Effective communication requires direct interaction between the hospitalist and the primary care provider using a standardized method of information exchange with the opportunity to ask questions and assign accountability for follow-up roles. The discharge summary is part of the process but does not provide the important aspects of handoff, such as closed loop communication and role assignments. Hospital discharge is a significant safety risk for patients, with more than half of discharged patients experiencing at least one error. Hospitalist and primary care providers need to collaborate to develop a standardized system to communicate about shared patients that meets handoff requirements.
Key points
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Effective communication requires direct interaction between the hospitalist and the primary care provider using a standardized method of information exchange with the opportunity to ask questions and assign accountability for follow-up roles.
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The discharge summary is a part of the process, but does not provide the important aspects of handoff, such as closed loop communication and assignment of roles.
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Hospital discharge is a significant safety risk for patients, with more than half of the discharged patients experiencing at least one error.
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Effective communication with the primary care provider can eliminate errors or mitigate the effect of an error.
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Current technologies provide increased options to improve communication with limited time investment.
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Hospitalists and primary care providers need to develop measurable goals for communication and share outcomes to optimize patient care.
Hospital medicine is a relatively new designation of medical care. First described in 1996 by R. Watcher in the New England Journal of Medicine , hospital medicine has rapidly grown among adult providers and then pediatricians. As a result, there has been a shift in the attending for hospitalized patients from the primary care physician to the hospitalist. Research has demonstrated several benefits of hospital medicine, including decreased cost and length of stay; however, one unexpected consequence is the increased number of handoffs between providers. The most significant handoff is the one between the hospitalist and the primary care provider.
Before the growth of hospital medicine, the primary communication challenge for the primary care provider was with families, residents, and consultants. At its inception, hospital medicine added a new layer of care and communication challenge without a fully defined process for integration into the patient care continuum. Compounding this problem is the increased pressure to limit hospitalizations and shorten lengths of stay, resulting in the need to discharge patients “quicker and sicker.” The many demands of effective and efficient care highlight the need for ongoing clear communication between the hospitalist and the primary care provider, but too often the only communication is at the time of discharge in the form of the discharge summary.
Current US regulatory standards require a discharge summary to be completed within 30 days of discharge. In contrast, the discharge follow-up visit occurs much earlier, usually within 1 to 2 weeks after discharge. This disconnect demonstrates that the current use of the discharge summary does not reflect the new paradigm of care. The discharge summary simply provides documentation of the hospital stay rather than effective communication between providers. In 2006, the Joint Commission established a National Patient Safety Goal which required the adoption of a standardized approach to patient handoffs. Although this resulted in close scrutiny of handoffs within the hospital, the handoff to the primary care provider has not received the same attention. Recent literature on safe and effective handoffs recommends that a formal handoff plan be instituted at any change in service. Effective handoffs include a verbal exchange of information that affords an opportunity for questions, a handoff procedure that is standardized and simplified, and uses closed looped communication with a readback/hearback technique. Arora and colleagues developed handoff recommendations for hospitalists that were peer-reviewed at the 2007 Hospital Medicine Annual Meeting ( Box 1 ). However, very few of these components are used in the handoff to the primary care provider or included in the usual discharge summary.
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Time dedicated for a verbal exchange of information
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Interactive process
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Ill patients given priority in time
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The focus is to inform the receiving provider on what to expect and what to do after the patient is discharged
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Ability to access and record patient information during the handoff (standardized discharge summary template and access to electronic record)
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Train new users on handoff expectations
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System to identify the correct provider caring for a specific patient during the discharge transition
Current state of communication
It is no surprise that half of primary care providers report communication with hospitalists as fair to poor. In a large multicenter study of adult providers, Bell and colleagues found that 23% of primary care providers did not know their patient was admitted to the hospital; less than half received a discharge summary by 2 weeks after discharge, and only 18% had direct communication with the inpatient provider. The lack of timely communication has been echoed in other studies, which found that 58% to 75% of all discharge summaries fail to arrive in a timely manner. Delay in receiving a timely handoff of information limits the ability of the primary care provider to provide adequate care in 24% of hospital follow-up visits. Furthermore, even when the discharge summary arrived in a timely manner, it did not provide sufficient information for appropriate transfer of care, specifically, discharge medications, pending laboratory results, and suggested follow-up testing.
