Robert L. Fogerty, MD, MPH

Hospital medicine is a main component of healthcare in the United States and is growing.[1] In 1995, 9% of inpatient care performed by general internists to Medicare patients was provided by hospitalists; by 2006, this had increased to 37%.[2] The estimated 30,000 practicing hospitalists account for 19% of all practicing general internists[2, 3, 4] and have had a major impact on the treatment of inpatients at US hospitals.[5] Other specialties are adopting the hospital‐based physician model.[6, 7] The hospitalist model does have unique challenges. One notable aspect of hospitalist care, which is frequently shift based, is the transfer of care among providers at shift change.

The Society of Hospital Medicine recognizes patient handoffs/sign‐outs as a core competency for hospitalists,[8] but there is little literature evaluating hospitalist sign‐out quality.[9] A systematic review in 2009 found no studies of hospitalist handoffs.[8] Furthermore, early work suggests that hospitalist handoffs are not consistently effective.[10] In a recent survey, 13% of hospitalists reported they had received an incomplete handoff, and 16% of hospitalists reported at least 1 near‐miss attributed to incomplete communication.[11] Last, hospitalists perform no better than housestaff on evaluations of sign‐out quality.[12]

Cross‐coverage situations, in which sign‐out is key, have been shown to place patients at risk.[13, 14] One study showed 7.1 problems related to sign‐out per 100 patient‐days.[15] Failure during sign‐out can ultimately threaten patient safety.[16] Therefore, evaluating the quality of hospitalist sign‐outs by assessing how well the sign‐out prepares the night team for overnight events is necessary to improve hospitalist sign‐outs and ultimately increase patient safety.

METHODS

Data Collection

Hospitalists who consented were provided a single pocket card during their shift. For every inquiry that involved a patient that the hospitalist was covering, the hospitalist recorded who originated the inquiry, the clinical significance, the sufficiency of written sign‐out, which information was used other than the written sign‐out, and information regarding the anticipation of the event by the daytime team (Figure 1).

Figure 1

Data were collected on 6 days and distributed from April 30, 2012 through June 12, 2012. Dates were chosen based on staffing to maximize the number of eligible physicians each night and included both weekdays and weekend days. The written sign‐out for the entire service was printed for each night data collection took place.

RESULTS

Hospitalists recorded 124 inquiries about 96 patients. Altogether, 15 of 19 (79%) eligible hospitalists returned surveys. Of the 96 patients, we obtained the written sign‐out for 68 (71%). The remainder were new patients for whom the sign‐out had not yet been prepared, or patients who had not yet been assigned to the hospitalist service at the time the sign‐out report was printed.

Hospitalists referenced the sign‐out for 89 (74%) inquiries, and the sign‐out was considered sufficient to respond to 27 (30%) of these inquiries (ie, the sign‐out was adequate to answer the inquiry without any supplemental information). Hospitalists physically saw the patient for 14 (12%) inquiries. Nurses were the originator for most inquiries (102 [82%]). The most common inquiry topics were medications (55 [45%]), plan of care (26 [21%]) and clinical changes (26 [21%]). Ninety‐five (77%) inquiries were considered to be somewhat or very clinically important by the hospitalist (Table 1).

No written sign‐outs had a composite score of 0 or 1; 3 (4%) had a composite score of 2; 31 (46%) had a composite score of 3; and 34 (50%) had a composite score of 4. Seventy‐two percent of written sign‐outs included neither anticipatory guidance nor tasks, 21% had 1 anticipatory guidance item or task, and 6% had 2 or more anticipatory guidance items and/or tasks.

The primary team caring for a patient did not predict 102 (86%) inquiries, and hospitalists rated 47 (46%) of those unpredicted events as possible for the primary team to predict. Five responses to this question were incomplete and excluded. Of the 64 events predicted by the primary team or rated as predictable by the night hospitalists, 17 (27%) were predicted by the primary team (Table 1).

Sign‐out was considered sufficient in isolation to answer the majority of order reconciliation inquiries (5 [71%]), but was less effective at helping to answer inquiries about clinical change (7 [29%]), medications (10 [28%]), and plan of care (5 [24%]) (P=0.001). (Table 2) Ninety‐five events were rated as either very or somewhat clinically important, but this did not affect the likelihood of sign‐out being sufficient in isolation relative to the not at all clinically important group. Specifically, 33% of sign‐outs were rated sufficient in the very important group, 19% in the somewhat important group, and 50% in the not at all group (P=0.059).

Sign‐out was considered sufficient in isolation more frequently for inquiries about patients admitted <2 days prior to data collection than for inquiries about patients admitted more than 2 days prior to data collection (21 [40%] vs 6 [16%], respectively) (P=0.015) (Table 2).

Sign‐outs with 2 or more anticipatory guidance items were considered sufficient in isolation more often than sign‐outs with 1 or fewer anticipatory guidance item (60% for 2 or more, 14% for 1, 34% for 0; P=0.006) (Table 2). The composite score was grouped into 2 categoriesscore <4 and score=4with no statistical difference in sign‐out sufficiency between the 2 groups (P=0.22) (Table 2).

In multivariable analysis, no predictor variable was significantly associated with sufficient sign‐out (Table 3).

DISCUSSION

In this study of written sign‐out among hospitalists and physician‐extenders on a hospitalist service, we found that the sign‐out was used to answer three‐quarters of overnight inquiries, despite the advanced level of training (completion of all postgraduate medical education) of the covering clinicians and the presence of a robust EHR. The effectiveness of the written sign‐out, however, was not as consistently high as its use. Overall, the sign‐out was sufficient to answer less than a third of inquiries in which it was referenced. Thus, although most studies of sign‐out quality have focused on trainees, our results make it clear that hospitalists also rely on sign‐out, and its effectiveness can be improved.

There are few studies of attending‐level sign‐outs. Hinami et al. found that nearly 1 in 5 hospitalists was uncertain of the care plan after assuming care of a new set of patients, despite having received a handoff from the departing hospitalist.[11] Handoffs between emergency physicians and hospitalists have repeatedly been noted to have content omissions and to contribute to adverse events.[7, 12, 21, 22] Ilan et al. videotaped attending handoffs in the intensive care unit and found that they did not follow any of 3 commonly recommended structures; however, this study did not assess the effectiveness of the handoffs.[23] Williams et al. found that the transfer of patient information among surgical team members, including attending surgeons, was suboptimal, and these problems were commonly related to decreased surgeon familiarity with a particular patient, a theme common to hospital medicine, and a contributor to adverse events and decreased efficiency.[24]

This study extends the literature in several ways. By studying overnight events, we generate a comprehensive view of the information sources hospitalists use to care for patients overnight. Interestingly, our results were similar to the overnight information‐gathering habits of trainees in a study of pediatric trainees.[25] Furthermore, by linking each inquiry to the accompanying written sign‐out, we are able to analyze which characteristics of a written sign‐out are associated with sign‐out effectiveness, and we are able to describe the utility of written sign‐out to answer different types of clinical scenarios.

