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The effect of workload reduction on the quality of residents' discharge summaries.

ABSTRACT: BACKGROUND: The completeness of hospital discharge summaries may reflect the overall quality of inter-professional communications. The effect of reducing resident workload on clinical performance is largely unknown. OBJECTIVE: We examined the impact of reducing housestaff workload on the quality of discharge summaries, an indicator of clinical performance, as compared to discharge summaries created by trainees on a team with a more typical workload. DESIGN: Patients admitted to a medicine service at a community teaching hospital affiliated with an academic medical center were alternately allocated between a control and intervention care team of residents. First-year residents on the intervention team carried an average census of 3.5 patients compared with 6.6 patients for peers on the control team. A random selection of 142 discharge summaries from a 3-month period were blindly evaluated using a structured tool based on professional documentation standards. PARTICIPANTS: 61 internal medicine residents. MAIN RESULTS: Inter-rater reliability of discharge summary quality was 0.9. Discharge summaries produced by residents on the intervention team with a reduced workload had significantly more of the required elements (74 vs 65%, p<0.001). Intervention team summaries were more frequently complete and contained significantly more of the required elements describing the patient history (65.7% vs 36.1%, p=0.0005), the inpatient narrative (47.1% vs 22.2%, p=0.003), discharge planning (20.0% vs 5.5%, p=0.012), and continuity of care (24.3% vs 6.9%, p=0.005). Fewer than a quarter of the summaries reviewed included discharge instructions, information on follow-up care, or a discharge medication list. CONCLUSIONS: Reducing resident workload can significantly improve discharge summary quality, a measure of resident performance.

SUBMITTER: Coit MH

PROVIDER: S-EPMC3024111 | biostudies-literature | 2011 Jan

REPOSITORIES: biostudies-literature

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The effect of workload reduction on the quality of residents' discharge summaries.

Coit Margaret H MH Katz Joel T JT McMahon Graham T GT

Journal of general internal medicine 20100810 1

<h4>Background</h4>The completeness of hospital discharge summaries may reflect the overall quality of inter-professional communications. The effect of reducing resident workload on clinical performance is largely unknown.<h4>Objective</h4>We examined the impact of reducing housestaff workload on the quality of discharge summaries, an indicator of clinical performance, as compared to discharge summaries created by trainees on a team with a more typical workload.<h4>Design</h4>Patients admitted t ...[more]

PMID: 20697967

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Project description:BackgroundAcute kidney injury (AKI) increases the risk of hospital readmission, chronic kidney disease, and death. Therefore, effective communication in discharge summaries is essential for safe transitions of care.ObjectiveThe objectives of this study were to determine the quality of discharge summaries in AKI survivors and identify predictors of higher quality discharge summaries.DesignRetrospective chart review.SettingTertiary care academic center in Ontario, Canada.PatientsWe examined the discharge summary quality of 300 randomly selected adult patients who survived a hospitalization with AKI at our tertiary care hospital, stratified by AKI severity. We included 150 patients each from 2015 to 2016 and 2018 to 2019, before and after introduction of a post-AKI clinic in 2017.MeasurementsWe reviewed charts for 9 elements of AKI care to create a composite score summarizing discharge summary quality.MethodsWe used multivariable logistic regression to identify predictors of discharge summary quality.ResultsThe median discharge summary composite score was 4/9 (interquartile range, 2-6). The least frequently mentioned elements were baseline creatinine (n = 55, 18%), AKI-specific follow-up labs (n = 66, 22%), and medication recommendations (n = 80, 27%). The odds of having a higher quality discharge summary (composite score ≥4/9) was greater for every increase in baseline creatinine of 25 μmol/L (adjusted odds ratio [aOR]: 1.27; 95% confidence interval [CI]: 1.03, 1.56), intrarenal etiology (aOR: 2.32; 95% CI: 1.26, 4.27), and increased AKI severity (stage 2 aOR: 2.57; 95% CI: 1.35, 4.91 and stage 3 aOR: 3.36; 95% CI: 1.56, 7.22). There was no association between discharge summary quality and the years before and after introduction of a post-AKI clinic (aOR: 0.77; 95% CI: 0.46, 1.29).LimitationsThe single-center study design limits generalizability.ConclusionsMost discharge summaries are missing key AKI elements, even in patients with severe AKI. These gaps suggest several opportunities exist to improve discharge summary communication following AKI.

