Chapter 42. Information Transfer (continued)
Subchapter 42.2. Sign-Out Systems for Cross-Coverage
Background
As physicians go off duty, they provide information to a
"cross-covering" physician who will care for patients in the interim. The
process of information transfer, known as "sign-out," is often informal and
unstructured. Various methods are used, including handwritten lists, PC-based
word processing or spreadsheet programs, and personal digital assistants (PDAs),
but little literature has assessed their effectiveness in assuring continuity of
care for patients and preventing medical errors. Although notes in the medical
record often contain all the information needed to care for patients,
cross-covering physicians make many decisions without the benefit of the
patients' charts.1 Jelley found lack of consistency in the content of
weekend sign-out lists in a community-based internal medicine inpatient
program.1 Lee and colleagues found that medical interns recorded
information elements such as patient age, DNR status, and medications more often
when a standardized sign-out card was used.2 In this section, we
review evidence of a computerized sign-out system to reduce medical errors
during cross-coverage.
Practice Description
The proposed safety practice is a structured sign-out process
in which patient information is provided for various standardized data fields.
The computerized sign-out program described by Peterson and colleagues consisted
of a summary of the patient's medical status, a problem list, recent laboratory
data, resuscitation status, allergies, and a "to do" list.3 This
information was accessible from any computer within the hospital and was
accessed and maintained on a daily basis by housestaff physicians.
Prevalence and Severity of the Target Safety Problem
Discontinuities in provider care during hospitalization have
been associated with an increased risk of adverse events. The Petersen et al
study found the odds ratio for a preventable adverse medical event occurring
during cross-coverage as opposed to regular provider coverage to be 6.1 (95% CI:
1.4-26.7).4 In the surgical domain, the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) publication on wrong-site
surgeries noted a number of cases involving last minute personnel
changes.5 It is possible that these rapid substitutions in the
operating room with inadequate communication may have contributed to these
adverse events.
Opportunities for Impact
The number of hospitals using either a computerized or
paper-based sign-out process is unknown, but computerized sign-outs are probably
unusual. One study found that 26% of adverse events in a single institution
occurred during cross-coverage.4 These data suggest that a
standardized sign-out procedure could have a significant impact on improving
patient safety.
Study Design and Outcomes
We identified one study evaluating the effect of a standardized
sign-out system on the occurrence of adverse events (Table 42.2.1). In this
study, adverse medical events detected by self-report were compared before and
after implementation of a computerized sign-out system (Level 3).3
This study involved internal medicine housestaff and any management of a patient
performed by an intern from a different team or a night-float resident was
considered cross-coverage. During chart review, the investigators recorded
whether the physician at the time of the event was the patient's regular
physician or a cross-covering physician. Adverse medical events, defined as "an
injury due to medical therapy that prolonged hospital stay or disability at
discharge"3 were the primary outcomes (Level 2).
Evidence for Effectiveness of the Practice
There were significantly fewer adverse events during the
intervention period compared with the baseline period (2.38% vs. 3.94%,
p<0.0002). There was also a trend toward fewer preventable adverse events
with the intervention (1.23% vs. 1.72%, p<0.1) but no significant difference
in the rate of preventable events during cross-coverage (0.38% vs. 0.24%,
p>0.10). Using a logistic regression model including factors for Acute
Physiology and Chronic Health Evaluations (APACHE) II scores and alcohol use
(the 2 variables significantly associated with adverse events during the
intervention period), the authors calculated the odds ratio for a patient to
experience an adverse medical event during cross-coverage in the baseline period
to be 5.2 (95% CI: 1.5-18.2).
After implementation, the odds ratio for a cross-coverage
adverse event was no longer statistically significant (OR 1.5, 95% CI:
0.2-9.0).3 The authors noted that housestaff used the sign-out
information not only for cross-coverage but for their primary patients as well,
which may have contributed to the overall decrease in adverse events. Secular
trends may also have played a role in this reduction.
Another limitation of this study was that it relied on
self-report to capture adverse medical events. The investigators performed a
review of a random sample of 250 charts and detected only 8 unreported,
preventable adverse medical events. If extrapolated to the entire sample (3747),
this represents 120 missed adverse events. These adverse events could have
influenced the results either toward or away form the null hypothesis, depending
on their distribution among regular and cross-covering physicians.