Our data show that hospitalists rely heavily on written sign‐out to care for patients overnight, with the physician note being the most‐utilized secondary reference used by covering physicians. The written sign‐out was most useful for order clarification compared to other topics, and the patient was only seen for 12% of inquiries. Most notable, however, was the suggestion that sign‐outs with more anticipatory guidance were more likely to be effective for overnight care, as were sign‐outs created earlier in the hospital course. Future efforts to improve the utility of the written sign‐out might focus on these items, whether through training or audit/feedback.

The use of electronic handoff tools has been shown to increase the ease of use, efficiency, and perceptions of patient safety and quality in several studies.[3, 26, 27] This study relied on an electronic tool as the only means of information transfer during sign‐out. Without the confounding effect of verbal information transfer, we are better able to understand the efficacy of the written component alone. Nonetheless, most expert opinion statements as well as The Joint Commission include a recommendation for verbal and written components to handoff communication.[8, 20, 28, 29, 30] It is possible that sign‐outs would more often have been rated sufficient if the handoff process had reliably included verbal handoff. Future studies are warranted to compare written‐only to written‐plus‐verbal sign‐out, to determine the added benefit of verbal communication. With a robust EHR, it is also an open question whether sign‐out needs to be sufficient to answer overnight inquiries or whether it would be acceptable or even preferable to have overnight staff consistently review the EHR directly, especially as the physician notes are the most common nonsign‐out reference used. Nonetheless, the fact that hospitalists rely heavily on written sign‐out despite the availability of other information sources suggests that hospitalists find specific benefit in written sign‐out.

Limitations of this study include the relatively small sample size, the limited collection time period, and the single‐site nature. The YNHH Hospitalist Service uses only written documents to sign out, so the external validity to programs that use verbal sign‐out is limited. The written‐only nature, however, removes the variable of the discussion at time of sign‐out, improving the purity of the written sign‐out assessment. We did not assess workload, which might have affected sign‐out quality. The interpretation of the composite score is limited, due to little variation in scoring in our sample, as well as lack of validation in other studies. An additional limitation is that sign‐outs are not entirely drafted by the hospitalist attendings. Hospitalists draft the initial sign‐out document, but it is updated on subsequent days by the mid‐level provider under the direction of the hospitalist attending. It is therefore possible that sign‐outs maintained directly by hospitalists would have been of different quality. In this regard it is interesting to note that in a different study of verbal sign‐out we were not able to detect a difference in quality among hospitalists, trainees, and midlevels.[12] Last, hindsight bias may be present, as the covering physician's perspective of the event includes more information than available to the provider creating the sign‐out document.

Overall, we found that attending hospitalists rely heavily on written sign‐out documents to address overnight inquiries, but those sign‐outs are not reliably effective. Future work to better understand the roles of written and verbal components in sign‐out is needed to help improve the safety of overnight care.

Hospital medicine is a main component of healthcare in the United States and is growing.[1] In 1995, 9% of inpatient care performed by general internists to Medicare patients was provided by hospitalists; by 2006, this had increased to 37%.[2] The estimated 30,000 practicing hospitalists account for 19% of all practicing general internists[2, 3, 4] and have had a major impact on the treatment of inpatients at US hospitals.[5] Other specialties are adopting the hospital‐based physician model.[6, 7] The hospitalist model does have unique challenges. One notable aspect of hospitalist care, which is frequently shift based, is the transfer of care among providers at shift change.

The Society of Hospital Medicine recognizes patient handoffs/sign‐outs as a core competency for hospitalists,[8] but there is little literature evaluating hospitalist sign‐out quality.[9] A systematic review in 2009 found no studies of hospitalist handoffs.[8] Furthermore, early work suggests that hospitalist handoffs are not consistently effective.[10] In a recent survey, 13% of hospitalists reported they had received an incomplete handoff, and 16% of hospitalists reported at least 1 near‐miss attributed to incomplete communication.[11] Last, hospitalists perform no better than housestaff on evaluations of sign‐out quality.[12]

Cross‐coverage situations, in which sign‐out is key, have been shown to place patients at risk.[13, 14] One study showed 7.1 problems related to sign‐out per 100 patient‐days.[15] Failure during sign‐out can ultimately threaten patient safety.[16] Therefore, evaluating the quality of hospitalist sign‐outs by assessing how well the sign‐out prepares the night team for overnight events is necessary to improve hospitalist sign‐outs and ultimately increase patient safety.

METHODS

Data Collection

Hospitalists who consented were provided a single pocket card during their shift. For every inquiry that involved a patient that the hospitalist was covering, the hospitalist recorded who originated the inquiry, the clinical significance, the sufficiency of written sign‐out, which information was used other than the written sign‐out, and information regarding the anticipation of the event by the daytime team (Figure 1).

Figure 1

Data were collected on 6 days and distributed from April 30, 2012 through June 12, 2012. Dates were chosen based on staffing to maximize the number of eligible physicians each night and included both weekdays and weekend days. The written sign‐out for the entire service was printed for each night data collection took place.

RESULTS

Hospitalists recorded 124 inquiries about 96 patients. Altogether, 15 of 19 (79%) eligible hospitalists returned surveys. Of the 96 patients, we obtained the written sign‐out for 68 (71%). The remainder were new patients for whom the sign‐out had not yet been prepared, or patients who had not yet been assigned to the hospitalist service at the time the sign‐out report was printed.

Hospitalists referenced the sign‐out for 89 (74%) inquiries, and the sign‐out was considered sufficient to respond to 27 (30%) of these inquiries (ie, the sign‐out was adequate to answer the inquiry without any supplemental information). Hospitalists physically saw the patient for 14 (12%) inquiries. Nurses were the originator for most inquiries (102 [82%]). The most common inquiry topics were medications (55 [45%]), plan of care (26 [21%]) and clinical changes (26 [21%]). Ninety‐five (77%) inquiries were considered to be somewhat or very clinically important by the hospitalist (Table 1).

No written sign‐outs had a composite score of 0 or 1; 3 (4%) had a composite score of 2; 31 (46%) had a composite score of 3; and 34 (50%) had a composite score of 4. Seventy‐two percent of written sign‐outs included neither anticipatory guidance nor tasks, 21% had 1 anticipatory guidance item or task, and 6% had 2 or more anticipatory guidance items and/or tasks.

The primary team caring for a patient did not predict 102 (86%) inquiries, and hospitalists rated 47 (46%) of those unpredicted events as possible for the primary team to predict. Five responses to this question were incomplete and excluded. Of the 64 events predicted by the primary team or rated as predictable by the night hospitalists, 17 (27%) were predicted by the primary team (Table 1).

Sign‐out was considered sufficient in isolation to answer the majority of order reconciliation inquiries (5 [71%]), but was less effective at helping to answer inquiries about clinical change (7 [29%]), medications (10 [28%]), and plan of care (5 [24%]) (P=0.001). (Table 2) Ninety‐five events were rated as either very or somewhat clinically important, but this did not affect the likelihood of sign‐out being sufficient in isolation relative to the not at all clinically important group. Specifically, 33% of sign‐outs were rated sufficient in the very important group, 19% in the somewhat important group, and 50% in the not at all group (P=0.059).

Sign‐out was considered sufficient in isolation more frequently for inquiries about patients admitted <2 days prior to data collection than for inquiries about patients admitted more than 2 days prior to data collection (21 [40%] vs 6 [16%], respectively) (P=0.015) (Table 2).

