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Evaluation of an Enhanced Discharge Summary Template: Building a Better Handoff Document
From the Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE.
Abstract
- Objective: To design and implement an enhanced discharge summary for use by internal medicine providers and evaluate its impact.
- Methods. Pre/post-intervention study in which discharge summaries created in the 3 months before (n = 57) and 3 months after (n = 57) introduction of an enhanced discharge summary template were assessed using a 24-item scoring instrument. Measures evaluated included a composite discharge summary quality score, individual content item scores, global rating score, redundant documentation of consultants and procedures, documentation of non-active conditions, discharge summary word count, and time to completion. Physician satisfaction with the enhanced discharge summary was evaluated by survey.
- Results: The composite discharge summary quality score increased following the intervention (19.07 vs. 13.37, P < 0.001). Ten items showed improved documentation, including documented need for follow-up tests, cognitive status, code status, and communication with the next provider. The global rating score improved from 3.04 to 3.46 (P = 0.01). Discharge summary word count decreased from 717 to 701 (P = 0.002), with no change in the time to discharge summary completion. Surveyed physicians reported improved satisfaction with the enhanced discharge summary compared with the prior template.
- Conclusion: An enhanced discharge summary, designed to serve as a handoff between inpatient and outpatient providers, improved quality without negative effects on document length, time to completion, or physician satisfaction.
Patient safety is often compromised during the transition period following an acute hospitalization. Half of patients may experience an error related to discontinuity of care between inpatient and outpatient providers [1], frequently resulting in preventable adverse events [2,3]. The discharge summary document serves as the primary and often only method of communication between inpatient and outpatient providers [4,5]. Despite its intended purpose, the discharge summary is frequently unavailable at the time of post-discharge clinic visits [4,6,7]. Even when available, the traditional discharge summary may have limited effectiveness as a handoff document due to disorganization or excessive length [8–11].
The Joint Commission requires that a minimum set of elements are documented in every discharge summary, including reason for hospitalization, significant findings, procedures and treatment provided, discharge condition, patient and family instructions, and medication reconciliation [12]. Unfortunately, the required components fail to address many of the complexities encountered in the discharge process and have not adapted to changes in health care delivery. Discharge summary elements related to patients’ future care plans are often inaccurate or omitted [13], including pending diagnostic tests [14–17], recommended outpatient evaluations [18], pertinent discharge condition information [19], and medication changes [1,20,21].
In 2007, the Transitions of Care Consensus Conference made recommendations to address quality gaps in care transitions from inpatient to outpatient settings. This policy statement recommended the adoption of standard discharge summary templates and provided guidance on the addition of specific data elements, including patients’ preferences and goals and clear delineation of care responsibility during the transition period [22]. The use of note templates within the electronic health record (EHR) may help prevent omission of certain data elements [23,24], but inclusion of higher-level management information may require that health providers rethink the function and structure of the discharge summary. Rather than a “captain’s log” narrative of inpatient events, the discharge summary should be considered a handoff document, meant to communicate “a strategic plan for future care. . .lessons learned. . .unresolved issues, and include a projection of how the author believes patients’ clinical condition will evolve over time” [25].
We created and implemented an evidence-based, enhanced discharge summary template to serve as a practical handoff document between inpatient and outpatient providers. This article reports on the evaluation of the enhanced discharge summary in comparison to a traditional discharge summary template.
Methods
Setting
The intervention took place within the inpatient internal medicine service at a 621-bed academic medical center. The internal medicine service includes teaching and non-teaching teams that collectively discharge approximately 4700 patients per year. Approximately 40 staff physicians and 75 residents per year rotate on the inpatient service. The hospital system uses an EHR that supports all clinical activities, including documentation and physician order entry. The EHR also automatically faxes discharge summaries to the primary care physician (PCP) of record when finalized by the inpatient provider. Prior to the intervention, a default discharge summary template was used throughout the hospital system. No formal education on discharge summary composition was provided to inpatient providers or residents prior to this project. This research project was approved by the university institutional review board and was performed without external funding.
Template Redesign
The project was initiated by 2 hospital medicine physicians (CJS and MB) who recruited volunteer representatives from key stakeholder groups to participate in a quality improvement project. The final template redesign team was made up of 4 hospital medicine physicians, 2 ambulatory clinic physicians, 1 internal medicine chief resident, and 1 second-year internal medicine house officer. Two of the physicians (MB and AV) were the departmental EHR champions, serving as the liaisons between providers and EHR technology support/administration. Hospital administration provided analytics and EHR build-support. The team created an enhanced discharge summary template based on recommendations from professional societies [22,26] and published literature [25,27]. We made 4 key changes to the existing discharge summary template.
First, we added a section to the template that listed information crucial to follow-up care needs: tests needed after discharge and provider responsible for follow-up, pending labs at the time of discharge and provider responsible for follow-up, and follow-up appointment information. Provider feedback suggested these elements were frequently omitted or difficult to locate within the body of the discharge summary, so this section was prioritized at the top of the template. To stress the importance of direct communication, we added a heading asking for documentation of contact with the PCP.
Second, in recognition of the increasingly complicated condition of many of our discharging patients, we introduced subheadings and menus that addressed specific elements of patient condition, including cognitive status, indwelling lines and catheters, and activity level at discharge.
Third, a menu-supported section on advance care planning was added that included both code status and an outline of goals-of-care discussions that occurred during the hospitalization.
Finally, we made the template well-organized and succinct. The stand-alone diagnosis list from the pre-intervention template was eliminated and incorporated as part of the problem-based hospital course. In addition, EHR enhancements were introduced to minimize repetition in the lists of consultants, procedures, and chronic medical conditions. We added discrete, prioritized headings with drop down menus and minimized redundancies found in the prior generic template. For example, auto-populated information in the prior default discharge summary included redundant and clinically irrelevant consultants (eg, multiple listings for pharmacy consultation), procedures (eg, recurring hemodialysis encounters), and stable, chronic conditions (eg, hyperlipidemia) that lengthened the discharge summary without adding to its function as a handoff document.
The template was pilot-tested for 2 weeks with teaching and non-teaching teams. A focus group of 5 inpatient providers gave feedback via semi-structured interviews. The research team also solicited unstructured feedback from hospital medicine providers during a required standing administrative meeting. These suggestions informed revisions to the enhanced discharge summary, which was then made the default option for all internal medicine providers.
Education
A 30-minute educational session was developed and delivered by the authors. The objectives of the didactic portion were to describe how discharge summaries can impact patient care, understand how discharge summaries serve as a handoff document, list the components of an effective discharge summary, and describe strategies to avoid common errors in writing discharge summaries. The session included a review of pertinent literature [1,12,13,21], an outline of discharge summary best-practices [22,25], and an introduction to the new template. Trainers reviewed strategies for keeping the discharge summary concise, including using problem-based formatting, focusing on active hospital problems, and eliminating unnecessary or redundant information. Participants were encouraged to complete their discharge summaries and directly contact outpatient providers within 24 hours of discharge. Following the didactic session, participants critically reviewed an example discharge summary and discussed what was done well, what was done poorly, and what strategies they would have used to make it a more effective handoff document. Residents rotating on the inpatient internal medicine services received the education during their mandatory monthly orientation. Faculty physicians were provided the education at a required section meeting.
Quality Scoring of Discharge Summaries and Analysis
To evaluate the quality of discharge summaries, we developed a scoring instrument to measure inclusion of 24 key elements (Table 1). The scoring instrument (available from the authors) was pilot tested by 4 general internal medicine physicians on 5 sample discharge summaries. After independent scoring, this group met with members of the research team to provide feedback. Iterative revisions were made to the scoring instrument until scorers reached consensus in their understanding and application of the scoring instrument. Each discharge summary received a quality score from 0 to 24, based on the number of elements found to be present. Secondary quality metrics included a global quality rating using a 1 to 5 scale (described in Results); frequency of redundant documentation of consultants and procedures; frequency of documentation of non-active, chronic conditions; the length of the discharge summary (total word count); and time to completion. 
We analyzed a sample of discharge summaries completed during the 3-month period prior to the intervention and the 3-month period following the intervention. A non-stratified random technique was employed by an independent party to generate discharge summary samples from the EHR. Living patients discharged from the internal medicine services after an inpatient admission of at least 48 hours were eligible for inclusion. Each discharge summary was scored by 2 general internal medicine physicians. Each scoring dyad comprised one of the authors paired with a volunteer non–research team member who scored discharge summaries independently. Discordant results were examined by the dyad and settled by consensus.
Physician Survey
We surveyed inpatient and outpatient physicians to determine their views about discharge summaries and their views about the template before and after the intervention. Respondents were asked to indicate to what degree they agreed with statements using a 5-point Likert scale. An email containing a consent cover letter and a link to an anonymous online survey was sent to residents rotating on internal medicine services during the study period and all hospital medicine faculty. Outpatient providers affiliated with the hospital system were sent the survey if they had received at least 5 discharge summaries from the internal medicine services over the preceding 6 months. Post-intervention surveys were timed to capture responses after an adequate exposure to the enhanced discharge summary template. Inpatient physicians were re-surveyed 3 months after introduction of the enhanced discharge summary and outpatient providers were re-surveyed after 1 year.
Statistical Analysis
We reviewed 10 pre-intervention discharge summaries to estimate baseline discharge summary quality scores. Anticipating a two-fold improvement following the intervention [24], we calculated a goal sample size of 108 discharge summaries (54 pre- and 54 post-intervention) assuming alpha of 0.05 and 80% power using a two-tailed chi-square test. Expecting that some discharge summaries may not meet our inclusion criteria, 114 summaries (57 pre- and 57 post-intervention) were included in the final sample. All analyses were performed on Stata v10.1 (StataCorp; College Station, TX).
For discharge summary quality scoring, inter-rater reliability was measured by calculating the kappa statistic and percent agreement for scoring elements. Chi-square analysis was used to compare individual scoring elements before and after the intervention when the sample size was 5 or greater. Fisher’s exact test was used when the sample size was less than 5. Counts, including number of inactive diagnoses, redundant consults, redundant procedures, and total words were compared using univariate Poisson regression. Wilcoxon rank sum analysis was utilized to compare pre-intervention to post-intervention composite scores and global scores. Patient and provider characteristics were compared using the t-test, chi-square test, Fisher’s exact test, or Wilcoxon rank sum, as appropriate.
For the surveys, pre-intervention and post-intervention matched pairs were compared. Likert score responses were analyzed using the Wilcoxon signed-rank test.
Results
Discharge Summary Quality Scores
Characteristics of the pre- and post-intervention discharge summaries are displayed in Table 2. Both samples were similar with respect to patient demographics, length of stay, medical complexity, and provider characteristics. The mean composite discharge summary quality score improved from 13.4 at baseline to 19.1 in the post-intervention sample (P < 0.001) (Table 3). Ten of 24 quality elements exhibited significant improvement following the intervention, but 3 items were documented less often after the intervention (Table 3). 
The global rating of discharge summary quality improved from 3.04 to 3.46 (P = 0.010) (Table 4). Documentation of superfluous and redundant information decreased in the 3 areas evaluated: number of non-active, chronic diagnoses (2.33 to 1.35, P < 0.001), redundant consults (1.4 to 0.09, P < 0.001), and redundant procedures (0.74 to 0.26, P < 0.001). Inter-rater reliability was generally high for individual items, although kappa score was not calculable in one case and scores of zero were obtained for 3 highly concordant items. Inter-rater reliability was moderate for global rating (kappa = 0.59). The overall length of discharge summaries decreased from 717 to 701 words (P = 0.002). There was no significant change in time to discharge summary completion following the intervention (10.9 hours pre-intervention vs. 14.5 post-intervention, P = 0.605) (Table 4). 
Survey Results
The inpatient provider response rate for the pre-intervention survey was 51/86 (59%) and 33/65 (51%) for the post-intervention survey, resulting in 21 paired responses. House officers represented the majority of paired respondents (14/21, 66%) with hospitalist faculty making up the remainder. Among outpatient physicians, the pre-intervention response rate was 19/25 (76%) and the post-intervention rate was 20/25 (80%), resulting in 16 paired responses. Half (8/16) of outpatient physicians provided only outpatient care, the other half practicing in a traditional model, providing both inpatient and outpatient care. Nearly half (7/16) had been in practice for over 15 years. Inpatient physicians’ agreement with all 4 statements related to discharge summary quality improved, including their perception of discharge summary effectiveness as a handoff document (P = 0.004). Inpatient providers estimated that the enhanced discharge summary took significantly less time to complete (19.3 vs. 24.6 minutes, P = 0.043). Outpatient providers’ perceptions of discharge summary quality trended toward improvement but did not reach statistical significance (Table 5). 
Discussion
We found that a restructured note template in combination with physician education can improve discharge summary quality without sacrificing timeliness of note completion, document length, or physician satisfaction. The Joint Commission requires that discharge summaries include condition at discharge, but global assessments such as “good” or “stable” provide little clinically meaningful information to the next provider. Through our enhanced discharge summary we were able to significantly improve communication of several more specific elements relevant to discharge condition, including cognitive status. Similar to prior studies [7,13], cognitive condition was rarely documented prior to our intervention, but improved to 88% after introduction of the enhanced discharge summary. This is especially important, as we found that 25% of the post-intervention patients had a cognitive deficit at discharge. This information is critical for the next provider, who assumes responsibility for monitoring the patient’s trajectory.
Similarly, we improved the inclusion of patient preferences regarding advanced care planning. Whereas code status was rarely included the pre-intervention discharge summaries, we found that 1 in 5 patients in the post-intervention group did not want cardiopulmonary resuscitation. Beyond code status, we were also able to improve documentation of other advanced care conversations, such as end-of-life planning and power-of-attorney assignment. These conversations are increasingly common in the inpatient setting [28] but inconsistently documented [29,30].
To encourage inpatient-outpatient provider communication, the enhanced discharge summary template prompted documentation of communication with the PCP, with a resultant improvement from 25% to 72% (P < 0.001). The template also increased documentation of contact information for the hospital provider from 4% to 95% (P < 0.001). This improvement is notable, as hospital and outpatient physicians communicate infrequently [4,5], despite the fact that direct, “high-touch” communication is often preferred [10,11].
Our intervention builds upon prior research [23,24,31] through its deliberate focus on template formatting, evaluation of comprehensive clinical data elements using clearly defined scoring criteria, inclusion of teaching and non-teaching inpatient services, and assessment of inpatient and outpatient provider satisfaction. By restructuring the enhanced discharge summary template, we were able to improve documentation of clinical information, patient preferences, and physician communication, while keeping notes concise, prioritized, and timely. This restructuring included re-ordering information within the note, adding clear headings, devising intuitive drop-down menus, and removing unnecessary information. The amount of redundant information, document length, and perceived time required to write the discharge summary improved in the post-intervention period. Finally, our intervention was carried out with few resources and without financial incentives.
Although we found overall improvements following our intervention, there were several notable exceptions. Three content areas that were routinely documented in the pre-intervention period showed significant declines in the post-intervention phase: diet, activity, and procedures. Additionally, despite improvements in the post-intervention group, certain elements continued to be unreliably communicated in the discharge summary. Sporadic inclusion of pending tests (47%) was a particularly concerning finding. One possible explanation is that the addition of new elements and a focus on concise documentation encouraged physicians to skip or delete these areas of the enhanced discharge summary. It is also possible that reliance on drop-down menus and manual text entry, rather than auto-populated data, contributed to these deficits. As organizations re-design their electronic note templates, they should consider different content importing options [32] based on local institutional needs, culture, and EHR capabilities [33].
This study had several limitations. It was conducted at a single academic institution, so findings may not be generalizable to other settings. Although the magnitude and specificity of many of the measured outcomes suggests they were caused by the intervention, our pre/post study design cannot rule out the possibility that time-varying factors other than the intervention may have influenced our findings. We also used a novel scoring instrument, as a psychometrically tested discharge summary scoring instrument was not available at the time of the study [34]. Because it was based on similar concepts and evidence, the scoring instrument mirrored the data elements included in the intervention, which may have biased our results away from the null. However, the global rating score, which provided an overall appraisal of discharge summary quality unrelated to specific elements of the intervention, also showed significant improvement following the intervention. The distinct formatting of pre- and post-intervention templates meant that scorers were not blinded, thus making social desirability bias a possibility. We attempted to minimize the risk for bias by having all discharge summaries scored by 2 scorers, including one physician who was not a member of the research team. Small sample sizes, particularly with regard to the outpatient survey, may have contributed to type II errors. Additionally, although the discharge summary education was delivered during required meetings, we did not track attendance, so we were unable analyze for differences between providers who received the education and those that did not. Finally, while we evaluated discharge summaries for inclusion of key information, we did not perform chart reviews or contact PCPs to confirm the accuracy of documented information. Future study should evaluate the sustainability of our intervention and its impact on patient-level outcomes.
