Transcript Aging Q3: Hospital Care and Transitions

Aging Q3:
Hospital Care and Transitions
Focus on the Discharge Summary
Neal Axon, MD
Medical University of South Carolina
Funding provided by D.W. Reynolds Foundation
Hospital Care and Transitions Team
 William Moran, MD
 Kim Davis, MD
 Rogers Kyle, MD
 Fletcher Penney, MD
 Paul Rousseau, MD
 Lauren Angotti, MD
 Neal Axon, MD
 Amy Thompson, PharmD
 Karen Lucas, RN
 Justin Marsden
 Patty Iverson
Overall Program Learning Objectives
1.
2.
3.
4.
5.
6.
Appreciate the importance of timely, comprehensive, concise
discharge summaries as a tool to help prevent adverse events.
Know local and national policies with respect to timing of
discharge summary completion.
Know the elements which constitute a comprehensive discharge
summary.
Know format and style to help make summaries concise and
readable.
Construct a discharge summary which reflects standardized
quality criteria.
Critique a discharge summary according to standardized
assessment criteria.
JCAHO Requirements for Discharge
Summaries
“A concise discharge summary providing information to other caregivers and facilitating
continuity of care includes the following:
• Reason for hospitalization
• Significant findings
• Procedures performed
• Care, treatment, and services provided
• Patient's condition at discharge
• Discharge Information provided to the patient and family, as appropriate, to
include:
• Medications
• Diet
• Physical Activity
• Follow-up care”
****Discharge information must be documented or dictated and authenticated within 30 days
post discharge. *****
MUSC Discharge Summary
Requirements
 ALL discharge summaries must be dictated by a responsible
provider within 48
hours.
 All discharge summaries must be signed by an Attending provider
within 14 days.
 Standard elements for discharge summaries approved by the
Medical Executive committee (Spring 2010)
Common Discharge Summary
Deficiencies
 Only 12-33% of discharge summaries available at first follow up
 Many summaries leave out important information
 14% omit hospital course
 17% omit responsible inpatient provider
 21% omit discharge medications
 38% omit key test results
 65% omit pending tests at discharge
 91% omit patient counseling/instructions
MUSC Discharge Summaries
Items scored as either present or absent
Item
Percent Compete
Referring Provider
89%
Past History
98%
Condition at Discharge
58%
Patient Instructions
50%
Tests Pending at Discharge
17%
MUSC Discharge Summaries
Items Requiring Editing for Content
Item
Percent Omitted Percent with too Percent with
much or not
appropriate
enough detail
amount of detail
HPI
0%
5%
95%
Physical Exam
16%
46%
37%
Ancillary Test
Results
13%
13%
74%
Hospital Course
2%
35%
63%
MUSC Discharge Summaries
Items Requiring Additional Information
Item
Percent Omitted Percent with
intermediate
score
Percent with top
score
Allergies
12%
23%
65%
Discharge
medications
4%
68%
28%
Specific Followup Plans
5%
60%
35%
Can Discharge Summaries Improve?
 Single center study, 59 Medical Interns
 Residents receiving feedback were significantly more likely
to include:
 Key discharge summary components
 Headings
 Procedures
 Primary diagnoses
 Residents had higher ratings for:
 Overall readability
 Overall length
 HPI
 Hospital course
Myers JS. Academic Medicine, Vol. 81, No. 10 / October
2006 Supplement
Key Attributes
 Timely
 Clear, concise, complete
 Forward looking
 Medications reconciled
 Pending tests enumerated
 Specific follow up plans noted
How will it all work?
