Communication is a complex phenomenon that is woven into virtually every aspect of medicine. It occurs at all hours of the day between various care team members (eg, between physicians, between nurses, between physicians and patients, etc) and in multiple settings and scenarios, making a universal approach or even standardization seemingly impossible. Yet, research has revealed that effective communication improves patient outcomes and decreases medical errors and/or adverse events.1 In contrast, poor communication may generate unintended adverse events, medical errors, and/or provider and patient dissatisfaction and is often cited as a root cause of sentinel events.2,3 With the advance of pediatric hospital medicine as a subspecialty, the divide between inpatient and outpatient care has grown, adding a new layer of complexity and leaving a critical communication gap between hospitalists and primary care providers (PCPs) ripe for intervention.4–10 In recognition of the importance of communication and the existing gaps in discharge communication, this month’s issue of Hospital Pediatrics features a series of admirable quality improvement (QI) studies.11–13 In these articles, researchers tackle the vital yet multifaceted and often challenging topic of communication between inpatient and outpatient providers surrounding patient discharge.
Clark et al11 aimed to increase documentation of 2-way communication between hospitalists and PCPs for patients determined to be “high-risk” discharges. Of the average weekly high-risk discharges, their team was able to improve this 2-way communication, from a baseline of 7% to a peak of 39%, but met challenges reaching their goal of 60%. Any documented discharge communication attempts also increased but, similarly, remained below their goal. Interestingly, authors noted that the hospitalist dissatisfaction rate increased throughout the study in follow-up surveys; they attributed this to disagreement with high-risk criteria and discontent with the new communication expectation. In another QI report, Ostermeier et al12 sought to increase the percentage of 1-way communication by using leave-a-message (LAM) calls by hospitalists to PCPs for uncomplicated admissions of patients with 1 of 12 common diagnoses. LAM calls were not used before this study; the use of LAM calls initially increased, meeting the goal of 35% during the first 9 months, but decreased to 8% over the following 7 months. However, the use of LAM calls saved >30 hours of cumulative call time through a reduction of 11.1 PCP return phone calls per week, and only 5.8% of LAM calls required an additional 2-way conversation afterward. Notably, there was no significant change in the 7-day readmission rate. Finally, Goodrich et al13 sought to improve documentation of attempted communication with PCPs within 72 hours of discharge from the pediatric hospital medicine service. The 3 options for communication included telephone calls, secure electronic health record (EHR) messages, and in-person communication. Telephone calls with office staff (other than PCP) was the most common method with in-person and direct telephone conversations with PCPs being a rare use, occurring in a maximum of 3% of communications. A secondary outcome measure was to assess the impact of institutional financial incentives on sustaining timely discharge communication. Interestingly, once the financial incentive was removed for participating physicians, the rate of documented discharge communication decreased below their goal of 60% to 54%.
Each of these articles uses QI methodology and a slightly different approach to address the communication gap between hospitalists and PCPs, but there are some common themes shared among these studies. All studies leveraged the EHR to support the interventions. Clark et al11 leveraged the EHR to streamline communication by linking directly to PCP contact information and built checkbox prompts to transparently track discharge tasks. Ostermeier et al12 used the EHR to store the information collected during LAM calls. Goodrich et al13 created an EHR phrase with the purpose of documenting discharge communication attempts. The EHR phrase not only facilitated special cause variation but, also, data collection and, therefore, the ability to audit and provide individualized feedback for physicians involved in the project. Use of the EHR can be an impactful way to generate change because it incorporates a higher level of reliability with less likelihood of failure. Another common theme among these articles is the involvement of multiple stakeholders and solicitation of input. Whether it is reaching consensus on the definition of “high-risk” discharges warranting 2-way communication (Clark et al11 ) or diagnoses most appropriate for 1-way communication (Ostermeier et al12 ) or creating a team to perform an in- depth literature review to inform development of a key driver diagram (Goodrich et al13 ), in each study, researchers looked beyond their own inpatient-focused environment. This approach yields buy-in and accountability, which is critical to virtually all QI projects but perhaps most especially those involving a complex topic, like that of discharge communication.