In conclusion, we found that revising our electronic template to better function as a handoff document could improve discharge summary quality. While most content areas evaluated showed improvement, there were several elements that were negatively impacted. Hospitals should be deliberate when reformatting their discharge summary templates so as to balance the need for efficient, manageable template navigation with accurate, complete, and necessary information.
Corresponding author: Christopher J. Smith, MD, 986430 Nebraska Medical Center Omaha, NE 68198-6430 Email: csmithj@unmc.edu.
Financial disclosures: None.
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From the Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE.
Abstract
- Objective: To design and implement an enhanced discharge summary for use by internal medicine providers and evaluate its impact.
- Methods. Pre/post-intervention study in which discharge summaries created in the 3 months before (n = 57) and 3 months after (n = 57) introduction of an enhanced discharge summary template were assessed using a 24-item scoring instrument. Measures evaluated included a composite discharge summary quality score, individual content item scores, global rating score, redundant documentation of consultants and procedures, documentation of non-active conditions, discharge summary word count, and time to completion. Physician satisfaction with the enhanced discharge summary was evaluated by survey.
- Results: The composite discharge summary quality score increased following the intervention (19.07 vs. 13.37, P < 0.001). Ten items showed improved documentation, including documented need for follow-up tests, cognitive status, code status, and communication with the next provider. The global rating score improved from 3.04 to 3.46 (P = 0.01). Discharge summary word count decreased from 717 to 701 (P = 0.002), with no change in the time to discharge summary completion. Surveyed physicians reported improved satisfaction with the enhanced discharge summary compared with the prior template.
- Conclusion: An enhanced discharge summary, designed to serve as a handoff between inpatient and outpatient providers, improved quality without negative effects on document length, time to completion, or physician satisfaction.
Patient safety is often compromised during the transition period following an acute hospitalization. Half of patients may experience an error related to discontinuity of care between inpatient and outpatient providers [1], frequently resulting in preventable adverse events [2,3]. The discharge summary document serves as the primary and often only method of communication between inpatient and outpatient providers [4,5]. Despite its intended purpose, the discharge summary is frequently unavailable at the time of post-discharge clinic visits [4,6,7]. Even when available, the traditional discharge summary may have limited effectiveness as a handoff document due to disorganization or excessive length [8–11].
The Joint Commission requires that a minimum set of elements are documented in every discharge summary, including reason for hospitalization, significant findings, procedures and treatment provided, discharge condition, patient and family instructions, and medication reconciliation [12]. Unfortunately, the required components fail to address many of the complexities encountered in the discharge process and have not adapted to changes in health care delivery. Discharge summary elements related to patients’ future care plans are often inaccurate or omitted [13], including pending diagnostic tests [14–17], recommended outpatient evaluations [18], pertinent discharge condition information [19], and medication changes [1,20,21].
In 2007, the Transitions of Care Consensus Conference made recommendations to address quality gaps in care transitions from inpatient to outpatient settings. This policy statement recommended the adoption of standard discharge summary templates and provided guidance on the addition of specific data elements, including patients’ preferences and goals and clear delineation of care responsibility during the transition period [22]. The use of note templates within the electronic health record (EHR) may help prevent omission of certain data elements [23,24], but inclusion of higher-level management information may require that health providers rethink the function and structure of the discharge summary. Rather than a “captain’s log” narrative of inpatient events, the discharge summary should be considered a handoff document, meant to communicate “a strategic plan for future care. . .lessons learned. . .unresolved issues, and include a projection of how the author believes patients’ clinical condition will evolve over time” [25].
We created and implemented an evidence-based, enhanced discharge summary template to serve as a practical handoff document between inpatient and outpatient providers. This article reports on the evaluation of the enhanced discharge summary in comparison to a traditional discharge summary template.
Methods
Setting
The intervention took place within the inpatient internal medicine service at a 621-bed academic medical center. The internal medicine service includes teaching and non-teaching teams that collectively discharge approximately 4700 patients per year. Approximately 40 staff physicians and 75 residents per year rotate on the inpatient service. The hospital system uses an EHR that supports all clinical activities, including documentation and physician order entry. The EHR also automatically faxes discharge summaries to the primary care physician (PCP) of record when finalized by the inpatient provider. Prior to the intervention, a default discharge summary template was used throughout the hospital system. No formal education on discharge summary composition was provided to inpatient providers or residents prior to this project. This research project was approved by the university institutional review board and was performed without external funding.
Template Redesign
The project was initiated by 2 hospital medicine physicians (CJS and MB) who recruited volunteer representatives from key stakeholder groups to participate in a quality improvement project. The final template redesign team was made up of 4 hospital medicine physicians, 2 ambulatory clinic physicians, 1 internal medicine chief resident, and 1 second-year internal medicine house officer. Two of the physicians (MB and AV) were the departmental EHR champions, serving as the liaisons between providers and EHR technology support/administration. Hospital administration provided analytics and EHR build-support. The team created an enhanced discharge summary template based on recommendations from professional societies [22,26] and published literature [25,27]. We made 4 key changes to the existing discharge summary template.
First, we added a section to the template that listed information crucial to follow-up care needs: tests needed after discharge and provider responsible for follow-up, pending labs at the time of discharge and provider responsible for follow-up, and follow-up appointment information. Provider feedback suggested these elements were frequently omitted or difficult to locate within the body of the discharge summary, so this section was prioritized at the top of the template. To stress the importance of direct communication, we added a heading asking for documentation of contact with the PCP.
Second, in recognition of the increasingly complicated condition of many of our discharging patients, we introduced subheadings and menus that addressed specific elements of patient condition, including cognitive status, indwelling lines and catheters, and activity level at discharge.
Third, a menu-supported section on advance care planning was added that included both code status and an outline of goals-of-care discussions that occurred during the hospitalization.
Finally, we made the template well-organized and succinct. The stand-alone diagnosis list from the pre-intervention template was eliminated and incorporated as part of the problem-based hospital course. In addition, EHR enhancements were introduced to minimize repetition in the lists of consultants, procedures, and chronic medical conditions. We added discrete, prioritized headings with drop down menus and minimized redundancies found in the prior generic template. For example, auto-populated information in the prior default discharge summary included redundant and clinically irrelevant consultants (eg, multiple listings for pharmacy consultation), procedures (eg, recurring hemodialysis encounters), and stable, chronic conditions (eg, hyperlipidemia) that lengthened the discharge summary without adding to its function as a handoff document.
The template was pilot-tested for 2 weeks with teaching and non-teaching teams. A focus group of 5 inpatient providers gave feedback via semi-structured interviews. The research team also solicited unstructured feedback from hospital medicine providers during a required standing administrative meeting. These suggestions informed revisions to the enhanced discharge summary, which was then made the default option for all internal medicine providers.
Education
A 30-minute educational session was developed and delivered by the authors. The objectives of the didactic portion were to describe how discharge summaries can impact patient care, understand how discharge summaries serve as a handoff document, list the components of an effective discharge summary, and describe strategies to avoid common errors in writing discharge summaries. The session included a review of pertinent literature [1,12,13,21], an outline of discharge summary best-practices [22,25], and an introduction to the new template. Trainers reviewed strategies for keeping the discharge summary concise, including using problem-based formatting, focusing on active hospital problems, and eliminating unnecessary or redundant information. Participants were encouraged to complete their discharge summaries and directly contact outpatient providers within 24 hours of discharge. Following the didactic session, participants critically reviewed an example discharge summary and discussed what was done well, what was done poorly, and what strategies they would have used to make it a more effective handoff document. Residents rotating on the inpatient internal medicine services received the education during their mandatory monthly orientation. Faculty physicians were provided the education at a required section meeting.
Quality Scoring of Discharge Summaries and Analysis
To evaluate the quality of discharge summaries, we developed a scoring instrument to measure inclusion of 24 key elements (Table 1). The scoring instrument (available from the authors) was pilot tested by 4 general internal medicine physicians on 5 sample discharge summaries. After independent scoring, this group met with members of the research team to provide feedback. Iterative revisions were made to the scoring instrument until scorers reached consensus in their understanding and application of the scoring instrument. Each discharge summary received a quality score from 0 to 24, based on the number of elements found to be present. Secondary quality metrics included a global quality rating using a 1 to 5 scale (described in Results); frequency of redundant documentation of consultants and procedures; frequency of documentation of non-active, chronic conditions; the length of the discharge summary (total word count); and time to completion.
We analyzed a sample of discharge summaries completed during the 3-month period prior to the intervention and the 3-month period following the intervention. A non-stratified random technique was employed by an independent party to generate discharge summary samples from the EHR. Living patients discharged from the internal medicine services after an inpatient admission of at least 48 hours were eligible for inclusion. Each discharge summary was scored by 2 general internal medicine physicians. Each scoring dyad comprised one of the authors paired with a volunteer non–research team member who scored discharge summaries independently. Discordant results were examined by the dyad and settled by consensus.
Physician Survey
We surveyed inpatient and outpatient physicians to determine their views about discharge summaries and their views about the template before and after the intervention. Respondents were asked to indicate to what degree they agreed with statements using a 5-point Likert scale. An email containing a consent cover letter and a link to an anonymous online survey was sent to residents rotating on internal medicine services during the study period and all hospital medicine faculty. Outpatient providers affiliated with the hospital system were sent the survey if they had received at least 5 discharge summaries from the internal medicine services over the preceding 6 months. Post-intervention surveys were timed to capture responses after an adequate exposure to the enhanced discharge summary template. Inpatient physicians were re-surveyed 3 months after introduction of the enhanced discharge summary and outpatient providers were re-surveyed after 1 year.
Statistical Analysis
We reviewed 10 pre-intervention discharge summaries to estimate baseline discharge summary quality scores. Anticipating a two-fold improvement following the intervention [24], we calculated a goal sample size of 108 discharge summaries (54 pre- and 54 post-intervention) assuming alpha of 0.05 and 80% power using a two-tailed chi-square test. Expecting that some discharge summaries may not meet our inclusion criteria, 114 summaries (57 pre- and 57 post-intervention) were included in the final sample. All analyses were performed on Stata v10.1 (StataCorp; College Station, TX).
For discharge summary quality scoring, inter-rater reliability was measured by calculating the kappa statistic and percent agreement for scoring elements. Chi-square analysis was used to compare individual scoring elements before and after the intervention when the sample size was 5 or greater. Fisher’s exact test was used when the sample size was less than 5. Counts, including number of inactive diagnoses, redundant consults, redundant procedures, and total words were compared using univariate Poisson regression. Wilcoxon rank sum analysis was utilized to compare pre-intervention to post-intervention composite scores and global scores. Patient and provider characteristics were compared using the t-test, chi-square test, Fisher’s exact test, or Wilcoxon rank sum, as appropriate.
For the surveys, pre-intervention and post-intervention matched pairs were compared. Likert score responses were analyzed using the Wilcoxon signed-rank test.
Results
Discharge Summary Quality Scores
Characteristics of the pre- and post-intervention discharge summaries are displayed in Table 2. Both samples were similar with respect to patient demographics, length of stay, medical complexity, and provider characteristics. The mean composite discharge summary quality score improved from 13.4 at baseline to 19.1 in the post-intervention sample (P < 0.001) (Table 3). Ten of 24 quality elements exhibited significant improvement following the intervention, but 3 items were documented less often after the intervention (Table 3).
The global rating of discharge summary quality improved from 3.04 to 3.46 (P = 0.010) (Table 4). Documentation of superfluous and redundant information decreased in the 3 areas evaluated: number of non-active, chronic diagnoses (2.33 to 1.35, P < 0.001), redundant consults (1.4 to 0.09, P < 0.001), and redundant procedures (0.74 to 0.26, P < 0.001). Inter-rater reliability was generally high for individual items, although kappa score was not calculable in one case and scores of zero were obtained for 3 highly concordant items. Inter-rater reliability was moderate for global rating (kappa = 0.59). The overall length of discharge summaries decreased from 717 to 701 words (P = 0.002). There was no significant change in time to discharge summary completion following the intervention (10.9 hours pre-intervention vs. 14.5 post-intervention, P = 0.605) (Table 4).
Survey Results
The inpatient provider response rate for the pre-intervention survey was 51/86 (59%) and 33/65 (51%) for the post-intervention survey, resulting in 21 paired responses. House officers represented the majority of paired respondents (14/21, 66%) with hospitalist faculty making up the remainder. Among outpatient physicians, the pre-intervention response rate was 19/25 (76%) and the post-intervention rate was 20/25 (80%), resulting in 16 paired responses. Half (8/16) of outpatient physicians provided only outpatient care, the other half practicing in a traditional model, providing both inpatient and outpatient care. Nearly half (7/16) had been in practice for over 15 years. Inpatient physicians’ agreement with all 4 statements related to discharge summary quality improved, including their perception of discharge summary effectiveness as a handoff document (P = 0.004). Inpatient providers estimated that the enhanced discharge summary took significantly less time to complete (19.3 vs. 24.6 minutes, P = 0.043). Outpatient providers’ perceptions of discharge summary quality trended toward improvement but did not reach statistical significance (Table 5).
Discussion
We found that a restructured note template in combination with physician education can improve discharge summary quality without sacrificing timeliness of note completion, document length, or physician satisfaction. The Joint Commission requires that discharge summaries include condition at discharge, but global assessments such as “good” or “stable” provide little clinically meaningful information to the next provider. Through our enhanced discharge summary we were able to significantly improve communication of several more specific elements relevant to discharge condition, including cognitive status. Similar to prior studies [7,13], cognitive condition was rarely documented prior to our intervention, but improved to 88% after introduction of the enhanced discharge summary. This is especially important, as we found that 25% of the post-intervention patients had a cognitive deficit at discharge. This information is critical for the next provider, who assumes responsibility for monitoring the patient’s trajectory.
Similarly, we improved the inclusion of patient preferences regarding advanced care planning. Whereas code status was rarely included the pre-intervention discharge summaries, we found that 1 in 5 patients in the post-intervention group did not want cardiopulmonary resuscitation. Beyond code status, we were also able to improve documentation of other advanced care conversations, such as end-of-life planning and power-of-attorney assignment. These conversations are increasingly common in the inpatient setting [28] but inconsistently documented [29,30].
To encourage inpatient-outpatient provider communication, the enhanced discharge summary template prompted documentation of communication with the PCP, with a resultant improvement from 25% to 72% (P < 0.001). The template also increased documentation of contact information for the hospital provider from 4% to 95% (P < 0.001). This improvement is notable, as hospital and outpatient physicians communicate infrequently [4,5], despite the fact that direct, “high-touch” communication is often preferred [10,11].
Our intervention builds upon prior research [23,24,31] through its deliberate focus on template formatting, evaluation of comprehensive clinical data elements using clearly defined scoring criteria, inclusion of teaching and non-teaching inpatient services, and assessment of inpatient and outpatient provider satisfaction. By restructuring the enhanced discharge summary template, we were able to improve documentation of clinical information, patient preferences, and physician communication, while keeping notes concise, prioritized, and timely. This restructuring included re-ordering information within the note, adding clear headings, devising intuitive drop-down menus, and removing unnecessary information. The amount of redundant information, document length, and perceived time required to write the discharge summary improved in the post-intervention period. Finally, our intervention was carried out with few resources and without financial incentives.
Although we found overall improvements following our intervention, there were several notable exceptions. Three content areas that were routinely documented in the pre-intervention period showed significant declines in the post-intervention phase: diet, activity, and procedures. Additionally, despite improvements in the post-intervention group, certain elements continued to be unreliably communicated in the discharge summary. Sporadic inclusion of pending tests (47%) was a particularly concerning finding. One possible explanation is that the addition of new elements and a focus on concise documentation encouraged physicians to skip or delete these areas of the enhanced discharge summary. It is also possible that reliance on drop-down menus and manual text entry, rather than auto-populated data, contributed to these deficits. As organizations re-design their electronic note templates, they should consider different content importing options [32] based on local institutional needs, culture, and EHR capabilities [33].
This study had several limitations. It was conducted at a single academic institution, so findings may not be generalizable to other settings. Although the magnitude and specificity of many of the measured outcomes suggests they were caused by the intervention, our pre/post study design cannot rule out the possibility that time-varying factors other than the intervention may have influenced our findings. We also used a novel scoring instrument, as a psychometrically tested discharge summary scoring instrument was not available at the time of the study [34]. Because it was based on similar concepts and evidence, the scoring instrument mirrored the data elements included in the intervention, which may have biased our results away from the null. However, the global rating score, which provided an overall appraisal of discharge summary quality unrelated to specific elements of the intervention, also showed significant improvement following the intervention. The distinct formatting of pre- and post-intervention templates meant that scorers were not blinded, thus making social desirability bias a possibility. We attempted to minimize the risk for bias by having all discharge summaries scored by 2 scorers, including one physician who was not a member of the research team. Small sample sizes, particularly with regard to the outpatient survey, may have contributed to type II errors. Additionally, although the discharge summary education was delivered during required meetings, we did not track attendance, so we were unable analyze for differences between providers who received the education and those that did not. Finally, while we evaluated discharge summaries for inclusion of key information, we did not perform chart reviews or contact PCPs to confirm the accuracy of documented information. Future study should evaluate the sustainability of our intervention and its impact on patient-level outcomes.
