Reports From the Field

Evaluation of an Enhanced Discharge Summary Template: Building a Better Handoff Document


 

References

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.

Education

A 30-minute educational session was developed and delivered by the authors. The objectives of the didactic portion were to describe how discharge summaries can impact patient care, understand how discharge summaries serve as a handoff document, list the components of an effective discharge summary, and describe strategies to avoid common errors in writing discharge summaries. The session included a review of pertinent literature [1,12,13,21], an outline of discharge summary best-practices [22,25], and an introduction to the new template. Trainers reviewed strategies for keeping the discharge summary concise, including using problem-based formatting, focusing on active hospital problems, and eliminating unnecessary or redundant information. Participants were encouraged to complete their discharge summaries and directly contact outpatient providers within 24 hours of discharge. Following the didactic session, participants critically reviewed an example discharge summary and discussed what was done well, what was done poorly, and what strategies they would have used to make it a more effective handoff document. Residents rotating on the inpatient internal medicine services received the education during their mandatory monthly orientation. Faculty physicians were provided the education at a required section meeting.

Quality Scoring of Discharge Summaries and Analysis

To evaluate the quality of discharge summaries, we developed a scoring instrument to measure inclusion of 24 key elements (Table 1). The scoring instrument (available from the authors) was pilot tested by 4 general internal medicine physicians on 5 sample discharge summaries. After independent scoring, this group met with members of the research team to provide feedback. Iterative revisions were made to the scoring instrument until scorers reached consensus in their understanding and application of the scoring instrument. Each discharge summary received a quality score from 0 to 24, based on the number of elements found to be present. Secondary quality metrics included a global quality rating using a 1 to 5 scale (described in Results); frequency of redundant documentation of consultants and procedures; frequency of documentation of non-active, chronic conditions; the length of the discharge summary (total word count); and time to completion.

We analyzed a sample of discharge summaries completed during the 3-month period prior to the intervention and the 3-month period following the intervention. A non-stratified random technique was employed by an independent party to generate discharge summary samples from the EHR. Living patients discharged from the internal medicine services after an inpatient admission of at least 48 hours were eligible for inclusion. Each discharge summary was scored by 2 general internal medicine physicians. Each scoring dyad comprised one of the authors paired with a volunteer non–research team member who scored discharge summaries independently. Discordant results were examined by the dyad and settled by consensus.

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