Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending Results and Outpatient Follow-up Providers

BACKGROUND  Poor communication of tests whose results are pending at hospital discharge can lead to medical errors. OBJECTIVE  To determine the adequacy with which hospital discharge summaries document tests with pending results and the appropriate follow-up providers. DESIGN  Retrospective study of a randomly selected sample PATIENTS  Six hundred ninety-six patients discharged from two large academic medical centers, who had test results identified as pending at discharge through queries of electronic medical records. INTERVENTION AND MEASUREMENTS  Each patient’s discharge summary was reviewed to identify whether information about pending tests and follow-up providers was mentioned. Factors associated with documentation were explored using clustered multivariable regression models. MAIN RESULTS  Discharge summaries were available for 99.2% of 668 patients whose data were analyzed. These summaries mentioned only 16% of tests with pending results (482 of 2,927). Even though all study patients had tests with pending results, only 25% of discharge summaries mentioned any pending tests, with 13% documenting all pending tests. The documentation rate for pending tests was not associated with level of experience of the provider preparing the summary, patient’s age or race, length of hospitalization, or duration it took for results to return. Follow-up providers’ information was documented in 67% of summaries. CONCLUSION  Discharge summaries are grossly inadequate at documenting both tests with pending results and the appropriate follow-up providers.     

A Hospital Discharge Summary Quality Improvement Program Featuring Individual and Team-based Feedback and Academic Detailing

BackgroundDischarge summaries are an important component of hospital care transitions typically completed by interns in teaching hospitals. However, these documents are often not completed in a timely fashion or do not include pertinent details of hospitalization. This report outlines the development and impact of a curriculum intervention to improve the quality of discharge summaries by interns and residents in Internal Medicine. A previous study demonstrated that a discharge summary curriculum featuring individualized feedback was associated with improved summary quality, but few subsequent studies have described implementation of similar curricula. No information exists on the utility of other strategies such as team-based feedback or academic detailing.MethodsStudy participants were 96 Internal Medicine intern and resident physicians at an academic medical center-based training program. A comprehensive evidence-based discharge summary quality improvement program was developed and implemented that featured a discharge summary template to facilitate summary preparation, individual feedback, team-based feedback, academic detailing and an objective discharge summary evaluation instrument.ResultsThe discharge summary evaluation instrument had moderate interrater reliability (κ = 0.72). Discharge summary scores improved from mean score of 70% to 82% (P = 0.05). Interns and residents participating in this program also reported increased confidence in producing and critiquing summaries.ConclusionsA comprehensive discharge summary curriculum can be feasibly implemented within the context of a residency program. Team-based feedback and academic detailing may serve to reinforce individual feedback and extend program reach.     

Incidental vertebral fractures on chest radiographs

BACKGROUND: Recognition of incidental vertebral fractures may be an important opportunity for identifying and treating osteoporosis. OBJECTIVE: To assess osteoporosis documentation rates in patients with vertebral fractures, and to define patient and hospitalization characteristics associated with osteoporosis management. DESIGN: Hospital and outpatient records were abstracted for patients with vertebral fractures on inpatient radiograph reports. The primary outcome of interest was discharge summary fracture documentation. Covariates associated with fracture documentation and treatment were examined with multivariate regression models. Secondary outcomes included osteoporosis documentation and management 6 months following discharge. PATIENTS: Women > or =50 years hospitalized at an academic medical center. RESULTS: Among 10,291 women with chest radiographs, 142 (1.4%) had vertebral fractures reported. Among patients with a reported fracture, 58 (41%) had their fracture noted in the findings section but not in the final impression. Only 23 (16%) discharge summaries documented a vertebral fracture. Factors associated with documentation of the fracture in the discharge summary included notation of the fracture in the impression section (odds ratio [OR] 3.7, 95% confidence interval [CI] 1.0 to 13.1), tobacco use (OR 3.7; 95% CI 1.1 to 12.2), discharge from a medical service (OR 7.6; 95% CI 0.9 to 66.2) and glucocorticoid use (OR 3.7; 95% CI 0.8 to 17.0). Only 36% of patients were using any osteoporosis medications at discharge. Fracture notation in the impression section was associated with fracture documentation in subsequent outpatient notes (OR 3.6, 95% CI 0.9 to 13.8). Discharge summary fracture documentation was associated with an increased likelihood of starting an osteoporosis medication by 6 months (OR 2.8; 95% CI 0.8 to 9.2). CONCLUSIONS: Incidental vertebral fractures from inpatient chest radiographs may represent a missed opportunity for osteoporosis management.     