 Individual Feedback
 Team Feedback (Inpatient setting)
 Critiquing discharge summaries
 Morning report (Inpatient Setting)
 Outpatient setting
Individual Feedback
 Who: All Interns
 What: Individualized feedback on discharge summaries
 Review specific discharge summaries for standardized criteria
 Suggestions for improvement
 When: December 9th, 12:00 pm
 Where: 300 CSB
Team Feedback
 Who: Inpatient General Medicine Teams
 What: Recent discharge summaries reviewed according to
standard criteria
 When: Approximately once per week
 Where: During or after team rounds
Morning Report Detailing
 Who: All residents and interns attending morning report
 What: Review (de-identified) discharge summaries
illustrating key teaching points
 Where: 300 CSB
 When: 8:30 AM Mondays/Fridays
Critique Discharge Summaries
 Who: All residents
 What: Review discharge summaries of recently discharged
patients. 4 key attributes
 Timely
 Concise
 Medication Reconciliation
 Pending Tests
 When: Whenever a patient recently discharged patient is seen in
follow up
 Where: UIM Continuity Clinic
Blue Sheet: PCT Tasks
PCT TASKS:
1. Ask “Have you been
hospitalized in the past 3
months?”
YES
2. If yes to #1, Ask “Were you
hospitalized at MUSC?”
Yes
NO
No
3. If yes, please pull the MUSC discharge summary for the
resident physician from Practice Partner OR provide a copy of any
outside hospital summary if available.
Blue Sheet: Resident Tasks
RESIDENT TASKS
1.
Review Discharge Summary, if available answering the questions
below.
A.
Was the discharge summary concise?
Not at all concise, overly wordy
Somewhat concise, with a few
extraneous details
Very concise, without any extraneous
details
A.
A.
Was the discharge medication list complete
with evidence of reconciliation with
outpatient medications?
Yes
Were pending test results and/or
recommended follow up tests noted?
Yes
1.
Discuss Discharge Summary with Outpatient Attending.
1.
Complete Practice Partner Template.
1.
Place Blue Sheet in AQ3 Bin in the Resident Charting area.
No
No
Outpatient Detailing: Attending Tips
Emphasize the 4 key points!!!!
Timely: If the summary is not yet dictated at the time of follow
up, then ITS NOT TIMELY!
2. Concise: Point out sections that are not concise
a. HPI unchanged from H&P, still in present tense
b. Physical Exam with more than 2 systems without positive
findings listed
c. Hospital Course with unnecessary details, or poorly
organized without discrete sections for each problem
addressed
3. Medications Reconciled:
a.
Admit/discharge lists OR annotated discharge meds list
4. Pending Tests Results Listed
1.
Questions?
Inpatient Detailing Steps
 Briefly review and discuss Discharge Summary when




approached by an AQ3-HCT ACOVE member before
rounds.
Use the provided yellow sheet, discharge summary, and
grading sheet to facilitate a team discussion about high
quality discharge summaries
Write your name and the names of all the interns/residents
who have been detailed on the yellow sheet
Drop the yellow sheet in the bin on 8E OR fill in the
detailing posters on 8E or in the resident library
Properly discard the summary/grading sheets
ID _____________
Date of Review _____________
Initials of Reviewer _____________
Item
Referring Provider
History of Present Illness
Pertinent Past History
Allergies
Physical Exam
Section
Value
20% of
Total
Ancillary Test Results
Hospital Course
Discharge Diagnoses
Medications
Discharge Condition
Patient Discharge
Instructions
Tests Pending at
Discharge
Follow Up
30% of
Total
50% of
Total
Scoring Scale
0
0
0
1
1
1
2
0
1
2
0
1
2
0
1
2
Mul Poi Comments
tipli nts
er
5
2.5
2.5
1.2
5
1.2
5
1.2
5
0
1
2
3
10
0
0
0
1
1
1
2
2
3
5
5
5
0
1
5
0
1
5
0
1
2
5
Total Score (out of 100 points)
Letter Grade
“OK, but what do I actually say about
Discharge Summaries?”
 Point out the medical literature: Discharge summaries have room
for improvement (Yellow sheet)
 Emphasize the key attributes of a high quality discharge summary
(Yellow sheet)
 Point out specific deficiencies on the graded discharge summary,
and suggest how to do better
 Encourage the residents/interns to use a template (Pocket Card)
each and every time to improve their performance
Questions?