In conclusion, we found that revising our electronic template to better function as a handoff document could improve discharge summary quality. While most content areas evaluated showed improvement, there were several elements that were negatively impacted. Hospitals should be deliberate when reformatting their discharge summary templates so as to balance the need for efficient, manageable template navigation with accurate, complete, and necessary information.
Corresponding author: Christopher J. Smith, MD, 986430 Nebraska Medical Center Omaha, NE 68198-6430 Email: csmithj@unmc.edu.
Financial disclosures: None.
From the Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE.
Abstract
- Objective: To design and implement an enhanced discharge summary for use by internal medicine providers and evaluate its impact.
- Methods. Pre/post-intervention study in which discharge summaries created in the 3 months before (n = 57) and 3 months after (n = 57) introduction of an enhanced discharge summary template were assessed using a 24-item scoring instrument. Measures evaluated included a composite discharge summary quality score, individual content item scores, global rating score, redundant documentation of consultants and procedures, documentation of non-active conditions, discharge summary word count, and time to completion. Physician satisfaction with the enhanced discharge summary was evaluated by survey.
- Results: The composite discharge summary quality score increased following the intervention (19.07 vs. 13.37, P < 0.001). Ten items showed improved documentation, including documented need for follow-up tests, cognitive status, code status, and communication with the next provider. The global rating score improved from 3.04 to 3.46 (P = 0.01). Discharge summary word count decreased from 717 to 701 (P = 0.002), with no change in the time to discharge summary completion. Surveyed physicians reported improved satisfaction with the enhanced discharge summary compared with the prior template.
- Conclusion: An enhanced discharge summary, designed to serve as a handoff between inpatient and outpatient providers, improved quality without negative effects on document length, time to completion, or physician satisfaction.
Patient safety is often compromised during the transition period following an acute hospitalization. Half of patients may experience an error related to discontinuity of care between inpatient and outpatient providers [1], frequently resulting in preventable adverse events [2,3]. The discharge summary document serves as the primary and often only method of communication between inpatient and outpatient providers [4,5]. Despite its intended purpose, the discharge summary is frequently unavailable at the time of post-discharge clinic visits [4,6,7]. Even when available, the traditional discharge summary may have limited effectiveness as a handoff document due to disorganization or excessive length [8–11].
The Joint Commission requires that a minimum set of elements are documented in every discharge summary, including reason for hospitalization, significant findings, procedures and treatment provided, discharge condition, patient and family instructions, and medication reconciliation [12]. Unfortunately, the required components fail to address many of the complexities encountered in the discharge process and have not adapted to changes in health care delivery. Discharge summary elements related to patients’ future care plans are often inaccurate or omitted [13], including pending diagnostic tests [14–17], recommended outpatient evaluations [18], pertinent discharge condition information [19], and medication changes [1,20,21].
In 2007, the Transitions of Care Consensus Conference made recommendations to address quality gaps in care transitions from inpatient to outpatient settings. This policy statement recommended the adoption of standard discharge summary templates and provided guidance on the addition of specific data elements, including patients’ preferences and goals and clear delineation of care responsibility during the transition period [22]. The use of note templates within the electronic health record (EHR) may help prevent omission of certain data elements [23,24], but inclusion of higher-level management information may require that health providers rethink the function and structure of the discharge summary. Rather than a “captain’s log” narrative of inpatient events, the discharge summary should be considered a handoff document, meant to communicate “a strategic plan for future care. . .lessons learned. . .unresolved issues, and include a projection of how the author believes patients’ clinical condition will evolve over time” [25].
We created and implemented an evidence-based, enhanced discharge summary template to serve as a practical handoff document between inpatient and outpatient providers. This article reports on the evaluation of the enhanced discharge summary in comparison to a traditional discharge summary template.
Methods
Setting
The intervention took place within the inpatient internal medicine service at a 621-bed academic medical center. The internal medicine service includes teaching and non-teaching teams that collectively discharge approximately 4700 patients per year. Approximately 40 staff physicians and 75 residents per year rotate on the inpatient service. The hospital system uses an EHR that supports all clinical activities, including documentation and physician order entry. The EHR also automatically faxes discharge summaries to the primary care physician (PCP) of record when finalized by the inpatient provider. Prior to the intervention, a default discharge summary template was used throughout the hospital system. No formal education on discharge summary composition was provided to inpatient providers or residents prior to this project. This research project was approved by the university institutional review board and was performed without external funding.
Template Redesign
The project was initiated by 2 hospital medicine physicians (CJS and MB) who recruited volunteer representatives from key stakeholder groups to participate in a quality improvement project. The final template redesign team was made up of 4 hospital medicine physicians, 2 ambulatory clinic physicians, 1 internal medicine chief resident, and 1 second-year internal medicine house officer. Two of the physicians (MB and AV) were the departmental EHR champions, serving as the liaisons between providers and EHR technology support/administration. Hospital administration provided analytics and EHR build-support. The team created an enhanced discharge summary template based on recommendations from professional societies [22,26] and published literature [25,27]. We made 4 key changes to the existing discharge summary template.
First, we added a section to the template that listed information crucial to follow-up care needs: tests needed after discharge and provider responsible for follow-up, pending labs at the time of discharge and provider responsible for follow-up, and follow-up appointment information. Provider feedback suggested these elements were frequently omitted or difficult to locate within the body of the discharge summary, so this section was prioritized at the top of the template. To stress the importance of direct communication, we added a heading asking for documentation of contact with the PCP.
Second, in recognition of the increasingly complicated condition of many of our discharging patients, we introduced subheadings and menus that addressed specific elements of patient condition, including cognitive status, indwelling lines and catheters, and activity level at discharge.
Third, a menu-supported section on advance care planning was added that included both code status and an outline of goals-of-care discussions that occurred during the hospitalization.
Finally, we made the template well-organized and succinct. The stand-alone diagnosis list from the pre-intervention template was eliminated and incorporated as part of the problem-based hospital course. In addition, EHR enhancements were introduced to minimize repetition in the lists of consultants, procedures, and chronic medical conditions. We added discrete, prioritized headings with drop down menus and minimized redundancies found in the prior generic template. For example, auto-populated information in the prior default discharge summary included redundant and clinically irrelevant consultants (eg, multiple listings for pharmacy consultation), procedures (eg, recurring hemodialysis encounters), and stable, chronic conditions (eg, hyperlipidemia) that lengthened the discharge summary without adding to its function as a handoff document.
The template was pilot-tested for 2 weeks with teaching and non-teaching teams. A focus group of 5 inpatient providers gave feedback via semi-structured interviews. The research team also solicited unstructured feedback from hospital medicine providers during a required standing administrative meeting. These suggestions informed revisions to the enhanced discharge summary, which was then made the default option for all internal medicine providers.
Education
A 30-minute educational session was developed and delivered by the authors. The objectives of the didactic portion were to describe how discharge summaries can impact patient care, understand how discharge summaries serve as a handoff document, list the components of an effective discharge summary, and describe strategies to avoid common errors in writing discharge summaries. The session included a review of pertinent literature [1,12,13,21], an outline of discharge summary best-practices [22,25], and an introduction to the new template. Trainers reviewed strategies for keeping the discharge summary concise, including using problem-based formatting, focusing on active hospital problems, and eliminating unnecessary or redundant information. Participants were encouraged to complete their discharge summaries and directly contact outpatient providers within 24 hours of discharge. Following the didactic session, participants critically reviewed an example discharge summary and discussed what was done well, what was done poorly, and what strategies they would have used to make it a more effective handoff document. Residents rotating on the inpatient internal medicine services received the education during their mandatory monthly orientation. Faculty physicians were provided the education at a required section meeting.
Quality Scoring of Discharge Summaries and Analysis
To evaluate the quality of discharge summaries, we developed a scoring instrument to measure inclusion of 24 key elements (Table 1). The scoring instrument (available from the authors) was pilot tested by 4 general internal medicine physicians on 5 sample discharge summaries. After independent scoring, this group met with members of the research team to provide feedback. Iterative revisions were made to the scoring instrument until scorers reached consensus in their understanding and application of the scoring instrument. Each discharge summary received a quality score from 0 to 24, based on the number of elements found to be present. Secondary quality metrics included a global quality rating using a 1 to 5 scale (described in Results); frequency of redundant documentation of consultants and procedures; frequency of documentation of non-active, chronic conditions; the length of the discharge summary (total word count); and time to completion.
We analyzed a sample of discharge summaries completed during the 3-month period prior to the intervention and the 3-month period following the intervention. A non-stratified random technique was employed by an independent party to generate discharge summary samples from the EHR. Living patients discharged from the internal medicine services after an inpatient admission of at least 48 hours were eligible for inclusion. Each discharge summary was scored by 2 general internal medicine physicians. Each scoring dyad comprised one of the authors paired with a volunteer non–research team member who scored discharge summaries independently. Discordant results were examined by the dyad and settled by consensus.
Physician Survey
We surveyed inpatient and outpatient physicians to determine their views about discharge summaries and their views about the template before and after the intervention. Respondents were asked to indicate to what degree they agreed with statements using a 5-point Likert scale. An email containing a consent cover letter and a link to an anonymous online survey was sent to residents rotating on internal medicine services during the study period and all hospital medicine faculty. Outpatient providers affiliated with the hospital system were sent the survey if they had received at least 5 discharge summaries from the internal medicine services over the preceding 6 months. Post-intervention surveys were timed to capture responses after an adequate exposure to the enhanced discharge summary template. Inpatient physicians were re-surveyed 3 months after introduction of the enhanced discharge summary and outpatient providers were re-surveyed after 1 year.
Statistical Analysis
We reviewed 10 pre-intervention discharge summaries to estimate baseline discharge summary quality scores. Anticipating a two-fold improvement following the intervention [24], we calculated a goal sample size of 108 discharge summaries (54 pre- and 54 post-intervention) assuming alpha of 0.05 and 80% power using a two-tailed chi-square test. Expecting that some discharge summaries may not meet our inclusion criteria, 114 summaries (57 pre- and 57 post-intervention) were included in the final sample. All analyses were performed on Stata v10.1 (StataCorp; College Station, TX).
For discharge summary quality scoring, inter-rater reliability was measured by calculating the kappa statistic and percent agreement for scoring elements. Chi-square analysis was used to compare individual scoring elements before and after the intervention when the sample size was 5 or greater. Fisher’s exact test was used when the sample size was less than 5. Counts, including number of inactive diagnoses, redundant consults, redundant procedures, and total words were compared using univariate Poisson regression. Wilcoxon rank sum analysis was utilized to compare pre-intervention to post-intervention composite scores and global scores. Patient and provider characteristics were compared using the t-test, chi-square test, Fisher’s exact test, or Wilcoxon rank sum, as appropriate.
For the surveys, pre-intervention and post-intervention matched pairs were compared. Likert score responses were analyzed using the Wilcoxon signed-rank test.
Results
Discharge Summary Quality Scores
Characteristics of the pre- and post-intervention discharge summaries are displayed in Table 2. Both samples were similar with respect to patient demographics, length of stay, medical complexity, and provider characteristics. The mean composite discharge summary quality score improved from 13.4 at baseline to 19.1 in the post-intervention sample (P < 0.001) (Table 3). Ten of 24 quality elements exhibited significant improvement following the intervention, but 3 items were documented less often after the intervention (Table 3).
The global rating of discharge summary quality improved from 3.04 to 3.46 (P = 0.010) (Table 4). Documentation of superfluous and redundant information decreased in the 3 areas evaluated: number of non-active, chronic diagnoses (2.33 to 1.35, P < 0.001), redundant consults (1.4 to 0.09, P < 0.001), and redundant procedures (0.74 to 0.26, P < 0.001). Inter-rater reliability was generally high for individual items, although kappa score was not calculable in one case and scores of zero were obtained for 3 highly concordant items. Inter-rater reliability was moderate for global rating (kappa = 0.59). The overall length of discharge summaries decreased from 717 to 701 words (P = 0.002). There was no significant change in time to discharge summary completion following the intervention (10.9 hours pre-intervention vs. 14.5 post-intervention, P = 0.605) (Table 4).
Survey Results
The inpatient provider response rate for the pre-intervention survey was 51/86 (59%) and 33/65 (51%) for the post-intervention survey, resulting in 21 paired responses. House officers represented the majority of paired respondents (14/21, 66%) with hospitalist faculty making up the remainder. Among outpatient physicians, the pre-intervention response rate was 19/25 (76%) and the post-intervention rate was 20/25 (80%), resulting in 16 paired responses. Half (8/16) of outpatient physicians provided only outpatient care, the other half practicing in a traditional model, providing both inpatient and outpatient care. Nearly half (7/16) had been in practice for over 15 years. Inpatient physicians’ agreement with all 4 statements related to discharge summary quality improved, including their perception of discharge summary effectiveness as a handoff document (P = 0.004). Inpatient providers estimated that the enhanced discharge summary took significantly less time to complete (19.3 vs. 24.6 minutes, P = 0.043). Outpatient providers’ perceptions of discharge summary quality trended toward improvement but did not reach statistical significance (Table 5).
Discussion
We found that a restructured note template in combination with physician education can improve discharge summary quality without sacrificing timeliness of note completion, document length, or physician satisfaction. The Joint Commission requires that discharge summaries include condition at discharge, but global assessments such as “good” or “stable” provide little clinically meaningful information to the next provider. Through our enhanced discharge summary we were able to significantly improve communication of several more specific elements relevant to discharge condition, including cognitive status. Similar to prior studies [7,13], cognitive condition was rarely documented prior to our intervention, but improved to 88% after introduction of the enhanced discharge summary. This is especially important, as we found that 25% of the post-intervention patients had a cognitive deficit at discharge. This information is critical for the next provider, who assumes responsibility for monitoring the patient’s trajectory.
Similarly, we improved the inclusion of patient preferences regarding advanced care planning. Whereas code status was rarely included the pre-intervention discharge summaries, we found that 1 in 5 patients in the post-intervention group did not want cardiopulmonary resuscitation. Beyond code status, we were also able to improve documentation of other advanced care conversations, such as end-of-life planning and power-of-attorney assignment. These conversations are increasingly common in the inpatient setting [28] but inconsistently documented [29,30].
To encourage inpatient-outpatient provider communication, the enhanced discharge summary template prompted documentation of communication with the PCP, with a resultant improvement from 25% to 72% (P < 0.001). The template also increased documentation of contact information for the hospital provider from 4% to 95% (P < 0.001). This improvement is notable, as hospital and outpatient physicians communicate infrequently [4,5], despite the fact that direct, “high-touch” communication is often preferred [10,11].
Our intervention builds upon prior research [23,24,31] through its deliberate focus on template formatting, evaluation of comprehensive clinical data elements using clearly defined scoring criteria, inclusion of teaching and non-teaching inpatient services, and assessment of inpatient and outpatient provider satisfaction. By restructuring the enhanced discharge summary template, we were able to improve documentation of clinical information, patient preferences, and physician communication, while keeping notes concise, prioritized, and timely. This restructuring included re-ordering information within the note, adding clear headings, devising intuitive drop-down menus, and removing unnecessary information. The amount of redundant information, document length, and perceived time required to write the discharge summary improved in the post-intervention period. Finally, our intervention was carried out with few resources and without financial incentives.
Although we found overall improvements following our intervention, there were several notable exceptions. Three content areas that were routinely documented in the pre-intervention period showed significant declines in the post-intervention phase: diet, activity, and procedures. Additionally, despite improvements in the post-intervention group, certain elements continued to be unreliably communicated in the discharge summary. Sporadic inclusion of pending tests (47%) was a particularly concerning finding. One possible explanation is that the addition of new elements and a focus on concise documentation encouraged physicians to skip or delete these areas of the enhanced discharge summary. It is also possible that reliance on drop-down menus and manual text entry, rather than auto-populated data, contributed to these deficits. As organizations re-design their electronic note templates, they should consider different content importing options [32] based on local institutional needs, culture, and EHR capabilities [33].
This study had several limitations. It was conducted at a single academic institution, so findings may not be generalizable to other settings. Although the magnitude and specificity of many of the measured outcomes suggests they were caused by the intervention, our pre/post study design cannot rule out the possibility that time-varying factors other than the intervention may have influenced our findings. We also used a novel scoring instrument, as a psychometrically tested discharge summary scoring instrument was not available at the time of the study [34]. Because it was based on similar concepts and evidence, the scoring instrument mirrored the data elements included in the intervention, which may have biased our results away from the null. However, the global rating score, which provided an overall appraisal of discharge summary quality unrelated to specific elements of the intervention, also showed significant improvement following the intervention. The distinct formatting of pre- and post-intervention templates meant that scorers were not blinded, thus making social desirability bias a possibility. We attempted to minimize the risk for bias by having all discharge summaries scored by 2 scorers, including one physician who was not a member of the research team. Small sample sizes, particularly with regard to the outpatient survey, may have contributed to type II errors. Additionally, although the discharge summary education was delivered during required meetings, we did not track attendance, so we were unable analyze for differences between providers who received the education and those that did not. Finally, while we evaluated discharge summaries for inclusion of key information, we did not perform chart reviews or contact PCPs to confirm the accuracy of documented information. Future study should evaluate the sustainability of our intervention and its impact on patient-level outcomes.
