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First Author: Katherine Y. Wu, Duke University School of
Medicine, Class of 2014
Timely discharge (DC) communication is critical for high-quality
care transitions from inpatient to outpatient settings. DC
communication usually relies upon discharge summaries. Inadequate
DC communication is associated with negative patient outcomes. The
purpose of this quality improvement (QI) project was to improve the
quality of DC communication via improved timeliness of DC summary
completion and transmission from general medicine (GM) inpatient to
DC summaries from Duke University Hospital GM inpatient services
were typically dictated by a resident. An attending physician
signed the transcribed DC summary, and the document was
automatically faxed to outpatient providers listed by the dictating
physician as needing to receive a copy. DC communication timeliness
was measured by time between DC date and 1) date of dictating
provider signature (DC summary "completion") and 2) date of
attending provider signature (DC summary "transmission"). These
timeliness metrics and date of first post-DC follow-up (F/U)
appointment were abstracted in a pre-intervention manual chart
review of GM inpatients discharged to home in January 2012.
From April-May 2013, a multi-modal intervention was implemented
consisting of: 1) physician awareness campaign to encourage timely
DC communication, 2) establishment of 24 hours post-DC as the
benchmark for DC summary completion, and 3) real-time performance
feedback. Weekly during this intervention period, timeliness
metrics were manually abstracted from patient charts. We determined
the proportion of DC summaries completed within 24 of DC,
transmitted within 48 hours of DC, and transmitted before the first
F/U appointment. All patients discharged to home from resident-led
GM teams were included. Intervention-period performance data were
stratified by team and provider and fed back in real-time to
providers. We analyzed pre-intervention and intervention-period
data with an unpaired t-test and Fisher's Exact Probability
58 pre-intervention patients and 277 intervention-period patients
were included. Pre-intervention median time to DC summary
completion was 1.72 days (95% CI: 1.00-2.18) and to transmission to
F/U providers was 2.62 days (95% CI: 1.94-3.86). 36% of summaries
were completed within 24 hours, 40% were transmitted within 48
hours, and 45% were transmitted before the first F/U appointment.
Intervention-period median time to DC summary completion was 1.14
days (95% CI: 0.97-1.49; p=0.01) and to transmission to F/U
providers was 2.84 days (95% CI: 2.27-3.05; p=0.73). 45% of
summaries were completed within 24 hours (p=0.24), 37% were
transmitted within 48 hours (p=0.77), and 45% were transmitted
before the first F/U appointment (p=1.00).
This multi-modal QI project achieved a significant decrease in time
to DC summary completion by housestaff. This modest improvement in
DC communication timeliness was achieved with low-intensity
interventions. Improvements could be augmented and sustained with
implementation of an automated system for provider-level, real-time
November 2014 Issue of IMpact