Potential for Harm
The study reported no adverse events as a result of the
sign-out system. As with other sign-out systems, particularly those that are
computerized or Web-enabled, the issues of data security and protection of
confidentiality must be addressed.6
Costs and Implementation
Implementation of a computerized sign-out system like that
described by Peterson et al would require information systems that allow
extraction and aggregation of patient specific data (e.g., laboratory and
pharmacy) and financial support for programming. These resources may not be
present at some institutions. Although housestaff responded favorably to the
computerized system, physicians at other institutions or in other specialties
may not be as willing to use this system.
Comment
One study has shown that an inpatient's risk of preventable
adverse events was less after implementation of a computerized sign-out process.
The method appears appropriately suited for hospitals with cross-coverage
arrangements similar to those described by Peterson et al, specifically in-house
coverage by resident trainees. It will be important to know if similar systems
are as effective and well received at other institutions, including those
without trainees. Such systems would be difficult to implement in hospitals with
limited information systems or where physicians outside the hospital provide
coverage through paging systems. Although a computerized system has the
advantage of being accessible from any location in the hospital and may be able
to automatically import important information, events attributable to faulty
communication during cross-coverage could also be amenable to other strategies
for standardizing the process (e.g., sign-out cards, Web-based programs, PDAs). No
evidence is available concerning the relative effectiveness of other
standardized sign-out methods. Future research should address what data fields
are most helpful to physicians providing cross-coverage in preventing adverse
events and how different methods of standardized sign-out compare in
effectiveness (e.g., handwritten cards vs. PDAs).
Table 42.2.1. Computerized sign-out program
Study Setting |
Study Design, Outcome |
Results (95% Confidence Intervals) |
8767 patients admitted to the medical service of a tertiary care
teaching hospital in Boston3 |
Level 3, Level 2 |
Odds ratio (OR) of preventable adverse events occurring during
cross-coverage compared with care under regular physician:
Baseline, OR 5.2 (1.5-18.2)
With intervention, OR 1.5 (0.2-9.0) |
References
1. Jelley MJ. Tools of continuity: the content of inpatient check-out lists.
J Gen Intern Med 1994;9:77.
2. Lee LH, Levine JA, Schultz HJ. Utility of a standardized sign-out card for
new medical interns. J Gen Intern Med 1996;11:753-755.
3. Petersen LA, Orav EJ, Teich JM, O'Neil AC, Brennan TA. Using a
computerized sign-out program to improve continuity of inpatient care and
prevent adverse events. Jt Comm J Qual Improv 1998;24:77-87.
4. Petersen LA, Brennan TA, O'Neil AC, Cook EF, Lee TH. Does housestaff
discontinuity of care increase the risk for preventable adverse events? Ann
Intern Med 1994;121:866-872.
5. The Joint Commission on Accreditation of Healthcare Organizations.
Sentinel event alert. Lessons learned: wrong site surgery. 1998. Available at:
http://www.jcaho.org/edu_pub/sealert/sea6.html. Accessed June 27, 2001.
6. Balsbaugh TA. The family physician and handheld computers: a beginner's
guide. The Internet Journal of Family Practice 1[2].
2001.
Return to Contents
Subchapter 42.3. Discharge Summaries and
Follow-up
Background
Discharge summaries are important tools for communicating
pertinent patient information regarding hospitalizations to outpatient care
providers. Yet their relatively unstructured, narrative format often invites
inaccuracies.1 In addition, there can be significant delays
transmitting discharge summaries to patients' healthcare
providers.2,3
Prior studies have investigated processes to improve discharge
summaries, such as standardizing their format4-6 and instituting
physician education programs.7 This chapter focuses on the use of
structured, database-generated discharge summaries to improve the quality of the
information content communicated after patient discharge, as well as to reduce
the time required for this information transfer.8
Practice description
During the hospital course, physicians provide information
corresponding to specific sections of the computerized discharge summary either
on data collection forms which are manually entered into a database8
or directly into a computer system. When the patient is discharged the database
generates a structured discharge summary that can be sent to the patient's
outpatient providers.