In conclusion, we found that revising our electronic template to better function as a handoff document could improve discharge summary quality. While most content areas evaluated showed improvement, there were several elements that were negatively impacted. Hospitals should be deliberate when reformatting their discharge summary templates so as to balance the need for efficient, manageable template navigation with accurate, complete, and necessary information.
Corresponding author: Christopher J. Smith, MD, 986430 Nebraska Medical Center Omaha, NE 68198-6430 Email: csmithj@unmc.edu.
Financial disclosures: None.
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23. O’Leary KJ, Liebovitz DM, Feinglass J, et al. Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary. J Hosp Med 2009;4:219–25.
24. Bischoff K, Goel A, Hollander H, et al. The Housestaff Incentive Program: improving the timeliness and quality of discharge summaries by engaging residents in quality improvement. BMJ Qual Safety 2013;22:768–74.
25. Lenert LA, Sakaguchi FH, Weir CR. Rethinking the discharge summary: a focus on handoff communication. Acad Med 2014;89:393–8.
26. Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients--development of a discharge checklist for hospitalists. J Hosp Med 2006;1:354–60.
27. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med 2007;2:314–23.
28. Huijberts S, Buurman BM, de Rooij SE. End-of-life care during and after an acute hospitalization in older patients with cancer, end-stage organ failure, or frailty: A sub-analysis of a prospective cohort study. Palliat Med 2016;30:75–82.
29. Butler J, Binney Z, Kalogeropoulos A, et al. Advance directives among hospitalized patients with heart failure. JACC Heart Fail 2015;3:112–21.
30. Oulton J, Rhodes SM, Howe C, et al. Advance directives for older adults in the emergency department: a systematic review. J Palliat Med 2015;18:500–5.
31. Shaikh U, Slee C. Triple duty: integrating graduate medical education with maintenance of board certification to improve clinician communication at hospital discharge. J Grad Med Educ 2015;7:462–5.
32. Weis JM, Levy PC. Copy, paste, and cloned notes in electronic health records: prevalence, benefits, risks, and best practice recommendations. Chest 2014;145:632–8.
33. Dixon DR. The behavioral side of information technology. Int J Med Inform 1999;56:117–23.
34. Hommos MS, Kuperman EF, Kamath A, Kreiter CD. The development and evaluation of a novel instrument assessing residents’ discharge summaries. Acad Med 2017;92:550–5.
1. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 2003;18:646–51.
2. Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003;138:161–7.
3. Forster AJ, Murff HJ, Peterson JF, et al. Adverse drug events occurring following hospital discharge. J Gen Intern Med 2005;20:317–23.
4. Kripalani S, LeFevre F, Phillips CO, et al. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA 2007;297:831–41.
5. Bell CM, Schnipper JL, Auerbach AD, et al. Association of communication between hospital-based physicians and primary care providers with patient outcomes. J Gen Intern Med 2009;24:381–6.
6. van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med 2002;17:186-92.
7. Horwitz LI, Jenq GY, Brewster UC, et al. Comprehensive quality of discharge summaries at an academic medical center. J Hosp Med 2013;8:436–43.
8. van Walraven C, Rokosh E. What is necessary for high-quality discharge summaries? Am J Med Qual 1999;14:160–9.
9. van Walraven C, Duke SM, Weinberg AL, Wells PS. Standardized or narrative discharge summaries. Which do family physicians prefer? Can Fam Physician 1998;44:62–9.
10. Sheu L, Fung K, Mourad M, et al. We need to talk: Primary care provider communication at discharge in the era of a shared electronic medical record. J Hosp Med 2015;10:307–10.
11. Jones CD, Vu MB, O’Donnell CM, et al. A failure to communicate: a qualitative exploration of care coordination between hospitalists and primary care providers around patient hospitalizations. J Gen Intern Med 2015;30:417–24.
12. Kind AJH, Smith MA. Documentation of mandated discharge summary components in transitions from acute to subacute care. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in patient safety: new directions and alternative approaches (Vol 2: Culture and Redesign). Rockville, MD: Agency for Healthcare Quality and Research; 2008.
13. Kind AJ, Thorpe CT, Sattin JA, et al. Provider characteristics, clinical-work processes and their relationship to discharge summary quality for sub-acute care patients. J Gen Intern Med 2012;27:78–84.
14. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med 2005;143:121–8.
15. Were MC, Li X, Kesterson J, et al. Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers. J Gen Intern Med 2009;24:1002–6.
16. Walz SE, Smith M, Cox E, et al. Pending laboratory tests and the hospital discharge summary in patients discharged to sub-acute care. J Gen Intern Med 2011;26:393–8.
17. Kantor MA, Evans KH, Shieh L. Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge. J Gen Intern Med 2015;30:312–8.
18. Moore C, McGinn T, Halm E. Tying up loose ends: discharging patients with unresolved medical issues. Arch Intern Med 2007;167:1305–11.
19. Al-Damluji MS, Dzara K, Hodshon B, et al. Hospital variation in quality of discharge summaries for patients hospitalized with heart failure exacerbation. Circulation Cardiovasc Qual Outcomes 2015;8:77–86.
20. Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med 2005;165:1842–7.
21. Lindquist LA, Yamahiro A, Garrett A, et al. Primary care physician communication at hospital discharge reduces medication discrepancies. J Hosp Med 2013;8:672–7.
22. Snow V, Beck D, Budnitz T, et al. Transitions of care consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med 2009;4:364–70.
23. O’Leary KJ, Liebovitz DM, Feinglass J, et al. Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary. J Hosp Med 2009;4:219–25.
24. Bischoff K, Goel A, Hollander H, et al. The Housestaff Incentive Program: improving the timeliness and quality of discharge summaries by engaging residents in quality improvement. BMJ Qual Safety 2013;22:768–74.
25. Lenert LA, Sakaguchi FH, Weir CR. Rethinking the discharge summary: a focus on handoff communication. Acad Med 2014;89:393–8.
26. Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients--development of a discharge checklist for hospitalists. J Hosp Med 2006;1:354–60.
27. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med 2007;2:314–23.
28. Huijberts S, Buurman BM, de Rooij SE. End-of-life care during and after an acute hospitalization in older patients with cancer, end-stage organ failure, or frailty: A sub-analysis of a prospective cohort study. Palliat Med 2016;30:75–82.
29. Butler J, Binney Z, Kalogeropoulos A, et al. Advance directives among hospitalized patients with heart failure. JACC Heart Fail 2015;3:112–21.
30. Oulton J, Rhodes SM, Howe C, et al. Advance directives for older adults in the emergency department: a systematic review. J Palliat Med 2015;18:500–5.
31. Shaikh U, Slee C. Triple duty: integrating graduate medical education with maintenance of board certification to improve clinician communication at hospital discharge. J Grad Med Educ 2015;7:462–5.
32. Weis JM, Levy PC. Copy, paste, and cloned notes in electronic health records: prevalence, benefits, risks, and best practice recommendations. Chest 2014;145:632–8.
33. Dixon DR. The behavioral side of information technology. Int J Med Inform 1999;56:117–23.
34. Hommos MS, Kuperman EF, Kamath A, Kreiter CD. The development and evaluation of a novel instrument assessing residents’ discharge summaries. Acad Med 2017;92:550–5.
Handoffs From ED to Inpatient Care
Handoffs are the exchange of information between health professionals that accompany the transfer of patient‐care responsibility.[1] Poor handoff practices are associated with unsafe and inefficient care.[2, 3, 4] Teaching hospitals are especially at risk, as resident work‐hour restrictions have increased the number of handoffs.[5] Accreditation agencies now require that hospitals and residency programs have structured handoff processes[6, 7] and that medical students[8] and residents[9, 10, 11, 12] demonstrate competency in handoffs.
Physician handoff research has primarily focused on handoffs within a service or discipline. These within‐unit handoffs should be differentiated from interunit handoffs.[13, 14] Interunit handoffs, such as the transition from the emergency department (ED) to inpatient setting, are subject to unique challenges. The ED admission process involves changes in personnel, provider specialty, and location.[15] The transition occurs when the patient's clinical trajectory is uncertain, treatments are being initiated, and test results are pending. Other barriers include interdisciplinary cultural differences, interphysician conflict, unstructured communication, environmental factors, and complex care coordination.[13, 14, 15, 16, 17, 18] Despite these challenges, there is relatively little research specifically examining ED to inpatient handoffs, and most of what is available has focused on individual services within an institution.[13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25]
As part of an institutional effort to improve our ED admission handoff practices, we conducted a cross‐sectional, survey‐based needs‐assessment involving emergency medicine (EM) and 5 inpatient medical services. The objective of this study was to determine physicians' perceptions of the ED admission handoff process and to identify potential barriers to safe patient care.
METHODS
Survey Design
A study group comprised of resident and faculty physicians in internal medicine (IM) and EM, as well as a healthcare communication expert, designed analogous cross‐sectional surveys to determine the perceptions of admitting (see Supporting Information, Appendix 1, in the online version of this article) and EM (see Supporting Information, Appendix 2, in the online version of this article) physicians toward the admission handoff process. Using an iterative process to ensure content validity, we created questions in 6 domains based on the expert opinion of the authors and emergent themes identified in the literature.[15, 19, 22, 24] These themes were general communication quality, clinical information, interpersonal perceptions, responsibilities, organizational factors, and patient safety. We asked respondents to report their answers using 5‐point Likert and Likert‐like scales. Questions regarding frequency were assigned semiquantitative values: rarely=0% to 24%, sometimes=25% to 49%, often=50% to 74%, very often 75% to 99%, and always=100%. We also asked an open‐ended question, asking respondents to describe any handoff‐related adverse events (defined as patient harm or near miss) they encountered in the past 3 months. We pilot tested the survey for clarity and relevance prior to distribution on a group of 5 physicians from the participating services. The institutional internal review board approved the protocol (#046‐13‐EX).
Setting, Participants, and Recruitment
We conducted the study at a 627‐bed tertiary care academic medical center. Eligible participants included all resident, fellow, and faculty physicians directly involved in admission handoffs from EM and 5 medical inpatient services (university‐based IM, university‐based family medicine [FM], community‐based FM, cardiology, and critical care medicine). The admitting services accounted for two‐thirds of the institution's 10,000 annual adult, nonobstetric ED admissions. Physicians who had not participated in admission handoffs in the past 3 months were excluded.
At the time of the study, there was no standardized institutional process for admission handoff communication, nor was there policy delineating when patient‐care responsibility transferred from the EM to admitting physician. The admission handoff process generally relied on verbal handoff via telephone between EM and admitting physicians. All services used the same electronic health record, but there was no written handoff note, and EM physician documentation generally was not available at the time of handoff. To determine patient assignment schemes following admission handoff, we questioned leadership from the participating admitting services.
We distributed and collected anonymous hard‐copy surveys at educational conferences in March 2013. We emailed a link to an online survey to eligible participants who could not be reached in person. Subjects voluntarily participated and provided consent via cover letter.
Data Analysis
We compiled survey data and performed descriptive analysis. We assessed the internal consistency of the survey domains that were made up of at least 3 questions using Cronbach's . To compare the distribution of aggregate admitting service responses to EM responses, we used the Mann‐Whitney test. We used the Fisher exact test to examine the associations of dichotomized responses (<50% vs 50%) to the level of training (intern vs resident vs fellow/faculty) and to the admitting service affiliation (university‐based IM vs university‐based FM vs aggregate of other services). When indicated, we made pairwise comparisons using the Bonferroni method to compute adjusted P values. We analyzed data independently using both SPSS version 20 (IBM Corp., Armonk, NY) and SAS version 9.3 (SAS Inc., Cary, NC) software and considered a P value <0.05 to be significant. Three researchers independently categorized descriptions of adverse events based on a previously published qualitative analysis,[15] with disagreements settled by consensus.
RESULTS
After applying exclusion criteria, the survey response rate was 63% for admitting physicians (94/150) and 86% for EM physicians (32/37). Participants' service affiliation and level of training are shown in the Table 1. Table 2 provides the distribution of survey responses for EM and admitting physicians.
| Service Affiliation | Level of Training | Total | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| PGY1 | PGY2 | PGY3 | Fellow | Staff | |||||||
| No. | % | No. | % | No. | % | No. | % | No. | % | No. | |
| |||||||||||
| Admitting services | |||||||||||
| University‐based IM | 12 | 32.4 | 7 | 18.9 | 5 | 13.5 | 1 | 2.7 | 12 | 32.4 | 37 |
| University‐based FM | 15 | 44.1 | 13 | 38.2 | 5 | 14.7 | 1 | 2.9 | 0 | 0 | 34 |
| Community‐based FM | 5 | 50.0 | 1 | 10.0 | 3 | 30.0 | 0 | 0 | 1 | 10.0 | 10 |
| Critical care medicine | 0 | 0 | 0 | 0 | 0 | 0 | 6 | 100.0 | 0 | 0 | 6 |
| Cardiology | 0 | 0 | 0 | 0 | 0 | 0 | 7 | 100.0 | 0 | 0 | 7 |
| Admitting services total | 32 | 34.0 | 21 | 22.3 | 13 | 13.8 | 15 | 16.0 | 13 | 13.8 | 94 |
| Emergency medicine | 6 | 18.8 | 8 | 25.0 | 5 | 15.6 | 0 | 0 | 13 | 40.6 | 32 |
| Question | Service | Very Poor | Poor | Fair | Good | Very Good | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| No. | % | No. | % | No. | % | No. | % | No. | % | ||
| Rarely (0%24%) | Sometimes (25%49%) | Often (50%74%) | Very Often (75%99%) | Always (100%) | |||||||
| |||||||||||
| Generally, the quality of communication between EM and admitting physicians is: | Admitting | 0 | 0 | 8 | 8.6% | 37 | 39.7% | 46 | 49.4% | 2 | 2.1% |
| EM | 0 | 0 | 2 | 6.2% | 4 | 12.5% | 20 | 62.5% | 6 | 18.7% | |
| The current handoff system's ability to ensure patient safety is generally: | Admitting | 1 | 1.0% | 10 | 10.7% | 43 | 46.2% | 37 | 39.7% | 2 | 2.1% |
| EM | 1 | 3.1% | 1 | 3.1% | 11 | 34.3% | 15 | 46.8% | 4 | 12.5% | |
| The current handoff system's ability to ensure efficient patient care is generally: | Admitting | 3 | 3.2% | 20 | 21.7% | 31 | 33.6% | 36 | 39.1% | 2 | 2.1% |
| EM | 2 | 6.2% | 5 | 15.6% | 15 | 46.8% | 10 | 31.2% | 0 | ||
| During handoff, how often does the EM physician provide the following information to the admitting service? | |||||||||||
| The working diagnosis of the EM physician | Admitting | 5 | 5.4% | 19 | 20.6% | 30 | 32.6% | 30 | 32.6% | 8 | 8.6% |
| EM | 0 | 4 | 12.5% | 0 | 12 | 37.5% | 16 | 50.0% | |||
| Relevant past medical/surgical history | Admitting | 5 | 5.4% | 25 | 27.1% | 40 | 43.4% | 18 | 19.5% | 4 | 4.3% |
| EM | 1 | 3.1% | 2 | 6.2% | 5 | 15.6% | 17 | 53.1% | 7 | 21.8% | |
| Relevant physical exam findings (including abnormal vital signs) | Admitting | 3 | 3.2% | 25 | 27.1% | 41 | 44.5% | 21 | 22.8% | 2 | 2.1% |
| EM | 0 | 5 | 15.6% | 2 | 6.2% | 15 | 46.8% | 10 | 31.2% | ||
| Results of relevant diagnostic studies (labs, imaging) | Admitting | 2 | 2.1% | 10 | 10.8% | 39 | 42.3% | 37 | 40.2% | 4 | 4.3% |
| EM | 1 | 3.1% | 0 | 3 | 9.3% | 14 | 43.7% | 14 | 43.7% | ||
| Procedures and therapeutic interventions initiated while in the ED | Admitting | 3 | 3.2% | 20 | 21.7% | 34 | 36.9% | 29 | 31.5% | 6 | 6.5% |
| EM | 1 | 3.1% | 0 | 3 | 9.3% | 18 | 56.2% | 10 | 31.2% | ||
| Trend in the patient's clinical condition while in the ED | Admitting | 12 | 13.1% | 27 | 29.6% | 33 | 36.2% | 17 | 18.6% | 2 | 2.1% |
| EM | 4 | 12.5% | 1 | 3.1% | 5 | 15.6% | 13 | 40.6% | 9 | 28.1% | |
| Current clinical condition of the patient (at time of handoff) | Admitting | 3 | 3.2% | 24 | 26.0% | 41 | 44.5% | 18 | 19.5% | 6 | 6.5% |
| EM | 1 | 3.1% | 1 | 3.1% | 3 | 9.3% | 13 | 40.6% | 14 | 43.7% | |
| Pending diagnostic studies (labs, imaging), if ordered | Admitting | 12 | 13.0% | 32 | 34.7% | 29 | 31.5% | 17 | 18.4% | 2 | 2.1% |
| EM | 0 | 5 | 15.6% | 6 | 18.7% | 14 | 43.7% | 7 | 21.8% | ||
| During handoff, how often are clinical questions asked about the patient being admitted? | Admitting | 2 | 2.1% | 1 | 1.0% | 13 | 14.1% | 29 | 31.5% | 47 | 51.0% |
| EM | 0 | 0 | 5 | 15.6% | 8 | 25.0% | 13 | 40.6% | 6 | 18.7% | |
| In general, how often do you agree with the clinical decisions made by the EM physician? | Admitting | 1 | 1.0% | 26 | 27.9% | 56 | 60.2% | 10 | 10.7% | 0 | 0 |
| Generally, how often do you feel you have to defend your clinical decisions to the admitting service? | EM | 2 | 6.2% | 15 | 46.8% | 5 | 15.6% | 10 | 31.2% | 0 | 0 |
| How often do you have clinically meaningful face‐to‐face communication with the EM/admitting physician about the patient being admitted? | Admitting | 24 | 25.8% | 38 | 40.8% | 22 | 23.6% | 8 | 8.6% | 1 | 1.0% |
| EM | 14 | 43.7% | 13 | 40.6% | 4 | 12.5% | 1 | 3.1% | 0 | ||
| On average, how often do competing clinical responsibilities distract you during handoff? | Admitting | 6 | 6.5% | 34 | 36.9% | 29 | 31.5% | 20 | 21.7% | 3 | 3.2% |
| EM | 7 | 21.8% | 8 | 25.0% | 9 | 28.1% | 8 | 25.0% | 0 | 0 | |
| On average, how often do environmental factors distract you during handoff? | Admitting | 44 | 48.3% | 31 | 34.0% | 10 | 10.9% | 6 | 6.5% | 0 | 0 |
| EM | 7 | 21.8% | 11 | 34.3% | 8 | 25.0% | 4 | 12.5% | 2 | 6.2% | |
The processes for assigning responsibilities following the initial handoff differed between admitting services, and within a service the process was often dynamic. For example, within the university‐based IM and community‐based FM services, the assignment process varied depending on timing (day vs night, weekday vs weekend). For the critical care medicine and cardiology services, fellows accepted admission handoff calls, and depending on competing clinical responsibilities and the patient's stability, either evaluated the patient independently or sent a resident to perform a preliminary evaluation. We reviewed and classified these varied admission assignment strategies into 4 general schemes (Figure 1). All 5 admitting services relied partly or entirely on housestaff for receiving admission handoffs, as did the EM service.
