May 20, 2009 (Chicago, Illinois) — The percentage of hospital-discharge documents that contained all required information rose from 65% to 96% during a 31-month quality-improvement process at an integrated healthcare system, a new study from Partners HealthCare of Boston, Massachusetts, found. The results were presented here at Hospital Medicine 2009: the Society of Hospital Medicine (SHM) Annual Meeting.
The large improvement in discharge communication resulted from a multidisciplinary, multimodal effort at 5 Partners HealthCare–affiliated hospitals, without financial incentive to the physicians, said the principal author, Esteban Gandara, MD, a research fellow in the Division of General Internal Medicine and Primary Care at Brigham and Women's Hospital and at Harvard Medical School in Boston.
This quality-improvement initiative was an attempt to better comply with Joint Commission requirements for what information needs to be included in discharge communications, he said during his presentation. Previous research from his hospital found "important deficits" in medication reconciliation lists and several other critical data elements, Dr. Gandara said.
Ahead of the Field
Their progress during less than 3 years was "impressive," according to a member of the audience who was not involved in the study, David Meltzer, MD, PhD, chair of the SHM Research Committee. Dr. Meltzer, associate professor and chief of the Section of Hospital Medicine at the University of Chicago in Illinois, told Medscape Internal Medicine in an interview that Brigham and Women's Hospital "is probably somewhat ahead of the field in addressing problems in discharge documentation."
The new study reviewed discharge-documentation packets for 3101 patients being discharged to subacute-care facilities from Brigham and Women's and 4 other hospitals in the Partners HealthCare system between March 2005 and September 2008, the authors report in their abstract. Documentation for at least 50 patients from each hospital was selected for review for each of the 11 quarters during the study period (quarterly mean, 281.9). Discharge documents included discharge summaries, discharge orders, and nursing instructions. A trained resident physician or nurse practitioner from the acute-care sites reviewed the discharge documents. The 5 acute-care sites were a mix of academic medical centers and community hospitals.
Data elements that Partners HealthCare requires for all discharges to subacute-care facilities are as follows: treatment rendered, the patient's response to treatment, procedures and tests given, preadmission medications, medications at discharge, allergies, follow-up information, the hospital physician's contact information, and warfarin use. (Data elements for warfarin use included the indication, duration of therapy, target international normalized ratio, and sufficient dosing and monitoring information to safely prescribe warfarin for the subsequent 72 hours, according to the abstract.) A discharge document that included all of these elements was considered "defect free."
Quality-improvement interventions included computer-technology improvements to discharge-ordering systems, such as the ability to auto-import required information into discharge documents, creation of discharge templates, physician education, predischarge review of documentation by nurse coordinators, and ongoing feedback about the quality of discharge documentation to clinicians and their section chiefs. The discharge template differed by hospital, but had to include the required data. Some sites used only some of the interventions, and 1 community hospital did not employ technological improvements, Dr. Gandara told the audience.
The improvement in the defect-free rate from 65% to 96% was statistically significant (P < .001 for trend), according to the abstract. All sites observed higher defect-free rates, with academic medical centers improving slightly more than community hospitals, Dr. Gandara reported. The data component with the largest improvement was preadmission medications, which had a 19% increase, from 81% to 100% (P < .001). Response to treatment and follow-up information did not achieve a 100% defect-free rate by the end of the study because of incomplete data fields or unchecked boxes, he explained in response to a question.
Reasons for Success
Because the community hospital that did not use technological improvements experienced the lowest quality improvement, Dr. Gandara told Medscape Internal Medicine, "information technology was most important to our improvement."
This study shows that this approach to improving the quality of discharge documentation works, said the University of Chicago's Dr. Meltzer. "But as with all quality-improvement activities, you have to ask what the value is and whether it is worth the effort," he told Medscape Internal Medicine.
"My guess is that the 100% defect-free discharge summary will never happen," Dr. Meltzer said, explaining that the extra time to ensure such completeness would likely need to come at the expense of neglecting the care of hospitalized patients.
However, he pointed to components of the reported approach that he believes helped its success, including the use of discharge templates and a set of quality-improvement interventions that the hospitals could customize to their needs, rather than a single required intervention.
"It's crucial not only to improve quality but also to make change as easy as possible . . . and to do it in ways that are important locally," Dr. Meltzer said.
Source : http://www.medscape.com/viewarticle/703082?src=mpnews&spon=34&uac=133298AG
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