Prevalence and Severity of the Target Safety Problem
In one study examining the effectiveness of inpatient follow-up
care, 9.7% of discharged patients experienced worsening of symptoms or
functional capacity as a result of an inadequately managed discharge
process.2 Hospital discharge summaries are an important means of
communication between hospital and community physicians, but have several
problems. First, community physicians do not always receive summaries for
recently discharged patients. In one study only 34% of patients had a discharge
summary sent to their outpatient care provider.2 Although no analysis
was undertaken to determine if receiving a discharge summary had an effect on
patients' follow-up, another study demonstrated that patients may be less likely
to be readmitted to the hospital if their primary care provider receives a
discharge summary.9
As mentioned above (Subchapter 42.1), patients frequently have
their medication regimen changed while admitted.10 The majority of
ambulatory providers would like to have information regarding these medication
changes.11 Improvement in information transfer from acute care to
ambulatory care might reduce medication discrepancies; however, patient
compliance will also heavily influence these factors.
Opportunities for Impact
We found no data describing how many hospitals currently use
database-driven discharge summaries.
Study Design and Outcomes
Several studies were identified that evaluated electronically
generated discharge summaries, but these were limited by a lack of randomization
or limited outcomes reporting.12-14 One randomized controlled trial
was identified that compared traditional dictated discharge summaries to
summaries generated from a database (Table 42.3.1).8 The primary
outcome was the proportion of admissions with a discharge summary completed by 4
weeks after discharge (Level 3).8 Overall quality of the discharge
summaries was also assessed (Level 3) but patient level outcomes were
not.
Evidence for Effectiveness of the Practice
Patients randomized to the database group were significantly
more likely to have a discharge summary generated within 4 weeks of discharge
than were patients randomized to the dictation group (113/142 vs. 86/151,
p<0.001). Even with the database method, 20% of patients did not have a
completed discharge summary by 4 weeks. Of the patients with a discharge summary
generated within 4 weeks of discharge, 94.7% of the database-generated summaries
were produced within one week, while only 80.2% of the dictated discharge
summaries were completed in this timeframe (p<0.001). Physician ratings of
the quality and timeliness of the discharge summaries were available for 210 of
302 (69.5%) summaries. The quality and timeliness of the 2 summaries were judged
to be similar overall, but differed when stratified by provider specialty.
Database-generated summaries were thought to be more timely by family physicians
(p=0.04) and of lower quality by consultant physicians (p=0.02).
Potential for Harm
No adverse events were mentioned as a result of the
database-generated discharge summary study.
Costs and Implementation
The direct and indirect costs of implementing and maintaining a
system for database-generated discharge summaries have not been formally
evaluated in the literature. Results of a mail survey of housestaff in the van
Walraven study8 suggest their intervention did not adversely affect
the workflow of housestaff physicians. Housestaff significantly preferred
(p<0.001) the database system and found it less burdensome (p=0.002). With
the advent of electronic medical record systems, data can be automatically
abstracted from various fields and collated into a discharge summary,
eliminating the costs associated with abstraction form distribution, collection,
and data entry. This is already a practice at some
institutions.12,15
Comment
With the documented inefficiencies, inaccuracies and
incompleteness of discharge summary information, interventions that improve the
hospital discharge communication process without increasing provider workload
could have a significant impact. A database method can significantly decrease
the time for completion of discharge summaries. The amount of work required to
generate the database discharge summaries could potentially be reduced in the
future through electronic record-keeping. Further studies are required to
determine how to best transfer discharge summary information to outpatient
providers. A feasibility study has assessed the utility of faxing discharge
summaries to community providers.3 This remains an active area for
study, recognizing that the optimal strategy to reduce discontinuities in care
after hospital discharge will depend on the methods for generating discharge
summaries, the accuracy and usefulness of their content, and the timeliness and
method of their delivery to patients' providers.
