From the Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE.
- Objective: To design and implement an enhanced discharge summary for use by internal medicine providers and evaluate its impact.
- Methods. Pre/post-intervention study in which discharge summaries created in the 3 months before (n = 57) and 3 months after (n = 57) introduction of an enhanced discharge summary template were assessed using a 24-item scoring instrument. Measures evaluated included a composite discharge summary quality score, individual content item scores, global rating score, redundant documentation of consultants and procedures, documentation of non-active conditions, discharge summary word count, and time to completion. Physician satisfaction with the enhanced discharge summary was evaluated by survey.
- Results: The composite discharge summary quality score increased following the intervention (19.07 vs. 13.37, P < 0.001). Ten items showed improved documentation, including documented need for follow-up tests, cognitive status, code status, and communication with the next provider. The global rating score improved from 3.04 to 3.46 (P = 0.01). Discharge summary word count decreased from 717 to 701 (P = 0.002), with no change in the time to discharge summary completion. Surveyed physicians reported improved satisfaction with the enhanced discharge summary compared with the prior template.
- Conclusion: An enhanced discharge summary, designed to serve as a handoff between inpatient and outpatient providers, improved quality without negative effects on document length, time to completion, or physician satisfaction.
Patient safety is often compromised during the transition period following an acute hospitalization. Half of patients may experience an error related to discontinuity of care between inpatient and outpatient providers , frequently resulting in preventable adverse events [2,3]. The discharge summary document serves as the primary and often only method of communication between inpatient and outpatient providers [4,5]. Despite its intended purpose, the discharge summary is frequently unavailable at the time of post-discharge clinic visits [4,6,7]. Even when available, the traditional discharge summary may have limited effectiveness as a handoff document due to disorganization or excessive length [8–11].
The Joint Commission requires that a minimum set of elements are documented in every discharge summary, including reason for hospitalization, significant findings, procedures and treatment provided, discharge condition, patient and family instructions, and medication reconciliation . Unfortunately, the required components fail to address many of the complexities encountered in the discharge process and have not adapted to changes in health care delivery. Discharge summary elements related to patients’ future care plans are often inaccurate or omitted , including pending diagnostic tests [14–17], recommended outpatient evaluations , pertinent discharge condition information , and medication changes [1,20,21].
In 2007, the Transitions of Care Consensus Conference made recommendations to address quality gaps in care transitions from inpatient to outpatient settings. This policy statement recommended the adoption of standard discharge summary templates and provided guidance on the addition of specific data elements, including patients’ preferences and goals and clear delineation of care responsibility during the transition period . The use of note templates within the electronic health record (EHR) may help prevent omission of certain data elements [23,24], but inclusion of higher-level management information may require that health providers rethink the function and structure of the discharge summary. Rather than a “captain’s log” narrative of inpatient events, the discharge summary should be considered a handoff document, meant to communicate “a strategic plan for future care. . .lessons learned. . .unresolved issues, and include a projection of how the author believes patients’ clinical condition will evolve over time” .
We created and implemented an evidence-based, enhanced discharge summary template to serve as a practical handoff document between inpatient and outpatient providers. This article reports on the evaluation of the enhanced discharge summary in comparison to a traditional discharge summary template.
The intervention took place within the inpatient internal medicine service at a 621-bed academic medical center. The internal medicine service includes teaching and non-teaching teams that collectively discharge approximately 4700 patients per year. Approximately 40 staff physicians and 75 residents per year rotate on the inpatient service. The hospital system uses an EHR that supports all clinical activities, including documentation and physician order entry. The EHR also automatically faxes discharge summaries to the primary care physician (PCP) of record when finalized by the inpatient provider. Prior to the intervention, a default discharge summary template was used throughout the hospital system. No formal education on discharge summary composition was provided to inpatient providers or residents prior to this project. This research project was approved by the university institutional review board and was performed without external funding.
The project was initiated by 2 hospital medicine physicians (CJS and MB) who recruited volunteer representatives from key stakeholder groups to participate in a quality improvement project. The final template redesign team was made up of 4 hospital medicine physicians, 2 ambulatory clinic physicians, 1 internal medicine chief resident, and 1 second-year internal medicine house officer. Two of the physicians (MB and AV) were the departmental EHR champions, serving as the liaisons between providers and EHR technology support/administration. Hospital administration provided analytics and EHR build-support. The team created an enhanced discharge summary template based on recommendations from professional societies [22,26] and published literature [25,27]. We made 4 key changes to the existing discharge summary template.
First, we added a section to the template that listed information crucial to follow-up care needs: tests needed after discharge and provider responsible for follow-up, pending labs at the time of discharge and provider responsible for follow-up, and follow-up appointment information. Provider feedback suggested these elements were frequently omitted or difficult to locate within the body of the discharge summary, so this section was prioritized at the top of the template. To stress the importance of direct communication, we added a heading asking for documentation of contact with the PCP.
Second, in recognition of the increasingly complicated condition of many of our discharging patients, we introduced subheadings and menus that addressed specific elements of patient condition, including cognitive status, indwelling lines and catheters, and activity level at discharge.
Third, a menu-supported section on advance care planning was added that included both code status and an outline of goals-of-care discussions that occurred during the hospitalization.
Finally, we made the template well-organized and succinct. The stand-alone diagnosis list from the pre-intervention template was eliminated and incorporated as part of the problem-based hospital course. In addition, EHR enhancements were introduced to minimize repetition in the lists of consultants, procedures, and chronic medical conditions. We added discrete, prioritized headings with drop down menus and minimized redundancies found in the prior generic template. For example, auto-populated information in the prior default discharge summary included redundant and clinically irrelevant consultants (eg, multiple listings for pharmacy consultation), procedures (eg, recurring hemodialysis encounters), and stable, chronic conditions (eg, hyperlipidemia) that lengthened the discharge summary without adding to its function as a handoff document.
The template was pilot-tested for 2 weeks with teaching and non-teaching teams. A focus group of 5 inpatient providers gave feedback via semi-structured interviews. The research team also solicited unstructured feedback from hospital medicine providers during a required standing administrative meeting. These suggestions informed revisions to the enhanced discharge summary, which was then made the default option for all internal medicine providers.