The Patient Handoff: Communication The Patient Handoff: Communication between Primary Physicians between Primary Physicians

and Hospitalistsand Hospitalists

Julia S. Wright, M.D.Julia S. Wright, M.D.

July 11, 2007July 11, 2007

Primary Care-Hospitalist Primary Care-Hospitalist Patient SharingPatient Sharing

Division of LaborDivision of LaborQuality of careQuality of careMedicolegalMedicolegalPhysician InteractionPhysician InteractionContinuityContinuity

Handoff: transfer of patient care Handoff: transfer of patient care responsibility from outpatient to inpatient responsibility from outpatient to inpatient MD. Note: Intervention IndependentMD. Note: Intervention Independent

Goals of HandoffGoals of Handoff

Effective information transferEffective information transfer Communication system providing timely, Communication system providing timely,

accurate, thorough informationaccurate, thorough information

Deficits in Communication and Information Deficits in Communication and Information Transfer Between Hospital-Based and Primary Transfer Between Hospital-Based and Primary Care Physicians: Implications for Patient Safety Care Physicians: Implications for Patient Safety and Continuity of Care. and Continuity of Care. Kripalani S, LeFevre F, Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. JAMA, Phillips CO, Williams MV, Basaviah P, Baker DW. JAMA, 2007;297(8):831-841.2007;297(8):831-841.

Information gapInformation gap Suggested decreased quality of care at Suggested decreased quality of care at

followup and adverse outcomes if poor followup and adverse outcomes if poor information transfer occurs.information transfer occurs.

Literature review of deficits of information Literature review of deficits of information transfer at discharge, and interventions to transfer at discharge, and interventions to improve them.improve them.

Primary physicians report limited role.Primary physicians report limited role.<3% involved, <20% notified <3% involved, <20% notified

Information at discharge: accuracy/completenessInformation at discharge: accuracy/completeness

JCAHO requirements: p. 832, first paragraphJCAHO requirements: p. 832, first paragraph Missing data common, readmission/compromise care? Missing data common, readmission/compromise care?

Pending tests 40%, 10% requiring action.Pending tests 40%, 10% requiring action.

Mechanics of TransferMechanics of Transfer Formats: Database-generated, letter, discharge Formats: Database-generated, letter, discharge

summarysummary Route: patient carried, faxedRoute: patient carried, faxed Timing: JCAHO 30 days; ½ not available at FU appt, Timing: JCAHO 30 days; ½ not available at FU appt,

STAT dictateSTAT dictate

Content: PMD Ratings of Content: PMD Ratings of Desired InformationDesired Information

Main diagnosisMain diagnosis Pertinent physical findingsPertinent physical findings Results of procedures/testsResults of procedures/tests Discharge meds with Discharge meds with reason for changesreason for changes Followup arrangementsFollowup arrangements Pending tests and specific followup needs (*)Pending tests and specific followup needs (*) Information given to patient/familyInformation given to patient/family

ConclusionsConclusions

Communication and information transfer is Communication and information transfer is often suboptimaloften suboptimal

Interventions had limited effect on outcomes. Interventions had limited effect on outcomes. Options for handoff policies and procedures: Options for handoff policies and procedures: white papers and discussionswhite papers and discussions

Recommendations:Recommendations:

Kripalani S, LeFevre F, Phillips CO, et al. JAMA, Kripalani S, LeFevre F, Phillips CO, et al. JAMA, 2007;297(8):8382007;297(8):838

Obligations of both physicians- patient care/Obligations of both physicians- patient care/continuity/informationcontinuity/information

Contact and communication between physiciansContact and communication between physicians

Information exchangeInformation exchange FrequencyFrequency ModeMode Value: respect and support, educationValue: respect and support, education

Actions: Hospital-based change? Hospitalist policy; pager Actions: Hospital-based change? Hospitalist policy; pager 66776677

Discussion Issues

Thorough dictations, templatesThorough dictations, templates Contacting Primary PhysicianContacting Primary Physician Hospitalist BrochureHospitalist Brochure Handoff Policy: internal and referralHandoff Policy: internal and referral

Hospitalist Measures