Project description:BackgroundThe National Institute for Health and Care Excellence recommends documenting all delirium episodes in the discharge summary using the term "delirium". Previous studies demonstrate poor delirium documentation rates in discharge summaries and no studies have assessed delirium documentation quality. The aim of this study was to determine the frequency and quality of delirium documentation in discharge summaries and explore differences between medical and surgical services.MethodsThis was a multi-center retrospective chart review. We included 110 patients aged ≥ 65 years identified to have delirium during their hospitalization using the Chart-based Delirium Identification Instrument (CHART-DEL). We assessed the frequency of any delirium documentation in discharge summaries, and more specifically, for the term "delirium". We evaluated the quality of delirium discharge documentation using the Joint Commission on Accreditation of Healthcare Organization's framework for quality discharge summaries. Comparisons were made between medical and surgical services. Secondary outcomes included assessing factors influencing the frequency of "delirium" being documented in the discharge summary.ResultsWe identified 110 patients with sufficient chart documentation to identify delirium and 80.9 % of patients had delirium documented in their discharge summary ("delirium" or other acceptable term). The specific term "delirium" was reported in 63.6 % of all delirious patients and more often by surgical than medical specialties (76.5 % vs. 52.5 %, p = 0.02). Documentation quality was significantly lower by surgical specialties in reporting delirium as a diagnosis (23.5 % vs. 57.6 %, p < 0.001), documenting delirium workup (23.4 % vs. 57.6 %, p = 0.001), etiology (43.3 % vs. 70.4 %, p = 0.03), treatment (36.7 % vs. 66.7 %, p = 0.02), medication changes (44.4 % vs. 100 %, p = 0.002) and follow-up (36.4 % vs. 88.2 %, p = 0.01).ConclusionsThe frequency of delirium documentation is higher than previously reported but remains subpar. Medical services document delirium with higher quality, but surgical specialties document the term "delirium" more frequently. The documentation of delirium in discharge summaries must improve to meet quality standards.

Project description:Around 110,000 people spend time in critical care units in England and Wales each year. The transition of care from the intensive care unit to the general ward exposes patients to potential harms from changes in healthcare providers and environment. Nurses working on general wards report anxiety and uncertainty when receiving patients from critical care. An innovative form of enhanced capability critical care outreach called 'iMobile' is being provided at King's College Hospital (KCH). Part of the remit of iMobile is to review patients who have been transferred from critical care to general wards. The iMobile team wished to improve the quality of critical care discharge summaries. A collaborative evidence-based quality improvement project was therefore undertaken by the iMobile team at KCH in conjunction with researchers from King's Improvement Science (KIS). Plan, Do, Study, Act (PDSA) methodology was used. Three PDSA cycles were undertaken. Methods adopted comprised: a scoping literature review to identify relevant guidelines and research evidence to inform all aspects of the quality improvement project; a process mapping exercise; informal focus groups / interviews with staff; patient story-telling work with people who had experienced critical care and subsequent discharge to a general ward; and regular audits of the quality of both medical and nursing critical care discharge summaries. The following behaviour change interventions were adopted, taking into account evidence of effectiveness from published systematic reviews and considering the local context: regular audit and feedback of the quality of discharge summaries, feedback of patient experience, and championing and education delivered by local opinion leaders. The audit results were mixed across the trajectory of the project, demonstrating the difficulty of sustaining positive change. This was particularly important as critical care bed occupancy and through-put fluctuates which then impacts on work-load, with new cohorts of staff regularly passing through critical care. In addition to presenting the results of this quality improvement project, we also reflect on the lessons learned and make suggestions for future projects.

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The effect of workload reduction on the quality of residents' discharge summaries.

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The effect of workload reduction on the quality of residents' discharge summaries.

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