Electronic Medical Record Discharge Template Use Improves Resident Efficiency

George Washington University internal medicine residents are challenged to deliver evidence-based, humanistic, and high-quality medical care. However, much of their time is spent on documentation instead of direct patient care or scholarly activities. The introduction of electronic medical records (“EMR”) has provided an opportunity for the improvement of both efficiency and quality of patient care. In reality, capitalizing on this opportunity has been particularly difficult in academic settings that experience high patient turnover and employ resident physicians at varying levels of training. The discharge instruction (“DCI”), which details the reason for a patient’s hospitalization, is among the most important documentation that a resident is responsible for. Despite this, only 16% of internal medicine residency programs have a discharge planning curriculum. This was addressed in a prior quality improvement (“QI”) project at George Washington University. The results of that project showed that DCI standardization through the use of templates led to a decrease in drafting time in addition to an increase in quality. Subsequently, the EMR system at the site of the project was changed. The present QI project aimed to adopt those previous instructions and replicate those results in the new system. Our aim was to increase the use of DCI templates by 25% in 4 months on the cardiology service. Templates were created for common diagnoses: acute heart failure exacerbation, syncope, noncardiac chest pain, and acute coronary syndrome. Initially, only 35% of respondents were using templates, however, after our final PDSA cycle 100% of respondents were using templates. This increase in use correlated with a decrease in the amount of time spent writing DCIs. The number of residents able to complete discharge instructions in less than 10 minutes increased by 28%. Despite the decrease in time, residents surveyed did not perceive a reduction in quality. Our study shows that the use of DCI templates or macros increases efficiency while maintaining quality. This will permit residents to devote more time to other aspects of patient care as well as to their pursuit of knowledge. Further PDSA cycles can be target the creation of additional templates for the cardiology service, and the expansion of template use to other services

Discharge Summaries: An Intervention To improve Standardized Requirements

Medical doctors write discharge summaries every day, documenting a summary of the hospital encounter of patients. Despite the critical role that these documents play in transitions of care, whether it is to a nursing facility or home, they are often times missing crucial information and physicians get little to no training in the creation of discharge summaries during medical school or residency. The existence of Joint Commission standards mandating discharge summary components has made it such that all discharge summaries should include six pieces of information and missing even one component can jeopardize patient safety. This was addressed in a prior study at the University of Wisconsin where Dr. Smith, et al. reviewed the Joint Commission Standard Requirements for discharge summaries, particularly studying discharge summaries for subacute rehabilitation facilities. In their study, they found that the patient’s discharge condition was often omitted. Although the impact on patient safety is not clearly known, it is safe to assume that when patients leave hospitals and are unable to verbalize their medical condition, it is of utmost importance to have documentation of discharge condition in the only paperwork that often follows the patient to their next place of care. The purpose of our quality improve project was to assess whether providing a training session to internal medicine interns at the start of their residency improved those measures as outlined by the Joint Commission. By comparing discharge summaries from September/October 2016, prior to any training session, to those of September/October 2017, after training, we found that there was a roughly twenty percent improvement in inclusion of all the criteria. Our study shows that one teaching session during orientation, particularly for interns who have often times had no exposure to discharge summary writing, can be vital in promoting patient safety. This may serve as a foundation for all residency programs to provide such sessions dedicated to discussing the Joint Commission Standard Requirements for Discharge Summaries, and will also provide ground to create more specific components within discharge summaries that are crucial for transition of care