Sign‐outs with 2 or more anticipatory guidance items were considered sufficient in isolation more often than sign‐outs with 1 or fewer anticipatory guidance item (60% for 2 or more, 14% for 1, 34% for 0; P=0.006) (Table 2). The composite score was grouped into 2 categoriesscore <4 and score=4with no statistical difference in sign‐out sufficiency between the 2 groups (P=0.22) (Table 2).

In multivariable analysis, no predictor variable was significantly associated with sufficient sign‐out (Table 3).

DISCUSSION

In this study of written sign‐out among hospitalists and physician‐extenders on a hospitalist service, we found that the sign‐out was used to answer three‐quarters of overnight inquiries, despite the advanced level of training (completion of all postgraduate medical education) of the covering clinicians and the presence of a robust EHR. The effectiveness of the written sign‐out, however, was not as consistently high as its use. Overall, the sign‐out was sufficient to answer less than a third of inquiries in which it was referenced. Thus, although most studies of sign‐out quality have focused on trainees, our results make it clear that hospitalists also rely on sign‐out, and its effectiveness can be improved.

There are few studies of attending‐level sign‐outs. Hinami et al. found that nearly 1 in 5 hospitalists was uncertain of the care plan after assuming care of a new set of patients, despite having received a handoff from the departing hospitalist.[11] Handoffs between emergency physicians and hospitalists have repeatedly been noted to have content omissions and to contribute to adverse events.[7, 12, 21, 22] Ilan et al. videotaped attending handoffs in the intensive care unit and found that they did not follow any of 3 commonly recommended structures; however, this study did not assess the effectiveness of the handoffs.[23] Williams et al. found that the transfer of patient information among surgical team members, including attending surgeons, was suboptimal, and these problems were commonly related to decreased surgeon familiarity with a particular patient, a theme common to hospital medicine, and a contributor to adverse events and decreased efficiency.[24]

This study extends the literature in several ways. By studying overnight events, we generate a comprehensive view of the information sources hospitalists use to care for patients overnight. Interestingly, our results were similar to the overnight information‐gathering habits of trainees in a study of pediatric trainees.[25] Furthermore, by linking each inquiry to the accompanying written sign‐out, we are able to analyze which characteristics of a written sign‐out are associated with sign‐out effectiveness, and we are able to describe the utility of written sign‐out to answer different types of clinical scenarios.

Our data show that hospitalists rely heavily on written sign‐out to care for patients overnight, with the physician note being the most‐utilized secondary reference used by covering physicians. The written sign‐out was most useful for order clarification compared to other topics, and the patient was only seen for 12% of inquiries. Most notable, however, was the suggestion that sign‐outs with more anticipatory guidance were more likely to be effective for overnight care, as were sign‐outs created earlier in the hospital course. Future efforts to improve the utility of the written sign‐out might focus on these items, whether through training or audit/feedback.

The use of electronic handoff tools has been shown to increase the ease of use, efficiency, and perceptions of patient safety and quality in several studies.[3, 26, 27] This study relied on an electronic tool as the only means of information transfer during sign‐out. Without the confounding effect of verbal information transfer, we are better able to understand the efficacy of the written component alone. Nonetheless, most expert opinion statements as well as The Joint Commission include a recommendation for verbal and written components to handoff communication.[8, 20, 28, 29, 30] It is possible that sign‐outs would more often have been rated sufficient if the handoff process had reliably included verbal handoff. Future studies are warranted to compare written‐only to written‐plus‐verbal sign‐out, to determine the added benefit of verbal communication. With a robust EHR, it is also an open question whether sign‐out needs to be sufficient to answer overnight inquiries or whether it would be acceptable or even preferable to have overnight staff consistently review the EHR directly, especially as the physician notes are the most common nonsign‐out reference used. Nonetheless, the fact that hospitalists rely heavily on written sign‐out despite the availability of other information sources suggests that hospitalists find specific benefit in written sign‐out.

Limitations of this study include the relatively small sample size, the limited collection time period, and the single‐site nature. The YNHH Hospitalist Service uses only written documents to sign out, so the external validity to programs that use verbal sign‐out is limited. The written‐only nature, however, removes the variable of the discussion at time of sign‐out, improving the purity of the written sign‐out assessment. We did not assess workload, which might have affected sign‐out quality. The interpretation of the composite score is limited, due to little variation in scoring in our sample, as well as lack of validation in other studies. An additional limitation is that sign‐outs are not entirely drafted by the hospitalist attendings. Hospitalists draft the initial sign‐out document, but it is updated on subsequent days by the mid‐level provider under the direction of the hospitalist attending. It is therefore possible that sign‐outs maintained directly by hospitalists would have been of different quality. In this regard it is interesting to note that in a different study of verbal sign‐out we were not able to detect a difference in quality among hospitalists, trainees, and midlevels.[12] Last, hindsight bias may be present, as the covering physician's perspective of the event includes more information than available to the provider creating the sign‐out document.

Overall, we found that attending hospitalists rely heavily on written sign‐out documents to address overnight inquiries, but those sign‐outs are not reliably effective. Future work to better understand the roles of written and verbal components in sign‐out is needed to help improve the safety of overnight care.

Hospital medicine is a main component of healthcare in the United States and is growing.[1] In 1995, 9% of inpatient care performed by general internists to Medicare patients was provided by hospitalists; by 2006, this had increased to 37%.[2] The estimated 30,000 practicing hospitalists account for 19% of all practicing general internists[2, 3, 4] and have had a major impact on the treatment of inpatients at US hospitals.[5] Other specialties are adopting the hospital‐based physician model.[6, 7] The hospitalist model does have unique challenges. One notable aspect of hospitalist care, which is frequently shift based, is the transfer of care among providers at shift change.

The Society of Hospital Medicine recognizes patient handoffs/sign‐outs as a core competency for hospitalists,[8] but there is little literature evaluating hospitalist sign‐out quality.[9] A systematic review in 2009 found no studies of hospitalist handoffs.[8] Furthermore, early work suggests that hospitalist handoffs are not consistently effective.[10] In a recent survey, 13% of hospitalists reported they had received an incomplete handoff, and 16% of hospitalists reported at least 1 near‐miss attributed to incomplete communication.[11] Last, hospitalists perform no better than housestaff on evaluations of sign‐out quality.[12]

Cross‐coverage situations, in which sign‐out is key, have been shown to place patients at risk.[13, 14] One study showed 7.1 problems related to sign‐out per 100 patient‐days.[15] Failure during sign‐out can ultimately threaten patient safety.[16] Therefore, evaluating the quality of hospitalist sign‐outs by assessing how well the sign‐out prepares the night team for overnight events is necessary to improve hospitalist sign‐outs and ultimately increase patient safety.

METHODS

Data Collection

Hospitalists who consented were provided a single pocket card during their shift. For every inquiry that involved a patient that the hospitalist was covering, the hospitalist recorded who originated the inquiry, the clinical significance, the sufficiency of written sign‐out, which information was used other than the written sign‐out, and information regarding the anticipation of the event by the daytime team (Figure 1).

Figure 1

Data were collected on 6 days and distributed from April 30, 2012 through June 12, 2012. Dates were chosen based on staffing to maximize the number of eligible physicians each night and included both weekdays and weekend days. The written sign‐out for the entire service was printed for each night data collection took place.

