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E-mails push patient sign-outs beyond the hospital walls
Even when they’re off duty, physicians can keep up-to-date
by Jay Greene



Published in the October 2007 issue of Today's Hospitalist

While face-to-face sign-outs may be the gold standard for hospitalists, they alone may not be enough to prevent handoff communication errors or to meet the Joint Commission patient safety goals.

As a result, many programs have moved to adopt different types of Web-based sign-out systems. The problem with such systems, however, is that they typically aren’t available outside of the hospital.

And given popular scheduling models, such as seven-on/seven-off, “as many as 50% of hospitalists are off at any given time,” says Vijay Gandla, MD, a hospitalist with Beth Israel Deaconess Health Care Services,
“You don’t need any special training. If you know how to type, that is all you need.”

–Vijay Gandla, MD
Beth Israel Deaconess Health Care Services
“but everyone needs to be in touch with what is going on in the hospital.” Because most hospitalist groups use staggered shifts to achieve 24/7 coverage, bringing everyone together for face-to-face hand-offs is virtually impossible.

That’s why the hospitalist program at Boston’s Beth Israel Deaconess Hospital created a sign-out system using basic email technology. Not only is the system easy to use, but it gives hospitalists access to patient information at any time of the day and from just about any location.

The e-mail sign-outs are distributed to the entire team of hospitalists—including those who are off-duty—twice a day, in addition to face-to-face sign-outs done by an incoming hospitalist each shift. Not only are the e-mail updates easy to create, with hospitalists simply typing patient information into the body of an e-mail, but they’re also popular.

A recent survey of the group’s hospitalists, for example, found that 100%were satisfied with a sign-out system that Dr. Gandla says “helps keep the hospitalists in touch and on the same page.”

Providing “virtual” care

According to Dr.Gandla, the big payoff of e-mail sign-offs is that they deliver information to physicians beyond the hospital walls. The hospitalists in his group, in fact, all say that they read the twice-daily e-mails even when they’re not working.

“At least once a day, our hospitalists tend to check the hospital e-mail just to browse through the e-mailed sign-offs,” says Dr.Gandla.

The fact that the system makes it easy for physicians to stay in touch clinically gives doctors a smoother transition in and out of their shifts and provides better continuity of care, he adds. “It prevents communication gaps,” he says, “and makes you more confident that you are in touch with the system no matter where you are.”

In addition, the hospitalists use this same e-mail distribution to communicate with primary care physicians and consultants. According to Dr. Gandla, that helps bridge many potential breaks in communication.

How it works

The first step in getting the sign-off e-mails off the ground was to create a secure e-mail distribution list that included all of the hospitalists.

Each weekday at Beth Israel Deaconess, three full-time hospitalists work staggered day shifts. The first hospitalist, who starts at 7 a.m., gets a verbal face-to-face sign-out, in addition to the e-mail version sent by the outgoing night-time physician to the entire hospitalist group. Assuming that the incoming hospitalist has followed the service “virtually” during his or her time off, Dr.Gandla says, the verbal sign-out becomes more dynamic, interactive and productive.

While the e-mails address the most important patient factors, the verbal process helps flesh out critical details. “When you talk,” he explains, “you talk more subjectively about the patient. Verbal sign-outs are more detailed.”

After the verbal sign-out, the incoming hospitalist next updates the night-shift’s e-mail information and then emails that updated information to the other day-team members, who have yet to arrive. Each physician is also assigned a group of patients that he or she needs to follow that day. During the day, team members e-mail each other status updates on patients, noting complications, admissions or discharges.

At the end of the day, another e-mail that contains all that updated information goes out to the entire group. The incoming night hospitalist gets this e-mail, in addition to the verbal face-to-face sign-out from the outgoing day hospitalist.

Features and format

One important feature of the Beth Israel Deaconess sign-out system is that critical patient information—major complications that need attention, or care that should be delivered right away—is flagged at the top of each e-mail in capital letters.

Physicians likewise make sure that the e-mailed information addresses thorny patient issues, such as family members who need a lot of attention. “We will italicize and underline and bold,” Dr. Gandla says, “and do whatever we can to make it pretty obvious.”

The hospitalists begin each entry with the patient’s name, primary care physician, code status and main diagnosis. Typically, the first e-mail entry after admission consists of three lines: main diagnosis, secondary active diagnosis and brief details of the initial care plan.

By the time a patient is in the hospital for five days, however, that person’s e-mail entry has been added to and updated close to a dozen times, and the entries ca be hard to follow.

“Sometimes the information is too much,” Dr. Gandla acknowledges. When an entry begins to take up half a page, the hospitalist in charge of that patient may convert those sprawling daily entries to a narrative form: “Patient admitted with COPD, initially improved but later complicated by CHF. Now doing well and probably going to the floor in the morning.”

Room for improvement?

When Dr. Gandla surveyed hospitalists about the system, he found some room for improvement. Nearly 80% of the group’s physicians, for example, said they’d like to see the e-mails more tightly formatted. That’s because physicians sometimes omit key information.

“Physicians sometimes forget to include code status in the e-mails, which is a critical piece of information,” Dr. Gandla says.

One suggestion being considered is to create an e-mail template that would include blank slots for different bits of patient information that need to be entered. But to make sure that information is entered and displayed properly, physicians wouldn’t be able to work within the body of an e-mail. Because they would need to use some type of word processing document such as an attachment, Dr. Gandla doesn’t think that solution would work.

“No one has the patience to open an attachment,” he points out. “If the connection is slow, it takes time to open.”

Some hospitalists in the group have also raised concerns about the security and confidentiality of patient data. To address such concerns, Dr. Gandla suggests using only highly secured, hospital-based e-mail systems, not the commercial e-mail systems freely available on the Web.

He also notes that because of each day’s multiple e-mails, physician mailboxes fill up quickly and have to be cleaned out periodically.

That’s a small hassle, he adds, for a sign-out system that just about every hospitalist can use. “You don’t need any special training,” he points out. “If you know how to type, that is all you need.”

Jay Greene is a freelance writer specializing in health care. He is based in St. Paul, Minn.
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