Moy Nicholas Y, Lee Sei J, Chan Tyrone, Grovey Brittany, Boscardin W John, Gonzales Ralph, Pierluissi Edgar
Jt Comm J Qual Patient Saf. 2014 May;40(5):219-27. doi: 10.1016/s1553-7250(14)40029-1.
After hospital discharge, patients are at risk for medication errors, missed test results, adverse events, and readmissions. Handoff communication between the inpatient and outpatient settings is primarily accomplished with the discharge summary. However, critical information can often be missing, such as the date of the first postdischarge follow-up visit, a complete and accurate list of discharge medications, and follow-up recommendations. There have been no studies focusing on identifying and implementing a parsimonious, clinically relevant, inpatient-to-outpatient discharge handoff tool within a fully integrated electronic medical record (EMR) system. A concise, written, electronic handoff communication tool was created to address this gap.
Using inpatient and outpatient provider stakeholder input, a standard, succinct, and clinically relevant handoff tool was designed and implemented within the Veterans Affairs EMR. Retrospective chart review at 3 and 15 months after the handoff tool rollout in December 2010 was conducted to monitor handoff uptake and outcomes.
At 15 months after implementation, 86% (129/150) of patients had a completed handoff at the time of discharge. More handoff notes were available in the EMR within 24 hours of discharge than discharge summaries (100% versus 77%, p < .0001). There was no difference between those patients with or without a handoff in the number of emergency department visits or readmissions.
A standardized clinically relevant discharge handoff tool had high user uptake and sustainability and improved timeliness of communication of information between the hospital and outpatient setting. Even within a fully integrated EMR system, simple and efficient handoffs between inpatient and outpatient providers may fulfill a communication gap at the time of discharge.
出院后，患者存在用药错误、检查结果遗漏、不良事件及再次入院的风险。住院部与门诊部之间的交接沟通主要通过出院小结来完成。然而，关键信息往往缺失，如出院后首次随访日期、完整准确的出院用药清单及随访建议。目前尚无研究聚焦于在完全集成的电子病历（EMR）系统中识别并实施一个简洁、临床相关的住院部到门诊部的出院交接工具。因此创建了一个简洁的书面电子交接沟通工具来弥补这一差距。
利用住院部和门诊部医护人员利益相关者的意见，在退伍军人事务部的电子病历系统中设计并实施了一个标准、简洁且临床相关的交接工具。对2010年12月交接工具推出后3个月和15个月时的病历进行回顾性审查，以监测交接工具的使用情况和结果。
实施15个月后，86%（129/150）的患者在出院时有完整的交接记录。出院后24小时内电子病历中可获取的交接记录比出院小结更多（100%对77%，p<.0001）。有或没有交接记录的患者在急诊就诊次数或再次入院次数上没有差异。
一个标准化的临床相关出院交接工具具有较高的用户接受度和可持续性，并改善了医院与门诊部之间信息沟通的及时性。即使在完全集成的电子病历系统中，住院部和门诊部医护人员之间简单高效的交接也可能弥补出院时的沟通差距。
