Aging Q3: Hospital Care and Transitions Focus on the Discharge Summary Neal Axon, MD Medical University of South Carolina Title Slide, acknowledging the Reynolds Foundation support for Aging Q3 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 Team members included Dr. Moran, the principle investigator, Dr. Davis as an outpatient MD representative, Dr. Kyle and Dr. Penney as inpatient representatives, Amy Thompson from Pharmacy, Karen Lucas from Social Work, Lauren Angotti as a resident representative, and others

Overall Program Learning Objectives 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. ***** The JCAHO requirements for discharge summaries are very minimal, and I would argue completely inadequate for high quality care. 30 days for completion of discharge summaries is also unrealistic and unhelpful.. Anecdote about a smug cardiac surgeon who refused to give me a discharge summary on a complex mechanically ventilated patient transferred to my facility from another state, stating "You'll get the summary in 30 days." WE owe our patients better. At MUSC we require them within 48 hours.

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) The current MUSC requirements for discharge summaries.

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 Unfortunately, according to the medical literature, discharge summaries are often not done in a timely fashion, and they miss critical pieces of information.

MUSC Discharge Summaries Items scored as either present or absent Percent Compete Referring Provider 89% Past History 98% Condition at Discharge 58% Patient Instructions 50% Tests Pending at Discharge 17% As we talked about in our earlier lecture, there are some elements that simply need to be in the discharge summary. This table shows the results from our initial review of MUSC Intern discharge summaries. You guys did fairly well at documenting a referring provider and past history, but there is still room for improvement with the number of times you include statements about the patients condition at the time of discharge, documentation of patient instructions, and statements about tests pending at discharge.

MUSC Discharge Summaries Items Requiring Editing for Content Percent Omitted Percent with too much or not enough detail Percent with appropriate amount of detail HPI 0% 5% 95% Physical Exam 16% 46% 37% Ancillary Test Results 13% 74% Hospital Course 2% 35% 63% Some other elements of discharge require you to do a little creative writing in that the require some editing for content. The goal is to include the needed information without adding extraneous information. Remember the primary end-user of a discharge summary is a busy outpatient primary care physician or other provider. He or she needs a complete and concise document. The history of present illness was frequently reported with adequate detail, However, the physical exam was often read verbatim from the H&P into the discharge summary. I would submit that this is NOT necessary. Only pertinent findings are necessary here. The other information is documented elsewhere and is extraneous in a discharge summary. My rule of thumb is that if you have more than 3 systems with "normal" findings, keep editing. There is some room for improvement in documenting test results. Remember, a good discharge summary should be a one-stop shop for understanding the hospital stay. Pertinent positives here too. Finally, the hospital course is the heart and soul of the discharge summary. Remember, it should contain a list of problems/diagnoses addressed during the hospital stay. Most of the hospital course sections we read were best described as "stream of consciousness often with extraneous information in some spots and omitted information in others.

MUSC Discharge Summaries Items Requiring Additional Information Percent Omitted Percent with intermediate score Percent with top score Allergies 12% 23% 65% Discharge medications 4% 68% 28% Specific Follow-up Plans 5% 60% 35% The last category of elements for the discharges summary are those items where we have the opportunity to make the information transfer better by "going the extra mile" so to speak. For example, make sure you document the type and severity of the allergies, show evidence of good medication reconciliation. This can be done by dictating complete admission and discharge meds lists (for comparison sake) or by dictating an annotated discharge medications list that notes 1) home medications continued 2) inpatinet medications continued 3) home medications discontinued. Lastly, It is really important to document specific follow up plans for patients at the time of discharge. Don't just say, "...Follow up with PCP in 2-3 weeks." Say, "Follow up with Dr. Jones on January 31st at 9am." Clearly, you have to put the right systems in your place to make this happen. We haven't gotten this just right yet at MUSC, but we're working on it.

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 So, just in case you're becoming discouraged, this study by Myers and colleagues shows that a program of individual feedback provided as part of a discharge summary curriculum can be effective at improving hospital discharge summary quality scores using and objectve scoring tool. 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 Again, these are the key attributes for a high-quality discharge summary.

How will it all work? Individual Feedback Team Feedback (Inpatient setting) Critiquing discharge summaries Morning report (Inpatient Setting) Outpatient setting This program includes 3 parts. First, we plan on providing each one of our Interns with individual feedback on their discharge summaries. Interns do over 85% of the summaries on our resident services, and yet they are the least experienced. I was certainly never taught how to do a high-quality summary, and I've rarely received any feedback. We're going to give you guys both. The second component will provide feedback and reinforcement to the teams on the inpatient service. We'll review discharge summaries done by your teams to give you prompt feedback in near-real time. Finally, in the clinic setting you'll get practice critiquing discharge summaries for your patients recently discharged from the hospital. As end-users, you can be the judges of the quality of your patients' discharge summaries.

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 We're also going to give you some "teasers" with quick-hitting examples of good and bad discharge summaries before morning report. You can help to "diagnose the lesions" and help decide how to make discharge summaries better.

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 This slide is for faculty detailing residents

Blue Sheet: PCT Tasks PCT TASKS: 1. Ask “Have you been hospitalized in the past 3 months?” YES NO 2. If yes to #1, Ask “Were you hospitalized at MUSC?” Yes 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. This is a prompting sheet for clinic nurses to ask patients if they were recently hospitalized and to pull discharge summaries if available for resident and attending review. This flow-sheet outlines how residents will evaluate discharge summaries, to be used for conversation with their clinic attendings.

Blue Sheet: Resident Tasks Review Discharge Summary, if available answering the questions below. Was the discharge summary concise? Not at all concise, overly wordy Somewhat concise, with a few extraneous details Very concise, without any extraneous details Was the discharge medication list complete with evidence of reconciliation with outpatient medications? Yes No Were pending test results and/or recommended follow up tests noted? Discuss Discharge Summary with Outpatient Attending. Complete Practice Partner Template. Place Blue Sheet in AQ3 Bin in the Resident Charting area. This is a prompting sheet for clinic nurses to ask patients if they were recently hospitalized and to pull discharge summaries if available for resident and attending review. This flow-sheet outlines how residents will evaluate discharge summaries, to be used for conversation with their clinic attendings.

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! Concise: Point out sections that are not concise HPI unchanged from H&P, still in present tense Physical Exam with more than 2 systems without positive findings listed Hospital Course with unnecessary details, or poorly organized without discrete sections for each problem addressed 3. Medications Reconciled: Admit/discharge lists OR annotated discharge meds list Pending Tests Results Listed

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 Tips for inpatient attending physicians providing team-based feedback

ID _____________ Date of Review _____________ Initials of Reviewer _____________ Item Section Value Scoring Scale Mul tipli er Poi nts Comments Referring Provider 20% of Total 1 5 History of Present Illness 2 2.5 Pertinent Past History Allergies 1.2 5 Physical Exam Ancillary Test Results Hospital Course 30% of Total 3 10 Discharge Diagnoses 50% of Total Medications Discharge Condition Patient Discharge Instructions Tests Pending at Discharge Follow Up Total Score (out of 100 points) Letter Grade Our discharge summary grading sheet

“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?