Good communication between hospitalists and primary care physicians at the time of discharge is critical to patient safety and to the reduction of risk.
Historically, this communication has been “one way” in the form of a discharge summary. Studies have shown that “following hospital discharges, nearly half (49 percent) of hospitalized patients experience at least one medical error in medication continuity, diagnostic workup, or test follow-up.” 1
The following risk reduction strategies will focus on the transition process from the inpatient to the outpatient setting. These strategies include: timely delivery and improved content and formatting of the discharge summary, as well as discussion on how to improve communication between hospitalists and PCPs.
Discharge Summaries
- Just 12 to 33 percent of discharge summaries were available to the PCP at time of first visit. 2
With the addition of hospitalists, discharge summaries have become a primary mechanism to convey information and to transfer responsibility from the inpatient physician to the outpatient physician. The discharge summary should inform the PCP about the patient’s hospitalization and should include, at a minimum, the diagnosis, reconciled discharge medications, results of procedures, follow-up needs, and pending test results.
Discharge summaries should be well-formatted and easy to read, with subheadings, and highlighting of crucial information. Also, for the discharge summary to be useful, the information conveyed must be timely (ideally within 24 to 48 hours) and should be received before the patient’s first visit with his or her PCP.
Pending Results and Abnormal Test Follow-Up
- Only 25 percent of discharge summaries mentioned pending tests and only 13 percent mentioned all pending test. 3
- About 25 percent of all medical liability lawsuits arise from failure to follow-up.
Many patients are discharged with pending or abnormal test results that require follow-up of which PCPs are not aware. The risk to patient safety occurs when no one takes responsibility for pending results or the follow-up of an abnormal test. The old adage “if you ordered it, you own it” still might be a good place to begin in determining who should take responsibility for pending tests.
Hospitalists, who order tests, are ultimately responsible for follow-up of those test results. A system should be developed that notifies the hospitalist of test results after the patient has been discharged. The system should also provide a method for communicating the results to the PCP. Lastly, abnormal test results that need follow-up should be documented in the discharge summary.
Communication
- At discharge from the hospital, only three to 20 percent of the time is there direct communication from hospitalist to PCP. 1
- More than half of all preventable adverse events that occur soon after discharge can be traced to poor communication.
The communication gold standard is direct physician-to-physician communication when a patient is discharged from the inpatient setting. However, limited time on both ends makes this system impractical. Some other suggestions include: telephone follow-up by the discharging hospitalist, phone message with name and contact information for questions, or electronic delivery through a Health Information Exchange (HIE) of the complete and accurate discharge summary.
No matter which system is used for communicating patient information between physicians, it should be routinely assessed for deficiencies, timeliness, and completeness by all parties to limit the risk of liability and improve patient safety.
References
- Kripalani S, Jackson A, Schnipper J, Coleman E. Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalist. J Hosp Med. 2007;2(5):31-323.
- Roy CL., Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143:121-128.
- Were M, Li X, Kesterson J, et al. Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers. J Gen Intern Med. 2009;24(9):1002-1006.
Ann Whitehead, RN, JD, is a vice president of risk management & patient safety for the Cooperative of American Physicians' CAPAssurance program, which offers hospitals, large medical groups, and other healthcare facilities access to liability protection and risk management services.