Table 42.3.1. Improvements in discharge summary communications
Study |
Study Setting |
Study Design, Outcome |
Results |
van Walraven, 199933 |
293 patients admitted to the General Medicine Service of a tertiary
care teaching hospital in Ottawa |
Level 1 Level 3 |
Discharge summary completed within 4 weeks:
Database group, 79.6%
Dictation group, 57% (p<0.001) |
References
1. Macaulay EM, Cooper GG, Engeset J, Naylor AR. Prospective audit of
discharge summary errors. Br J Surg 1996;83:788-790.
2. Brook RH, Appel FA, Avery C, Orman M, Stevenson RL. Effectiveness of
inpatient follow-up care. N Engl J Med 1971;285:1509-1514.
3. Paterson JM, Allega RL. Improving communication between hospital and
community physicians. Feasibility study of a handwritten, faxed hospital
discharge summary. Discharge Summary Study Group. Can Fam Physician 1999;45:2893-2899.
4. King MH, Barber SG. Towards better discharge summaries: brevity and
structure. West Engl Med J 1991;106:40-41,55.
5. Lloyd BW, Barnett P. Use of problem lists in letters between hospital
doctors and general practitioners. BMJ 1993;306:247.
6. Rawal J, Barnett P, Lloyd BW. Use of structured letters to improve
communication between hospital doctors and general practitioners. BMJ
1993;307:1044.
7. Flyer B, Rubenstein LZ, Robbins AS, Wieland GD, Henry D, Cugalj N. An
intervention to improve the hospital discharge summary. J Med Educ 1988;63:407-409.
8. van Walraven C, Laupacis A, Seth R, Wells G. Dictated versus
database-generated discharge summaries: a randomized clinical trial. CMAJ
1999;160:319-326.
9. van Walraven C, Seth R, Austin P, Laupacis A. The effect of discharge
summaries on readmission to hospital. 2001. [unpublished work]
10. Himmel W, Tabache M, Kochen MM. What happens to long-term medication when
general practice patients are referred to hospital? Eur J Clin Pharmacol
1996;50:253-257.
11. Munday A, Kelly B, Forrester JW, Timoney A, McGovern E. Do general
practitioners and community pharmacists want information on the reasons for drug
therapy changes implemented by secondary care? Br J Gen Pract 1997;47:563-566.
12. Lissauer T, Paterson CM, Simons A, Beard RW. Evaluation of computer
generated neonatal discharge summaries. Arch Dis Child 1991;66(4, Spec
No):433-436.
13. Llewelyn DE, Ewins DL, Horn J, Evans TG, McGregor AM. Computerised
updating of clinical summaries: new opportunities for clinical practice and
research? BMJ 1988;297:1504-1506.
14. Smith RP, Holzman GB. The application of a computer data base system to
the generation of hospital discharge summaries. Obstet Gynecol 1989;73(5
Pt 1):803-807.
15. Maresh M, Beard RW, Combe D, Dawson AM, Gillmer MDG, Smith G et al.
Selection of an obstetric data base for a microcomputer and its use for on-line
production of birth notification forms, discharge summaries and perinatal audit.
Br J Obstet and Gyn 1983;90:227-231.
Return to Contents
Subchapter 42.4. Notifying Patients of Abnormal
Results
Background
One of the most distressing safety issues of the clinical
encounter is the failure to follow-up on diagnostic tests, particularly when a
patient is not notified of an abnormal result. The complexities of this problem
are legion. Contact methods—whether by phone, mail, fax or e-mail, and whether
sent by the lab, clinic or individual clinician—vary widely in their reliability
(with most being imperfect). In some instances patients are told that if they do
not hear back regarding their test results it signifies normal results. Of
course, not hearing may mean that the test was lost or that the contact method
was faulty. Other issues arise when the content of the notification is not
clear, either as to result or the recommended follow-up for re-testing or
treatment options.
This chapter evaluates safety practices aimed at improving
patient notification of abnormal results. Adequate medical and/or surgical care
during follow-up is essential to reducing patient morbidity and
mortality, but practices to address this are beyond the scope of patient safety
as defined in this Compendium. We have chosen the example of Pap smear results,
although many of the issues should be transferable to other laboratory (e.g., PSA
level) and radiologic (e.g., mammogram) results.
