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Creating a better discharge summary

Is standardization the answer?

From the March ACP Hospitalist, copyright © 2009 by the American College of Physicians

By Kathleen Louden

The discharge summary is a vital tool for transferring information between the hospitalist and primary care physician, but it isn’t always given the priority it deserves. Too often, research suggests, summaries contain insufficient or unnecessary information and fail to reach the primary care physician in time for the patient’s follow-up visit, if they arrive at all.

“The problem is that every physician does a discharge summary differently,” said Surinder Yadav, ACP Member, a hospitalist and associate medical director of health care quality at Baystate Medical Center in Springfield, Mass. “In the past, we’ve done a poor job of communicating with the primary care physician, but we’re improving.”

A review of the literature published in the Feb. 28, 2007, Journal of the American Medical Association (JAMA), found that important data often were missing from discharge summaries. In the review of 73 studies, the primary diagnosis was omitted a median of 17.5% of the time, a list of medications at discharge did not appear in 21% of summaries, and pending test results were not included in 65%.

Creating a better discharge summaryFurthermore, between 66% and 88% of discharge summaries were not sent to the outpatient provider in time for the follow-up visit, the study found. For about 25% of patients, the outpatient physician did not receive the discharge summary at all. Discharge summaries also frequently suffer in quality by being too long and containing unnecessary information, reported authors of a study that appeared in the November/December 2005 issue of the American Journal of Medical Quality.

Standardization is one potential solution, and some hospitalists— including Dr. Yadav at Baystate—are helping their institutions develop templates for discharge summaries. Experts recommend that community physicians have input into this process.

A structured, standard discharge summary form ensures that all the important information is included and allows the receiving physician to more quickly identify how to respond to the patient’s hospitalization, said Mark Williams, FACP, chief of the hospital medicine division at Chicago’s Northwestern Medical Center and co-author of the JAMA article. “I think the discharge summary should be standard across the United States.”

What to include

The Joint Commission mandates that discharge summaries contain certain components: reason for hospitalization, significant findings, procedures and treatment provided, patient’s discharge condition, patient and family instructions, and attending physician’s signature. Also, a few health care groups, including the National Quality Forum (NQF) and the Society of Hospital Medicine (see sidebar), have proposed discharge checklists.

Experts advised keeping summaries short for easy readability— ideally no more than two pages long—and including information that is most relevant for the primary care physician.

Most important to include are the reason for admission, medications (indicating new, changed, and discontinued), follow- up plans and appointments, outstanding issues for followup, and results of any tests or lab work pending at time of discharge, said Jeffrey Greenwald, MD, a hospitalist and director of the hospital medicine unit at Boston Medical Center. His hospital started using a template several years ago.

The NQF, in its Safe Practice 11, recommends that a discharge summary include, at minimum, the following:

  • reason for hospitalization with specific principal diagnosis,
  • significant findings,
  • procedures performed and care, treatment, and services provided to the patient,
  • the patient’s condition at discharge,
  • education provided to the patient and family,
  • a comprehensive and reconciled medication list, and
  • a list of acute medical issues, tests, and studies for which confirmed results were unavailable at the time of discharge and that require follow-up.

Unfortunately, there is no uniform definition of significant findings. Although some might interpret it to mean only abnormal results, Dr. Yadav does not recommend always limiting the summary to abnormal findings. For instance, not to mention that a mass was benign could lead to repeated testing. Be specific about imaging and other tests, Dr. Yadav suggested.

Thomas Bodenheimer, FACP, an internist affiliated with the University of California, San Francisco, who has written about transitions in care, said that variability in discharge summaries and omission of important data occur not because physicians disagree on what needs inclusion but because hospitalists are busy and may not have time to adequately coordinate care with the primary care practice.

Don't be late

A larger problem than omissions, in Dr. Bodenheimer’s experience, is timeliness of the discharge summary. He noted that sometimes primary care physicians are not even informed of their patient’s discharge.

“Discharge is a critical time for the patient,” Dr. Bodenheimer said. “[When we don’t know about discharge], no one has charge of their care, and these patients get dropped in a major crack.”

At least one study has demonstrated a trend toward a decreased risk of readmission when the discharge summary arrives before the outpatient follow-up visit takes place. The study, by van Walraven and colleagues (J Gen Intern Med. 2002;17:186-192), found a 0.74 relative risk of decreased rehospitalization for these patients, compared with when the summary did not arrive on time.

“There is no reason why a discharge summary shouldn’t be [at the primary care provider] within 24 hours,” Dr. Bodenheimer said.

He sees unstable patients as early as the day after discharge and said, “It would make it a pretty worthless office visit to not have the discharge summary.”

If a 24-hour turnaround time is not possible, Dr. Bodenheimer said he wants a phone call to inform him of his patient’s discharge.

Speeding delivery

Few hospitalist programs have policies to ensure speedy completion of discharge summaries and transmission to outpatient providers, a study published in the September/October 2008 issue of the journal Health Affairs found.

The study’s lead author, Hoangmai Pham, MD, senior researcher at the Center for Health Systems Change in Washington, D.C., said there are several ways that hospitals can ensure timely transmission of the discharge summary. These include automated red flags. For instance, a hospital can allow hospitalists to discharge a patient only when they enter the summary.

The disadvantage with that safeguard, Dr. Williams said, is that patients receive care until “literally the moment of discharge.” If the physician had already entered the summary before discharge, last-minute care would not be included. “I don’t think you can complete the discharge summary until discharge,” he said. But he added that hospitalists should complete the summary on the day of discharge.

Another solution to ensuring timely completion and delivery of discharge summaries is for the hospital to audit hospital records However, Dr. Pham said that when audits discover infractions, “the reality is that penalization does not happen.”

In addition to directly sending the summary to the outpatient physician, all of the hospitalists interviewed for this article said their hospitals also give the discharged patient a copy of the discharge summary to hand-deliver to their physician.

Electronic health record systems also likely will speed both completion and transmission of the discharge summary as more hospitals go online. However, independent physicians often do not have the same electronic data systems as hospitals, Dr. Pham said. When they do, as is the case with many community physicians affiliated with Northwestern Medical Center, they may receive an email that their patient was discharged, Dr. Williams said.

Even with technological advances that improve discharge processes, Dr. Yadav said, “We’re still a long way off from having a perfect discharge summary.”

Kathleen Louden is a freelance health writer in Gurnee, Ill.

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Discharge summary checklist

Key elements of discharge summaries, according to the Society of Hospital Medicine, are as follows:

  • Problem that led to hospitalization
  • Key findings and test results
  • Final diagnoses (primary and secondary)
  • Brief hospital course
  • Condition at discharge
  • Discharge destination
  • Medications at discharge
  • Follow-up appointments and proposed management plan
  • Anticipated problems and suggested interventions
  • Pending laboratory work and tests
  • Recommendations of subspecialty consultants
  • Documentation of patient education
  • Name and 24-hour phone number for hospital physician records.

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