RESULTS

Hospitalists recorded 124 inquiries about 96 patients. Altogether, 15 of 19 (79%) eligible hospitalists returned surveys. Of the 96 patients, we obtained the written sign‐out for 68 (71%). The remainder were new patients for whom the sign‐out had not yet been prepared, or patients who had not yet been assigned to the hospitalist service at the time the sign‐out report was printed.

Hospitalists referenced the sign‐out for 89 (74%) inquiries, and the sign‐out was considered sufficient to respond to 27 (30%) of these inquiries (ie, the sign‐out was adequate to answer the inquiry without any supplemental information). Hospitalists physically saw the patient for 14 (12%) inquiries. Nurses were the originator for most inquiries (102 [82%]). The most common inquiry topics were medications (55 [45%]), plan of care (26 [21%]) and clinical changes (26 [21%]). Ninety‐five (77%) inquiries were considered to be somewhat or very clinically important by the hospitalist (Table 1).

No written sign‐outs had a composite score of 0 or 1; 3 (4%) had a composite score of 2; 31 (46%) had a composite score of 3; and 34 (50%) had a composite score of 4. Seventy‐two percent of written sign‐outs included neither anticipatory guidance nor tasks, 21% had 1 anticipatory guidance item or task, and 6% had 2 or more anticipatory guidance items and/or tasks.

The primary team caring for a patient did not predict 102 (86%) inquiries, and hospitalists rated 47 (46%) of those unpredicted events as possible for the primary team to predict. Five responses to this question were incomplete and excluded. Of the 64 events predicted by the primary team or rated as predictable by the night hospitalists, 17 (27%) were predicted by the primary team (Table 1).

Sign‐out was considered sufficient in isolation to answer the majority of order reconciliation inquiries (5 [71%]), but was less effective at helping to answer inquiries about clinical change (7 [29%]), medications (10 [28%]), and plan of care (5 [24%]) (P=0.001). (Table 2) Ninety‐five events were rated as either very or somewhat clinically important, but this did not affect the likelihood of sign‐out being sufficient in isolation relative to the not at all clinically important group. Specifically, 33% of sign‐outs were rated sufficient in the very important group, 19% in the somewhat important group, and 50% in the not at all group (P=0.059).

Sign‐out was considered sufficient in isolation more frequently for inquiries about patients admitted <2 days prior to data collection than for inquiries about patients admitted more than 2 days prior to data collection (21 [40%] vs 6 [16%], respectively) (P=0.015) (Table 2).

Sign‐outs with 2 or more anticipatory guidance items were considered sufficient in isolation more often than sign‐outs with 1 or fewer anticipatory guidance item (60% for 2 or more, 14% for 1, 34% for 0; P=0.006) (Table 2). The composite score was grouped into 2 categoriesscore <4 and score=4with no statistical difference in sign‐out sufficiency between the 2 groups (P=0.22) (Table 2).

In multivariable analysis, no predictor variable was significantly associated with sufficient sign‐out (Table 3).

DISCUSSION

In this study of written sign‐out among hospitalists and physician‐extenders on a hospitalist service, we found that the sign‐out was used to answer three‐quarters of overnight inquiries, despite the advanced level of training (completion of all postgraduate medical education) of the covering clinicians and the presence of a robust EHR. The effectiveness of the written sign‐out, however, was not as consistently high as its use. Overall, the sign‐out was sufficient to answer less than a third of inquiries in which it was referenced. Thus, although most studies of sign‐out quality have focused on trainees, our results make it clear that hospitalists also rely on sign‐out, and its effectiveness can be improved.

There are few studies of attending‐level sign‐outs. Hinami et al. found that nearly 1 in 5 hospitalists was uncertain of the care plan after assuming care of a new set of patients, despite having received a handoff from the departing hospitalist.[11] Handoffs between emergency physicians and hospitalists have repeatedly been noted to have content omissions and to contribute to adverse events.[7, 12, 21, 22] Ilan et al. videotaped attending handoffs in the intensive care unit and found that they did not follow any of 3 commonly recommended structures; however, this study did not assess the effectiveness of the handoffs.[23] Williams et al. found that the transfer of patient information among surgical team members, including attending surgeons, was suboptimal, and these problems were commonly related to decreased surgeon familiarity with a particular patient, a theme common to hospital medicine, and a contributor to adverse events and decreased efficiency.[24]

This study extends the literature in several ways. By studying overnight events, we generate a comprehensive view of the information sources hospitalists use to care for patients overnight. Interestingly, our results were similar to the overnight information‐gathering habits of trainees in a study of pediatric trainees.[25] Furthermore, by linking each inquiry to the accompanying written sign‐out, we are able to analyze which characteristics of a written sign‐out are associated with sign‐out effectiveness, and we are able to describe the utility of written sign‐out to answer different types of clinical scenarios.

Our data show that hospitalists rely heavily on written sign‐out to care for patients overnight, with the physician note being the most‐utilized secondary reference used by covering physicians. The written sign‐out was most useful for order clarification compared to other topics, and the patient was only seen for 12% of inquiries. Most notable, however, was the suggestion that sign‐outs with more anticipatory guidance were more likely to be effective for overnight care, as were sign‐outs created earlier in the hospital course. Future efforts to improve the utility of the written sign‐out might focus on these items, whether through training or audit/feedback.

The use of electronic handoff tools has been shown to increase the ease of use, efficiency, and perceptions of patient safety and quality in several studies.[3, 26, 27] This study relied on an electronic tool as the only means of information transfer during sign‐out. Without the confounding effect of verbal information transfer, we are better able to understand the efficacy of the written component alone. Nonetheless, most expert opinion statements as well as The Joint Commission include a recommendation for verbal and written components to handoff communication.[8, 20, 28, 29, 30] It is possible that sign‐outs would more often have been rated sufficient if the handoff process had reliably included verbal handoff. Future studies are warranted to compare written‐only to written‐plus‐verbal sign‐out, to determine the added benefit of verbal communication. With a robust EHR, it is also an open question whether sign‐out needs to be sufficient to answer overnight inquiries or whether it would be acceptable or even preferable to have overnight staff consistently review the EHR directly, especially as the physician notes are the most common nonsign‐out reference used. Nonetheless, the fact that hospitalists rely heavily on written sign‐out despite the availability of other information sources suggests that hospitalists find specific benefit in written sign‐out.

Limitations of this study include the relatively small sample size, the limited collection time period, and the single‐site nature. The YNHH Hospitalist Service uses only written documents to sign out, so the external validity to programs that use verbal sign‐out is limited. The written‐only nature, however, removes the variable of the discussion at time of sign‐out, improving the purity of the written sign‐out assessment. We did not assess workload, which might have affected sign‐out quality. The interpretation of the composite score is limited, due to little variation in scoring in our sample, as well as lack of validation in other studies. An additional limitation is that sign‐outs are not entirely drafted by the hospitalist attendings. Hospitalists draft the initial sign‐out document, but it is updated on subsequent days by the mid‐level provider under the direction of the hospitalist attending. It is therefore possible that sign‐outs maintained directly by hospitalists would have been of different quality. In this regard it is interesting to note that in a different study of verbal sign‐out we were not able to detect a difference in quality among hospitalists, trainees, and midlevels.[12] Last, hindsight bias may be present, as the covering physician's perspective of the event includes more information than available to the provider creating the sign‐out document.

