Making Hospital Discharges Safer

Bob Wachter blogged about an uninteresting topic in an interesting way. The topic (medical errors made because of care transition "fumbles") is "uninteresting" because directing your patient's care elsewhere represents "closure". Who wants to dwell on the past? 'He's not my patient anymore. He's not my problem anymore.'

More on this critical issue here.Bob Wachter blogged about an uninteresting topic in an interesting way. The topic (medical errors made because of care transition "fumbles") is "uninteresting" because directing your patient's care elsewhere represents "closure". Who wants to dwell on the past? 'He's not my patient anymore. He's not my problem anymore.'

Of course this is the wrong attitude but call me a liar for proclaiming it a norm throughout our health care system. There was once a time when doctors coveted their patients like greedy misers. Woe to the doctor who stole a patient from his colleague! Woe to the specialist who usurped the PCP's hegemony! The psychology was different when fee-for-service medicine was the standard. With declining reimbursements caused by the rise of government and private third party payers as well as capitated medicine; this all changed years ago.

Medical residents weren't that covetous even back then but hospital care by the housestaff has always been the antithesis of fee-for-service medicine. Residents are paid the same regardless of their census. This led to the popular technique of "turfing" (transferring a patient to someone else's service). If these turf wars in reverse sound like a game, read the medical field's version of a cult novel, The House of God to get the full flavor.

Unfortunately, the health care system as a whole has adopted the medical resident "model". If the modern transfer is uninteresting, it's because the patient has just become someone else's problem.

With fractionation of care and lack of ownership comes patient dissatisfaction and worse, medical errors. Of course there are other reasons for the increase in disjointed care: the increased complexity of medicine, the greater acuity of hospital patients, the declining reliance on face-to-face or at least telephone communications in medicine. But, I think that this lack of ownership is way up there.

Wachter points out that no one is currently accountable for transition-related goofs. I think this is partially right. I don't think it explains everything. He points out the current lack of quality measures specifically related to determinining the integrity of the hand-off process. But I think we've always been aware of the problem. I believe that high readmission rates (which are measured) are generally attributed to poor post-discharge planning as a first approximation. Obviously there are other causes but this is usually what is blamed first. The principle culprit of this poor planning is frequently miscommunication.

He is right though that easily measured indicators that are more specific to the quality of hand-off procedures are required.

His discussion of "transition coaches" and his interview with Eric Coleman is fascinating. I'm quite surprised to read that such coaches were found to be cost-effective though. They seem to be extremely hands on, spending much time with patients, visiting them at home, etc. This seems very expensive to me. Clearly the patients eligible for this type of intervention need to be closely screened. I'd think that for such a program to work, only patients classified as being at very high risk of bad outcomes should be considered.

I once worked as a hospitalist for a large IPA that achieved good results with some relatively simple and inexpensive procedures. We immediately dictated detailed discharge summaries at the time of discharge. The IPA had a special contractural arrangement with the hospital to have these transcribed immediately and they were FAX'ed to the PCP (and relevant subspecialists) by the following morning. Our IPA discharge summaries had a standard format that was designed to be specifically helpful to the doctors participating in after-care (and that met the discharge summary standards for the hospital as well).

We also arranged for a full-time RN who called every single discharged patient the next day. She was often able to troubleshoot problems before they became problems. Of course one of the big advantages of such a nurse was that screw-ups became less serious and were more easily rectified. The transition coaches discussed above appear mainly geared at preventing screw-ups in the first place -- always a better though I believe costly solution.

There are programs being studied that assign roving physicians to do housecalls on frequent flyer patients (often old, tenuous patients with multiple medical problems). Such programs appear to be cost-effective but are treating a somewhat different problem i.e. trying to prevent admissions in the first place.

One thing that really used to disturb me was the response of PCP's to phonecalls. If I was discharging a particularly challenging patient, I would call the PCP to give him a heads up. Surprisingly, the most common response was "Don't bother. Just FAX the D/C summary." They didn't even want to take the two minutes to discuss it.

Now if there's just a way of financially incentivizing doctors to take ownership (in ways that don't lead to overutilization) then we'd really have something!

Everyone be sure and have a great new year!