Patient discharge. It’s an everyday occurrence and, therefore, easily taken for granted. The hospitalist, who must help the patient transition back to the primary care physician, knows that this is a mistake. This transition takes an intense amount of communication among hospitalists, primary care and other physicians, nurses, case managers, social and therapy services, the patient, and the family.
Although smooth, effective patient handoffs are critical in maintaining patient safety and ensuring positive health outcomes, they are too often executed haphazardly, and the amount and precision of information as well as the means by which it is transmitted varies considerably. The journey is rife with communication landmines—communication can lapse or be absent, and when information falls through the cracks, continuity of care may be disrupted.
Considering post-discharge communication in general, “probably the most important thing is to make sure that the hospitalist conveys as much of an impression of how the patient is doing [as possible],” says Richard Frankel, PhD, professor of medicine and geriatrics at Indiana University School of Medicine, Indianapolis, “not only in terms of their medical care or their disease process, but [also] what the patient’s hospital stay has been like, what the perception of their hospital experience has been like. And to be open to additional questions from the primary care physician about issues that might arise post discharge and ambiguities that might exist in the discharge summary.”
After determining a standardized protocol for post-discharge handoffs, “then I think that the most important thing is just practicing using these various protocols,” says Dr. Frankel, who also serves as senior research scientist at the Regenstrief Institute (Indianapolis) and is a research sociologist in the Health Services Research Unit at the Roudebush Veterans Affairs Medical Center, Indianapolis. “When the astronauts train, they train for every possible contingency so that when [a problem] arises it seems like the most common thing in the world, when in fact, what they practice are very low-frequency events, very low-probability problems arising.”
The nuts and bolts of ideal practices include essentials such as dictating notes and, preferably, transcribing and transmitting them by the close of the business day on which the patient is discharged.1 If short notes are sent to the primary care physician at the time of discharge, a longer summary should arrive within a few days. Because primary care physicians disagree as to what should be included in that summary, communication among physicians becomes a key issue in the transition.
“There’s a paucity of data on the subject of how well physicians communicate with each other,” says Darrell Solet, MD, cardiology fellow at the University of Texas, Southwestern Medical Center in Dallas. “A number of organizations have jumped on the bandwagon of improving this process, especially [the] Joint Commission [on] Accreditation of Healthcare Organizations,” he says.
One of the major things the University of Texas Southwestern has emphasized in its residency program’s communication skills curriculum is not only how physicians communicate with their patients but also how well they communicate with each other. “This includes hearing a presentation on the most effective and efficient ways to perform their handoffs and also addressing the specific barriers to communication that they might face, says Dr. Solet.
These barriers to effective handoffs were identified in a study that Dr. Solet and his colleagues, including Dr. Frankel, conducted in 2005 in four hospitals in Indiana.2 At that time, Dr. Solet was the chief resident of ambulatory medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, and of medical service, Roudebush Veterans Affairs Medical Center, Indianapolis. In general, the study revealed that barriers to communication existed in four areas: physical settings, social settings, language, and communication styles.