Communication Quality and Content
Cronbach's was 0.72 for general handoff questions and 0.89 for clinical information questions. Compared with EM respondents, admitting physicians reported worse quality of communication (P < 0.001) and less confidence in the handoff system's ability to ensure patient safety (P=0.04). Admitting physicians reported communication of clinical information occurred less frequently than EM physicians for all 8 content areas (P < 0.001 for all). There were no significant differences in responses between various levels of training and service affiliations.
Interpersonal Perceptions
EM respondents reported admitting physicians asked clinical questions less frequently than did admitting respondents (P < 0.001). Ninety‐four percent of EM physicians (n=30) felt they had to defend their clinical decisions at least sometimes. EM interns (P=0.009) and faculty (P=0.01) were more likely than residents to report feeling defensive. Most admitting physicians (60%, n=56) often agreed with decisions made by the EM provider, but 29% (n=27) agreed less than half the time. One‐third of admitting (n=31) and 16% of EM physicians (n=5) reported routine (ie, >50% of admissions) meaningful face‐to‐face communication with one another at the time of admission.
Responsibilities
When asked who was primarily responsible for patients boarding in the ED, defined as nonemergent patient care that occurs after handoff, but before a patient is physically transferred from the ED, 37.6% (n=47) of respondents answered the admitting physician, 21.6% (n=27) answered the EM physician, 34.4% (n=43) answered both, and 6.4% (n=8) answered don't know. Responses were similar for EM and admitting physicians.
Organizational Factors
Fifty‐six percent of all respondents (n=69) reported they were distracted during handoffs by competing clinical duties 50% of the time. Environmental factors, such as noise, more commonly distracted EM physicians (P=0.001). Approximately 60% (n=56) of admitting physicians reported using a triage system to distribute admissions, with a resultant 57% (n=32) reporting sequential handoffs (ie, handoffs of handoffs) occurred at least sometimes. About 80% of EM physicians (n=23) reported that shift change led to sequential handoffs at least sometimes. Seventy‐eight percent (n=67) of physicians felt sequential handoffs had a negative impact on patient care.
Patient Safety
Thirty‐four percent of admitting (n=30) and 19% of EM physicians (n=6) reported a patient was harmed or suffered a near miss in the past 3 months because of an ineffective handoff, with 58% (n=21) reporting 2 examples. Twenty‐four respondents described 29 adverse events. Respondents described perceived mistakes in diagnosis (n=11), treatment (n=16), and disposition (n=12), with some examples falling into more than 1 category. Absent or ineffective communication contributed to 27 of 29 examples. Other commonly cited areas of vulnerability included uncertain assignment of responsibility, sequential handoffs, and patient boarding.
DISCUSSION
Based upon physician self‐reporting, we identified perceived barriers to safe ED admission handoff across several domains. This study adds to the literature, as it provides a cross‐section of multiple inpatient services with varying admission schemes to underscore the complexities facing hospitals in safely transitioning patients between units. As noted in previous studies, one‐third of physicians reported a handoff‐related adverse event,[15] and there was significant disagreement between handoff participants about communication of critical information.[21, 26] These differences in perceptions suggest a failure of physicians to accurately transfer information to create a shared understanding of patient care,[21] which is the central function of handoffs.
EM physicians frequently felt that admitting physicians did not trust their clinical decisions, a perception supported by the fact that over 25% of admitting respondents' usually disagreed with decisions in the ED. Interdisciplinary trust is central in negotiating a shared plan of care[13] and mitigating conflict to ensure a safe transition of patient care.[16] Handoffs are complex social interactions, and feelings of defensiveness and mistrust are likely exacerbated by in‐group/out‐group biases,[15] conflicting information expectations,[19] and discordant ways of interpreting and framing handoff interactions.[13] Interestingly, EM residents were less likely than interns or faculty to report feeling defensive. This may be in part because residents from EM and admitting services develop relationships during interdisciplinary rotations, which may help facilitate future handoff interactions.[27] The fact that EM respondents felt defensive, despite reporting less‐frequent questioning than admitting physicians, suggests that tone and content of questions played an important role. These findings support the importance of interdisciplinary education and standardization of handoff communication between ED and admitting physicians.[23] Beach and colleagues have recommended a conceptual framework for interunit handoffs between EM and hospital physicians, but further research is needed to measure its impact in real‐world settings.[14]
We also found great variability in admitting services' processes for assigning patient‐care responsibility following the initial handoff. Even within an individual service, these processes were often dynamic and relied on physicians at different levels of training. This has several potential consequences. First, it may be difficult for physicians engaged in a handoff to know the level of experience and expertise of one another. These contextual variables play an important role in how handoff information is conveyed, as less experienced clinicians may require explicit information that a more experienced provider may infer.[1, 21] Second, the variability in admission assignment processes may further exacerbate uncertainty regarding responsibility for patients boarding in the ED, making it increasingly difficult for nurses and ancillary staff to know which physician is ultimately responsible for patient care. Finally, the diversity of admission schemes may complicate the development of standardized interunit handoff protocols, policy, and education.
A related finding was that sequential handoffs were common within both EM and admitting services. EM shift handoffs have their own set of barriers,[28] which can lead to ineffective communication.[29] Likewise, about two‐thirds of admitting respondents reported using an admission triage system. The goal of such systems is to simplify complex call schedules and diverse patient assignment schemes within admitting services, thus streamlining the admission process. These systems may also allow for more consistency in the quality of handoff communication through the creation of triage specialists. These potential advantages need to be weighed against the increased risk of communication breakdown. The introduction of sequential handoffs creates a game of telephone, in which there is no direct communication between the first and final caregivers (Figure 1), allowing misinformation to be propagated forward.[30] Sequential handoffs contributed to several reported adverse events, and the majority of surveyed physicians felt they negatively impacted patient care. Further research is necessary to determine the impact of centralized triage systems and to explore strategies to mitigate information decay that results from sequential handoffs, as quality‐improvement interventions may be of limited benefit if downstream communication remains ineffective. Potential strategies may include standardizing sequential handoff communication, leveraging centralized handoff notes within electronic health records, or developing handoff systems that ensure direct communication between the EM physician and the ultimate admitting provider.
Limitations
This was a single‐institution study, so results may not be generalizable, as handoff processes vary among hospitals.[24] Our study relied on a novel survey instrument, for which validity and reliability are uncertain, although internal consistency was good for domains that could be tested (Cronbach's 0.720.89). As with other survey‐based studies, participant selection, hindsight, recall, and response biases may have influenced the results. We attempted to minimize these risks by pilot testing the survey, targeting a relatively large number of respondents across multiple services, and by making efforts to maximize the response rate by contacting eligible participants both in person and via email. Because results reflect self‐reported perceptions, we cannot prove that the factors studied are actually associated with adverse outcomes, nor can we quantify their relative importance. Nevertheless, the reported perceptions raise concerns that warrant further study.
FUTURE DIRECTIONS
Further research is needed to examine interventions that may improve clinically relevant outcomes. Development of structured admission handoff protocols should be collaborative[31] and focus on clinical judgment, rather than rote recitation of data.[14] Based on our study findings, we are pilot testing a standardized approach for ED‐to‐hospital handoffs, and portions of this survey will be repeated in the postintervention assessment.
At our institution, housestaff at all levels of training regularly participated in the handoff process. The Accreditation Council for Graduate Medical Education requires that residents demonstrate competence in performing handoffs,[7] yet handoff training and assessment are inconsistent,[23, 32, 33] and published interventions have focused primarily on within‐unit handoffs.[34, 35, 36] Additional training should focus on the unique aspects of interunit handoffs. Approaches could include interprofessional communication training, simulation training, and enhanced assessment methods. Additionally, increasing face‐to‐face communication, perhaps as part of bedside handoffs, could improve relationships and the development of a shared mental model of patient care. More direct involvement by attending physicians will also be important, as there is evidence that such oversight may improve training[36] and safety,[37] as more experienced physicians better integrate handoff information.[21]
CONCLUSION
We identified several perceived barriers to safe interunit handoff from the ED to the inpatient setting. Handoff‐related adverse events, a pattern of conflicting physician perceptions, and frequent sequential handoffs were of particular concern. Our findings support the need for collaborative efforts to improve interdisciplinary communication.
Disclosure
Nothing to report.
- , . Handoffs in hospitals: a review of the literature on information exchange while transferring patient responsibility or control. Available at: http://deepblue.lib.umich.edu/handle/2027.42/61498. Updated 2009. Accessed May 15, 2014.
- . Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34(10):563–570.
- . Consequences of inadequate sign‐out for patient care. Arch Intern Med. 2008;168(16):1755–1760.
- , . A systematic review of failures in handoff communication during intrahospital transfers. Jt Comm J Qual Patient Saf. 2011;37(6):274–284.
- , , , , . Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign‐out. J Hosp Med. 2006;1(4):257–266.
- , . A model for building a standardized hand‐off protocol. Jt Comm J Qual Patient Saf. 2006;32(11):646–655.
- Accreditation Council for Graduate Medical Education. ACGME common program requirements. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf. Updated 2013. Accessed May 7, 2014.
- Association of American Medical Colleges. Core entrustable professional activities for entering residency. Available at: https://members.aamc.org/eweb/upload/Core%20EPA%20Faculty%20and%20Learner%20Guide.pdf. Updated 2014. Accessed July 7, 2014.
- Accreditation Council for Graduate Medical Education and American Board of Internal Medicine. The internal medicine milestones. Available at: http://www.acgme.org/acgmeweb/portals/0/pdfs/milestones/internalmedicinemilestones.pdf. Updated 2012. Accessed December 23, 2013.
- Accreditation Council for Graduate Medical Education and American Board of Emergency Medicine. The emergency medicine milestones. Available at: https://www.abem.org/public/docs/default‐source/migrated‐documents‐and‐files/em‐milestones.pdf?sfvrsn=4. Updated 2012. Accessed December 23, 2013.
- Accreditation Council for Graduate Medical Education and American Board of Family Medicine. The family medicine milestone project. Available at: http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/FamilyMedicineMilestones.pdf. Updated 2013. Accessed October 31, 2014.
- Accreditation Council for Graduate Medical Education and American Board of Pediatrics. The pediatrics milestone project. Available at: http://acgme.org/acgmeweb/Portals/0/PDFs/Milestones/PediatricsMilestones.pdf. Updated 2013. Accessed October, 31, 2014.
- , . The unappreciated challenges of between‐unit handoffs: negotiating and coordinating across boundaries. Ann Emerg Med. 2013;61(2):155–160.
- , , , et al. Improving interunit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach. Acad Emerg Med. 2012;19(10):1188–1195.
- , , , , , . Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med. 2009;53(6):701–710.e4.
- , , , . Conflict prevention, conflict mitigation, and manifestations of conflict during emergency department consultations. Acad Emerg Med. 2014;21(3):308–313.
- , , , . I'm clear, you're clear, we're all clear: improving consultation communication skills in undergraduate medical education. Acad Med. 2013;88(6):753–758.
- , , , . Emergency physician to admitting physician handovers: an exploratory study. Proc Hum Factors Ergon Soc Annu Meet. 2002;46(16):1511–1515.
- , , . Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007;14(10):884–894.
- , . Chart biopsy: an emerging medical practice enabled by electronic health records and its impacts on emergency department‐inpatient admission handoffs. J Am Med Inform Assoc. 2013;20(2):260–267.
- , , , , . Admission handoff communications: clinician's shared understanding of patient severity of illness and problems. J Patient Saf. 2009;5(4):237–242.
- , , , et al. Exploring emergency physician‐hospitalist handoff interactions: development of the handoff communication assessment. Ann Emerg Med. 2010;55(2):161–170.
- , , , , , . Interunit handoffs of patients and transfers of information: a survey of current practices. Ann Emerg Med. 2014;64(4):343–349.e5.
- , , , et al. A conceptual framework for studying the safety of transitions in emergency care. In: Henriksen K, Battles JB, Marks ES, Lewin DI, eds. Advances in Patient Safety: From Research to Implementation. Vol. 2: Concepts and Methodology. Rockville, MD: Agency for Healthcare Research and Quality; 2005:309–321.
- , , , , , . Patient care transitions from the emergency department to the medicine ward: evaluation of a standardized electronic signout tool. Int J Qual Health Care. 2014;26(4):337–347.
- , , , , . Interns overestimate the effectiveness of their hand‐off communication. Pediatrics. 2010;125(3):491–496.
- , , , . Understanding the impact of residents' interpersonal relationships during emergency department referrals and consultations. J Grad Med Educ. 2013;5(4):576–581.
- , , , et al. Improving handoffs in the emergency department. Ann Emerg Med. 2010;55(2):171–180.
- , , . ED handoffs: observed practices and communication errors. Am J Emerg Med. 2011;29(5):502–511.
- , , , , . Characterizing information decay in patient handoffs. J Surg Educ. 2014;71(4):480–485.
- , , . Emergency medicine and hospital medicine: a call for collaboration. J Emerg Med. 2012;43(2):328–334.
- , , , et al. A survey of handoff practices in emergency medicine. Am J Med Qual. 2014;29(5):408–414.
- . Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166(11):1173–1177.
- , , , , , . Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program. J Gen Intern Med. 2013;28(8):986–993.
- , , , et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310(21):2262–2270.
- , , , et al. A structured handoff program for interns. Acad Med. 2009;84(3):347–352.
- , , , et al. Experience with faculty supervision of an electronic resident sign‐out system. Am J Med. 2010;123(4):376–381.
Handoffs are the exchange of information between health professionals that accompany the transfer of patient‐care responsibility.[1] Poor handoff practices are associated with unsafe and inefficient care.[2, 3, 4] Teaching hospitals are especially at risk, as resident work‐hour restrictions have increased the number of handoffs.[5] Accreditation agencies now require that hospitals and residency programs have structured handoff processes[6, 7] and that medical students[8] and residents[9, 10, 11, 12] demonstrate competency in handoffs.
