Summaries
    • Pre-intervention
      • 12 summaries – 4 each by 3 raters
    • Post-intervention
      • 5 summaries – each rated by 4 raters
  • 19. Preliminary 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
  • 20. Limitations and Future Directions
    • Preliminary data
    • Patient charts were not reviewed for accuracy
    • Analyze long-term effect of intervention
    • Evaluate impact of the intervention on patient outcomes and primary provider satisfaction
  • 21.  
  • 22. Additional References
    • www.hospitalmedicine.org/BOOST
    • Moore, C., McGinn, T., and Halm, E. (2007, June). &quot;Tying up loose ends: Discharging patients with unresolved medical issues.&quot; Archives of Internal Medicine 167, pp. 1305-1311.
    • Greenwald, J.L., Denham, C.R., and Jack, B.W. (2007, June). &quot;The hospital discharge: A review of a high risk care transition with highlights of a reengineered discharge process.&quot; Journal of Patient Safety 3(2), pp. 97-106.