Clinical question: Can a standardized discharge communication process, coupled with an electronic health record (EHR) system, improve the proportion of completed verbal handoffs from in-hospital physicians to PCPs within 24 hours of patient discharge?
Background: Discharge from the hospital setting is known to be a transition of care fraught with patient safety risks, with more than half of discharged patients experiencing at least one error.1 Previous studies identified core elements that pediatric hospitalists and PCPs consider essential in discharge communication, which included:
- Pending laboratory or test results;
- Follow-up appointments;
- Discharge medications;
- Admission and discharge diagnoses;
- Dates of admission and discharge; and
- Suggested management plan.2
Rates of transmission and receipt of information have been found to be suboptimal after hospital discharge, and PCPs have been found to be less satisfied than hospitalists with communication.2,3 Additionally, PCPs and hospitalists have been found to have incongruent views on who should be responsible for pending labs, adverse events, or status changes, differences which can have safety implications.3 PCPs who refer to general hospitals have been found to report superior completeness of discharge communication compared to freestanding children’s hospitals, where resident physicians are generally responsible for discharge summary completion.4 Standardizing and promoting a process of verbal handoff after hospital discharge may address some of these safety concerns, although a relationship has not been established between aspects of discharge communication and associated adverse clinical outcomes.5
Study design: Quality improvement study using improvement science methods and run charts.
Setting: An urban, 598-bed, freestanding children’s hospital.
Synopsis: A 24/7 telephone operator service had been established at the investigators’ institution that was designed to facilitate communication between providers inside and outside the institution. At baseline, only 52% of hospital medicine (HM) provider discharges had a record of a discharge day call initiated to the PCP. A project team consisting of hospitalists, a chief resident, operator service administrators, and IT analysts identified system issues that led to unsuccessful communication, which facilitated identification of key drivers of improving communication and associated interventions (see Table 1).
Discharging physicians, who were usually residents, were instructed to call the operator at the time of discharge. Operators would page the PCP, and PCPs were expected to return the page within 20 minutes. Discharging physicians were expected to return the call to the operator within two to four minutes. The EHR generated a message to the operator whenever a discharge order was placed for an HM patient, leading the operator to page the discharging physician to initiate the call.
Adaptations after project initiation included:
- Reassigning primary responsibility for discharge phone calls to the daily on-call resident, if the discharging physician was not available.
- Establishing a non-changing pager number on the automated discharge notification that would always reach the appropriate team member.
- Batching discharge phone calls at times of increased resident availability to minimize hold times for PCPs and work interruptions for discharging physicians.
Weekly failure data was generated and reviewed by the improvement team, and a call record was linked to the patient’s medical record. Team-specific and overall results for HM teams were posted weekly on a run-chart. The primary outcome measure was the percentage of completed calls between PCP and HM physician within 24 hours of discharge.
Over the approximately 32-month study period, the percentage of calls initiated improved from 50% to 97% after four interventions. After one year, data was collected to assess percentage of calls completed, a number that rose from 80% in the first eight weeks to a median of 93%, which was sustained for 18 months.
Bottom line: Utilizing improvement methods and reliability science, a process of improving verbal handoffs between hospital-based physicians and PCPs within 24 hours after discharge led to a sustained improvement, to above 90%, in successful verbal handoffs.
Citation: Mussman GM, Vossmeyer MT, Brady PW, Warrick DM, Simmons JM, White CM. Improving the reliability of verbal communication between primary care physicians and pediatric hospitalists at hospital discharge [published online ahead of print May 29, 2015]. J Hosp Med. doi: 10.1002/jhm.2392.
MAJORITY OF NONOBSTRUCTING ASYMPTOMATIC RENAL STONES REMAIN ASYMPTOMATIC OVER TIME
Retrospective trial of active surveillance of asymptomatic nonobstructing renal calculi demonstrated that 28% of stones became symptomatic, with 17% requiring surgical intervention and 2% causing asymptomatic hydronephrosis over three years.
Citation: Dropkin BM, Moses RA, Sharma D, Pais VM Jr. The natural history of nonobstructing asymptomatic renal stones managed with active surveillance. J Urol. 2015;193(4):1265-1269.
CPR USE IS HIGH, YET OUTCOMES ARE POOR IN HEMODIALYSIS PATIENTS
In a national cohort of hemodialysis patients, receipt of in-hospital CPR was significantly higher (6.3% vs. 0.3%) than the general population, but post-discharge survival was substantially shorter (33 vs. five months).
Citation: Wong SY, Kreuter W, Curtis JR, Hall YN, O’Hare AM. Trends in in-hospital cardiopulmonary resuscitation and survival in adults receiving maintenance dialysis. JAMA Intern Med. 2015;175(6):1028-1035. doi:10.1001/jamainternmed.2015.0406.
ULTRASOUND GUIDANCE INCREASES RATE OF SUCCESSFUL FIRST ATTEMPT RADIAL ARTERY CANNULATION
Randomized controlled trial of 749 anesthesia trainees showed that ultrasound guidance increased rate of first attempt radial artery cannulation by 14% when compared to Doppler and palpation (95% CI 5-22%).
Citation: Ueda K, Bayman EO, Johnson C, Odum NJ, Lee JJ. A randomised controlled trial of radial artery cannulation guided by Doppler vs palpation vs ultrasound [published online ahead of print April 8, 2015]. Anaesthesia. doi: 10.1111/anae.13062.
NO DIFFERENCE BETWEEN EPIDURAL STEROID INJECTIONS AND GABAPENTIN FOR TREATMENT OF LUMBOSACRAL RADICULAR PAIN
Multicenter, randomized study found no difference in lumbosacral radicular pain at one and three months in patients treated with epidural steroid injection versus gabapentin.
Citation: Cohen SP, Hanling S, Bicket MC, et al. Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study. BMJ. 2015;350:h1748 doi: 10.1136/bmj.h1748.
- Smith K. Effective communication with primary care providers. Pediatr Clin North Am. 2014;61(4):671-679.
- Coghlin DT, Leyenaar JK, Shen M, et al. Pediatric discharge content: a multisite assessment of physician preferences and experiences. Hosp Pediatr. 2014;4(1):9-15.
- Ruth JL, Geskey JM, Shaffer ML, Bramley HP, Paul IM. Evaluating communication between pediatric primary care physicians and hospitalists. Clin Pediatr (Phila). 2011;50(10):923-928.
- Leyenaar JK, Bergert L, Mallory LA, et al. Pediatric primary care providers’ perspectives regarding hospital discharge communication: a mixed methods analysis. Acad Pediatr. 2015;15(1):61-68.
- Bell CM, Schnipper JL, Auerbach AD, et al. Association of communication between hospital-based physicians and primary care providers with patient outcomes. J Gen Intern Med. 2009;24(3):381-386.