Overall, we found that attending hospitalists rely heavily on written sign‐out documents to address overnight inquiries, but those sign‐outs are not reliably effective. Future work to better understand the roles of written and verbal components in sign‐out is needed to help improve the safety of overnight care.

Hospitalized patients are often cared for by physicians who do not follow them in the community, creating a discontinuity of care that must be bridged through communication. This communication between inpatient and outpatient physicians occurs, in part via a discharge summary, which is intended to summarize events during hospitalization and prepare the outpatient physician to resume care of the patient. Yet, this form of communication has long been problematic.[1, 2, 3] In a 1960 study, only 30% of discharge letters were received by the primary care physician within 48 hours of discharge.[1]

More recent studies have shown little improvement. Direct communication between hospital and outpatient physicians is rare, and discharge summaries are still largely unavailable at the time of follow‐up.[4] In 1 study, primary care physicians were unaware of 62% of laboratory tests or study results that were pending on discharge,[5] in part because this information is missing from most discharge summaries.[6] Deficits such as these persist despite the fact that the rate of postdischarge completion of recommended tests, referrals, or procedures is significantly increased when the recommendation is included in the discharge summary.[7]

Regulatory mandates for discharge summaries from the Centers for Medicare and Medicaid Services[8] and from The Joint Commission[9] appear to be generally met[10, 11]; however, these mandates have no requirements for timeliness stricter than 30 days, do not require that summaries be transmitted to outpatient physicians, and do not require several content elements that might be useful to outside physicians such as condition of the patient at discharge, cognitive and functional status, goals of care, or pending studies. Expert opinion guidelines have more comprehensive recommendations,[12, 13] but it is uncertain how widely they are followed.

The existence of a discharge summary does not necessarily mean it serves a patient well in the transitional period.[11, 14, 15] Discharge summaries are a complex intervention, and we do not yet understand the best ways discharge summaries may fulfill needs specific to transitional care. Furthermore, it is uncertain what factors improve aspects of discharge summary quality as defined by timeliness, transmission, and content.[6, 16]

The goal of the DIagnosing Systemic failures, Complexities and HARm in GEriatric discharges study (DISCHARGE) was to comprehensively assess the discharge process for older patients discharged to the community. In this article we examine discharge summaries of patients enrolled in the study to determine the timeliness, transmission to outside physicians, and content of the summaries. We further examine the effect of provider training level and timeliness of dictation on discharge summary quality.

METHODS

RESULTS

Enrollment and Study Sample

A total of 3743 patients over 64 years old were discharged home from the medical service at YNHH during the study period; 3028 patients were screened for eligibility within 24 hours of admission. We identified 635 eligible admissions and enrolled 395 patients (62.2%) in the study. Of these, 377 granted permission for chart review and were included in this analysis (Figure 1).

Figure 1

The study sample had a mean age of 77.1 years (standard deviation: 7.8); 205 (54.4%) were male and 310 (82.5%) were non‐Hispanic white. A total of 195 (51.7%) had ACS, 91 (24.1%) had pneumonia, and 146 (38.7%) had HF; 54 (14.3%) patients had more than 1 qualifying condition. There were similar numbers of patients on the cardiology, medicine housestaff, and medicine hospitalist teams (Table 1).

Table 1.Study Sample Characteristics (N=377)

Characteristic	N (%) or Mean (SD)
NOTE: Abbreviations: APRN, advanced practice registered nurse; N=number of study participants; GED, general educational development; SD=standard deviation.
Condition
Acute coronary syndrome	195 (51.7)
Community‐acquired pneumonia	91 (24.1)
Heart failure	146 (38.7)
Training level of summary dictator
APRN	140 (37.1)
House staff	123 (32.6)
Hospitalist	114 (30.2)
Length of stay, mean, d	3.5 (2.5)
Total number of medications	8.9 (3.3)
Identify a usual source of care	360 (96.0)
Age, mean, y	77.1 (7.8)
Male	205 (54.4)
English‐speaking	366 (98.1)
Race/ethnicity
Non‐Hispanic white	310 (82.5)
Non‐Hispanic black	44 (11.7)
Hispanic	15 (4.0)
Other	7 (1.9)
High school graduate or GED Admission source	268 (73.4)
Emergency department	248 (66.0)
Direct transfer from hospital or nursing facility	94 (25.0)
Direct admission from office	34 (9.0)

DISCUSSION

In this prospective single‐site study of medical patients with 3 common conditions, we found that discharge summaries were completed relatively promptly, but were often not sent to the appropriate outpatient physicians. We also found that summaries were uniformly excellent at providing details of the hospitalization, but less reliable at providing details relevant to transitional care such as the patient's condition on discharge or existence of pending tests. On average, summaries included 57% of the elements included in consensus guidelines by 6 major medical societies. The content of discharge summaries dictated by hospitalists was slightly more comprehensive than that of APRNs and trainees, but no group exhibited high performance. In fact, not one discharge summary fully met all 3 quality criteria of timeliness, transmission, and content.

Our study, unlike most in the field, focused on multiple dimensions of discharge summary quality simultaneously. For instance, previous studies have found that timely receipt of a discharge summary does not reduce readmission rates.[11, 14, 15] Yet, if the content of the discharge summary is inadequate for postdischarge care, the summary may not be useful even if it is received by the follow‐up visit. Conversely, high‐quality content is ineffective if the summary is not sent to the outpatient physician.

This study suggests several avenues for improving summary quality. Timely discharge summaries in this study were more likely to include key content and to be transmitted to the appropriate physician. Strategies to improve discharge summary quality should therefore prioritize timely summaries, which can be expected to have downstream benefits for other aspects of quality. Some studies have found that templates improve discharge summary content.[22] In our institution, a template exists, but it favors a hospitalization‐focused rather than transition‐focused approach to the discharge summary. For instance, it includes instructions to dictate the admission exam, but not the discharge exam. Thus, designing templates specifically for transitional care is key. Maximizing capabilities of electronic records may help; many content elements that were commonly missing (e.g., pending results, discharge vitals, discharge weight) could be automatically inserted from electronic records. Likewise, automatic transmission of the summary to care providers listed in the electronic record might ameliorate many transmission failures. Some efforts have been made to convert existing electronic data into discharge summaries.[23, 24, 25] However, these activities are very preliminary, and some studies have found the quality of electronic summaries to be lower than dictated or handwritten summaries.[26] As with all automated or electronic applications, it will be essential to consider workflow, readability, and ability to synthesize information prior to adoption.

Hospitalists consistently produced highest‐quality summaries, even though they did not receive explicit training, suggesting experience may be beneficial,[27, 28, 29] or that the hospitalist community focus on transitional care has been effective. In addition, hospitalists at our institution explicitly prioritize timely and comprehensive discharge dictations, because their business relies on maintaining good relationships with outpatient physicians who contract for their services. Housestaff and APRNs have no such incentives or policies; rather, they typically consider discharge summaries to be a useful source of patient history at the time of an admission or readmission. Other academic centers have found similar results.[6, 16] Nonetheless, even though hospitalists had slightly better performance in our study, large gaps in the quality of summaries remained for all groups including hospitalists.

