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Study: Deficits in discharge docs of transferred patients
Risk rises for patients on anticoagulation
Anticoagulation therapy is effective and common treatment for many hospital patients, but there's a high risk for certain patients, including those over age 70.1
It's crucial that discharge planning include thorough education to prevent adverse events, says Esteban Gandara, MD, a medical doctor and researcher at Brigham and Women's Hospital in Boston.
"We know that during the transition of care, a lot of adverse events can occur," Gandara says. "So we wanted to see if all patients were receiving all of the information."
Communication problems for patients receiving anticoagulation treatment might cause dosing errors, adherence problems, drug-drug or food-drug interactions, and these problems could be especially dangerous in patients who have a history of bleeding, diabetes, anemia, obesity, renal insufficiency, or who have alcohol or drug abuse issues.1
Trained medical residents, admitting physicians, nurse practitioners, and other medical professionals at subacute sites evaluated discharge documentation of a sample of patients who were discharged to the subacute sites. The patients were either receiving anticoagulation for treatment or for prevention of thromboembolic disease.1
The discharge documentation packets included discharge summaries, discharge orders, nursing instructions, care coordination, and physical or occupational therapy notes.1
The sample included patients at five hospitals in the Partners Healthcare System between March 2005 and June 2007. All of the patients were being discharged to a subacute facility, including any of 30 rehabilitation hospitals and skilled nursing facilities.1
"What we were looking for were physicians who were writing discharge summaries or who were giving instructions," Gandara says. "We decided to ask questions about what sort of information should be included, according to a group of experts."
The reviewers, who were trained, filled out a survey that outlined whether the documentation included all of the data elements necessary for continuing patient care.1
For example, the essential items for patients receiving warfarin included indication, Target International Normalized Ratio (INR) range, duration of therapy, last three INR values with dates, last three warfarin doses, recommended dosing until next INR testing, and provider or clinic conducting follow-up monitoring.1
Investigators found that the most common deficits in documentation for patients on warfarin were dosing and monitoring information, Gandara says.
Also, the warfarin patient documentation sometimes lacked the recent INR levels, and nearly 84% of the warfarin cases were missing one necessary piece of documentation.1
In patients who were receiving unfractionated heparin (UFH) or low-molecular-weight-heparin (LMWH), the most common deficits in documentation were duration of therapy and monitoring parameters.1
"We found that only 16% of patients had all the information they needed if they were on warfarin, and only half of the patients on heparin had all of the information that was needed," Gandara says.
The findings likely are the result of forgetfulness during the discharge planning process, Gandara speculates.
"Usually this is something we do at the end of care of patients, and sometimes it tends to be something we all forget," he explains. "It isn't something that people think about."
The study also found that when discharges from community hospitals were compared with discharges from academic medical centers, the community hospitals provided better documentation, Gandara says.
"One explanation we have is that academic medical centers had interns do the discharge summary, compared with community hospitals having trained physicians do these, who might know what's more important for a patient," Gandara says.
Gandara recommends that hospitals use an electronic discharge summary to help clinicians make certain they've included all of the necessary discharge documentation.
"Electronic discharge summaries can take about 16 minutes to do, and they are not paper-based, but can have print-outs," Gandara says.
1. Gandara E, Moniz TT, Ungar J, et al. Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation. Joint Comm J Qual & Pat Safety. 2008;34(8):460-463.
For more information, contact:
Esteban Gandara, MD, Brigham and Women's Hospital, Boston, MA. Telephone: (857) 492-5547.