Practice Description
Our search revealed only one study evaluating patient notification
practices.1 In this study, the patient's mailing address was included
on the Pap smear request form. Two weeks after the patient's primary care
provider received the results, the laboratory directly notified the patient by
mail. The notification was by form letter advising the patient of her results
and providing advice on the recommended follow-up step: discuss results with the
doctor, return in two years time, or make an appointment to see the doctor
without delay.
Prevalence and Severity of the Target Safety Problem
Few data exist concerning physician follow-up and patient
notification of abnormal results. In a survey of attending physicians and
residents practicing at a large urban teaching hospital and 21 suburban primary
care practices, virtually all respondents believed it was moderately or
extremely important to notify patients of abnormal results, yet 36% of
physicians did not always do so.2 Among the most common reasons
reported by physicians were forgetfulness and inability to reach patients. One
large cross-sectional study examined physician documentation of notification to
patients of abnormal mammograms, Pap smears, and cholesterol tests. The results
demonstrated that certain patient characteristics such as race, language, and
education may be associated with a failure to transmit abnormal results to
patients.3
An estimated 4600 American women died of cervical cancer in
2000.4 There are no data regarding to what extent delays in
notification result in worse patient outcomes, including mortality. One study
evaluating processes to reduce non-adherence rates with the follow-up of
abnormal Pap smears noted that many women (the exact number was not presented)
reported that they were never notified of their abnormal Pap smear result
initially.5
Tracking systems for abnormal Pap smear results have been
briefly mentioned in the context of studies evaluating interventions to improve
overall follow-up, not patient notification.5,6 However, the
effectiveness of these tracking systems was not specifically evaluated so they
are not reviewed here.
Opportunities for Impact
Compliance rates with follow-up medical care after abnormal Pap
smears typically ranges from 50% to 70%.5,7-9 It is unclear how often
losses to follow-up resulted from failure to notify. There are no data
indicating how many practice groups directly mail abnormal Pap smear results to
patients. Even with successful patient notification practices, a corresponding
reduction in morbidity and mortality may not occur because of the other barriers
to adequate follow-up described in the literature.5,10
Study Design and Outcomes
The study reviewed for this chapter was a randomized control
design (Level 1).1 (Table 42.4.1). Providers were randomized into 2
groups. In the intervention group, the pre-cervical smear questionnaire form had
been redesigned to allow the patient to request that results be mailed directly
to her. The physicians in the intervention group determined which patients would
be offered direct notification. Patients of physicians in the control group were
notified of results using whatever protocol the provider typically used. The
authors did not elaborate on the methods used to notify patients in the control
group.
The primary outcome was adherence with follow-up visits (Level
2), which was defined by searching the laboratory records for evidence of a
follow-up Pap smear one year after notification. If a cervical smear result was
not located through the laboratory database search then the patient's provider
was contacted.1
Evidence for Effectiveness of the Practice
Significantly fewer women with cervical intraepithelial
neoplasia (CIN) on Pap smear who were randomized to the intervention group were
lost to follow-up (0/52 vs. 9/39 in the control group, p<0.001). In the group
of women with atypia, 13% (15/116) were lost to follow-up in the intervention
group and 10% (10/104) were lost to follow-up in the control (p=NS).
A limitation of this study was that providers decided who in
the intervention group actually received the intervention after randomization.
Only 41% of patients in the intervention group were actually mailed their
results. However, analysis was performed with an intention-to-treat
design.
Potential for Harm
Although the patients in this study were not interviewed, other
reports reveal that psychological distress is common after notification of an
abnormal Pap smear.11 Thus a potential harm of this practice, or any
practice to directly notify a patient of an abnormal result, could be anxiety
and distress that might be mitigated if a health practitioner were to deliver
the information.
Costs and Implementation
Buy-in of healthcare providers is an important aspect of
practice implementation and may be affected by the concern for potential harm
and the specifics of the notification process. In the Del Mar study, 23% of
providers were unhappy with the wording of the letter.1 Direct
patient notification systems require accuracy and reliability of the
administrative database. One study trying to improve adherence to follow-up
after an abnormal Pap smear result was only able to make telephone contact with
42% of the eligible patients.5 They found that 16%-20% of their
telephone and address data were inaccurate.