Providers describe transitions in care as “chaotic, unsystematic, and unstandardized.” They ask for a system whereby all providers acknowledge and understand their role. Presently, the roles of the sender and receiver of discharge information are not clear. Role confusion is most notable in the expected provider to follow-up laboratory tests pending at the time of discharge. Most hospitalists (65%) think the responsibility is the primary care provider, while most primary care providers (51%) think the responsibility lies with the ordering hospitalist.
Current state of communication
It is no surprise that half of primary care providers report communication with hospitalists as fair to poor. In a large multicenter study of adult providers, Bell and colleagues found that 23% of primary care providers did not know their patient was admitted to the hospital; less than half received a discharge summary by 2 weeks after discharge, and only 18% had direct communication with the inpatient provider. The lack of timely communication has been echoed in other studies, which found that 58% to 75% of all discharge summaries fail to arrive in a timely manner. Delay in receiving a timely handoff of information limits the ability of the primary care provider to provide adequate care in 24% of hospital follow-up visits. Furthermore, even when the discharge summary arrived in a timely manner, it did not provide sufficient information for appropriate transfer of care, specifically, discharge medications, pending laboratory results, and suggested follow-up testing.
Providers describe transitions in care as “chaotic, unsystematic, and unstandardized.” They ask for a system whereby all providers acknowledge and understand their role. Presently, the roles of the sender and receiver of discharge information are not clear. Role confusion is most notable in the expected provider to follow-up laboratory tests pending at the time of discharge. Most hospitalists (65%) think the responsibility is the primary care provider, while most primary care providers (51%) think the responsibility lies with the ordering hospitalist.
Communication and patient safety
Effective communication is crucial to patient safety. Multiple studies have shown that patients are at risk for medical errors on discharge from the hospital. Almost half (49%) of the adult patients experience a medical error after discharge. Medication errors, unviewed laboratory results or tests resulting after discharge, and missed follow-up testing are the most common adverse events. However, many of these adverse events are preventable or at least ameliorable if caught in time.
Medications are the most prevalent source of error in patient transitions. Kripalani and colleagues reported that 54% of patients experienced at least one unintended medication discrepancy on admission to the hospital and close to half of these errors were a potential threat to the patient. The most common error is omission of a medication taken at home. Hospitalization itself provides opportunity for error because of the various changes to a patient’s medication profile during the hospital stay. Often the change is due to the hospital formulary restrictions requiring substitution of one medication for another. By the time of discharge, 49% of patients have an unexplained discrepancy between admission and discharge medications. After discharge, patients are still at risk for error due to prescription-related problems. Patients on more than 5 medications were most likely to have a medication discrepancy. Inhaled medications are the most common group of medications for a prescription-related problem. However, a recent study found that patients were 70% less likely to have a medication discrepancy at the time of follow-up when their inpatient provider communicated with their primary care provider before discharge and the primary care provider called the patient within 24 hours of discharge.
Pending laboratory or microbiology tests at the time of discharge are a frequent occurrence. Although many pending test results may not impact or change treatment, nearly 10% to 15% of pending tests have potentially actionable results. Likewise, microbiology results finalized after discharge were noted to be clinically important and required a change in treatment in 2% to 4% of discharges. The current handoff process between the hospitalist and primary care provider still lacks the assignment of responsibility for the follow-up of pending tests.
Many patients require continued outpatient workup after discharge for either their primary condition or new findings discovered during their hospital stay. Moore and colleagues found that 54% of all discharge summaries did not document the recommended outpatient workup identified in the patient’s inpatient medical record. Furthermore, the authors found that patients who did not receive the suggested outpatient workup were 6 times more likely to be rehospitalized within 3 months.
A coordinated and comprehensive handoff to the primary care provider can help mitigate or eliminate many of these errors. Discharge follow-up with a provider that knows the patient well and follow-up phone calls have also been shown to improve outcomes and decrease errors ( Box 2 ). Although reduction in errors should lead to better long-term outcomes, recent research on discharge communication has failed to demonstrate consistent improvement in several key indicators: emergency room visits, readmission rates, and mortality. Some studies have been limited by the inclusion of all readmissions both planned and unplanned, although other observational studies have found that communication with primary care providers only occurred with the more complex patients who are at a higher risk readmission after discharge. The lack of clear and consistent improvement in the prevention of 30-day readmission rates has led many to consider whether a focused intervention with high-risk populations may demonstrate effectiveness compared with broad implementation with multiple patient populations. Pediatric populations at high risk for readmission include patients between 15 and 18 years of age with public insurance, increased number of secondary diagnoses, and increased length of stay.
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