Aging Q 3 : Hospital Care and Transitions

1. 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

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

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. *****

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)

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

7. MUSC Discharge SummariesItems scored as either present or absent

8. MUSC Discharge SummariesItems Requiring Editing for Content

9. MUSC Discharge SummariesItems Requiring Additional Information

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 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

12. How will it all work? • Individual Feedback • Team Feedback (Inpatient setting) • Critiquing discharge summaries • Morning report (Inpatient Setting) • Outpatient setting

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

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

18. Blue Sheet: PCT Tasks

19. Blue Sheet: Resident Tasks

20. Outpatient Detailing: Attending TipsEmphasize 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

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

23. ID _____________ Date of Review _____________ Initials of Reviewer _____________

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?