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The Patient Has Left the Building


 

The hospitalist service at the University of Wisconsin Hospital and Clinics in the Department of Medicine recently admitted a patient with altered sensorium, which the team determined most likely was narcotic-related. Going the extra distance, they did a spinal tap to rule out meningitis.

Within a day of changing the medication, the patient got better and was ready for discharge. However, says Julia S. Wright, MD, director of the Madison-based service, an important test remained from the spinal tap. “We thought that those results would not change the medical management of the case, but we knew if it were positive, it would be a big deal,” she recalls.

Not all medical-legal experts would agree the responsibility for patient care ends when patients leave the hospital. Often there are extenuating circumstances that may warrant the hospitalist’s continued communication and contact with patients and/or their providers and caregivers. Although there are no universally accepted standards of care that define these post-discharge issues, several hospitalists recently discussed their institutions’ and groups’ guiding principles for managing the nuances of post-discharge protocol.

Who’s Responsible?

Hospitalist Jeffrey Greenwald, MD, associate professor of medicine at Boston University School of Medicine, is a member of SHM’s Hospital Quality and Patient Safety Committee and also has been investigating pre- and post-discharge interventions through a grant-funded project from the Agency for Healthcare Research and Quality (AHRQ) called “Project RED” (the Re-Engineered Discharge, online at www.ahrq.gov/qual/pips).

One reason the post-discharge period is a “gray zone” of responsibility for care, he believes, is that the hospital system was designed to have a finite endpoint—the discharge. “This ‘out of sight, out of mind’ mentality has existed forever in the inpatient service, but it has become more highlighted in the post-hospitalist era,” he notes.

That mentality can sometimes take over in the hospitalists’ minds. “I think a lot of hospitalists are burying their heads [in the sand] about how these patients are being sent home and the chances for miscommunication and a ‘bounce-back,’ ” notes David Yu, MD, FACP, ABIM, medical director of hospitalist services, Decatur Memorial Hospital, Decatur, Ill., and clinical assistant professor of family and community medicine, Southern Illinois University School of Medicine. “This is going to be more of an issue as hospitalists become increasingly busy. The temptation is to squeeze time on discharges, because it takes an effort to reconcile medications and tie up loose ends at time of discharge. It is not acceptable to write, ‘resume current medications and follow up with PCP’ and think the job is done. It is magical thinking that discharge medications and follow-up instructions will be figured out somehow by the patient and discharging nurse.”

Potential Problem Scenarios

During discharge transitions, many factors outside the hospitalist’s control can lead to gaps in care. According to Dr. Grace, having a well-streamlined post-discharge period can be most problematic with:

  • Younger patients (“I feel fine; I don’t need to keep that appointment”);
  • Elderly patients living alone (especially those with mild, early dementia, and lack of family support systems); and
  • Indigent patients (for whom paying for outpatient care is often a barrier).

In addition, patients may not have a primary care physician to whom care can be transferred. If this is the case at Decatur Memorial Hospital, says Dr. Yu, “we either call one of our PCPs who is accepting new patients, or we’ll assign them to a local clinic and communicate that in our discharge. We always try to document some mechanism of follow up, because if you don’t tie up these loose ends, you’ll no longer be a hospitalist service, you’ll be a primary care physician.”

Dr. Grace shares this philosophical approach. “During orientation, I try to ingrain the concept in our new hospitalists that you have a continuing responsibility for patient care until the patients have re-established contact with their PCP after discharge,” he stresses.

His group employs a practice coordinator to supply extra continuity after discharge. The coordinator recently noticed a chest X-ray came back after a patient had been discharged. The X-ray originally had been ordered by the emergency department (ED) unbeknownst to the hospitalist. The patient was transferred upstairs before the ED physician saw the film and discharged prior to the report reaching the chart, where the hospitalist would have seen it. The coordinator flagged the X-ray; the hospitalists reviewed it, noticed a worrisome mass, and secured an appointment with a pulmonologist for the patient. “Had there been a bad outcome and the case ended up in court,” says Dr. Grace, “the jury would likely conclude that we were at fault. Without effective processes in place, an important test result may get filed away in the chart, never reaching the physician, and never to be seen again.”—GH

Cover the Gray Zone

Hospitalists describe differing approaches to ensuring patients get the care they need when they leave the hospital.

In the case of the UWHC patient who wanted to leave the hospital, the hospitalist team arranged to stay in touch with the patient. They watched for the test results during the next 24 hours. When the test came back positive, they called the patient back to the hospital, and began treatment.