Use of Discharge-Worksheet Enhances Compliance with Evidence-Based Myocardial Infarction Care

Background: Prior studies demonstrate that effective secondary prevention therapies are underutilized in patients with myocardial infarction (MI) at hospital discharge. At a US tertiary center, we developed and encouraged providers to complete a simple Acute MI Discharge Worksheet (MIDW) designed to educate patients, prompt caregivers, and provide chart documentation regarding evidence-based therapies post-MI. Methods and Results: The MIDW was introduced in May of 2000 with use encouraged in all surviving patients with MI. We calculated a patient discharge score by summing the number of quality indicators (aspirin use, beta-blocker use, ACE-inhibitor use, smoking cessation, lipid-lowering therapy, cardiac rehabilitation referral) and compared documentation of quality indicators at discharge between patients without (Group I, n = 65) and with (Group II, n = 60) the MIDW. Group II was subdivided into those with an incomplete worksheet (Group IIa, n = 26), and those with a completed worksheet (Group IIb, n = 34). Greater documentation of secondary prevention indicators occurred in patients with incomplete and completed discharge forms present. Mean Discharge scores were significantly higher for Group II vs. Group I (4.98 vs. 3.88, p < 0.0001), and Group IIb vs. Group IIa, (5.47 vs. 4.35, p < 0.001). Conclusion: A simple Acute MI Discharge Worksheet was associated with better adherence and documentation of evidence-based post MI care and be a useful component to improve post MI care.     

Electronic Versus Dictated Hospital Discharge Summaries: a Randomized Controlled Trial

BACKGROUND  Patient care transitions are periods of enhanced risk. Discharge summaries have been used to communicate essential information between hospital-based physicians and primary care physicians (PCPs), and may reduce rates of adverse events after discharge. OBJECTIVE  To assess PCP satisfaction with an electronic discharge summary (EDS) program as compared to conventional dictated discharge summaries. DESIGN  Cluster randomized trial. PARTICIPANTS  Four medical teams of an academic general medical service. MEASUREMENTS  The primary endpoint was overall discharge summary quality, as assessed by PCPs using a 100-point visual analogue scale. Other endpoints included housestaff satisfaction (using a 100-point scale), adverse outcomes after discharge (combined endpoint of emergency department visits, readmission, and death), and patient understanding of discharge details as measured by the Care Transition Model (CTM-3) score (ranging from 0 to 100). RESULTS  209 patient discharges were included over a 2-month period encompassing 1 housestaff rotation. Surveys were sent out for 188 of these patient discharges, and 119 were returned (63% response rate). No difference in PCP-reported overall quality was observed between the 2 methods (86.4 for EDS vs. 84.3 for dictation; P = 0.53). Housestaff found the EDS significantly easier to use than conventional dictation (86.5 for EDS vs. 49.2 for dictation; P = 0.03), but there was no difference in overall housestaff satisfaction. There was no difference between discharge methods for the combined endpoint for adverse outcomes (22 for EDS [21%] vs. 21 for dictation [20%]; P = 0.89), or for patient understanding of discharge details (CTM-3 score 80.3 for EDS vs. 81.3 for dictation; P = 0.81) CONCLUSION  An EDS program can be used by housestaff to more easily create hospital discharge summaries, and there was no difference in PCP satisfaction.