Published in the January 2010 issue of Today’s Hospitalist
When it comes to improving patient outcomes, effective communication is arguably just as important as clinical intelligence.
That’s not just a personal opinion of Joseph Li, MD, director of the hospital medicine program at Boston’s Beth Israel Deaconess Medical Center, who spoke about communications at a hospital medicine conference held last fall at the University of California, San Francisco. Improving inpatient communication was also one of the Joint Commission’s national patient safety goals in 2009, and for good reason.
“If you don’t get your hands around communication issues at transitions of care, you’re going to have breakdowns,” Dr. Li told a group of hospitalists. Given the level of discontinuity in hospital medicine, he added, hospitalists need to figure out how to maximize the effectiveness of how and what they communicate.
According to Dr. Li, crafting protocols that spell out what information needs to be shared “between hospitalists at shift or unit changes, and with outpatient physicians and other providers during hospitalization and at discharge “is one key to good communication. So is standardizing how you present that information.
“I’m a big admirer of Starbucks and McDonald’s, although I don’t drink coffee or eat at McDonald’s often,” Dr. Li said. “What I admire is the fact that they’re so consistent. Communications within your hospitalist group should be the same.”
A template for handoffs
One of the most critical areas of communication is hospitalist-to-hospitalist handoffs. Although a verbal discussion is important, “I’m a strong believer that there must be verbal and text,” Dr. Li said. “I’m one of these average intelligence docs. You might tell me things about a patient, but I can’t retain everything.”
That doesn’t mean, he pointed out, that doctors should rely on handwritten sign-outs, which are bound to become dangerously illegible over the course of a patient’s hospitalization. “Particularly if a list has 30 or 40 patients on it,” Dr. Li said, “it’s very useful to have a printout. Create a Word file or, better yet, put the information in the online medical record and have a computer-based, personalized team census list that can be easily updated.”
One key to making sign-outs more complete, he said, is to create a template that goes beyond history of present illness, past medical history and to-do lists.
“Docs are pretty good about listing the clinical issues at hand,” Dr. Li said, “but there are a number of other things that are extremely important.” A sign-out template needs to include, for instance, code status, medication allergies and cognitive status.
“One of my real pet peeves is walking into a patient’s room, and it’s not clear to me from the sign-out whether the patient was moderately demented or if this is an acute change in mental status,” he said. Another important piece of sign-out information is activity status: Was the patient ambulatory at baseline, or is this a marked change?
Sign-out templates should also include precautions such as VRE or MRSA precautions. And “as someone who wasn’t born in this country, I think that language is extremely important,” said Dr. Li. Sign-outs should always mention if a patient needs an interpreter.
Having a computerized template and signout record also facilitates another essential step: monitoring sign-off processes regularly for quality assurance. “If you don’t monitor,” Dr. Li stressed, “you never have an opportunity to improve the performance of your group.”
Bridging “the black hole”
Then there’s “the black hole” when patients transition in and out of the hospital, with the many potential “voltage drops” of key information. Several studies have pointed to important gaps in how inpatient-outpatient information is transmitted. (See
“Set a goal to communicate 100% of the time within 48 hours of an event,” Dr Li said. “This includes communication at the time of hospital admission, discharge, time of death and any significant change in clinical status.”
But when you set a goal of 100%, Dr. Li added, make sure you don’t set up your group to fail. For example, expecting hospitalists to call primary care physicians whenever a patient is admitted is unrealistic.
“That’s just not possible among the hospitalists in our group, particularly when we each have five or six admissions a day,” he said. The key, he says, is to use technology, if possible, and a standardized template.
For admissions, Dr. Li’s group relies on billing software that requires hospitalists to enter all patient names “including new patients “by 10 a.m. The group’s administrative assistant uses that patient list to generate a templated letter that’s faxed or e-mailed to the outpatient physician. A copy of that letter remains in the patient’s online medical record.
The letter includes a request to the primary care office for the patient’s past medical history and medication list. The letter also gives contact information.
“With 33 hospitalists in our group, there’s no way PCPs can ever know which hospitalist will be seeing their patient,” Dr. Lee said. “To solve this problem, we have a universal pager system and a single number and e-mail address for the on-call hospitalist. This makes it very simple for the PCP to contact a hospitalist.”
The group uses a similar process to report discharges, abnormal test findings (with a letter sent the day those findings come in) and other events. “It’s all templated, and it relies very heavily on our administrative assistant,” Dr. Li said. “I don’t believe that we can do it in a timely manner relying on our physicians.”
That standardized approach probably covers 80% of all hospitalizations. For the other 20%, Dr. Li said, hospitalists will have to communicate directly with outpatient physicians. As with shift sign-outs, his practice holds quarterly audits of communications to outpatient physicians, both for the entire group and for individual hospitalists.
Building a better discharge
Not surprisingly, Dr. Li said, communication deficits tend to stack up at discharge. A study in the Feb. 28, 2007, Journal of the American Medical Association found that only one-third “or fewer “of patients’ primary care physicians had a discharge summary available at the first post-discharge appointment. That percentage increased to only between 51% and 71% at four weeks post-discharge.