Physician handoff research has primarily focused on handoffs within a service or discipline. These within‐unit handoffs should be differentiated from interunit handoffs.[13, 14] Interunit handoffs, such as the transition from the emergency department (ED) to inpatient setting, are subject to unique challenges. The ED admission process involves changes in personnel, provider specialty, and location.[15] The transition occurs when the patient's clinical trajectory is uncertain, treatments are being initiated, and test results are pending. Other barriers include interdisciplinary cultural differences, interphysician conflict, unstructured communication, environmental factors, and complex care coordination.[13, 14, 15, 16, 17, 18] Despite these challenges, there is relatively little research specifically examining ED to inpatient handoffs, and most of what is available has focused on individual services within an institution.[13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25]
As part of an institutional effort to improve our ED admission handoff practices, we conducted a cross‐sectional, survey‐based needs‐assessment involving emergency medicine (EM) and 5 inpatient medical services. The objective of this study was to determine physicians' perceptions of the ED admission handoff process and to identify potential barriers to safe patient care.
METHODS
Survey Design
A study group comprised of resident and faculty physicians in internal medicine (IM) and EM, as well as a healthcare communication expert, designed analogous cross‐sectional surveys to determine the perceptions of admitting (see Supporting Information, Appendix 1, in the online version of this article) and EM (see Supporting Information, Appendix 2, in the online version of this article) physicians toward the admission handoff process. Using an iterative process to ensure content validity, we created questions in 6 domains based on the expert opinion of the authors and emergent themes identified in the literature.[15, 19, 22, 24] These themes were general communication quality, clinical information, interpersonal perceptions, responsibilities, organizational factors, and patient safety. We asked respondents to report their answers using 5‐point Likert and Likert‐like scales. Questions regarding frequency were assigned semiquantitative values: rarely=0% to 24%, sometimes=25% to 49%, often=50% to 74%, very often 75% to 99%, and always=100%. We also asked an open‐ended question, asking respondents to describe any handoff‐related adverse events (defined as patient harm or near miss) they encountered in the past 3 months. We pilot tested the survey for clarity and relevance prior to distribution on a group of 5 physicians from the participating services. The institutional internal review board approved the protocol (#046‐13‐EX).
Setting, Participants, and Recruitment
We conducted the study at a 627‐bed tertiary care academic medical center. Eligible participants included all resident, fellow, and faculty physicians directly involved in admission handoffs from EM and 5 medical inpatient services (university‐based IM, university‐based family medicine [FM], community‐based FM, cardiology, and critical care medicine). The admitting services accounted for two‐thirds of the institution's 10,000 annual adult, nonobstetric ED admissions. Physicians who had not participated in admission handoffs in the past 3 months were excluded.
At the time of the study, there was no standardized institutional process for admission handoff communication, nor was there policy delineating when patient‐care responsibility transferred from the EM to admitting physician. The admission handoff process generally relied on verbal handoff via telephone between EM and admitting physicians. All services used the same electronic health record, but there was no written handoff note, and EM physician documentation generally was not available at the time of handoff. To determine patient assignment schemes following admission handoff, we questioned leadership from the participating admitting services.
We distributed and collected anonymous hard‐copy surveys at educational conferences in March 2013. We emailed a link to an online survey to eligible participants who could not be reached in person. Subjects voluntarily participated and provided consent via cover letter.
Data Analysis
We compiled survey data and performed descriptive analysis. We assessed the internal consistency of the survey domains that were made up of at least 3 questions using Cronbach's . To compare the distribution of aggregate admitting service responses to EM responses, we used the Mann‐Whitney test. We used the Fisher exact test to examine the associations of dichotomized responses (<50% vs 50%) to the level of training (intern vs resident vs fellow/faculty) and to the admitting service affiliation (university‐based IM vs university‐based FM vs aggregate of other services). When indicated, we made pairwise comparisons using the Bonferroni method to compute adjusted P values. We analyzed data independently using both SPSS version 20 (IBM Corp., Armonk, NY) and SAS version 9.3 (SAS Inc., Cary, NC) software and considered a P value <0.05 to be significant. Three researchers independently categorized descriptions of adverse events based on a previously published qualitative analysis,[15] with disagreements settled by consensus.
RESULTS
After applying exclusion criteria, the survey response rate was 63% for admitting physicians (94/150) and 86% for EM physicians (32/37). Participants' service affiliation and level of training are shown in the Table 1. Table 2 provides the distribution of survey responses for EM and admitting physicians.
| Service Affiliation | Level of Training | Total | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| PGY1 | PGY2 | PGY3 | Fellow | Staff | |||||||
| No. | % | No. | % | No. | % | No. | % | No. | % | No. | |
| |||||||||||
| Admitting services | |||||||||||
| University‐based IM | 12 | 32.4 | 7 | 18.9 | 5 | 13.5 | 1 | 2.7 | 12 | 32.4 | 37 |
| University‐based FM | 15 | 44.1 | 13 | 38.2 | 5 | 14.7 | 1 | 2.9 | 0 | 0 | 34 |
| Community‐based FM | 5 | 50.0 | 1 | 10.0 | 3 | 30.0 | 0 | 0 | 1 | 10.0 | 10 |
| Critical care medicine | 0 | 0 | 0 | 0 | 0 | 0 | 6 | 100.0 | 0 | 0 | 6 |
| Cardiology | 0 | 0 | 0 | 0 | 0 | 0 | 7 | 100.0 | 0 | 0 | 7 |
| Admitting services total | 32 | 34.0 | 21 | 22.3 | 13 | 13.8 | 15 | 16.0 | 13 | 13.8 | 94 |
| Emergency medicine | 6 | 18.8 | 8 | 25.0 | 5 | 15.6 | 0 | 0 | 13 | 40.6 | 32 |
| Question | Service | Very Poor | Poor | Fair | Good | Very Good | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| No. | % | No. | % | No. | % | No. | % | No. | % | ||
| Rarely (0%24%) | Sometimes (25%49%) | Often (50%74%) | Very Often (75%99%) | Always (100%) | |||||||
| |||||||||||
| Generally, the quality of communication between EM and admitting physicians is: | Admitting | 0 | 0 | 8 | 8.6% | 37 | 39.7% | 46 | 49.4% | 2 | 2.1% |
| EM | 0 | 0 | 2 | 6.2% | 4 | 12.5% | 20 | 62.5% | 6 | 18.7% | |
| The current handoff system's ability to ensure patient safety is generally: | Admitting | 1 | 1.0% | 10 | 10.7% | 43 | 46.2% | 37 | 39.7% | 2 | 2.1% |
| EM | 1 | 3.1% | 1 | 3.1% | 11 | 34.3% | 15 | 46.8% | 4 | 12.5% | |
| The current handoff system's ability to ensure efficient patient care is generally: | Admitting | 3 | 3.2% | 20 | 21.7% | 31 | 33.6% | 36 | 39.1% | 2 | 2.1% |
| EM | 2 | 6.2% | 5 | 15.6% | 15 | 46.8% | 10 | 31.2% | 0 | ||
| During handoff, how often does the EM physician provide the following information to the admitting service? | |||||||||||
| The working diagnosis of the EM physician | Admitting | 5 | 5.4% | 19 | 20.6% | 30 | 32.6% | 30 | 32.6% | 8 | 8.6% |
| EM | 0 | 4 | 12.5% | 0 | 12 | 37.5% | 16 | 50.0% | |||
| Relevant past medical/surgical history | Admitting | 5 | 5.4% | 25 | 27.1% | 40 | 43.4% | 18 | 19.5% | 4 | 4.3% |
| EM | 1 | 3.1% | 2 | 6.2% | 5 | 15.6% | 17 | 53.1% | 7 | 21.8% | |
| Relevant physical exam findings (including abnormal vital signs) | Admitting | 3 | 3.2% | 25 | 27.1% | 41 | 44.5% | 21 | 22.8% | 2 | 2.1% |
| EM | 0 | 5 | 15.6% | 2 | 6.2% | 15 | 46.8% | 10 | 31.2% | ||
| Results of relevant diagnostic studies (labs, imaging) | Admitting | 2 | 2.1% | 10 | 10.8% | 39 | 42.3% | 37 | 40.2% | 4 | 4.3% |
| EM | 1 | 3.1% | 0 | 3 | 9.3% | 14 | 43.7% | 14 | 43.7% | ||
| Procedures and therapeutic interventions initiated while in the ED | Admitting | 3 | 3.2% | 20 | 21.7% | 34 | 36.9% | 29 | 31.5% | 6 | 6.5% |
| EM | 1 | 3.1% | 0 | 3 | 9.3% | 18 | 56.2% | 10 | 31.2% | ||
| Trend in the patient's clinical condition while in the ED | Admitting | 12 | 13.1% | 27 | 29.6% | 33 | 36.2% | 17 | 18.6% | 2 | 2.1% |
| EM | 4 | 12.5% | 1 | 3.1% | 5 | 15.6% | 13 | 40.6% | 9 | 28.1% | |
| Current clinical condition of the patient (at time of handoff) | Admitting | 3 | 3.2% | 24 | 26.0% | 41 | 44.5% | 18 | 19.5% | 6 | 6.5% |
| EM | 1 | 3.1% | 1 | 3.1% | 3 | 9.3% | 13 | 40.6% | 14 | 43.7% | |
| Pending diagnostic studies (labs, imaging), if ordered | Admitting | 12 | 13.0% | 32 | 34.7% | 29 | 31.5% | 17 | 18.4% | 2 | 2.1% |
| EM | 0 | 5 | 15.6% | 6 | 18.7% | 14 | 43.7% | 7 | 21.8% | ||
| During handoff, how often are clinical questions asked about the patient being admitted? | Admitting | 2 | 2.1% | 1 | 1.0% | 13 | 14.1% | 29 | 31.5% | 47 | 51.0% |
| EM | 0 | 0 | 5 | 15.6% | 8 | 25.0% | 13 | 40.6% | 6 | 18.7% | |
| In general, how often do you agree with the clinical decisions made by the EM physician? | Admitting | 1 | 1.0% | 26 | 27.9% | 56 | 60.2% | 10 | 10.7% | 0 | 0 |
| Generally, how often do you feel you have to defend your clinical decisions to the admitting service? | EM | 2 | 6.2% | 15 | 46.8% | 5 | 15.6% | 10 | 31.2% | 0 | 0 |
| How often do you have clinically meaningful face‐to‐face communication with the EM/admitting physician about the patient being admitted? | Admitting | 24 | 25.8% | 38 | 40.8% | 22 | 23.6% | 8 | 8.6% | 1 | 1.0% |
| EM | 14 | 43.7% | 13 | 40.6% | 4 | 12.5% | 1 | 3.1% | 0 | ||
| On average, how often do competing clinical responsibilities distract you during handoff? | Admitting | 6 | 6.5% | 34 | 36.9% | 29 | 31.5% | 20 | 21.7% | 3 | 3.2% |
| EM | 7 | 21.8% | 8 | 25.0% | 9 | 28.1% | 8 | 25.0% | 0 | 0 | |
| On average, how often do environmental factors distract you during handoff? | Admitting | 44 | 48.3% | 31 | 34.0% | 10 | 10.9% | 6 | 6.5% | 0 | 0 |
| EM | 7 | 21.8% | 11 | 34.3% | 8 | 25.0% | 4 | 12.5% | 2 | 6.2% | |
The processes for assigning responsibilities following the initial handoff differed between admitting services, and within a service the process was often dynamic. For example, within the university‐based IM and community‐based FM services, the assignment process varied depending on timing (day vs night, weekday vs weekend). For the critical care medicine and cardiology services, fellows accepted admission handoff calls, and depending on competing clinical responsibilities and the patient's stability, either evaluated the patient independently or sent a resident to perform a preliminary evaluation. We reviewed and classified these varied admission assignment strategies into 4 general schemes (Figure 1). All 5 admitting services relied partly or entirely on housestaff for receiving admission handoffs, as did the EM service.
Communication Quality and Content
Cronbach's was 0.72 for general handoff questions and 0.89 for clinical information questions. Compared with EM respondents, admitting physicians reported worse quality of communication (P < 0.001) and less confidence in the handoff system's ability to ensure patient safety (P=0.04). Admitting physicians reported communication of clinical information occurred less frequently than EM physicians for all 8 content areas (P < 0.001 for all). There were no significant differences in responses between various levels of training and service affiliations.
Interpersonal Perceptions
EM respondents reported admitting physicians asked clinical questions less frequently than did admitting respondents (P < 0.001). Ninety‐four percent of EM physicians (n=30) felt they had to defend their clinical decisions at least sometimes. EM interns (P=0.009) and faculty (P=0.01) were more likely than residents to report feeling defensive. Most admitting physicians (60%, n=56) often agreed with decisions made by the EM provider, but 29% (n=27) agreed less than half the time. One‐third of admitting (n=31) and 16% of EM physicians (n=5) reported routine (ie, >50% of admissions) meaningful face‐to‐face communication with one another at the time of admission.
Responsibilities
When asked who was primarily responsible for patients boarding in the ED, defined as nonemergent patient care that occurs after handoff, but before a patient is physically transferred from the ED, 37.6% (n=47) of respondents answered the admitting physician, 21.6% (n=27) answered the EM physician, 34.4% (n=43) answered both, and 6.4% (n=8) answered don't know. Responses were similar for EM and admitting physicians.
Organizational Factors
Fifty‐six percent of all respondents (n=69) reported they were distracted during handoffs by competing clinical duties 50% of the time. Environmental factors, such as noise, more commonly distracted EM physicians (P=0.001). Approximately 60% (n=56) of admitting physicians reported using a triage system to distribute admissions, with a resultant 57% (n=32) reporting sequential handoffs (ie, handoffs of handoffs) occurred at least sometimes. About 80% of EM physicians (n=23) reported that shift change led to sequential handoffs at least sometimes. Seventy‐eight percent (n=67) of physicians felt sequential handoffs had a negative impact on patient care.
Patient Safety
Thirty‐four percent of admitting (n=30) and 19% of EM physicians (n=6) reported a patient was harmed or suffered a near miss in the past 3 months because of an ineffective handoff, with 58% (n=21) reporting 2 examples. Twenty‐four respondents described 29 adverse events. Respondents described perceived mistakes in diagnosis (n=11), treatment (n=16), and disposition (n=12), with some examples falling into more than 1 category. Absent or ineffective communication contributed to 27 of 29 examples. Other commonly cited areas of vulnerability included uncertain assignment of responsibility, sequential handoffs, and patient boarding.
DISCUSSION
Based upon physician self‐reporting, we identified perceived barriers to safe ED admission handoff across several domains. This study adds to the literature, as it provides a cross‐section of multiple inpatient services with varying admission schemes to underscore the complexities facing hospitals in safely transitioning patients between units. As noted in previous studies, one‐third of physicians reported a handoff‐related adverse event,[15] and there was significant disagreement between handoff participants about communication of critical information.[21, 26] These differences in perceptions suggest a failure of physicians to accurately transfer information to create a shared understanding of patient care,[21] which is the central function of handoffs.
EM physicians frequently felt that admitting physicians did not trust their clinical decisions, a perception supported by the fact that over 25% of admitting respondents' usually disagreed with decisions in the ED. Interdisciplinary trust is central in negotiating a shared plan of care[13] and mitigating conflict to ensure a safe transition of patient care.[16] Handoffs are complex social interactions, and feelings of defensiveness and mistrust are likely exacerbated by in‐group/out‐group biases,[15] conflicting information expectations,[19] and discordant ways of interpreting and framing handoff interactions.[13] Interestingly, EM residents were less likely than interns or faculty to report feeling defensive. This may be in part because residents from EM and admitting services develop relationships during interdisciplinary rotations, which may help facilitate future handoff interactions.[27] The fact that EM respondents felt defensive, despite reporting less‐frequent questioning than admitting physicians, suggests that tone and content of questions played an important role. These findings support the importance of interdisciplinary education and standardization of handoff communication between ED and admitting physicians.[23] Beach and colleagues have recommended a conceptual framework for interunit handoffs between EM and hospital physicians, but further research is needed to measure its impact in real‐world settings.[14]
We also found great variability in admitting services' processes for assigning patient‐care responsibility following the initial handoff. Even within an individual service, these processes were often dynamic and relied on physicians at different levels of training. This has several potential consequences. First, it may be difficult for physicians engaged in a handoff to know the level of experience and expertise of one another. These contextual variables play an important role in how handoff information is conveyed, as less experienced clinicians may require explicit information that a more experienced provider may infer.[1, 21] Second, the variability in admission assignment processes may further exacerbate uncertainty regarding responsibility for patients boarding in the ED, making it increasingly difficult for nurses and ancillary staff to know which physician is ultimately responsible for patient care. Finally, the diversity of admission schemes may complicate the development of standardized interunit handoff protocols, policy, and education.