Despite the studies’ successes overall and an appreciation of the importance of discharge communication among stakeholders, the ability to sustain improvement was a notable difficulty in each initiative. This is likely attributable to a multitude of factors, although we propose a few here. First, because the preferred mode of discharge communication varies between institutions, offices, and individuals, choosing 1 type to be implemented as a universal standard is unlikely to be successful. Certainly, as outlined in these studies, engagement with stakeholders is critical. However, this engagement may not be sufficient to sustain change nor is it practical to accommodate the myriad of preferences that may be situation, practice, or person dependent. Given this, in these studies, the authors highlight the importance of prioritizing low risk and high yield initiatives and setting realistic goals for maximal impact. Secondly, time is a frequent barrier. The time required to perform the task of communication outreach to discuss a patient’s hospitalization and discharge plan is a challenge to incorporate into an already overdemanding clinical service schedule for both hospitalists and PCPs. Thirdly, as we reviewed these studies, we noted a lack of trainee and/or advanced practice provider involvement in the process of discharge communication. Although not every institution has trainees and/or advanced practice providers embedded within their teams, we propose that this may have contributed to some of the challenges with sustaining change, given that the burden of communication fell primarily to the attending physicians. Lastly, the coronavirus disease 2019 pandemic affected the health care system in multiple ways, and it is, therefore, possible that the impact of the pandemic on hospital and provider processes and workflows may have affected the authors’ ability to implement and sustain change during this time of crisis.
Appreciating the unique challenges of effective, timely, and sustainable discharge communication practices, one must ask how we can further modify and enhance these processes through rigorous improvement science. In future research, researchers can build on the solid foundation of work laid by these QI studies. We suggest several ideas here. As noted by all 3 author groups, a limitation of each of their studies was the inability to evaluate the perception of PCPs regarding the effectiveness, utility, and/or value of the discharge communication received. In future studies, researchers could consider partnering with PCPs to both develop a shared mental model of the valuable components of effective discharge communication as well obtain feedback after interventions, thereby directly assessing impact and informing next steps. Given that an objective outcome measure to evaluate perceptions of communication does not currently exist, this may be best explored by using qualitative methodology to more deeply and broadly describe the impact of interventions on both the giver and receiver of discharge communication. Similarly, evaluating patient-centered outcomes (such as adverse events secondary to incomplete or ineffective communication practices, postdischarge health care use, and patient satisfaction) is another area to be further explored in follow-up to these studies. Furthermore, although trainees have numerous obligations and demands on their time, the practice of effectively communicating via thorough handoffs is a vital component of training and important skill for their future careers. In addition, by formally integrating trainees into the discharge communication process, this valuable task would subsequently be spread across and shared by more physicians, thereby lessening the burden for any one particular individual. Expanding the team to include trainees could, therefore, hold both educational value and the potential to improve the sustainability of consistent discharge communication.
As evidenced in these and other improvement science studies, improving discharge communication between hospitalist and PCP teams is critical for patient safety and successful transitions of care. We commend these authors for revealing strategies for success in these initiatives while also highlighting the associated challenges. As the complexity of hospital admissions continues to grow and the communication barriers between hospitalists and PCPs evolve, developing standards for these communication practices is essential for exceptional patient care.
FUNDING: No external funding.
COMPANION PAPER: Companions to this article can be found online at www.hosppeds.org/cgi/doi/10.1542/hpeds.2020-005421, www.hosppeds.org/cgi/doi/10.1542/hpeds.2020-005637, and www.hosppeds.org/cgi/doi/10.1542/hpeds.2020-004804
Drs Kaissi and Solan conceptualized and designed the study, drafted the initial manuscript, reviewed and revised the manuscript, and approved the final manuscript as submitted.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
References
Competing Interests
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURES: The authors have indicated they have no financial relationships relevant to this article to disclose.
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