Hospitalists and hand-offs: the problems that plague the process ssues include discharge orders that never reach outpatient doctors, that arrive late, or are missing critical information
Published in the June/July 2004 issue of Today's Hospitalist6
Mary Jo Gorman, MD, MBA, remembers well a patient she cared for several years ago, when the hospitalist movement was still in its infancy. The elderly man, who had chronic obstructive pulmonary disease and pneumonia, had experienced a fairly unremarkable hospital stay. Before discharging him, Dr. Gorman had written orders for everything he would need, including oxygen, home health services, a walker and physical therapy.
Two days later, however, Dr. Gorman, who is now chief medical officer of IPC-The Hospitalist Company, received a call from an ER physician. He explained that her patient
“There is no substitution for the phone call to the primary physician on the day of discharge. It helps you build a relationship and it ensures the primary physician won’t get a ‘surprise.’ ”
Mary Jo Gorman, MD IPC-The Hospitalist Company
“was back,” and that the man wasn’t in particularly good shape.
When Dr. Gorman arrived at the emergency department, the patient looked at her and said, “I’m glad to see you, doctor. You told me all this stuff was going to come to my house, and nothing ever happened. No one came.”
At a workshop on clinical communication and continuity of care at the Society of Hospital Medicine (SHM) meeting in New Orleans, Dr. Gorman cited her story as an example of how discharge planning and the hand-off are critical to the care that hospitalists provide.
In the workshop, Dr. Gorman and co-presenter Sunil Kripalani, MD, MSc, assistant director for research at the Grady Hospitalist Program at Emory University School of Medicine in Atlanta, examined what can and does go wrong in the all important hand-off period, why it goes wrong and, most importantly, the strategies hospitalists can use to address these problems.
In opening the workshop, Dr. Kripalani painted what can be described as a good news-bad news picture. While most hospitalists deliver high quality care to their patients, he said, communication with referring primary physicians and post-discharge care are often sorely lacking.
To illustrate the problem, Dr. Kripalani cited a study of 400 patients published in the Annals of Internal Medicine in 2003. Researchers found that 19 percent of discharged patients experienced adverse events soon after hospitalization. Even worse, nearly half of those events could have been either prevented or ameliorated through adequate communication between the hospital caregiver and the outpatient physician or patient.
To address these types of issues, two groups—the SHM and the Society of General Internal Medicine—have formed a task force to examine continuity of care issues. The group reviewed more than 50 studies that focused on adult primary care and hospital medicine to identify both gaps in and opportunities for improvement.
Many of those studies detailed problems transferring information between hospital-based physicians (not just hospitalists) and adult primary care physicians. Others examined interventions to improve communication between hospital physicians and primary care physicians.
Dr. Kripalani said the task force quickly discovered that there is no standard for communicating information between the hospitalist and the primary care physician at discharge. That finding, however, paled in comparison to some of the other data the group uncovered during its literature review:
• Discharge summaries don’t reach the primary care physician up to 25 percent of the time. When they do arrive, it’s often too late.
• Half or more of discharged patients contacted their primary care physician before the physician received any discharge information, including notification that the patient had been hospitalized. Only 17 percent of primary care physicians reported receiving notification from hospitalists before their patients were discharged.
• That lack of information or delay in its arrival prevented optimal outpatient management in an estimated 10 percent to 15 percent of cases.
• Missing information in discharge summaries is a serious issue. Summaries sometimes lacked the patient’s full name, discharge date, diagnoses, lab results, name of the inpatient and outpatient physician, tests pending at discharge, and discharge medications.
• On the plus side, the task force found that 77 percent of primary care physicians who received discharge summaries considered them adequate. The group also identified several effective “interventions” that smoothed the transition.
Solutions included template-driven discharge summaries and communication “prompters,” as well as the old-fashioned, tried-and-true telephone call to the outpatient physician at the time of discharge.
“There is no substitution for the phone call to the primary physician on the day of discharge,” Dr. Gorman said. “It helps you build a relationship and it ensures the primary physician won’t get a ‘surprise.’ ”
Clearly, Dr. Kripalani added, there is ample room for improvement. “You can imagine how difficult it is for the outpatient physician to pick up care after this transition not knowing what happened in the hospital, what tests were pending, and what things needed to be followed up,” he said.
Communication and continuity of care breaks down for all kinds of reasons that often depend on the hospital, the patient base, and the community in which hospitalists and primary care physicians work.
