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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5537_Библиотеки_им_академика_М_И_Перельмана.pdf
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Patient Safety and Hospital Quality
https://avxhm.se/blogs/hill0
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Doctor to Doctor Communication
Brian A. Markoff *
Key Pearls
• The transition between the inpatient and outpatient venues puts
patients at risk for adverse events.
• Communication between inpatient and outpatient physicians is poor
despite the known risk of transition errors.
• Barriers to communication include lack of time, lack of perceived
benefit, and inability to identify primary care physicians (PCPs).
• Key principles of communication include accountability, timeliness,
inclusion of patient and family wishes, identification of and respect
for the patient’s medical home, and clear delineation of responsibility
of care at each step of the care continuum.
• Hospitalists need to be diligent and creative to improve communica-
tion with PCPs.
Background
Transitions of care entail inherent risks and jeopardize patient outcomes.
Poor transitions can affect patient safety, compliance with treatment, and
outcomes. As more and more primary care physicians (PCP) rely on
hospitalists to care for their patients when they are hospitalized, the need
for excellent communication at times of transitions has never been more
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5
Chapter
*Mount Sinai School of Medicine, New York, NY, USA.
https://avxhm.se/blogs/hill0
critical. Unfortunately, the known need for high-quality transitions has not
improved communication between inpatient and outpatient providers.
1
Multiple studies have shown that patients are at increased risk for
adverse events in the immediate period after discharge from the hospital.
One in five experiences an adverse event related to medical management.
2
In addition, 40% of patients have test results pending at the time of discharge, 9% of which require action by a provider; and 45% of outpatient
physicians are not aware of these results.
3
Medication discrepancies are common and lead to increased readmissions.
4
Overall, almost half of all patients experience an error in test
follow-up, diagnostic workup, and medication continuity.
5
A study using
patient interviews two weeks post-discharge found 42% of elderly
patients had at least one problem during this time frame. The most common problem was with obtaining follow-up tests and follow-up appointments. Also common was difficulty obtaining medications and treatments.
Many patients also felt ill-prepared for discharge. In the same study,
patients whose primary physicians were unaware of their hospitalization,
were two times more likely to report post-discharge issues.
6
Communication Standards
The discharge summary is one standard way for inpatient and outpatient
providers to communicate. However, numerous studies have shown that
these summaries are less then ideal, either because of a lack of timeliness
or a lack of key information.
1
Chapter 10 discusses the essential elements
of discharge summaries in detail.
Communication directly from inpatient to outpatient physician may
ameliorate much of the risk during the transition period. However,
direct communication is poor, with only 23% of PCPs receiving any
direct communication from an inpatient physician during a given hospitalization,
7
and 20% or less being notified about discharges.8These
studies and many others suggest that poor communication between
inpatient and outpatient physicians is the standard of care for many
patients.
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B.A. Markoff
Why are inpatient physicians so poor at communication with outpatient physicians? Three barriers have been identified — perceived lack of
benefit, lack of time, and inability to identify who to contact.
9
A lack of
understanding of the importance of transitions in patient care is a significant barrier, as physicians will not invest the time and effort to ensure satisfactory communication when they are unconvinced or unaware of the
benefit to their patents. Technology has the potential to improve communication through the use of electronic health records, email, text messaging, facsimiles, and cell phones. Though none of these methods will alter
the lack of importance many hospital physicians place on communication
with the outpatient provider, they may change behavior by making communication easier and more seamlessly integrated into the workflow.
In light of the above realities, six national physician groups came
together for the Transitions of Care Consensus Conference (TOCCC). The
TOCCC led to a consensus statement on how to improve communication
across the continuum of care.
10
The basic principles highlighted include:
• Accountability
• Communication
• Timeliness
• Inclusion of patient and family
• Identification of and respect for the patient’s medical home
• Clear delineation of responsibility of care at each step of the care
continuum
The statement sets standards for multiple aspects of transitions of care
(see Table 1).
Studies have shown that improving the quality of transitions can
improve outcomes, though these studies typically involved comprehensive
interventions utilizing multifaceted transition teams.
11
A structured discharge toolkit was also shown to decrease emergency department visits and
30-day readmissions in elderly patients.
13
To date, there is limited data on
whether simple, direct physician to physician communication alone can
improve outcomes. Bell et al. looked at a composite outcome of 30-day
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Doctor to Doctor Communication
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60
B.A. Markoff
Table 1. Standards for Safe Transitions form the Transitions of Care Consensus
Conference
Standard Key Elements
Care Plans/Transition Record Data • Principle diagnosis/ Problem list
• Medication list
• Medical home with contact information
• Cognitive status
• Test results/pending results
Communication Infrastructure • Secure/HIPPA compliant
• Two way with opportunity for clarification/
feedback
• Include core dataset
• Updateable database
• Available prior to arrival
• Medication list for patients
Standard Communication Formats • Standard data transfer forms
• Medical history accessible and modifiable
• Patient/family accessible
• Include patients’ preferences, goals, and
values (code status, etc.)
