Reports From the Field

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


 

References

Physician Survey

We surveyed inpatient and outpatient physicians to determine their views about discharge summaries and their views about the template before and after the intervention. Respondents were asked to indicate to what degree they agreed with statements using a 5-point Likert scale. An email containing a consent cover letter and a link to an anonymous online survey was sent to residents rotating on internal medicine services during the study period and all hospital medicine faculty. Outpatient providers affiliated with the hospital system were sent the survey if they had received at least 5 discharge summaries from the internal medicine services over the preceding 6 months. Post-intervention surveys were timed to capture responses after an adequate exposure to the enhanced discharge summary template. Inpatient physicians were re-surveyed 3 months after introduction of the enhanced discharge summary and outpatient providers were re-surveyed after 1 year.

Statistical Analysis

We reviewed 10 pre-intervention discharge summaries to estimate baseline discharge summary quality scores. Anticipating a two-fold improvement following the intervention [24], we calculated a goal sample size of 108 discharge summaries (54 pre- and 54 post-intervention) assuming alpha of 0.05 and 80% power using a two-tailed chi-square test. Expecting that some discharge summaries may not meet our inclusion criteria, 114 summaries (57 pre- and 57 post-intervention) were included in the final sample. All analyses were performed on Stata v10.1 (StataCorp; College Station, TX).

For discharge summary quality scoring, inter-rater reliability was measured by calculating the kappa statistic and percent agreement for scoring elements. Chi-square analysis was used to compare individual scoring elements before and after the intervention when the sample size was 5 or greater. Fisher’s exact test was used when the sample size was less than 5. Counts, including number of inactive diagnoses, redundant consults, redundant procedures, and total words were compared using univariate Poisson regression. Wilcoxon rank sum analysis was utilized to compare pre-intervention to post-intervention composite scores and global scores. Patient and provider characteristics were compared using the t-test, chi-square test, Fisher’s exact test, or Wilcoxon rank sum, as appropriate.

For the surveys, pre-intervention and post-intervention matched pairs were compared. Likert score responses were analyzed using the Wilcoxon signed-rank test.

Results

Discharge Summary Quality Scores

Characteristics of the pre- and post-intervention discharge summaries are displayed in Table 2. Both samples were similar with respect to patient demographics, length of stay, medical complexity, and provider characteristics. The mean composite discharge summary quality score improved from 13.4 at baseline to 19.1 in the post-intervention sample (P < 0.001) (Table 3). Ten of 24 quality elements exhibited significant improvement following the intervention, but 3 items were documented less often after the intervention (Table 3).

The global rating of discharge summary quality improved from 3.04 to 3.46 (P = 0.010) (Table 4). Documentation of superfluous and redundant information decreased in the 3 areas evaluated: number of non-active, chronic diagnoses (2.33 to 1.35, P < 0.001), redundant consults (1.4 to 0.09, P < 0.001), and redundant procedures (0.74 to 0.26, P < 0.001). Inter-rater reliability was generally high for individual items, although kappa score was not calculable in one case and scores of zero were obtained for 3 highly concordant items. Inter-rater reliability was moderate for global rating (kappa = 0.59). The overall length of discharge summaries decreased from 717 to 701 words (P = 0.002). There was no significant change in time to discharge summary completion following the intervention (10.9 hours pre-intervention vs. 14.5 post-intervention, P = 0.605) (Table 4).

Survey Results

The inpatient provider response rate for the pre-intervention survey was 51/86 (59%) and 33/65 (51%) for the post-intervention survey, resulting in 21 paired responses. House officers represented the majority of paired respondents (14/21, 66%) with hospitalist faculty making up the remainder. Among outpatient physicians, the pre-intervention response rate was 19/25 (76%) and the post-intervention rate was 20/25 (80%), resulting in 16 paired responses. Half (8/16) of outpatient physicians provided only outpatient care, the other half practicing in a traditional model, providing both inpatient and outpatient care. Nearly half (7/16) had been in practice for over 15 years. Inpatient physicians’ agreement with all 4 statements related to discharge summary quality improved, including their perception of discharge summary effectiveness as a handoff document (P = 0.004). Inpatient providers estimated that the enhanced discharge summary took significantly less time to complete (19.3 vs. 24.6 minutes, P = 0.043). Outpatient providers’ perceptions of discharge summary quality trended toward improvement but did not reach statistical significance (Table 5).

Discussion

We found that a restructured note template in combination with physician education can improve discharge summary quality without sacrificing timeliness of note completion, document length, or physician satisfaction. The Joint Commission requires that discharge summaries include condition at discharge, but global assessments such as “good” or “stable” provide little clinically meaningful information to the next provider. Through our enhanced discharge summary we were able to significantly improve communication of several more specific elements relevant to discharge condition, including cognitive status. Similar to prior studies [7,13], cognitive condition was rarely documented prior to our intervention, but improved to 88% after introduction of the enhanced discharge summary. This is especially important, as we found that 25% of the post-intervention patients had a cognitive deficit at discharge. This information is critical for the next provider, who assumes responsibility for monitoring the patient’s trajectory.

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