“Although tracking test results may be out of the hospitalist’s purview, I think we have a strong obligation to make sure we look at some of that data,” Dr. Wright says. “I think there has to be some redundancy, otherwise, the patient probably would not have seen the primary care physician in time and would have become more ill.”

Attention to detail before discharge can avoid problems in the post-discharge period. Partnering with the pharmacy to achieve medication reconciliation has been shown to reduce risk of readmission, notes Tom Bookwalter, PharmD, associate professor of health sciences at the University of California San Francisco School of Medicine and formerly clinical pharmacist there. Using standardized templates and electronic medical records (EMR), hospitalists at many academic centers can furnish real-time discharge summaries to patients’ primary care physicians.

Dr. Yu is especially proud of the EMR system at his institution, by which discharge summaries are faxed to the primary care physician (PCP) in real time. “A patient can call their primary care physician right after discharge, and that physician will know exactly what happened during the hospital course, and what the medications and the discharge plan are,” he explains.

In addition, computerized entry and transmission eliminates the risk of error introduced when handwritten instructions are given to patients. “We believe that communication is the ‘mother’s milk’ of the hospitalist,” Dr. Yu says. Accordingly, his hospitalist service also makes a courtesy call to the PCP following transmission of the EMR for the patient.

Attorney Patrick T. O’Rourke of the Office of University Counsel at Colorado University in Denver and legal columnist for The Hospitalist, advises how to avoid inviting unintended legal consequences. “It’s important for hospitalists to understand that they are the conduit of information about what happened during the hospitalization,” he notes. “Failing to define everyone’s job in the discharge process can expose people to liability.”

In that vein, he urges hospitalists not to delegate the process of giving discharge instructions to the patient. Patients should hear directly from the hospitalist about their condition, the recommended course of action, and how to respond in case of emergency post-discharge. When returning the patient to their regular physician, the hospitalist should also touch base with the patient’s physician via e-mail or telephone to prevent gaps in communication.

Other Strategies

If budgets allow, some groups employ ancillary staff who call patients after discharge.

Hospitalist David Grace, MD, area medical officer for the Schumacher Group, Hospital Medicine Division, in Lafayette, La., reports that having a practice coordinator who calls patients within 48 hours of discharge “adds one more layer of safety to the process.” “Yes” answers to some questions (e.g., “Have your symptoms worsened? Do you have any new symptoms?”) trigger follow-up calls to the on-call hospitalist to take appropriate steps. However, O’Rourke cautions that midlevel providers should possess adequate training to be able to act appropriately upon patients’ information.

Hospitalist Randy Ferrance, DC, MD, medical director at Riverside Tappahannock Hospice in Tappahannock, Va., agrees follow-up calls to patients are a good idea. “I think more aggressive follow up in the short term, and then turning the patient over, for continuity reasons, to their primary care physician as quickly as possible is very important.” His hospitalist group, comprising only four staff, struggles with having the time to devote to such activities. However, with an average inpatient age of 72, their patients often transition to home healthcare. His group enjoys an “excellent relationship” with all the area home health agencies. Those agencies are asked to call the hospitalist group during their first visit with the patient, in addition to sending their usual report to the primary care physician. “At that first home health visit, we consider ourselves still responsible for the patient,” he says.

Beyond Liability Protection

Adhering to the “higher standard” of patient safety can improve transitions of care even further, Dr. Greenwald believes. Such actions might include a mechanism for patients to reach a member of the hospitalist team (nurse, pharmacist or physician) if they have post-discharge concerns; empowering patients and family members to know what to do if an adverse event occurs; and enabling patients to have copies of their own medical information (discharge summary, lab tests, medication reconciliations).

“In addition, we need to involve the nonmedical caregivers who are going to help the patient recuperate,” he asserts. Physicians can educate patients and their caregivers about what happened while they were in the hospital, what treatments are planned, and what information is pending at discharge. While these efforts might require that hospitalists shift their thinking about doctor-patient roles, they can help to create a more comprehensive approach to patient care.

Inherent Dangers

Ironically, what hospitalists do best—promote effective inpatient management—can also lead to a disconnect when the patient leaves the hospital. “Part of what we do, as hospitalists, is to drive down the patient’s length of stay and get them home sooner,” Dr. Grace says. “While unquestionably beneficial for a variety of reasons, it increases the chance that a patient can leave before a result comes back.”

“This change from the continuity of healthcare [provided by a physician who also saw his or her hospitalized patients] to a division of labor does have some inherent fragmentation,” agrees Dr. Wright. “We need to still look at the patient as a whole and be in communication with [our primary care colleagues] and supporting each other on both ends so that the patient does get this more comprehensive care.” TH

Gretchen Henkel is a medical writer based in California.

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