This study has several limitations. First, as a single‐site study at an academic hospital, it may not be generalizable to other hospitals or other settings. It is noteworthy, however, that the average time to dictation in this study was much lower than that of other studies,[4, 14, 30, 31, 32] suggesting that practices at this institution are at least no worse and possibly better than elsewhere. Second, although there are some mandates and expert opinion‐based guidelines for discharge summary content, there is no validated evidence base to confirm what content ought to be present in discharge summaries to improve patient outcomes. Third, we had too few readmissions in the dataset to have enough power to determine whether discharge summary content, timeliness, or transmission predicts readmission. Fourth, we did not determine whether the information in discharge summaries was accurate or complete; we merely assessed whether it was present. For example, we gave every discharge summary full credit for including discharge medications because they are automatically appended. Yet medication reconciliation errors at discharge are common.[33, 34] In fact, in the DISCHARGE study cohort, more than a quarter of discharge medication lists contained a suspected error.[35]

In summary, this study demonstrated the inadequacy of the contemporary discharge summary for conveying information that is critical to the transition from hospital to home. It may be that hospital culture treats hospitalizations as discrete and self‐contained events rather than as components of a larger episode of care. As interest in reducing readmissions rises, reframing the discharge summary to serve as a transitional tool and targeting it for quality assessment will likely be necessary.

Disclosures

At the time this study was conducted, Dr. Horwitz was supported by the CTSA Grant UL1 RR024139 and KL2 RR024138 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), and NIH roadmap for Medical Research, and was a Centers of Excellence Scholar in Geriatric Medicine by the John A. Hartford Foundation and the American Federation for Aging Research. Dr. Horwitz is now supported by the National Institute on Aging (K08 AG038336) and by the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program. This work was also supported by a grant from the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (P30AG021342 NIH/NIA). Dr. Krumholz is supported by grant U01 HL105270‐01 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute. No funding source had any role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Aging, the National Center for Advancing Translational Sciences, the National Institutes of Health, The John A. Hartford Foundation, the National Heart, Lung, and Blood Institute, or the American Federation for Aging Research. Dr. Horwitz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. An earlier version of this work was presented as an oral presentation at the Society of General Internal Medicine Annual Meeting in Orlando, Florida on May 12, 2012. Dr. Krumholz chairs a cardiac scientific advisory board for UnitedHealth. Dr. Krumholz receives support from the Centers of Medicare and Medicaid Services (CMS) to develop and maintain performance measures that are used for public reporting, including readmission measures.

Histogram of days between discharge and dictation

Hospitalized patients are often cared for by physicians who do not follow them in the community, creating a discontinuity of care that must be bridged through communication. This communication between inpatient and outpatient physicians occurs, in part via a discharge summary, which is intended to summarize events during hospitalization and prepare the outpatient physician to resume care of the patient. Yet, this form of communication has long been problematic.[1, 2, 3] In a 1960 study, only 30% of discharge letters were received by the primary care physician within 48 hours of discharge.[1]

More recent studies have shown little improvement. Direct communication between hospital and outpatient physicians is rare, and discharge summaries are still largely unavailable at the time of follow‐up.[4] In 1 study, primary care physicians were unaware of 62% of laboratory tests or study results that were pending on discharge,[5] in part because this information is missing from most discharge summaries.[6] Deficits such as these persist despite the fact that the rate of postdischarge completion of recommended tests, referrals, or procedures is significantly increased when the recommendation is included in the discharge summary.[7]

Regulatory mandates for discharge summaries from the Centers for Medicare and Medicaid Services[8] and from The Joint Commission[9] appear to be generally met[10, 11]; however, these mandates have no requirements for timeliness stricter than 30 days, do not require that summaries be transmitted to outpatient physicians, and do not require several content elements that might be useful to outside physicians such as condition of the patient at discharge, cognitive and functional status, goals of care, or pending studies. Expert opinion guidelines have more comprehensive recommendations,[12, 13] but it is uncertain how widely they are followed.

The existence of a discharge summary does not necessarily mean it serves a patient well in the transitional period.[11, 14, 15] Discharge summaries are a complex intervention, and we do not yet understand the best ways discharge summaries may fulfill needs specific to transitional care. Furthermore, it is uncertain what factors improve aspects of discharge summary quality as defined by timeliness, transmission, and content.[6, 16]

The goal of the DIagnosing Systemic failures, Complexities and HARm in GEriatric discharges study (DISCHARGE) was to comprehensively assess the discharge process for older patients discharged to the community. In this article we examine discharge summaries of patients enrolled in the study to determine the timeliness, transmission to outside physicians, and content of the summaries. We further examine the effect of provider training level and timeliness of dictation on discharge summary quality.

METHODS

RESULTS

Enrollment and Study Sample

A total of 3743 patients over 64 years old were discharged home from the medical service at YNHH during the study period; 3028 patients were screened for eligibility within 24 hours of admission. We identified 635 eligible admissions and enrolled 395 patients (62.2%) in the study. Of these, 377 granted permission for chart review and were included in this analysis (Figure 1).

Figure 1

The study sample had a mean age of 77.1 years (standard deviation: 7.8); 205 (54.4%) were male and 310 (82.5%) were non‐Hispanic white. A total of 195 (51.7%) had ACS, 91 (24.1%) had pneumonia, and 146 (38.7%) had HF; 54 (14.3%) patients had more than 1 qualifying condition. There were similar numbers of patients on the cardiology, medicine housestaff, and medicine hospitalist teams (Table 1).

Table 1.Study Sample Characteristics (N=377)

Characteristic	N (%) or Mean (SD)
NOTE: Abbreviations: APRN, advanced practice registered nurse; N=number of study participants; GED, general educational development; SD=standard deviation.
Condition
Acute coronary syndrome	195 (51.7)
Community‐acquired pneumonia	91 (24.1)
Heart failure	146 (38.7)
Training level of summary dictator
APRN	140 (37.1)
House staff	123 (32.6)
Hospitalist	114 (30.2)
Length of stay, mean, d	3.5 (2.5)
Total number of medications	8.9 (3.3)
Identify a usual source of care	360 (96.0)
Age, mean, y	77.1 (7.8)
Male	205 (54.4)
English‐speaking	366 (98.1)
Race/ethnicity
Non‐Hispanic white	310 (82.5)
Non‐Hispanic black	44 (11.7)
Hispanic	15 (4.0)
Other	7 (1.9)
High school graduate or GED Admission source	268 (73.4)
Emergency department	248 (66.0)
Direct transfer from hospital or nursing facility	94 (25.0)
Direct admission from office	34 (9.0)

DISCUSSION

In this prospective single‐site study of medical patients with 3 common conditions, we found that discharge summaries were completed relatively promptly, but were often not sent to the appropriate outpatient physicians. We also found that summaries were uniformly excellent at providing details of the hospitalization, but less reliable at providing details relevant to transitional care such as the patient's condition on discharge or existence of pending tests. On average, summaries included 57% of the elements included in consensus guidelines by 6 major medical societies. The content of discharge summaries dictated by hospitalists was slightly more comprehensive than that of APRNs and trainees, but no group exhibited high performance. In fact, not one discharge summary fully met all 3 quality criteria of timeliness, transmission, and content.