A related finding was that sequential handoffs were common within both EM and admitting services. EM shift handoffs have their own set of barriers,[28] which can lead to ineffective communication.[29] Likewise, about two‐thirds of admitting respondents reported using an admission triage system. The goal of such systems is to simplify complex call schedules and diverse patient assignment schemes within admitting services, thus streamlining the admission process. These systems may also allow for more consistency in the quality of handoff communication through the creation of triage specialists. These potential advantages need to be weighed against the increased risk of communication breakdown. The introduction of sequential handoffs creates a game of telephone, in which there is no direct communication between the first and final caregivers (Figure 1), allowing misinformation to be propagated forward.[30] Sequential handoffs contributed to several reported adverse events, and the majority of surveyed physicians felt they negatively impacted patient care. Further research is necessary to determine the impact of centralized triage systems and to explore strategies to mitigate information decay that results from sequential handoffs, as quality‐improvement interventions may be of limited benefit if downstream communication remains ineffective. Potential strategies may include standardizing sequential handoff communication, leveraging centralized handoff notes within electronic health records, or developing handoff systems that ensure direct communication between the EM physician and the ultimate admitting provider.
Limitations
This was a single‐institution study, so results may not be generalizable, as handoff processes vary among hospitals.[24] Our study relied on a novel survey instrument, for which validity and reliability are uncertain, although internal consistency was good for domains that could be tested (Cronbach's 0.720.89). As with other survey‐based studies, participant selection, hindsight, recall, and response biases may have influenced the results. We attempted to minimize these risks by pilot testing the survey, targeting a relatively large number of respondents across multiple services, and by making efforts to maximize the response rate by contacting eligible participants both in person and via email. Because results reflect self‐reported perceptions, we cannot prove that the factors studied are actually associated with adverse outcomes, nor can we quantify their relative importance. Nevertheless, the reported perceptions raise concerns that warrant further study.
FUTURE DIRECTIONS
Further research is needed to examine interventions that may improve clinically relevant outcomes. Development of structured admission handoff protocols should be collaborative[31] and focus on clinical judgment, rather than rote recitation of data.[14] Based on our study findings, we are pilot testing a standardized approach for ED‐to‐hospital handoffs, and portions of this survey will be repeated in the postintervention assessment.
At our institution, housestaff at all levels of training regularly participated in the handoff process. The Accreditation Council for Graduate Medical Education requires that residents demonstrate competence in performing handoffs,[7] yet handoff training and assessment are inconsistent,[23, 32, 33] and published interventions have focused primarily on within‐unit handoffs.[34, 35, 36] Additional training should focus on the unique aspects of interunit handoffs. Approaches could include interprofessional communication training, simulation training, and enhanced assessment methods. Additionally, increasing face‐to‐face communication, perhaps as part of bedside handoffs, could improve relationships and the development of a shared mental model of patient care. More direct involvement by attending physicians will also be important, as there is evidence that such oversight may improve training[36] and safety,[37] as more experienced physicians better integrate handoff information.[21]
CONCLUSION
We identified several perceived barriers to safe interunit handoff from the ED to the inpatient setting. Handoff‐related adverse events, a pattern of conflicting physician perceptions, and frequent sequential handoffs were of particular concern. Our findings support the need for collaborative efforts to improve interdisciplinary communication.
Disclosure
Nothing to report.
Handoffs are the exchange of information between health professionals that accompany the transfer of patient‐care responsibility.[1] Poor handoff practices are associated with unsafe and inefficient care.[2, 3, 4] Teaching hospitals are especially at risk, as resident work‐hour restrictions have increased the number of handoffs.[5] Accreditation agencies now require that hospitals and residency programs have structured handoff processes[6, 7] and that medical students[8] and residents[9, 10, 11, 12] demonstrate competency in handoffs.
Physician handoff research has primarily focused on handoffs within a service or discipline. These within‐unit handoffs should be differentiated from interunit handoffs.[13, 14] Interunit handoffs, such as the transition from the emergency department (ED) to inpatient setting, are subject to unique challenges. The ED admission process involves changes in personnel, provider specialty, and location.[15] The transition occurs when the patient's clinical trajectory is uncertain, treatments are being initiated, and test results are pending. Other barriers include interdisciplinary cultural differences, interphysician conflict, unstructured communication, environmental factors, and complex care coordination.[13, 14, 15, 16, 17, 18] Despite these challenges, there is relatively little research specifically examining ED to inpatient handoffs, and most of what is available has focused on individual services within an institution.[13, 14, 15, 18, 19, 20, 21, 22, 23, 24, 25]
As part of an institutional effort to improve our ED admission handoff practices, we conducted a cross‐sectional, survey‐based needs‐assessment involving emergency medicine (EM) and 5 inpatient medical services. The objective of this study was to determine physicians' perceptions of the ED admission handoff process and to identify potential barriers to safe patient care.
METHODS
Survey Design
A study group comprised of resident and faculty physicians in internal medicine (IM) and EM, as well as a healthcare communication expert, designed analogous cross‐sectional surveys to determine the perceptions of admitting (see Supporting Information, Appendix 1, in the online version of this article) and EM (see Supporting Information, Appendix 2, in the online version of this article) physicians toward the admission handoff process. Using an iterative process to ensure content validity, we created questions in 6 domains based on the expert opinion of the authors and emergent themes identified in the literature.[15, 19, 22, 24] These themes were general communication quality, clinical information, interpersonal perceptions, responsibilities, organizational factors, and patient safety. We asked respondents to report their answers using 5‐point Likert and Likert‐like scales. Questions regarding frequency were assigned semiquantitative values: rarely=0% to 24%, sometimes=25% to 49%, often=50% to 74%, very often 75% to 99%, and always=100%. We also asked an open‐ended question, asking respondents to describe any handoff‐related adverse events (defined as patient harm or near miss) they encountered in the past 3 months. We pilot tested the survey for clarity and relevance prior to distribution on a group of 5 physicians from the participating services. The institutional internal review board approved the protocol (#046‐13‐EX).
Setting, Participants, and Recruitment
We conducted the study at a 627‐bed tertiary care academic medical center. Eligible participants included all resident, fellow, and faculty physicians directly involved in admission handoffs from EM and 5 medical inpatient services (university‐based IM, university‐based family medicine [FM], community‐based FM, cardiology, and critical care medicine). The admitting services accounted for two‐thirds of the institution's 10,000 annual adult, nonobstetric ED admissions. Physicians who had not participated in admission handoffs in the past 3 months were excluded.
At the time of the study, there was no standardized institutional process for admission handoff communication, nor was there policy delineating when patient‐care responsibility transferred from the EM to admitting physician. The admission handoff process generally relied on verbal handoff via telephone between EM and admitting physicians. All services used the same electronic health record, but there was no written handoff note, and EM physician documentation generally was not available at the time of handoff. To determine patient assignment schemes following admission handoff, we questioned leadership from the participating admitting services.
We distributed and collected anonymous hard‐copy surveys at educational conferences in March 2013. We emailed a link to an online survey to eligible participants who could not be reached in person. Subjects voluntarily participated and provided consent via cover letter.
Data Analysis
We compiled survey data and performed descriptive analysis. We assessed the internal consistency of the survey domains that were made up of at least 3 questions using Cronbach's . To compare the distribution of aggregate admitting service responses to EM responses, we used the Mann‐Whitney test. We used the Fisher exact test to examine the associations of dichotomized responses (<50% vs 50%) to the level of training (intern vs resident vs fellow/faculty) and to the admitting service affiliation (university‐based IM vs university‐based FM vs aggregate of other services). When indicated, we made pairwise comparisons using the Bonferroni method to compute adjusted P values. We analyzed data independently using both SPSS version 20 (IBM Corp., Armonk, NY) and SAS version 9.3 (SAS Inc., Cary, NC) software and considered a P value <0.05 to be significant. Three researchers independently categorized descriptions of adverse events based on a previously published qualitative analysis,[15] with disagreements settled by consensus.
RESULTS
After applying exclusion criteria, the survey response rate was 63% for admitting physicians (94/150) and 86% for EM physicians (32/37). Participants' service affiliation and level of training are shown in the Table 1. Table 2 provides the distribution of survey responses for EM and admitting physicians.
| Service Affiliation | Level of Training | Total | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| PGY1 | PGY2 | PGY3 | Fellow | Staff | |||||||
| No. | % | No. | % | No. | % | No. | % | No. | % | No. | |
| |||||||||||
| Admitting services | |||||||||||
| University‐based IM | 12 | 32.4 | 7 | 18.9 | 5 | 13.5 | 1 | 2.7 | 12 | 32.4 | 37 |
| University‐based FM | 15 | 44.1 | 13 | 38.2 | 5 | 14.7 | 1 | 2.9 | 0 | 0 | 34 |
| Community‐based FM | 5 | 50.0 | 1 | 10.0 | 3 | 30.0 | 0 | 0 | 1 | 10.0 | 10 |
| Critical care medicine | 0 | 0 | 0 | 0 | 0 | 0 | 6 | 100.0 | 0 | 0 | 6 |
| Cardiology | 0 | 0 | 0 | 0 | 0 | 0 | 7 | 100.0 | 0 | 0 | 7 |
| Admitting services total | 32 | 34.0 | 21 | 22.3 | 13 | 13.8 | 15 | 16.0 | 13 | 13.8 | 94 |
| Emergency medicine | 6 | 18.8 | 8 | 25.0 | 5 | 15.6 | 0 | 0 | 13 | 40.6 | 32 |
| Question | Service | Very Poor | Poor | Fair | Good | Very Good | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| No. | % | No. | % | No. | % | No. | % | No. | % | ||
| Rarely (0%24%) | Sometimes (25%49%) | Often (50%74%) | Very Often (75%99%) | Always (100%) | |||||||
| |||||||||||
| Generally, the quality of communication between EM and admitting physicians is: | Admitting | 0 | 0 | 8 | 8.6% | 37 | 39.7% | 46 | 49.4% | 2 | 2.1% |
| EM | 0 | 0 | 2 | 6.2% | 4 | 12.5% | 20 | 62.5% | 6 | 18.7% | |
| The current handoff system's ability to ensure patient safety is generally: | Admitting | 1 | 1.0% | 10 | 10.7% | 43 | 46.2% | 37 | 39.7% | 2 | 2.1% |
| EM | 1 | 3.1% | 1 | 3.1% | 11 | 34.3% | 15 | 46.8% | 4 | 12.5% | |
| The current handoff system's ability to ensure efficient patient care is generally: | Admitting | 3 | 3.2% | 20 | 21.7% | 31 | 33.6% | 36 | 39.1% | 2 | 2.1% |
| EM | 2 | 6.2% | 5 | 15.6% | 15 | 46.8% | 10 | 31.2% | 0 | ||
| During handoff, how often does the EM physician provide the following information to the admitting service? | |||||||||||
| The working diagnosis of the EM physician | Admitting | 5 | 5.4% | 19 | 20.6% | 30 | 32.6% | 30 | 32.6% | 8 | 8.6% |
| EM | 0 | 4 | 12.5% | 0 | 12 | 37.5% | 16 | 50.0% | |||
| Relevant past medical/surgical history | Admitting | 5 | 5.4% | 25 | 27.1% | 40 | 43.4% | 18 | 19.5% | 4 | 4.3% |
| EM | 1 | 3.1% | 2 | 6.2% | 5 | 15.6% | 17 | 53.1% | 7 | 21.8% | |
| Relevant physical exam findings (including abnormal vital signs) | Admitting | 3 | 3.2% | 25 | 27.1% | 41 | 44.5% | 21 | 22.8% | 2 | 2.1% |
| EM | 0 | 5 | 15.6% | 2 | 6.2% | 15 | 46.8% | 10 | 31.2% | ||
| Results of relevant diagnostic studies (labs, imaging) | Admitting | 2 | 2.1% | 10 | 10.8% | 39 | 42.3% | 37 | 40.2% | 4 | 4.3% |
| EM | 1 | 3.1% | 0 | 3 | 9.3% | 14 | 43.7% | 14 | 43.7% | ||
| Procedures and therapeutic interventions initiated while in the ED | Admitting | 3 | 3.2% | 20 | 21.7% | 34 | 36.9% | 29 | 31.5% | 6 | 6.5% |
| EM | 1 | 3.1% | 0 | 3 | 9.3% | 18 | 56.2% | 10 | 31.2% | ||
| Trend in the patient's clinical condition while in the ED | Admitting | 12 | 13.1% | 27 | 29.6% | 33 | 36.2% | 17 | 18.6% | 2 | 2.1% |
| EM | 4 | 12.5% | 1 | 3.1% | 5 | 15.6% | 13 | 40.6% | 9 | 28.1% | |
| Current clinical condition of the patient (at time of handoff) | Admitting | 3 | 3.2% | 24 | 26.0% | 41 | 44.5% | 18 | 19.5% | 6 | 6.5% |
| EM | 1 | 3.1% | 1 | 3.1% | 3 | 9.3% | 13 | 40.6% | 14 | 43.7% | |
| Pending diagnostic studies (labs, imaging), if ordered | Admitting | 12 | 13.0% | 32 | 34.7% | 29 | 31.5% | 17 | 18.4% | 2 | 2.1% |
| EM | 0 | 5 | 15.6% | 6 | 18.7% | 14 | 43.7% | 7 | 21.8% | ||
| During handoff, how often are clinical questions asked about the patient being admitted? | Admitting | 2 | 2.1% | 1 | 1.0% | 13 | 14.1% | 29 | 31.5% | 47 | 51.0% |
| EM | 0 | 0 | 5 | 15.6% | 8 | 25.0% | 13 | 40.6% | 6 | 18.7% | |
| In general, how often do you agree with the clinical decisions made by the EM physician? | Admitting | 1 | 1.0% | 26 | 27.9% | 56 | 60.2% | 10 | 10.7% | 0 | 0 |
| Generally, how often do you feel you have to defend your clinical decisions to the admitting service? | EM | 2 | 6.2% | 15 | 46.8% | 5 | 15.6% | 10 | 31.2% | 0 | 0 |
| How often do you have clinically meaningful face‐to‐face communication with the EM/admitting physician about the patient being admitted? | Admitting | 24 | 25.8% | 38 | 40.8% | 22 | 23.6% | 8 | 8.6% | 1 | 1.0% |
| EM | 14 | 43.7% | 13 | 40.6% | 4 | 12.5% | 1 | 3.1% | 0 | ||
| On average, how often do competing clinical responsibilities distract you during handoff? | Admitting | 6 | 6.5% | 34 | 36.9% | 29 | 31.5% | 20 | 21.7% | 3 | 3.2% |
| EM | 7 | 21.8% | 8 | 25.0% | 9 | 28.1% | 8 | 25.0% | 0 | 0 | |
| On average, how often do environmental factors distract you during handoff? | Admitting | 44 | 48.3% | 31 | 34.0% | 10 | 10.9% | 6 | 6.5% | 0 | 0 |
| EM | 7 | 21.8% | 11 | 34.3% | 8 | 25.0% | 4 | 12.5% | 2 | 6.2% | |
The processes for assigning responsibilities following the initial handoff differed between admitting services, and within a service the process was often dynamic. For example, within the university‐based IM and community‐based FM services, the assignment process varied depending on timing (day vs night, weekday vs weekend). For the critical care medicine and cardiology services, fellows accepted admission handoff calls, and depending on competing clinical responsibilities and the patient's stability, either evaluated the patient independently or sent a resident to perform a preliminary evaluation. We reviewed and classified these varied admission assignment strategies into 4 general schemes (Figure 1). All 5 admitting services relied partly or entirely on housestaff for receiving admission handoffs, as did the EM service.
Communication Quality and Content
Cronbach's was 0.72 for general handoff questions and 0.89 for clinical information questions. Compared with EM respondents, admitting physicians reported worse quality of communication (P < 0.001) and less confidence in the handoff system's ability to ensure patient safety (P=0.04). Admitting physicians reported communication of clinical information occurred less frequently than EM physicians for all 8 content areas (P < 0.001 for all). There were no significant differences in responses between various levels of training and service affiliations.
Interpersonal Perceptions
EM respondents reported admitting physicians asked clinical questions less frequently than did admitting respondents (P < 0.001). Ninety‐four percent of EM physicians (n=30) felt they had to defend their clinical decisions at least sometimes. EM interns (P=0.009) and faculty (P=0.01) were more likely than residents to report feeling defensive. Most admitting physicians (60%, n=56) often agreed with decisions made by the EM provider, but 29% (n=27) agreed less than half the time. One‐third of admitting (n=31) and 16% of EM physicians (n=5) reported routine (ie, >50% of admissions) meaningful face‐to‐face communication with one another at the time of admission.
Responsibilities
When asked who was primarily responsible for patients boarding in the ED, defined as nonemergent patient care that occurs after handoff, but before a patient is physically transferred from the ED, 37.6% (n=47) of respondents answered the admitting physician, 21.6% (n=27) answered the EM physician, 34.4% (n=43) answered both, and 6.4% (n=8) answered don't know. Responses were similar for EM and admitting physicians.
Organizational Factors
Fifty‐six percent of all respondents (n=69) reported they were distracted during handoffs by competing clinical duties 50% of the time. Environmental factors, such as noise, more commonly distracted EM physicians (P=0.001). Approximately 60% (n=56) of admitting physicians reported using a triage system to distribute admissions, with a resultant 57% (n=32) reporting sequential handoffs (ie, handoffs of handoffs) occurred at least sometimes. About 80% of EM physicians (n=23) reported that shift change led to sequential handoffs at least sometimes. Seventy‐eight percent (n=67) of physicians felt sequential handoffs had a negative impact on patient care.
