Provider characteristics, clinical-work processes and their relationship to discharge summary quality for sub-acute care patients.

BACKGROUND: Discharge summaries play a pivotal role in the transitional care of patients discharged to sub-acute care facilities, but the best ways to facilitate document completeness/quality remain unknown. OBJECTIVE: To examine the relationship among clinical-work processes, provider characteristics, and discharge summary content to identify approaches that promote high-quality discharge documentation. DESIGN: Retrospective cohort study. SUBJECTS: All hip fracture and stroke patients discharged to sub-acute care facilities during 2003-2005 from a large Midwestern academic medical center (N = 489). Patients on hospice/comfort care were excluded. MAIN MEASURES: We abstracted 32 expert-recommended components in four categories ('patient's medical course,' 'functional/cognitive ability at discharge,' 'future plan of care,' and 'name/contact information') from the discharge summaries of sample patients. We examined predictors for the number of included components within each category using Poisson regression models. Predictors included work processes (document completion in relation to discharge day; completion time of day) and provider characteristics (training year; specialty). KEY RESULTS: Historical components (i.e., 'patient's medical course' category) were included more often than components that directly inform the admission orders in the sub-acute care facility (i.e., 'future plan of care'). In this latter category, most summaries included a discharge medication list (99%), disposition (90%), and instructions for follow-up (91%), but less frequently included diet (68%), activity instructions (58%), therapy orders (56%), prognosis/diagnosis communication to patient/family (15%), code status (7%), and pending studies (6%). 'Future plan of care' components were more likely to be omitted if a discharge summary was created >24 h after discharge (incident rate ratio = 0.91, 95% confidence interval = 0.84-0.98) or if an intern created the summary (0.90, 0.83-0.97). CONCLUSION: Critical component omissions in discharge summaries were common, and were associated with delayed document creation and less experienced providers. More research is needed to understand the impact of discharge documentation quality on patient/system outcomes.

Pending laboratory tests and the hospital discharge summary in patients discharged to sub-acute care.

BACKGROUND: Previous studies have noted a high (41%) prevalence and poor discharge summary communication of pending laboratory (lab) tests at the time of hospital discharge for general medical patients. However, the prevalence and communication of pending labs within a high-risk population, specifically those patients discharged to sub-acute care (i.e., skilled nursing, rehabilitation, long-term care), remains unknown. OBJECTIVE: To determine the prevalence and nature of lab tests pending at hospital discharge and their inclusion within hospital discharge summaries, for common sub-acute care populations. DESIGN: Retrospective cohort study. PARTICIPANTS: Stroke, hip fracture, and cancer patients discharged from a single large academic medical center to sub-acute care, 2003-2005 (N = 564) MAIN MEASURES: Pending lab tests were abstracted from the laboratory information system (LIS) and from each patient's discharge summary, then grouped into 14 categories and compared. Microbiology tests were sub-divided by culture type and number of days pending prior to discharge. KEY RESULTS: Of sub-acute care patients, 32% (181/564) were discharged with pending lab tests per the LIS; however, only 11% (20/181) of discharge summaries documented these. Patients most often left the hospital with pending microbiology tests (83% [150/181]), particularly blood and urine cultures, and reference lab tests (17% [30/181]). However, 82% (61/74) of patients' pending urine cultures did not have 24-hour preliminary results, and 19% (13/70) of patients' pending blood cultures did not have 48-hour preliminary results available at the time of hospital discharge. CONCLUSIONS: Approximately one-third of the sub-acute care patients in this study had labs pending at discharge, but few were documented within hospital discharge summaries. Even after considering the availability of preliminary microbiology results, these omissions remain common. Future studies should focus on improving the communication of pending lab tests at discharge and evaluating the impact that this improved communication has on patient outcomes.

Interventions to Improve Follow-Up of Laboratory Test Results Pending at Discharge: A Systematic Review.