Although patient tracking systems are not evaluated in this
chapter because of the lack of published literature, in one study clinical
personnel stated that they were reluctant to perform the tracking function of
the intervention, and even discontinued the Pap smear log once the study was
completed.12
Comment
Failure to notify patients of abnormal results is a
little-studied but major problem involving both patient safety and healthcare
quality. One study evaluated direct mailings of abnormal results to patients and
found improved follow-up in one subset of patients. More data are required
before recommending implementation of this practice.
We were unable to find any studies evaluating specific
interventions aimed at providers that resulted in increased notification to
patients of abnormal results. Interventions that target providers through
computerized reminders linked with patient tracking systems might have an impact
on improving patient notification of abnormal results. This area is an important
source of future investigation.
Table 42.4.1. Randomized controlled trial of direct notification of abnormal
Pap smear results*
Study |
Study Setting |
Outcomes |
Results (95% Confidence Interval)a |
Del Mar, 19951 |
311 women with abnormal Pap smears from 42 general practices in
Australia |
Level 2 |
Patients with CIN lost to follow-up:
Direct mail notification: 0 (0-0.07)
Control: 0.23 (0.11-0.39)
Patients with atypia lost to follow-up
Direct mail notification: 0.10
Control: 0.13 (p=NS) |
* CIN indicates cervical intraepithelial neoplasia; NS, not statistically
significant.
a Proportion of patients lost to follow-up reported in intervention
group vs. control group.
References
1. Del Mar CB, Wright RG. Notifying women of the results of their cervical
smear tests by mail: does it result in a decreased loss to follow-up of abnormal
smears? Aust J Public Health 1995;19:211-213.
2. Bookhaker EA, Ward RE, Uman JE, McCarthy BD. Patient notification and
follow-up of abnormal test results: a physician survey. Arch Intern Med
1996;156:327-331.
3. Burstin HR, Puoplolo AL, Haas JS, Cook EF, Brennan TA. Patients at risk
for missed follow-up after abnormal tests [abstract]. J Gen Intern Med
13, 46A. 1998.
4. American Cancer Society. Cancer Facts &Figures 2000. Atlanta, GA .
2000.
5. Marcus AC, Kaplan CP, Crane LA, Berek JS, Bernstein G, Gunning JE et al.
Reducing loss-to-follow-up among women with abnormal Pap smears. Results from a
randomized trial testing an intensive follow-up protocol and economic
incentives. Med Care 1998;36:397-410.
6. Paskett ED, White E, Carter WB, Chu J. Improving follow-up after an
abnormal Pap smear: a randomized controlled trial. Prev Med 1990;
19:630-641.
7. Marcus AC, Crane LA, Kaplan CP, Reading AE, Savage E, Gunning J et al.
Improving adherence to screening follow-up among women with abnormal Pap smears:
results from a large clinic-based trial of three intervention strategies. Med
Care 1992;30:216-230.
8. Michielutte R, Diseker RA, Young LD, May WJ. Noncompliance in screening
follow-up among family planning clinic patients with cervical dysplasia. Prev
Med 1985;14:248-258.
9. Singer A. The abnormal cervical smear. Br Med J (Clin Res Ed) 1986;293:1551-1556.
10. Stewart DE, Buchegger PM, Lickrish GM, Sierra S. The effect of
educational brochures on follow-up compliance in women with abnormal
Papanicolaou smears. Obstet Gynecol 1994;83:583-585.
11. Stewart DE, Lickrish GM, Sierra S, Parkin H. The effect of educational
brochures on knowledge and emotional distress in women with abnormal
Papanicolaou smears. Obstet Gynecol 1993;81:280-282.
12. Paskett ED, Phillips KC, Miller ME. Improving compliance among women with
abnormal Papanicolaou smears. Obstet Gynecol 1995;86:353-359.
Final Comment to Chapter 42
Faulty information transfer causes discontinuities of care that may result in
adverse events. However, interventions to improve information transfer have
received relatively little attention in the medical literature. Unfortunately,
numerous barriers impede the appropriate transfer of information between
institutions and between patient and provider. Future technologies that allow
for more seamless transfer of information may mitigate these gaps in patient
care. Further evaluation is critical.
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