Patient Safety
Thirty‐four percent of admitting (n=30) and 19% of EM physicians (n=6) reported a patient was harmed or suffered a near miss in the past 3 months because of an ineffective handoff, with 58% (n=21) reporting 2 examples. Twenty‐four respondents described 29 adverse events. Respondents described perceived mistakes in diagnosis (n=11), treatment (n=16), and disposition (n=12), with some examples falling into more than 1 category. Absent or ineffective communication contributed to 27 of 29 examples. Other commonly cited areas of vulnerability included uncertain assignment of responsibility, sequential handoffs, and patient boarding.
DISCUSSION
Based upon physician self‐reporting, we identified perceived barriers to safe ED admission handoff across several domains. This study adds to the literature, as it provides a cross‐section of multiple inpatient services with varying admission schemes to underscore the complexities facing hospitals in safely transitioning patients between units. As noted in previous studies, one‐third of physicians reported a handoff‐related adverse event,[15] and there was significant disagreement between handoff participants about communication of critical information.[21, 26] These differences in perceptions suggest a failure of physicians to accurately transfer information to create a shared understanding of patient care,[21] which is the central function of handoffs.
EM physicians frequently felt that admitting physicians did not trust their clinical decisions, a perception supported by the fact that over 25% of admitting respondents' usually disagreed with decisions in the ED. Interdisciplinary trust is central in negotiating a shared plan of care[13] and mitigating conflict to ensure a safe transition of patient care.[16] Handoffs are complex social interactions, and feelings of defensiveness and mistrust are likely exacerbated by in‐group/out‐group biases,[15] conflicting information expectations,[19] and discordant ways of interpreting and framing handoff interactions.[13] Interestingly, EM residents were less likely than interns or faculty to report feeling defensive. This may be in part because residents from EM and admitting services develop relationships during interdisciplinary rotations, which may help facilitate future handoff interactions.[27] The fact that EM respondents felt defensive, despite reporting less‐frequent questioning than admitting physicians, suggests that tone and content of questions played an important role. These findings support the importance of interdisciplinary education and standardization of handoff communication between ED and admitting physicians.[23] Beach and colleagues have recommended a conceptual framework for interunit handoffs between EM and hospital physicians, but further research is needed to measure its impact in real‐world settings.[14]
We also found great variability in admitting services' processes for assigning patient‐care responsibility following the initial handoff. Even within an individual service, these processes were often dynamic and relied on physicians at different levels of training. This has several potential consequences. First, it may be difficult for physicians engaged in a handoff to know the level of experience and expertise of one another. These contextual variables play an important role in how handoff information is conveyed, as less experienced clinicians may require explicit information that a more experienced provider may infer.[1, 21] Second, the variability in admission assignment processes may further exacerbate uncertainty regarding responsibility for patients boarding in the ED, making it increasingly difficult for nurses and ancillary staff to know which physician is ultimately responsible for patient care. Finally, the diversity of admission schemes may complicate the development of standardized interunit handoff protocols, policy, and education.
A related finding was that sequential handoffs were common within both EM and admitting services. EM shift handoffs have their own set of barriers,[28] which can lead to ineffective communication.[29] Likewise, about two‐thirds of admitting respondents reported using an admission triage system. The goal of such systems is to simplify complex call schedules and diverse patient assignment schemes within admitting services, thus streamlining the admission process. These systems may also allow for more consistency in the quality of handoff communication through the creation of triage specialists. These potential advantages need to be weighed against the increased risk of communication breakdown. The introduction of sequential handoffs creates a game of telephone, in which there is no direct communication between the first and final caregivers (Figure 1), allowing misinformation to be propagated forward.[30] Sequential handoffs contributed to several reported adverse events, and the majority of surveyed physicians felt they negatively impacted patient care. Further research is necessary to determine the impact of centralized triage systems and to explore strategies to mitigate information decay that results from sequential handoffs, as quality‐improvement interventions may be of limited benefit if downstream communication remains ineffective. Potential strategies may include standardizing sequential handoff communication, leveraging centralized handoff notes within electronic health records, or developing handoff systems that ensure direct communication between the EM physician and the ultimate admitting provider.
Limitations
This was a single‐institution study, so results may not be generalizable, as handoff processes vary among hospitals.[24] Our study relied on a novel survey instrument, for which validity and reliability are uncertain, although internal consistency was good for domains that could be tested (Cronbach's 0.720.89). As with other survey‐based studies, participant selection, hindsight, recall, and response biases may have influenced the results. We attempted to minimize these risks by pilot testing the survey, targeting a relatively large number of respondents across multiple services, and by making efforts to maximize the response rate by contacting eligible participants both in person and via email. Because results reflect self‐reported perceptions, we cannot prove that the factors studied are actually associated with adverse outcomes, nor can we quantify their relative importance. Nevertheless, the reported perceptions raise concerns that warrant further study.
FUTURE DIRECTIONS
Further research is needed to examine interventions that may improve clinically relevant outcomes. Development of structured admission handoff protocols should be collaborative[31] and focus on clinical judgment, rather than rote recitation of data.[14] Based on our study findings, we are pilot testing a standardized approach for ED‐to‐hospital handoffs, and portions of this survey will be repeated in the postintervention assessment.
At our institution, housestaff at all levels of training regularly participated in the handoff process. The Accreditation Council for Graduate Medical Education requires that residents demonstrate competence in performing handoffs,[7] yet handoff training and assessment are inconsistent,[23, 32, 33] and published interventions have focused primarily on within‐unit handoffs.[34, 35, 36] Additional training should focus on the unique aspects of interunit handoffs. Approaches could include interprofessional communication training, simulation training, and enhanced assessment methods. Additionally, increasing face‐to‐face communication, perhaps as part of bedside handoffs, could improve relationships and the development of a shared mental model of patient care. More direct involvement by attending physicians will also be important, as there is evidence that such oversight may improve training[36] and safety,[37] as more experienced physicians better integrate handoff information.[21]
CONCLUSION
We identified several perceived barriers to safe interunit handoff from the ED to the inpatient setting. Handoff‐related adverse events, a pattern of conflicting physician perceptions, and frequent sequential handoffs were of particular concern. Our findings support the need for collaborative efforts to improve interdisciplinary communication.
Disclosure
Nothing to report.
- , . Handoffs in hospitals: a review of the literature on information exchange while transferring patient responsibility or control. Available at: http://deepblue.lib.umich.edu/handle/2027.42/61498. Updated 2009. Accessed May 15, 2014.
- . Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34(10):563–570.
- . Consequences of inadequate sign‐out for patient care. Arch Intern Med. 2008;168(16):1755–1760.
- , . A systematic review of failures in handoff communication during intrahospital transfers. Jt Comm J Qual Patient Saf. 2011;37(6):274–284.
- , , , , . Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign‐out. J Hosp Med. 2006;1(4):257–266.
- , . A model for building a standardized hand‐off protocol. Jt Comm J Qual Patient Saf. 2006;32(11):646–655.
- Accreditation Council for Graduate Medical Education. ACGME common program requirements. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf. Updated 2013. Accessed May 7, 2014.
- Association of American Medical Colleges. Core entrustable professional activities for entering residency. Available at: https://members.aamc.org/eweb/upload/Core%20EPA%20Faculty%20and%20Learner%20Guide.pdf. Updated 2014. Accessed July 7, 2014.
- Accreditation Council for Graduate Medical Education and American Board of Internal Medicine. The internal medicine milestones. Available at: http://www.acgme.org/acgmeweb/portals/0/pdfs/milestones/internalmedicinemilestones.pdf. Updated 2012. Accessed December 23, 2013.
- Accreditation Council for Graduate Medical Education and American Board of Emergency Medicine. The emergency medicine milestones. Available at: https://www.abem.org/public/docs/default‐source/migrated‐documents‐and‐files/em‐milestones.pdf?sfvrsn=4. Updated 2012. Accessed December 23, 2013.
- Accreditation Council for Graduate Medical Education and American Board of Family Medicine. The family medicine milestone project. Available at: http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/FamilyMedicineMilestones.pdf. Updated 2013. Accessed October 31, 2014.
- Accreditation Council for Graduate Medical Education and American Board of Pediatrics. The pediatrics milestone project. Available at: http://acgme.org/acgmeweb/Portals/0/PDFs/Milestones/PediatricsMilestones.pdf. Updated 2013. Accessed October, 31, 2014.
- , . The unappreciated challenges of between‐unit handoffs: negotiating and coordinating across boundaries. Ann Emerg Med. 2013;61(2):155–160.
- , , , et al. Improving interunit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach. Acad Emerg Med. 2012;19(10):1188–1195.
- , , , , , . Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med. 2009;53(6):701–710.e4.
- , , , . Conflict prevention, conflict mitigation, and manifestations of conflict during emergency department consultations. Acad Emerg Med. 2014;21(3):308–313.
- , , , . I'm clear, you're clear, we're all clear: improving consultation communication skills in undergraduate medical education. Acad Med. 2013;88(6):753–758.
- , , , . Emergency physician to admitting physician handovers: an exploratory study. Proc Hum Factors Ergon Soc Annu Meet. 2002;46(16):1511–1515.
- , , . Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007;14(10):884–894.
- , . Chart biopsy: an emerging medical practice enabled by electronic health records and its impacts on emergency department‐inpatient admission handoffs. J Am Med Inform Assoc. 2013;20(2):260–267.
- , , , , . Admission handoff communications: clinician's shared understanding of patient severity of illness and problems. J Patient Saf. 2009;5(4):237–242.
- , , , et al. Exploring emergency physician‐hospitalist handoff interactions: development of the handoff communication assessment. Ann Emerg Med. 2010;55(2):161–170.
- , , , , , . Interunit handoffs of patients and transfers of information: a survey of current practices. Ann Emerg Med. 2014;64(4):343–349.e5.
- , , , et al. A conceptual framework for studying the safety of transitions in emergency care. In: Henriksen K, Battles JB, Marks ES, Lewin DI, eds. Advances in Patient Safety: From Research to Implementation. Vol. 2: Concepts and Methodology. Rockville, MD: Agency for Healthcare Research and Quality; 2005:309–321.
- , , , , , . Patient care transitions from the emergency department to the medicine ward: evaluation of a standardized electronic signout tool. Int J Qual Health Care. 2014;26(4):337–347.
- , , , , . Interns overestimate the effectiveness of their hand‐off communication. Pediatrics. 2010;125(3):491–496.
- , , , . Understanding the impact of residents' interpersonal relationships during emergency department referrals and consultations. J Grad Med Educ. 2013;5(4):576–581.
- , , , et al. Improving handoffs in the emergency department. Ann Emerg Med. 2010;55(2):171–180.
- , , . ED handoffs: observed practices and communication errors. Am J Emerg Med. 2011;29(5):502–511.
- , , , , . Characterizing information decay in patient handoffs. J Surg Educ. 2014;71(4):480–485.
- , , . Emergency medicine and hospital medicine: a call for collaboration. J Emerg Med. 2012;43(2):328–334.
- , , , et al. A survey of handoff practices in emergency medicine. Am J Med Qual. 2014;29(5):408–414.
- . Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166(11):1173–1177.
- , , , , , . Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program. J Gen Intern Med. 2013;28(8):986–993.
- , , , et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310(21):2262–2270.
- , , , et al. A structured handoff program for interns. Acad Med. 2009;84(3):347–352.
- , , , et al. Experience with faculty supervision of an electronic resident sign‐out system. Am J Med. 2010;123(4):376–381.
- , . Handoffs in hospitals: a review of the literature on information exchange while transferring patient responsibility or control. Available at: http://deepblue.lib.umich.edu/handle/2027.42/61498. Updated 2009. Accessed May 15, 2014.
- . Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34(10):563–570.
- . Consequences of inadequate sign‐out for patient care. Arch Intern Med. 2008;168(16):1755–1760.
- , . A systematic review of failures in handoff communication during intrahospital transfers. Jt Comm J Qual Patient Saf. 2011;37(6):274–284.
- , , , , . Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign‐out. J Hosp Med. 2006;1(4):257–266.
- , . A model for building a standardized hand‐off protocol. Jt Comm J Qual Patient Saf. 2006;32(11):646–655.
- Accreditation Council for Graduate Medical Education. ACGME common program requirements. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/CPRs2013.pdf. Updated 2013. Accessed May 7, 2014.
- Association of American Medical Colleges. Core entrustable professional activities for entering residency. Available at: https://members.aamc.org/eweb/upload/Core%20EPA%20Faculty%20and%20Learner%20Guide.pdf. Updated 2014. Accessed July 7, 2014.
- Accreditation Council for Graduate Medical Education and American Board of Internal Medicine. The internal medicine milestones. Available at: http://www.acgme.org/acgmeweb/portals/0/pdfs/milestones/internalmedicinemilestones.pdf. Updated 2012. Accessed December 23, 2013.
- Accreditation Council for Graduate Medical Education and American Board of Emergency Medicine. The emergency medicine milestones. Available at: https://www.abem.org/public/docs/default‐source/migrated‐documents‐and‐files/em‐milestones.pdf?sfvrsn=4. Updated 2012. Accessed December 23, 2013.
- Accreditation Council for Graduate Medical Education and American Board of Family Medicine. The family medicine milestone project. Available at: http://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/FamilyMedicineMilestones.pdf. Updated 2013. Accessed October 31, 2014.
- Accreditation Council for Graduate Medical Education and American Board of Pediatrics. The pediatrics milestone project. Available at: http://acgme.org/acgmeweb/Portals/0/PDFs/Milestones/PediatricsMilestones.pdf. Updated 2013. Accessed October, 31, 2014.
- , . The unappreciated challenges of between‐unit handoffs: negotiating and coordinating across boundaries. Ann Emerg Med. 2013;61(2):155–160.
- , , , et al. Improving interunit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach. Acad Emerg Med. 2012;19(10):1188–1195.
- , , , , , . Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med. 2009;53(6):701–710.e4.
- , , , . Conflict prevention, conflict mitigation, and manifestations of conflict during emergency department consultations. Acad Emerg Med. 2014;21(3):308–313.
- , , , . I'm clear, you're clear, we're all clear: improving consultation communication skills in undergraduate medical education. Acad Med. 2013;88(6):753–758.
- , , , . Emergency physician to admitting physician handovers: an exploratory study. Proc Hum Factors Ergon Soc Annu Meet. 2002;46(16):1511–1515.
- , , . Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007;14(10):884–894.
- , . Chart biopsy: an emerging medical practice enabled by electronic health records and its impacts on emergency department‐inpatient admission handoffs. J Am Med Inform Assoc. 2013;20(2):260–267.
- , , , , . Admission handoff communications: clinician's shared understanding of patient severity of illness and problems. J Patient Saf. 2009;5(4):237–242.
- , , , et al. Exploring emergency physician‐hospitalist handoff interactions: development of the handoff communication assessment. Ann Emerg Med. 2010;55(2):161–170.
- , , , , , . Interunit handoffs of patients and transfers of information: a survey of current practices. Ann Emerg Med. 2014;64(4):343–349.e5.
- , , , et al. A conceptual framework for studying the safety of transitions in emergency care. In: Henriksen K, Battles JB, Marks ES, Lewin DI, eds. Advances in Patient Safety: From Research to Implementation. Vol. 2: Concepts and Methodology. Rockville, MD: Agency for Healthcare Research and Quality; 2005:309–321.
- , , , , , . Patient care transitions from the emergency department to the medicine ward: evaluation of a standardized electronic signout tool. Int J Qual Health Care. 2014;26(4):337–347.
- , , , , . Interns overestimate the effectiveness of their hand‐off communication. Pediatrics. 2010;125(3):491–496.
- , , , . Understanding the impact of residents' interpersonal relationships during emergency department referrals and consultations. J Grad Med Educ. 2013;5(4):576–581.
- , , , et al. Improving handoffs in the emergency department. Ann Emerg Med. 2010;55(2):171–180.
- , , . ED handoffs: observed practices and communication errors. Am J Emerg Med. 2011;29(5):502–511.
- , , , , . Characterizing information decay in patient handoffs. J Surg Educ. 2014;71(4):480–485.
- , , . Emergency medicine and hospital medicine: a call for collaboration. J Emerg Med. 2012;43(2):328–334.
- , , , et al. A survey of handoff practices in emergency medicine. Am J Med Qual. 2014;29(5):408–414.
- . Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166(11):1173–1177.
- , , , , , . Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program. J Gen Intern Med. 2013;28(8):986–993.
- , , , et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310(21):2262–2270.
- , , , et al. A structured handoff program for interns. Acad Med. 2009;84(3):347–352.
- , , , et al. Experience with faculty supervision of an electronic resident sign‐out system. Am J Med. 2010;123(4):376–381.
© 2015 Society of Hospital Medicine