Failure to follow up test results pending at discharge (TPAD) from hospitals or emergency departments is a major patient safety concern. The purpose of this review is to systematically evaluate the effectiveness of interventions to improve follow-up of laboratory TPAD. We conducted literature searches in PubMed, CINAHL, Cochrane, and EMBASE using search terms for relevant health care settings, transition of patient care, laboratory tests, communication, and pending or missed tests. We solicited unpublished studies from the clinical laboratory community and excluded articles that did not address transitions between settings, did not include an intervention, or were not related to laboratory TPAD. We also excluded letters, editorials, commentaries, abstracts, case reports, and case series. Of the 9,592 abstracts retrieved, eight met the inclusion criteria and reported the successful communication of TPAD. A team member abstracted predetermined data elements from each study, and a senior scientist reviewed the abstraction. Two experienced reviewers independently appraised the quality of each study using published Laboratory Medicine Best Practices (LMBP™) A-6 scoring criteria. We assessed the body of evidence using the A-6 methodology, and the evidence suggested that electronic tools or one-on-one education increased documentation of pending tests in discharge summaries. We also found that automated notifications improved awareness of TPAD. The interventions were supported by suggestive evidence; this type of evidence is below the level of evidence required for LMBP™ recommendations. We encourage additional research into the impact of these interventions on key processes and health outcomes.

Validation of an enzyme-linked immunosorbent assay kit using herpesvirus papio 2 (HVP2) antigen for detection of herpesvirus simiae (B virus) infection in rhesus monkeys.

Serologic testing for antibody to monkey B virus (BV) in macaque sera is problematic due to the biohazardous nature of BV antigens. Herpesvirus papio 2 (HVP2), a herpesvirus of baboons, is nonpathogenic to humans and is genetically and antigenically more closely related to BV than is human herpes simplex virus 1. This paper describes the results of our in-house laboratory that compared a BV antigen-based enzyme-linked immunosorbent assay (ELISA) by commercial testing laboratory and an HVP2-based ELISA in our laboratory by using 447 sera from 290 rhesus monkeys. The HVP2-based ELISA identified as positive 99.11% of the sera identified as BV-positive by the BV ELISA. The BV antigen-based ELISA identified as positive 98.21% of the sera identified as BV-positive by the HVP2-based ELISA. The HVP2 ELISA also identified two BV-negative and six BV-equivocal sera as positive. Both ELISAs identified the same 85 negative and three equivocal samples as negative and equivocal, respectively. The high degree of correlation (weighted kappa coefficient, 0.94) between the two tests indicates that the HVP2 ELISA is a sensitive and reliable assay for in-house testing of the BV status of rhesus monkeys.

Cytologic assessment of the vaginal epithelium in the common marmoset (Callithrix jacchus): a preliminary new approach to reproductive screening.

The application of vaginal cytology in defining reproductive events is a widely accepted and applied diagnostic tool in many species. Here we present a preliminary approach to recognizing a correlation between changes in vaginal epithelial cytology and circulating plasma progesterone in the common marmoset, Callithrix jacchus, such that vaginal cytology could be diagnostically appropriate for reproductive management. We assessed six captive-born adult female common marmosets for the duration of one complete estrus cycle. Cytologic samples, collected by vaginal swab, and blood for plasma progesterone concentration were collected twice weekly. Cytologic samples were blindly assessed, and vaginal epithelial maturation was defined on the basis of the karyopyknotic index (KPI). In the three consistently cycling females (cj0328, cj0732, and cj0678), a marked increase in KPI corresponded with rising plasma progesterone levels, which subsequently decreased throughout the duration of follicular phase. The remaining three females who had previously irregular estrus cycles (cj0608, cj0680, cj0724) demonstrated irregularity in their progesterone profiles which correlated with inconsistent KPIs. Although KPI is not a very sensitive single sampling indicator of ovulation, evaluating changes in cytologic morphology over time aid in predicting the timing of an ovulatory event. Our results suggest that vaginal cytology can be an effective alternative to blood sampling for reproductive management of the common marmoset.

Patient safety & post-analytical error.

Post-analytical laboratory processes have been considered to be less prone to error than preanalytical processes because of the widespread adoption of laboratory automation and interfaced laboratory reporting. Quality monitors and controls for the post-analytical process have focused on critical result notification, meeting established turnaround time goals, and review of changed reports. The rapid increase in the adoption of electronic health records has created a new role for laboratory professionals in the management of patient test results. Laboratory professionals must interface with the clinical side of the health care team in establishing quality control for post-analytical processes, particularly in high-risk transitions of care.