Workshop participants discussed some common themes and concerns. The lack of administrative and other support—from hospital dictation departments or understaffed and time-crunched hospitalist services—was identified as a key factor. Another is the lack of a systematic approach to the hand-off, a factor that can be addressed by implementing practices that ensure that the critical hospitalist-to-outpatient physician discharge communication occurs.
Based on its findings, the task force made several recommendations to improve communication and continuity of care. They include the following measures:
• Ensure confirmation, on patient admission, of the primary care physician’s name, address, phone and fax numbers, and e-mail address. The outpatient physician’s preferred method of receiving discharge communications should also be identified.
Both Drs. Gorman and Kripalani urged hospitalists to discuss with outpatient physicians’ office personnel the method of receipt and the urgency of delivery to the physician. “You need to make the point that this document needs to be treated like lab work,” Dr. Gorman said, “so that it goes on the physician’s desk to be read, initialed and filed.”
• Ensure that at the very least, a brief, structured discharge document—a letter or note to precede the full summary—is prepared and delivered on the day of discharge.
“We know that the median time of a patient’s visit to the primary physician is six days, but many patients show up in two to three days,” Dr. Kripalani noted. Up to half of patients, he added, contact their physician before the doctor has received any discharge information.
“That means that 50 percent of those visits are essentially blinded to what took place in the hospital,” he explained.
• To make sure discharge notes are created, give physicians a financial incentive. Dr. Gorman said that since IPC began linking discharge notes to physician compensation, its compliance rate has jumped to 98 percent.
She suggested using computer-generated summaries. These can be formatted with a template that identifies key information and prompts physicians to provide that information.
Practices can also encourage and train new physicians to avoid writing overly long documents, which likely go unread. “Some new physicians write a three-page, single-spaced version of ‘War and Peace’ for a hangnail,” she explained. “They should be trained to write a one- to one-and-a-half-page document that the outpatient physician can look at briefly.”
• Ensure that the medical content of discharge summaries covers the basics: discharge medications (and reasons for changes); discharge diagnoses; results of procedures or abnormal labs; needed appointments or other follow-up; pending tests; and specialist consults and conclusions. The patient’s functional status at discharge should also be included, along with related instructions.
• Arrange for delivery of detailed discharge summaries to the outpatient physician within seven days. Some studies have found a lag of up to three weeks, Dr. Kripalani said.
“Surveys have shown that outpatient physicians are happier (with hospitalist services) when these summaries are delivered within seven days,” he said. “We certainly want to keep our referring doctors happy.”
Ensuring continuity of care for discharged patients is a challenge for both small and large hospitalist practices, but it’s key. Dr. Gorman noted that IPC studies have found that up to 26 percent of patients have issues requiring follow-up after discharge, and that 38 percent have multiple issues.
Certain administrative “interventions” can help bridge that care-continuity gap, the presenters said. IPC uses specially trained patient care representatives, supported by nurses as needed, to make sure that patients receive a follow-up call to identify potential problems during the transition period. That call, placed within one to three days of discharge, focuses on medications, follow-up care access, and symptom deterioration or development of new symptoms.
Dr. Gorman urged hospitalist practices to develop at least a simple post-discharge algorithm—with triggers for key questions—for those follow-up calls. When patient advocacy is needed, as in situations in which patients are informed by their physician’s office that no appointment slots are available for several weeks, IPC physicians or staff intervene.
“It sounds complicated, but there are things that can be done, even in a small group,” Dr. Gorman said. “The main point is to figure out who will make that call. It doesn’t necessarily need to be a nurse, just someone who has some health care experience and who knows what constitutes an emergency.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.
What’s wrong with discharge summaries?
In a literature review of articles examining discharge instructions, a task force uncovered some of the problems in how inpatient physicians communicate with their outpatient colleagues. While the following information applies to all hospital-based physicians, not just hospitalists, it illustrates how the hand off from hospitalist to primary care physician can go wrong.
• Discharge summaries don’t reach the primary care physician in up to 25% of cases.
• Half or more of discharged patients contacted their primary care physician before the physician received any discharge information, including notification that the patient had been hospitalized.
• Only 17 percent of primary care physicians reported receiving notification from hospitalists before their patients were discharged.
• Incomplete or delayed information arrival prevented optimal outpatient management in an estimated 10 percent to 15 percent of cases.