Our study, unlike most in the field, focused on multiple dimensions of discharge summary quality simultaneously. For instance, previous studies have found that timely receipt of a discharge summary does not reduce readmission rates.[11, 14, 15] Yet, if the content of the discharge summary is inadequate for postdischarge care, the summary may not be useful even if it is received by the follow‐up visit. Conversely, high‐quality content is ineffective if the summary is not sent to the outpatient physician.

This study suggests several avenues for improving summary quality. Timely discharge summaries in this study were more likely to include key content and to be transmitted to the appropriate physician. Strategies to improve discharge summary quality should therefore prioritize timely summaries, which can be expected to have downstream benefits for other aspects of quality. Some studies have found that templates improve discharge summary content.[22] In our institution, a template exists, but it favors a hospitalization‐focused rather than transition‐focused approach to the discharge summary. For instance, it includes instructions to dictate the admission exam, but not the discharge exam. Thus, designing templates specifically for transitional care is key. Maximizing capabilities of electronic records may help; many content elements that were commonly missing (e.g., pending results, discharge vitals, discharge weight) could be automatically inserted from electronic records. Likewise, automatic transmission of the summary to care providers listed in the electronic record might ameliorate many transmission failures. Some efforts have been made to convert existing electronic data into discharge summaries.[23, 24, 25] However, these activities are very preliminary, and some studies have found the quality of electronic summaries to be lower than dictated or handwritten summaries.[26] As with all automated or electronic applications, it will be essential to consider workflow, readability, and ability to synthesize information prior to adoption.

Hospitalists consistently produced highest‐quality summaries, even though they did not receive explicit training, suggesting experience may be beneficial,[27, 28, 29] or that the hospitalist community focus on transitional care has been effective. In addition, hospitalists at our institution explicitly prioritize timely and comprehensive discharge dictations, because their business relies on maintaining good relationships with outpatient physicians who contract for their services. Housestaff and APRNs have no such incentives or policies; rather, they typically consider discharge summaries to be a useful source of patient history at the time of an admission or readmission. Other academic centers have found similar results.[6, 16] Nonetheless, even though hospitalists had slightly better performance in our study, large gaps in the quality of summaries remained for all groups including hospitalists.

This study has several limitations. First, as a single‐site study at an academic hospital, it may not be generalizable to other hospitals or other settings. It is noteworthy, however, that the average time to dictation in this study was much lower than that of other studies,[4, 14, 30, 31, 32] suggesting that practices at this institution are at least no worse and possibly better than elsewhere. Second, although there are some mandates and expert opinion‐based guidelines for discharge summary content, there is no validated evidence base to confirm what content ought to be present in discharge summaries to improve patient outcomes. Third, we had too few readmissions in the dataset to have enough power to determine whether discharge summary content, timeliness, or transmission predicts readmission. Fourth, we did not determine whether the information in discharge summaries was accurate or complete; we merely assessed whether it was present. For example, we gave every discharge summary full credit for including discharge medications because they are automatically appended. Yet medication reconciliation errors at discharge are common.[33, 34] In fact, in the DISCHARGE study cohort, more than a quarter of discharge medication lists contained a suspected error.[35]

In summary, this study demonstrated the inadequacy of the contemporary discharge summary for conveying information that is critical to the transition from hospital to home. It may be that hospital culture treats hospitalizations as discrete and self‐contained events rather than as components of a larger episode of care. As interest in reducing readmissions rises, reframing the discharge summary to serve as a transitional tool and targeting it for quality assessment will likely be necessary.

Disclosures

At the time this study was conducted, Dr. Horwitz was supported by the CTSA Grant UL1 RR024139 and KL2 RR024138 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), and NIH roadmap for Medical Research, and was a Centers of Excellence Scholar in Geriatric Medicine by the John A. Hartford Foundation and the American Federation for Aging Research. Dr. Horwitz is now supported by the National Institute on Aging (K08 AG038336) and by the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program. This work was also supported by a grant from the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (P30AG021342 NIH/NIA). Dr. Krumholz is supported by grant U01 HL105270‐01 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute. No funding source had any role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Aging, the National Center for Advancing Translational Sciences, the National Institutes of Health, The John A. Hartford Foundation, the National Heart, Lung, and Blood Institute, or the American Federation for Aging Research. Dr. Horwitz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. An earlier version of this work was presented as an oral presentation at the Society of General Internal Medicine Annual Meeting in Orlando, Florida on May 12, 2012. Dr. Krumholz chairs a cardiac scientific advisory board for UnitedHealth. Dr. Krumholz receives support from the Centers of Medicare and Medicaid Services (CMS) to develop and maintain performance measures that are used for public reporting, including readmission measures.

Histogram of days between discharge and dictation

Hospitalized patients are often cared for by physicians who do not follow them in the community, creating a discontinuity of care that must be bridged through communication. This communication between inpatient and outpatient physicians occurs, in part via a discharge summary, which is intended to summarize events during hospitalization and prepare the outpatient physician to resume care of the patient. Yet, this form of communication has long been problematic.[1, 2, 3] In a 1960 study, only 30% of discharge letters were received by the primary care physician within 48 hours of discharge.[1]

More recent studies have shown little improvement. Direct communication between hospital and outpatient physicians is rare, and discharge summaries are still largely unavailable at the time of follow‐up.[4] In 1 study, primary care physicians were unaware of 62% of laboratory tests or study results that were pending on discharge,[5] in part because this information is missing from most discharge summaries.[6] Deficits such as these persist despite the fact that the rate of postdischarge completion of recommended tests, referrals, or procedures is significantly increased when the recommendation is included in the discharge summary.[7]

Regulatory mandates for discharge summaries from the Centers for Medicare and Medicaid Services[8] and from The Joint Commission[9] appear to be generally met[10, 11]; however, these mandates have no requirements for timeliness stricter than 30 days, do not require that summaries be transmitted to outpatient physicians, and do not require several content elements that might be useful to outside physicians such as condition of the patient at discharge, cognitive and functional status, goals of care, or pending studies. Expert opinion guidelines have more comprehensive recommendations,[12, 13] but it is uncertain how widely they are followed.

The existence of a discharge summary does not necessarily mean it serves a patient well in the transitional period.[11, 14, 15] Discharge summaries are a complex intervention, and we do not yet understand the best ways discharge summaries may fulfill needs specific to transitional care. Furthermore, it is uncertain what factors improve aspects of discharge summary quality as defined by timeliness, transmission, and content.[6, 16]

The goal of the DIagnosing Systemic failures, Complexities and HARm in GEriatric discharges study (DISCHARGE) was to comprehensively assess the discharge process for older patients discharged to the community. In this article we examine discharge summaries of patients enrolled in the study to determine the timeliness, transmission to outside physicians, and content of the summaries. We further examine the effect of provider training level and timeliness of dictation on discharge summary quality.

METHODS

RESULTS

Enrollment and Study Sample

A total of 3743 patients over 64 years old were discharged home from the medical service at YNHH during the study period; 3028 patients were screened for eligibility within 24 hours of admission. We identified 635 eligible admissions and enrolled 395 patients (62.2%) in the study. Of these, 377 granted permission for chart review and were included in this analysis (Figure 1).

