Dr. Solet says that inconsistent information poses the biggest threat in the post-discharge communications he has seen. Another high-risk area involves documentation in which the physician writes only a line or two, such as, “This is a 50-ish-year-old man with COPD. Those one-liners are very dangerous,” he says.
In addition to the risks inherent in documentation, the biggest danger areas include pending test results, recommended follow-up studies, misunderstood medication instructions, never-purchased medications, and missed follow-up visits with the primary care physician.
Nelson and Whitcomb1 suggest that a post-discharge summary containing all essential information could overwhelm the primary care physician. They recommend standard forms with separate headings for diagnoses, medications, and hospital course, along with categories such as tests pending and evaluations needed. “Ideally, each hospitalist in a group should use the same format for these reports, so that a reader can quickly become accustomed to extracting information from them,” they write.
Tailor the Summary
Edward J. Merrens, MD, section chief of hospital medicine at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., was one of the authors of a study investigating ways to enhance the timeliness, accuracy, and breadth of clinical information gathered at discharge.3 The improvement project was conducted in a 330-bed tertiary care teaching hospital that averages 12,800 discharges a year.
“In general,” says Dr. Merrens, “we’re sending people out sicker and sicker, and often [the subsequent providers] don’t need a summary of all the interventions and studies and meds and antibiotics [done during the hospitalization], but what to do with the patient next. … Hospitalizations have become less therapeutic confinements where everything gets done, but [rather] where complex interventions occur and patients go out on therapy and are still often sick.”
The discharge summary should be designed in such a way that the primary care physician can simply “pick it up and go” from there, says Dr. Merrens. “We’ve tried to think, who really reads this thing? It could be [the] primary care physician, it may be a patient, it could be a doctor taking care of a patient in a rehabilitation facility, or it may be a visiting nurse service. We try to tailor the summary to those audiences, not just summarize what we’ve done.” His team has included a section on the summary where one can write, for example, “The patient might need more diuresis for their heart failure. They’re probably going to need a follow-up with this,” and Dr. Merrens says this structure has worked well.
“As we move from the Marcus Welby model of ‘you’re always on, you’re always covering, you’re the only doc’ to shift-based care,” he says, “the core of the [provider] group itself needs to communicate well, and it needs to agree on principles.” And this, he says, is a key component of job satisfaction for hospitalists.
We’ve tried to think, who really reads [the discharge summary]? It could be [the] primary care physician, it may be a patient, it could be a doctor taking care of a patient in a rehabilitation facility, or it may be a visiting nurse service. We try to tailor the summary to those audiences, not just summarize what we’ve done.
—Edward J. Merrens, MD
Back to Long-Term Care
The goals of transitional care include ensuring continuity, providing for safe discharge, and preventing rehospitalization.4 Hospitalists have to recognize which patients are at risk for poor outcomes and devise ways to help prevent these problems. At particularly high risk are patients with the following characteristics:
- Age 80 and older;
- A history of depression;
- Multiple chronic diseases;
- Moderate-to-severe functional impairment;
- Noncompliance with therapy;
- Inadequate social supports;
- Multiple hospitalizations in the previous six months;
- Hospitalization in the last 30 days; and
- Fair or poor self-rating of health.4