Sentinel Events

The Hospitalist. 2006 October;2006(10):

October 1, 2006 | The Hospitalist

Joen Kinnan is a freelance medical writer based in Chicago.

The Hospitalist-PCP Handoff: A Weak Link in the Chain?

Hospitalists provide continuity of care within the inpatient setting, but what happens when the patient returns to the care of his or her primary care provider (PCP)? Although every handoff has the potential for someone to drop the ball and lose information, the discharge handoff is often the most critical. This is partly because patients are often left on their own to make follow-up appointments with their PCPs and take their medications as ordered. Elderly patients and those with language barriers may not get it right, creating the potential for serious problems. This risk makes good hospitalist-PCP handoff communications imperative.

In their book Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes, Robert Wachter, MD, and Kaveh Shojania, MD, cite early discharge—“sicker and quicker”—as another source for potential problems at handoff. They report that nearly one in five patients suffered an adverse event in the transition from hospital to home, two-thirds of which could have been prevented with better communication. A case in point: In the hospital, a patient was started on a new heart medicine known to cause major swings in blood potassium, but no one set up post-discharge plans for monitoring blood chemistry. The patient developed extreme weakness and was eventually found to have a potassium level double the normal range—enough to have been fatal. A simple follow-up phone call might have averted this situation.

Studies show that primary care physicians want this handoff communication. A survey of the members of the California Academy of Physicians found that PCPs prefer to talk by telephone with the hospitalists managing their patients—at admission and discharge. Only slightly more than half (56%) of PCP respondents believe their communication with hospitalists was adequate, though the majority liked the idea of hospitalist care.

Overwhelmingly, patients’ primary physicians stated that communication about discharge diagnoses and discharge medications was extremely important, yet only a third said that discharge information arrived in a timely manner (i.e., before the patient’s first visit to the PCP after hospital discharge).

Some experts suggest that PCPs make so-called “continuity visits” to their hospitalized patients as a means of enhancing continuity of care. If coordinated with hospitalists’ rounds, these visits could establish a basic working relationship between the hospitalist and the PCP that would mitigate errors during the handoff at discharge. Continuity works both ways, though. Hospitalists who follow up with patients after discharge help to ensure that patients understand their medication regimens and that things are going as planned.

Post-discharge follow-up is in the best interests of hospitalists, too. Legal experts point out that physicians have a legal duty to provide follow-up care to patients with whom they have a relationship. According to one report, “The obligation to provide follow-up care endures even when the patient misses a scheduled appointment or does not adhere to the follow-up regimen. In general, the physician who began the care must fulfill that obligation. An essential component of follow-up care includes educating the patient about what symptoms require follow-up care and why it is important. The duty to provide adequate follow-up care is shared by the hospitalist and the PCP.”1—JK

REFERENCE

Alpers A. Key legal principles for hospitalists. Dis Mon. 2002 Apr;48(4):197-206.