Figure 1

The study sample had a mean age of 77.1 years (standard deviation: 7.8); 205 (54.4%) were male and 310 (82.5%) were non‐Hispanic white. A total of 195 (51.7%) had ACS, 91 (24.1%) had pneumonia, and 146 (38.7%) had HF; 54 (14.3%) patients had more than 1 qualifying condition. There were similar numbers of patients on the cardiology, medicine housestaff, and medicine hospitalist teams (Table 1).

Table 1.Study Sample Characteristics (N=377)

Characteristic	N (%) or Mean (SD)
NOTE: Abbreviations: APRN, advanced practice registered nurse; N=number of study participants; GED, general educational development; SD=standard deviation.
Condition
Acute coronary syndrome	195 (51.7)
Community‐acquired pneumonia	91 (24.1)
Heart failure	146 (38.7)
Training level of summary dictator
APRN	140 (37.1)
House staff	123 (32.6)
Hospitalist	114 (30.2)
Length of stay, mean, d	3.5 (2.5)
Total number of medications	8.9 (3.3)
Identify a usual source of care	360 (96.0)
Age, mean, y	77.1 (7.8)
Male	205 (54.4)
English‐speaking	366 (98.1)
Race/ethnicity
Non‐Hispanic white	310 (82.5)
Non‐Hispanic black	44 (11.7)
Hispanic	15 (4.0)
Other	7 (1.9)
High school graduate or GED Admission source	268 (73.4)
Emergency department	248 (66.0)
Direct transfer from hospital or nursing facility	94 (25.0)
Direct admission from office	34 (9.0)

DISCUSSION

In this prospective single‐site study of medical patients with 3 common conditions, we found that discharge summaries were completed relatively promptly, but were often not sent to the appropriate outpatient physicians. We also found that summaries were uniformly excellent at providing details of the hospitalization, but less reliable at providing details relevant to transitional care such as the patient's condition on discharge or existence of pending tests. On average, summaries included 57% of the elements included in consensus guidelines by 6 major medical societies. The content of discharge summaries dictated by hospitalists was slightly more comprehensive than that of APRNs and trainees, but no group exhibited high performance. In fact, not one discharge summary fully met all 3 quality criteria of timeliness, transmission, and content.

Our study, unlike most in the field, focused on multiple dimensions of discharge summary quality simultaneously. For instance, previous studies have found that timely receipt of a discharge summary does not reduce readmission rates.[11, 14, 15] Yet, if the content of the discharge summary is inadequate for postdischarge care, the summary may not be useful even if it is received by the follow‐up visit. Conversely, high‐quality content is ineffective if the summary is not sent to the outpatient physician.

This study suggests several avenues for improving summary quality. Timely discharge summaries in this study were more likely to include key content and to be transmitted to the appropriate physician. Strategies to improve discharge summary quality should therefore prioritize timely summaries, which can be expected to have downstream benefits for other aspects of quality. Some studies have found that templates improve discharge summary content.[22] In our institution, a template exists, but it favors a hospitalization‐focused rather than transition‐focused approach to the discharge summary. For instance, it includes instructions to dictate the admission exam, but not the discharge exam. Thus, designing templates specifically for transitional care is key. Maximizing capabilities of electronic records may help; many content elements that were commonly missing (e.g., pending results, discharge vitals, discharge weight) could be automatically inserted from electronic records. Likewise, automatic transmission of the summary to care providers listed in the electronic record might ameliorate many transmission failures. Some efforts have been made to convert existing electronic data into discharge summaries.[23, 24, 25] However, these activities are very preliminary, and some studies have found the quality of electronic summaries to be lower than dictated or handwritten summaries.[26] As with all automated or electronic applications, it will be essential to consider workflow, readability, and ability to synthesize information prior to adoption.

Hospitalists consistently produced highest‐quality summaries, even though they did not receive explicit training, suggesting experience may be beneficial,[27, 28, 29] or that the hospitalist community focus on transitional care has been effective. In addition, hospitalists at our institution explicitly prioritize timely and comprehensive discharge dictations, because their business relies on maintaining good relationships with outpatient physicians who contract for their services. Housestaff and APRNs have no such incentives or policies; rather, they typically consider discharge summaries to be a useful source of patient history at the time of an admission or readmission. Other academic centers have found similar results.[6, 16] Nonetheless, even though hospitalists had slightly better performance in our study, large gaps in the quality of summaries remained for all groups including hospitalists.

This study has several limitations. First, as a single‐site study at an academic hospital, it may not be generalizable to other hospitals or other settings. It is noteworthy, however, that the average time to dictation in this study was much lower than that of other studies,[4, 14, 30, 31, 32] suggesting that practices at this institution are at least no worse and possibly better than elsewhere. Second, although there are some mandates and expert opinion‐based guidelines for discharge summary content, there is no validated evidence base to confirm what content ought to be present in discharge summaries to improve patient outcomes. Third, we had too few readmissions in the dataset to have enough power to determine whether discharge summary content, timeliness, or transmission predicts readmission. Fourth, we did not determine whether the information in discharge summaries was accurate or complete; we merely assessed whether it was present. For example, we gave every discharge summary full credit for including discharge medications because they are automatically appended. Yet medication reconciliation errors at discharge are common.[33, 34] In fact, in the DISCHARGE study cohort, more than a quarter of discharge medication lists contained a suspected error.[35]

In summary, this study demonstrated the inadequacy of the contemporary discharge summary for conveying information that is critical to the transition from hospital to home. It may be that hospital culture treats hospitalizations as discrete and self‐contained events rather than as components of a larger episode of care. As interest in reducing readmissions rises, reframing the discharge summary to serve as a transitional tool and targeting it for quality assessment will likely be necessary.

Disclosures

At the time this study was conducted, Dr. Horwitz was supported by the CTSA Grant UL1 RR024139 and KL2 RR024138 from the National Center for Advancing Translational Sciences (NCATS), a component of the National Institutes of Health (NIH), and NIH roadmap for Medical Research, and was a Centers of Excellence Scholar in Geriatric Medicine by the John A. Hartford Foundation and the American Federation for Aging Research. Dr. Horwitz is now supported by the National Institute on Aging (K08 AG038336) and by the American Federation for Aging Research through the Paul B. Beeson Career Development Award Program. This work was also supported by a grant from the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (P30AG021342 NIH/NIA). Dr. Krumholz is supported by grant U01 HL105270‐01 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute. No funding source had any role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute on Aging, the National Center for Advancing Translational Sciences, the National Institutes of Health, The John A. Hartford Foundation, the National Heart, Lung, and Blood Institute, or the American Federation for Aging Research. Dr. Horwitz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. An earlier version of this work was presented as an oral presentation at the Society of General Internal Medicine Annual Meeting in Orlando, Florida on May 12, 2012. Dr. Krumholz chairs a cardiac scientific advisory board for UnitedHealth. Dr. Krumholz receives support from the Centers of Medicare and Medicaid Services (CMS) to develop and maintain performance measures that are used for public reporting, including readmission measures.

Histogram of days between discharge and dictation