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Discharge Communication, the Achilles Heel in Pediatric Hospital Medicine

September 27, 2021

t’s the summer of RSV and the pediatric hospitalist teaching service is busy in volume and acuity. Fully recognizing the importance of patient handoff to the primary care clinician (PCP), you take a few minutes after rounds to sit, have a bite to eat, and call the offices. Some of the challenges you may face include long hold times to reach a clinician, the office is on lunch break, an outside hospital is simultaneously calling you to transfer a patient or the resident is calling to discuss an admission or change in patient acuity. Alternatively, it’s a no-break kind of day and it’s well after 6pm when you are able to review charts, write some notes and try again to call PCPs, connecting with the on-call provider who often does not know the patient but agrees to pass on the message. As a pediatric hospital medicine (PHM) community, we can do better with communicating with a patient’s PCP at discharge. There are quality and safety implications to underscore the importance. So how do we do this better?

In this month’s Hospital Pediatrics, several investigators share their experience with trying to tackle this problem. In one study by Clark et al (10.1542/hpeds.2020-005421), investigators aimed to increase documentation of 2-way communication (discharge summary and verbal hand-off) with PCPs for high-risk discharges on a PHM service. The investigators report some success with their interventions and highlight the challenges of well-intentioned efforts to communicate with PCPs. Among the interventions that were related to special cause improvements, offloading the task of coordinating the communication from hospitalists to support staff was interesting.

In another study by Ostermeier et al (10.1542/hpeds.2020-005637), investigators chose to focus on uncomplicated discharges and streamline the number of calls by utilizing a system where the hospitalist left a message with a PCP with an option to return the call. The number of calls to PCPs increased from 0 to 35% and 0.4% of calls were returned by PCPs. The investigators utilized a specialized group of operators to co-ordinate the calls and similar to the previous study, 2-way communication was expected for more complex discharges.

In a third study by Goodrich et al (10.1542/hpeds.2020-004804), investigators utilized audits and feedback, a communication phrase in the electronic medical record and a financial incentive to drive discharge communication between the hospitalist group and PCP offices. This group was able to increase documented PCP communication to 66% and noted a decrease following removal of the financial incentive. Authors suggest that the financial incentive may have negatively impacted the intrinsic motivations of providers and also shifted their attention when the financial incentive was applied to a different quality improvement project.

In an accompanying commentary (10.1542/hpeds.2021-006188), Dr. Kaissi highlights central themes in these 3 quality improvement projects, specifically leveraging of the electronic health record, the solicitation of input from and collaboration with multiple stakeholders to obtain critical buy-in and accountability and challenges with sustainability in maintaining high rates of successful communication. Dr. Kaissi points out opportunities for partnering with PCPs to develop shared mental models, evaluating patient-centered outcomes and trainee engagement with the discharge communication process.

In summary, the authors of these articles have highlighted a major vulnerability in transitions of care for the PHM community to reflect and act on and I highly recommend reading their work. In the meantime, I have some PCP calls to catch up on…..

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