Hospital Discharge Summaries Are Insufficient Following ICU Stays: A Qualitative Study

Abstract

OBJECTIVES: Primary care providers (PCPs) receive limited information about their patients’ ICU stays; we sought to understand what additional information PCPs desire to support patients’ recovery following critical illness. DESIGN: Semistructured interviews with PCPs conducted between September 2020 and April 2021. SETTING: Academic health system with central quaternary-care hospital and associated Veterans Affairs medical center. SUBJECTS: Fourteen attending internal medicine or family medicine physicians working in seven clinics across Southeast Michigan (median, 10.5 yr in practice). MAIN OUTCOMES AND MEASURES: We analyzed using a modified Rigorous and Accelerated Data Reduction (RADaR) technique to identify gaps in current discharge summaries for patients with ICU stays, impacts of these gaps, and desired ICU-specific information. We employed RADaR to efficiently consolidate data in Excel Microsoft (Redmond, WA) tables across multiple formats (lists, themes, etc.). RESULTS: PCPs reported receiving limited ICU-specific information in hospital discharge summaries. PCPs often spent significant time reading inpatient records for additional information. Information desired included life-support interventions provided and duration (mechanical ventilation, dialysis, etc.), reasons for treatment decisions (code status changes, medication changes, etc.), and potential complications (delirium, dysphagia, postintensive care syndrome, etc.). Pervasive discharge gaps (ongoing needs, incidental findings, etc.) were described as worse among patients with ICU stays due to more complex illness and required interventions. Insufficient information was felt to lead to incomplete follow-up on critical issues, PCP frustration, and patient harm. PCPs stated that the COVID-19 pandemic exacerbated gaps due to decreased staffing, limited visitation policies, and reliance on telehealth follow-up visits. CONCLUSIONS AND RELEVANCE: Our results identified key data elements sought by PCPs about patients’ ICU stays and suggest opportunities to improve care through developing tools/templates to provide PCPs with ICU-specific information for outpatient follow-up.

Interviews with primary care physicians identify unmet transition needs after ICU

“…We conducted semi-structured interviews about hospital discharge summaries with 14 primary care providers in Internal Medicine and Family Medicine at a large US academic institution between September 2020 and April 2021 [5]. Our study was classified as exempt by the University of Michigan Institutional Review Board.…”

“…We used a modified Rigorous and Accelerated Data Reduction (RADaR) [7] process to identify critical issues described by participants. In another paper [5], we describe results focused on improving hospital discharge summaries. This letter focuses on patients' unmet transition needs that also arose during these interviews (see Additional file 1: appendix for more information).…”

Healthcare delivery and recovery after critical illness

“…A recent single-centre US study explored the primary care providers’ perspectives on how hospital discharge summaries could improve. Primary care providers wanted hospital discharge summaries to provide information about why patients were admitted; what interventions were undertaken; what complications occurred; what treatment choices were made by the patient; what potential post-ICU problems may be encountered by the patient [17].…”

Communication Strategies and Patient Care Transitions in the Early ICU Aftercare Period*

“…The need for effective communication via handoff documentation for patient care transitions during acute hospitalization is indisputable (2, 3). Structured ICU discharge documentation strategies are maturing by leveraging features within EHRs to temper delayed and incomplete records (4, 7, 9). Attention to the ICU discharge transition handoff is particularly relevant and understudied despite persistent characterizations of higher rates of adverse events relative to other periods of hospitalization (1, 5).…”

“…In this issue of Critical Care Medicine, Wang et al (7) build upon their previous work, demonstrating that among critically ill patients admitted to the CICU without elevated phenylalanine levels (< 11.2 µmol/dL) at admission, those with a genetic predisposition toward developing hyperphenylalaninemia are at increased risk of mortality. They performed a single-center prospective observational study in their tertiary-level CICU where they enrolled 497 critically ill patients from 2017 to 2021.…”