From the 2022 HVPA National Conference
Matan Arnon DO (Lewis Katz School of Medicine at Temple University), Dharmini Shah Pandya MD, FACP
Background
Post hospitalization discharge instructions have been established as integral for guidance and communication for patients in this vulnerable period1,2. At our academic institution there is no standardized accepted practice amongst providers regarding the contents of the discharge instructions. As health care and medical education models are changing to achieve equitable care, it is imperative to utilize patients, sub-specialists, trainees, clinician educators and expert informatics clinicians to help guide curricular and institutional changes3.
Objective
To obtain baseline trainee behaviors regarding contents of discharge instruction, assess patient-level difficulty in identifying critical components of the discharge instructions. Obtain clinical educator and sub-specialty input on quality of discharge instructions. Utilize this data to drive electronic changes to institutional after visit summary (AVS), and to guide curricular innovation for internal medicine residents.
Methods
Trainees from multi-institutional academic medical centers, patients from Patient and Family Advisory Council (PFAC), Clinical educators (Medicine inpatient/outpatient, curriculum directors), and sub-specialists provided a combination of qualitative and survey based quantitative assessment. Reviewed same AVS with mentioned stakeholders and obtained qualitative feedback. Discussed with informatics specialists (CMIO, Associate CMIO, Performance Improvement Chair, Co-Chief patient experience) limitations and application of findings.
Results
43 trainee respondents demonstrated variability in use of smart phrases in the EMR (76.7%) and contents of the discharge instructions. In review of IM residents baseline documentation practices: Primary diagnosis was documented in 86.0%, Secondary diagnosis 48.8%, rationale of medication changes 76.7%, follow up appointments 88.4%, recommendations of sub-specialty consultants 58.1%, anticipated problems and suggested interventions 51.2%, 24/7 call-back number 65.1%, identify referring and receiving providers 39.5%. 18 patients were surveyed through our PFAC committee across the health system demonstrated 72% knew what to do when they encountered problems at home, 66.7% knew who/where to call if they needed help after returning home, 61% knew where/when there follow up appointments are. They described confusion with the order of the information provided resulting in missed information and a large page burden. Clinical educators provided qualitative recommendations during walk through of a sample AVS. Informatics specialists provided qualitative input regarding limitations and actionable interventions for optimization of the AVS based on stakeholder feedback.
Conclusion
To deliver patient centered care input from multiple parties is vital. Lack of consistency and standardization in discharge instructions has resulted in both missed information written by the provider and patient difficulty in identifying integral information. This assessment has led to curricular changes in the internal medicine residency focusing on practice changes related to TOC and emphasis on these skills. Currently, we are in the process of changing our system wide AVS and have implemented a series of workshops for interns at the beginning of the year and as they transition to their leadership roles as upper years to reiterate standardized evidence-based patient directed practices.
Clinical Implications
Moving towards quality and value-based care as the ultimate model for care delivery, it is increasingly important to align patient, faculty, and trainee input to guide curriculum change and system wide improvements in the discharge process. Creating a culture of ownership, safety and shared goals of the system and educational models is the ultimate way to achieve equitable care. Through creating a standard for discharge instructions, educating providers regarding contents required in the discharge instruction, we will reduce unwarranted practice variability, improve care transitions, and reduce avoidable ED use and re-hospitalization.
