Dialogue: Communication at discharge

Lee W. Roof, ACP Member, a primary care internist, and Dawn Brezina, ACP Member, a hospitalist, offer their perspectives on how hospitalists and PCPs can improve communication during handoffs at discharge.

The PCP's perspective: Improvements needed in technology, personnel

Lee W. Roof, ACP Member

Dr Roof is a primary care internist a part-time hospitalist and medical director for quality improvement at Whidbey General Hospital in Coupeville Wash
Dr. Roof is a primary care internist, a part-time hospitalist and medical director for quality improvement at Whidbey General Hospital in Coupeville, Wash.

A patient in his 80s with a history of myocardial infarction with cardiac arrest, ischemic cardiomyopathy and coronary artery bypass grafting presented to his PCP with fevers and an exudative pleural effusion. Once it became apparent that parenteral antibiotics and tapping the effusion dry would not resolve his problem, he was referred to a medical center for thoracoscopy.

The PCP's next contact with the patient was at an office visit weeks later, a few days after his discharge. He was on parenteral antibiotics by a home infusion service, oral antibiotics (for which he received no written prescription) and a warfarin program for new-onset atrial fibrillation. He had no specific instructions as to when to follow up his protime. The PCP's office staff had to request discharge papers from the hospital.

This true vignette illuminates two crucial areas of communication problems between the hospitalist service and the PCP ultimately responsible for a patient's follow-up care.

The first problem is system failure. Hospitals need to set up a systematic method of communication from the inpatient setting. Computer-generated admission notes, progress notes, operative notes and discharge summaries should be tied to the PCP's name, and every note should be automatically forwarded to the PCP. Simple computer programming documenting the referring PCP should make this happen without the inpatient physician's direct involvement and instruction.

Autofaxing would allow such notes to be deposited routinely on PCPs' desks. PCPs could then follow up on the immediate issues and contact the hospitalist about issues requiring input. The time of discharge is the most critical for this communication piece. Systems need to be instituted to forward current information to the PCP immediately. Faxing the patient's discharge instruction sheet to the PCP would let the PCP know that the patient is back home and that a medical plan has been set up by the hospitalist service. The PCP can then proactively contact the patient and make sure there are no problems before the next office visit.

The second area involves physicians themselves. Discharging any patient, particularly one who is medically unsophisticated, elderly or cognitively impaired, should be considered a “high-risk” procedure. The discharging hospitalist should assess this risk and in turn attempt to contact the outpatient PCP on the day of discharge or, failing that, should make arrangements for communication on the next convenient occasion. The office-based physician should stress to his or her employees the importance of phone calls from the hospitalist and, in turn, take such calls promptly.

A caring physician, be that a hospitalist, an office-based physician or a combination of both, should ultimately insist on good two-way communication for the benefit of the patient.

The hospitalist's perspective: Flexibility can help

Dawn Brezina, ACP Member

Dr Brezina is a hospitalist at Durham Regional Hospital in Durham NC
Dr. Brezina is a hospitalist at Durham Regional Hospital in Durham, N.C.

Good communication with the PCP at discharge is imperative to ensuring a seamless transition home. The PCP must know the result of the diagnostic evaluation, what was done, what discharge medications were prescribed and any part of the workup or labs that is still pending. A study in the July/August issue of the Journal of Hospital Medicine reported that only 14% of discharge summaries and 53% of discharge letters were available to PCPs at a follow-up visit one week after discharge.

At our institution, discharge summaries are dictated and available in the computer within 24 hours for any practice that has a connected computer system. For PCPs who don't use this type of system, there is a low-tech solution: An audio version of the admission or discharge dictation can be accessed by telephone as soon as it is completed, even before it has been transcribed. This is a good method of making information accessible, but it is not widely utilized in my community. Education efforts to make PCPs more aware of this option may significantly improve communication.

After a patient is discharged, in-person or phone conversations with the PCP would be ideal. However, hospitalists can spend an inordinate amount of time calling PCPs' offices. In my experience, it's not uncommon, after holding for 10 to 15 minutes, to be cut off with an automated message: “Goodbye.”

Email is a fast and easy way to communicate, and many hospitalists would be agreeable to using it. However, it's sometimes difficult to get PCPs to commit to consistently checking their messages every 24 to 48 hours, and some doctors in our community don't want to use email. Other limitations include concerns about privacy issues, particularly when commercial vendors are involved, and the fact that email addresses change frequently.

The gold standard for seamless transitions is a systemwide electronic medical record. If a patient is admitted to our hospital from a PCP in our system, his or her entire medical record is available online. When the patient is discharged, the admission history and physical, all consults and labs, and the discharge summary are online within 24 hours. Despite best efforts, however, universal EMRs will not be an option for some time.

If all else fails, a backup option is to use the discharge instruction sheet that is given to the patient. A designated small box—identified as “To the doctor”—could be used to document the primary diagnosis during the hospitalization and immediate issues that need to be followed up (e.g., “Check potassium” or “Needs f/up CXR”). I often squeeze this information into the margin of the discharge sheet and tell the patient to be sure to take it to the follow-up doctor visit. A hand-carried message is probably as close as we can come to foolproof information transfer at discharge—providing the patient does not forget to take the sheet.

In a system with shared electronic capability, information is readily available. But for most communities with multiple private practices, ensuring appropriate communication at the time of discharge requires a variety of methods—and considerable redundancy.