1. 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

2. 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

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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

11. 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.

12. 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.

13. 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

14. 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

15. 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.

16. 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

18. 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.

19. 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.

20. 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
Medications Reconciled:
Admit/discharge lists OR annotated discharge meds list
Pending Tests Results Listed

21. Questions?

22. 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

23. 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

24. “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

25. Questions?