In the News

Test result documentation in discharge summaries, and more.

Studies assess discharge summaries for test result documentation, satisfaction

Hospital discharge summaries were found to be grossly inadequate in a recent analysis of pending test result documentation.

The retrospective study, published in the September Journal of General Internal Medicine, examined discharge summaries for 696 patients released from two academic medical centers. All of the patients had pending test results, but only 25% of their discharge summaries mentioned the tests and only 13% listed all pending results. In all, only 16% of the 2,927 pending test results were recorded in a discharge summary. The transmission of test results was also hampered by failure to include a follow-up clinician in the summary; only 67% of the discharge summaries made it possible to discern what clinician or clinic should receive the pending results.

The study authors concluded that discharge summaries have large deficiencies in their documentation of pending test results and they suggested some strategies for improvement, including using a checklist, enforcing documentation of pending tests, or having an electronic system automatically query all parts of the hospital's computer system to identify pending tests. The same strategies could improve documentation of follow-up physicians as well, the authors said.

Another study published in the same journal compared electronic and dictated hospital discharge summaries. The 209 studied summaries, generated by four medical teams of an academic general medicine service, were assessed for overall quality by primary care physicians, the level of satisfaction they provided for housestaff, patient understanding of discharge details, and adverse outcomes after discharge.

Housestaff found the electronic system to be easier to use than the phone dictation system (mean rating, 86.5 vs. 49.2; P=0.03). They were also slightly more satisfied with the electronic process although it was more time-consuming, but both differences were statistically insignificant. There was no difference in primary care physician satisfaction, patient satisfaction or follow-up or patient outcomes within 30 days. The study authors concluded that electronic discharge systems can play a key role in efforts to computerize patient care and enhance discharge.

ACE inhibitors before cardiac surgery may increase risk of death

Angiotensin-converting enzyme (ACE) inhibitor therapy before coronary artery bypass grafting (CABG) was associated with an increased risk of death and postoperative cardiac events, a large observational study reported.

The retrospective cohort study included data on 10,023 consecutive patients undergoing CABG between 1996 and 2008. About 3,000 of the patients who received preoperative ACE inhibitors were matched to a control group by propensity score analysis. Those who received ACE inhibitors before surgery had a twofold increase in the risk of death compared with patients who did not receive preoperative therapy (1.3% vs. 0.7%; odds ratio, 2.00, 95% CI, 1.17 to 3.42; P=0.013). The ACE inhibitor group also had a higher risk of postoperative renal dysfunction (defined as a serum creatinine level >200 µmol/L plus an increase of at least 1.5 times preoperative baseline concentrations), atrial fibrillation (AF), and increased use of inotropic support. The study was published online Aug. 12 in the Journal of the American College of Cardiology.

The results are significant considering that ACE inhibitors have been shown in past studies to reduce the rate of mortality and to prevent cardiovascular events in patients with CAD, especially after MI. The authors theorized that the discrepancies might be because other studies were small with insufficient power to detect differences in mortality. In addition, two previous meta-analyses did not include any cardiac surgery patients, making the evidence weak for the potential benefit of ACE inhibitors to prevent postoperative AF. In contrast, the current study included a very large cohort that examined only patients undergoing CABG.

The authors also noted that the increased risk of postoperative AF found during the study may stem from ACE inhibitors' effect on lowering systemic vascular resistance and vasoplegia in the early postoperative phase, resulting in hypotension and administration of more fluids and inotropic/vasoconstrictor drugs, which are risk factors for new onset of AF. In light of their findings, the authors suggested that omitting ACE inhibitors before surgery and restarting them postoperatively might be a reasonable approach to improving outcomes after CABG.

Caregivers don't always want doctors' advice on life-support decisions, study finds

A recent study challenges the commonly held notion that most caregivers of critically ill patients want to hear doctors' opinions on life-support decisions. The study, published in the Aug. 15 American Journal of Respiratory and Critical Care Medicine, prospectively recruited 169 surrogates from four ICUs and asked them to watch and respond to two videos depicting hypothetical conferences in which surrogates must decide whether to withdraw or continue life support. In one version, the doctor offers his opinion on a course of action while in the other version the doctor urges the family to make their own decision consistent with the patient's values. Fifty-six percent of surrogates preferred the version in which the doctor offers an opinion, while 42% preferred no recommendation and 2% had no preference. The authors recommended that physicians first ask surrogates about whether they would like to hear an opinion and use any recommendation as a starting point for shared deliberations.