Transition Responsibility • Sending provider/institution responsible until
transfer of responsibility is confirmed
• Sending provider available for clarification
• Patient should be able to identify responsible
provider
• Hospital provider will not be required to assume
responsibility after discharge for patients without
a medical home
Timeliness • Timeliness of information contingent on setting,
circumstances, acuity, and responsibility
• Information available at time of patient encounter
Community Standards • Medical communities/institutions must
be accountable for the quality of transitions
Measurement • Standardized metrics should be monitored
• Continuing transitions improvement based on
metrics
mortality, readmission rate, and emergency department use and tried to correlate these with inpatient to primary care physician communication. In
their study, 77% of PCPs were aware of the index admission but only 23%
had direct communication with the medicine service. Only 42% of PCPs
received a discharge summary within two weeks of discharge. The composite outcome was similar in both groups (22% when the PCP was aware
of the hospitalization and 20% when unaware).
7
This suggests that the quality of communication may be a more important factor than simply whether
communication took place.
Systematic Approaches
Innovative and aggressive approaches to facilitate and foster communication are needed. Audits, feedback, and incentives for timely and complete
discharge summaries can be implemented. Documentation of communication with PCPs may also be beneficial. Periodic surveys of outpatient
physicians on the communication practices of individual hospitalists and
the hospitalist group as a whole can be done and physicians made aware
of their own performance relative to the group. Another approach is to use
administrative staff as physician liaisons, which may include sending outpatient physicians the name and contact information of the treating hospitalist or alternatively, providing the hospitalist with contact information
for the outpatient physician. Improving direct availability and access to
inpatient physicians by PCPs, such as via Internet access and dissemination of cell phone numbers, can be helpful. Maximizing the use of electronic communication and electronic medical records to facilitate
communication across venues is needed. Lastly, emphasizing the benefit
and added value of direct communication to all physicians is essential.
Conclusions
The growing use of hospitalists is one cause of the discontinuity in patient
care. Though current systems make communication difficult, the burden is
on hospitalists to ensure communication is suitable at all transition points.
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Doctor to Doctor Communication
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Hospitalist groups should seek out ways to facilitate quality communication
for every patient, including enhanced use of advanced electronic solutions
and producing a culture that recognizes the value of a simple telephone call.
References
1. Kripalani S, LeFevre F, Phillips CO, et al. (2007) Deficits in commu-
nication and information transfer between hospital-based and primary
care physicians. JAMA 297: 831–841.
2. Forster AJ, Murff HJ, Peterson JF, et al. (2003) The incidence and
severity of adverse events affecting patients after discharge from the
hospital. Ann Intern Med 138: 161–167.
3. Roy CL, Poon EG, Karson AS, et al. (2005) Improving patient care:
patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med 143: 121–128.
4. Coleman EA, Smith JD, Raha D, Min SJ. (2005) Posthospital medication discrepancies: Prevalence and contributing factors. Arch
Intern Med 165: 1842–1847.
5. Moore C, Wisnivesky J, Williams S, McGinn T. (2003) Medical errors
related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 18: 646–651.
6. Arora VM, Prochaska ML, Farnan JM, et al. (2010) Problems after
discharge and understanding of communication with their primary
care physicians among hospitalized seniors: a mixed methods study.
J Hosp Med 5: 385–391.
7. Bell CM, Schnipper JL, Auerbach AD, et al. (2009) Association of
communication between hospital-based physicians and primary care
providers with patient outcomes. J Gen Intern Med 24: 381–386.
8. Pantilat SZ, Lindenauer PK, Katz PP, Wachter RM. (2001) Primary
care physician attitudes regarding communication with hospitalists.
Am J Med 111: 15S–20S.
9. Roy CL, Kachalia A, Woolf S, et al. (2009) Hospital readmissions:
Physician awareness and communication practices. J Gen Intern Med
24: 374–380.
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10. Snow V, Beck D, Budnitz T, et al. (2009) 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 PhysiciansSociety of Academic Emergency Medicine. J Gen Intern Med 24:
971–976.
11. Coleman EA, Parry C, Chalmers S, Min SJ. (2006) The care transitions intervention: Results of a randomized controlled trial. Arch
Intern Med 166: 1822–1828.
12. Jack BW, Chetty VK, Anthony D, et al. (2009) A reengineered hospi-
tal discharge program to decrease rehospitalization: A randomized
trial. Ann Intern Med 150: 178–187.
13. Dedhia P, Kravet S, Bulger J, et al. (2009) A quality improvement
intervention to facilitate the transition of older adults from three hospitals back to their homes. J Am Geriatr Soc 57: 1540–1546.
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