Published in the November 2016 issue of Today’s Hospitalist
A RECENTLY DISCHARGED PATIENT calls her primary care physician complaining of stomach pains and bloody stools. Because the doctor has not yet received the patient’s discharge summary, he has no way of knowing the results of the endoscopy she had in the hospital. That means the doctor also doesn’t know that the patient’s GI bleeding can be managed on an outpatient basis, so he ends up readmitting her.
Could unnecessary readmissions like this one be prevented if discharge summaries were completed faster? Possibly. A study in the June 2016 Journal of Hospital Medicine found that taking more than three days after discharge to complete summaries raised the odds of a 30-day readmission by 9%, after adjusting for several factors including patient age, illness severity and comorbidities. The odds ratio increased another 1% for every three additional days it took to complete summaries and send them off.
A lot of physicians can relate to the experience of not knowing what happened during a patient’s hospital stay,” says lead author Erik H. Hoyer, MD, physician advisor for patient safety and quality in the department of physical medicine and rehabilitation at Baltimore’s Johns Hopkins University. “It means you’re starting from an ‘un-ideal’ place where you can’t make the best decisions for the patient.”
“Discharge summary times may be a marker of an over-stressed work environment.”
The study focused on patients discharged over two years from Johns Hopkins Hospital. Because all Maryland hospitals have to report readmissions to the state, researchers were able to identify John Hopkins’ patients who were readmitted to any Maryland hospital vs. only those who returned to John Hopkins. Among 88,000 patients, about 16% were readmitted—and 43% of those patients were readmitted before their discharge summaries were completed.
Physicians at John Hopkins took a median of eight days to complete discharge summaries—better than the hospital’s current 14-day goal, says Dr. Hoyer, “but certainly not ideal. We were disappointed by our completion rates. But these data have been important in changing some of our practices.”
Johns Hopkins’ focus on speeding up the release of discharge summaries is on track with a proposed rule issued in 2015 by the Centers for Medicare and Medicaid Services. That rule, if adopted, would mandate that summaries be turned around within 48 hours. Today’s Hospitalist spoke with Dr. Hoyer to learn more about improving discharge-summary turnaround time.
What tends to hold up the release of discharge summaries?
Physician bandwidth is a limitation. Clinicians have lots of responsibilities and duties. Trying to prioritize all of these and performing them all in a quality manner is absolutely challenging.
Some institutions have support staff, such as scribes, who can help with discharge summaries. Another option is to have nurse practitioners and other providers facilitate summary completion. I think we need more research around these different models to investigate the time-savings and the resulting impact on quality of care.
In the study, you suggest that the timeliness of discharge summaries may be a marker for other issues. What do you mean?
What’s nice about “discharge completion time” is that it is an easy metric to track, and it is a proxy to uncover how the institution is performing in terms of care coordination. If a facility’s discharge summary times are long, I think that deserves an evaluation on multiple levels.
The institution should, for instance, look at what’s being demanded of all the hospital’s service lines. Discharge summary times may be a marker of an overstressed work environment where clinicians do not have time to complete the summaries in a timely manner. If that is the case, it may be helpful to bring those data to hospital administrators, saying, “Hey, listen, we’re struggling to meet our responsibilities.”
Are discharge summaries more important for some types of discharges than others in terms of preventing readmissions?
Other research has suggested that surgical patients tend to be readmitted for new complications. In contrast, patients with medical problems tend to be readmitted for the same thing over and over.
While our study wasn’t designed to examine this question speciﬁcally, our ﬁndings help support past research. We did not ﬁnd an association between discharge summary completion and readmission for surgical services or for obstetrics/gynecology, which tends to admit patients for procedures. But we need more studies to conﬁrm our ﬁndings.
How quickly should hospitals complete discharge summaries?
Ideally, the same day as discharge. I know there are hospitals that have achieved this goal, and it would be great for those institutions to serve as models and describe their methods so we can learn from them.
What’s your advice on how to reduce the amount of time for completion?
One thing is to recognize that you don’t need to document a complete synopsis of everything that happened to the patient in the hospital. We hear this from primary care physicians a lot. They often have only 15 minutes with their patients, so it’s impossible for them to review a lot of documentation.
Even from a quality perspective, I think it’s important that there’s some process of synthesis. The summary should synthesize the most important points from the perspective of coordination of care. Why was the patient hospitalized? What’s pending at the time of discharge, and what are the medications and follow-up plans?
I’ve also heard from our residents who keep a running log of key information to pass along about a patient. They update this on a regular basis during a patient’s hospitalization, so when it comes to the ﬁnal summary they have something to work with.
What is Johns Hopkins doing to speed up discharge summary completion?
We’ve gone to our providers with data so they can see their discharge summary times. We’ve also said, “We really need to tackle this from an institutional perspective.” Physicians respond to data, and putting discharge completion times on a dashboard of sorts where providers can see their performance at a service line or unit level can have a real impact. Sometimes change can happen when you see your peers doing a better job and you are encouraged to do so as well.
We’ve also made eff orts to educate our residents and interns about the importance of the discharge summary and reinforce that. We’ve set the expectation from day 1 that this needs to be a priority.
At the time of the study, John Hopkins sent discharge summaries via fax. How can newer technologies speed up this process?
We’ve adopted an electronic medical record system, which is proving helpful. Currently, when a discharge summary is completed, it is immediately available within our electronic medical record to any provider with access to the system. That’s probably one of the most important technologies that is going to help with this process. I think having any ability to integrate the inpatient and outpatient settings is a huge win.
Maggie Van Dyke is a freelance writer and editor based in the Chicago area.