Diagnostic test results were missing in 33% to 63% of discharge summaries, while a list of discharge meds was absent in up to 40% of summaries, and pending test results were absent from 65%. Follow-up plans were not included in up to 43% of reports, and patient and family counseling recommendations were almost never mentioned.
To improve those dismal statistics, Dr. Li said his group again relies on a templated discharge summary with a uniform format. Information includes history and physical; all elements of follow-up, such as pending lab test results and primary or specialty visits; and recommendations for diet and physical activity.
Taking a standard approach to discharge communications with patients is also important. Dr. Li said he recommends instituting a discharge “time-out” ” similar to a pre-procedural time-out “to ensure that patients and family members are on the same page with the hospitalist in terms of discharge instructions and medications.
The technique, which is borrowed from the Society of Hospital Medicine’s Project, uses a teach-back method to confirm that the patient and family understand appropriate medication use. Many hospitalist groups also find that a call-back system using a nurse or pharmacist post-discharge helps identify problems. At a minimum, Dr. Li said, groups should consider targeting high-risk patients for follow-up calls within 72 hours of discharge.
Hospitalists also need to ensure that primary care physicians receive key information when patients are transferred to skilled nursing facilities. A checklist for such transfers should include history and physical, progress notes, consultant reports, diagnostic and lab reports, medication lists, and copies of advance directives and DNR forms.
What do you need from the PCP?
On the flip side, Dr. Li pointed out, hospitalists often fail to let primary care physicians know what they need in terms of communication.
Just as with information from the hospital, outpatient physicians should have an office protocol in place for getting information to hospitalists. Receiving a templated letter on an admission, for example, should automatically generate a fax of pertinent office records to the hospitalist.
Hospitalists should also work with primary care doctors to discuss standards used for templating discharge summaries. And primary care physicians should be urged to deliver an invaluable endorsement of the hospitalist group by discussing the hospitalists’ role with patients prior to any admission. (Distributing a brochure about the hospitalist group “with photos, bios, contact information and frequently asked questions ” to outpatient offices also helps.)
Dr. Li said his group also encourages outpatient physicians to stay involved during a patient’s hospital stay.
“We do something very simple: We often provide the PCPs with patients’ phone numbers in the room,” he pointed out. “Even if doctors don’t come over, they can call because some patients and some children need that interaction with their outpatient provider during their hospitalization, which I understand.”
Katherine Kahn is a freelance health care writer based in western Massachusetts.
MANY HOSPITALISTS ARE STRUGGLING to master a new forum: how to communicate during multidisciplinary rounds.
It takes practice to be able to maintain productive team rounds, according to Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess Medical Center in Boston, who spoke about communications at a hospital medicine conference last fall at the University of California, San Francisco. Many rounding teams fall victim to tolerating members who arrive just a few minutes late, or to frittering away valuable time on football scores or stock market blips.
Then there’s always one person, Dr. Li said “a doctor, a nurse, a case manager ” who just can’t pare down his or her communications to the spare, just-the-facts style that multidisciplinary rounds demand. “That person needs to be actively redirected,” Dr. Li pointed out. “You just have to keep saying, ‘You’ve got to move on.’ ”
Here are tips to help you get the most out of multidisciplinary teams:
- Hold rounds as early as possible.
- The entire point of these rounds is to save people time throughout the rest of their day by prioritizing what they need to do. At Beth Israel Deaconess, Dr. Li said, teams hold rounds at 9:30 a.m. He’d prefer, he said, to hold them at 8 a.m., but doctors and nurses changing shifts are still signing out then.
- Insist that everyone be on time and prepared to speak
when it’s his or her turn to contribute. Also, think about where to hold rounds. Dr. Li said that his rounds are not held at patients’ bedsides, but in a back nursing room. And if rounds end up consistently taking too long, consider having team members stand during rounds instead of sitting down and getting comfortable.
- Who needs to be included?
At a minimum, rounds should include a hospitalist, a nurse and a case manager. The team can also include social workers, physical therapists and pharmacists.
- Discuss every patient,
but keep it brief, preferably only one to two minutes on each. It can help, said Dr. Li, to have a timer that you restart every time you start discussing a new patient.
As for patients with issues that require extended discussion, “remove those patients from rounds and treat them as outliers,” Dr. Li said. “Discuss them at the end.”
- To keep discussions brief,
be sure everyone is clear on what information needs to be shared. That includes who’s really sick; what needs to be renewed in terms of telemetry, antibiotics and fluids; were there any issues overnight and what are vitals this morning; are there critical pending labs; and is there anything that needs to be ordered? Other important topics are barriers to discharge and what lines or catheters need to be pulled.
“At the end of rounds, I “and everyone else on the team “should be able to walk away having prioritized my day,” said Dr. Li. After rounds, he sees his sickest patients first, then those who are potentially early discharges, “then everyone else. If rounds go well and everyone communicates effectively,” he points out, “my pager shouldn’t go off for two to three hours.”
How do you know if you’re not using that time well? “The fact that you spent 30 minutes together,” Dr. Li said, “but your pager is still going off a short time after.”