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Barriers to Early Hospital Discharge: A Cross-Sectional Study at Five Academic Hospitals
Hospital discharges frequently occur in the afternoon or evening hours.1-5 Late discharges can adversely affect patient flow throughout the hospital,3,6-9 which, in turn, can result in delays in care,10-16 more medication errors,17 increased mortality,18-20 longer lengths of stay,20-22 higher costs,23 and lower patient satisfaction.24
Various interventions have been employed in the attempts to find ways of moving discharge times to earlier in the day, including preparing the discharge paperwork and medications the previous night,25 using checklists,1,25 team huddles,2 providing real-time feedback to unit staff,1 and employing multidisciplinary teamwork.1,2,6,25,26
The purpose of this study was to identify and determine the relative frequency of barriers to writing discharge orders in the hopes of identifying issues that might be addressed by targeted interventions. We also assessed the effects of daily team census, patients being on teaching versus nonteaching services, and how daily rounds were structured at the time that the discharge orders were written.
METHODS
Study Design, Setting, and Participants
We conducted a prospective, cross-sectional survey of house-staff and attending physicians on general medicine teaching and nonteaching services from November 13, 2014, through May 31, 2016. The study was conducted at the following five hospitals: Denver Health Medical Center (DHMC) and Presbyterian/Saint Luke’s Medical Center (PSL) in Denver, Colorado; Ronald Reagan University (UCLA) and Los Angeles County/University of Southern California Medical Center (LAC+USC) in Los Angeles, California; and Harborview Medical Center (HMC) in Seattle, Washington. The study was approved by the Colorado Multi-Institutional Review Board as well as by the review boards of the other participating sites.
Data Collection
The results of the focus groups composed of attending physicians at DHMC were used to develop our initial data collection template. Additional sites joining the study provided feedback, leading to modifications (Appendix 1).
Physicians were surveyed at three different time points on study days that were selected according to the convenience of the investigators. The sampling occurred only on weekdays and was done based on the investigators’ availability. Investigators would attempt to survey as many teams as they were able to but, secondary to feasibility, not all teams could be surveyed on study days. The specific time points varied as a function of physician workflows but were standardized as much as possible to occur in the early morning, around noon, and midafternoon on weekdays. Physicians were contacted either in person or by telephone for verbal consent prior to administering the first survey. All general medicine teams were eligible. For teaching teams, the order of contact was resident, intern, and then attending based on which physician was available at the time of the survey and on which member of the team was thought to know the patients the best. For the nonteaching services, the attending physicians were contacted.
During the initial survey, the investigators assessed the provider role (ie, attending or housestaff), whether the service was a teaching or a nonteaching service, and the starting patient census on that service primarily based on interviewing the provider of record for the team and looking at team census lists. Physicians were asked about their rounding style (ie, sickest patients first, patients likely to be discharged first, room-by-room, most recently admitted patients first, patients on the team the longest, or other) and then to identify all patients they thought would be definite discharges sometime during the day of the survey. Definite discharges were defined as patients whom the provider thought were either currently ready for discharge or who had only minor barriers that, if unresolved, would not prevent same-day discharge. They were asked if the discharge order had been entered and, if not, what was preventing them from doing so, if the discharge could in their opinion have occurred the day prior and, if so, why this did not occur. We also obtained the date and time of the admission and discharge orders, the actual discharge time, as well as the length of stay either through chart review (majority of sites) or from data warehouses (Denver Health and Presbyterian St. Lukes had length of stay data retrieved from their data warehouse).
Physicians were also asked to identify all patients whom they thought might possibly be discharged that day. Possible discharges were defined as patients with barriers to discharge that, if unresolved, would prevent same-day discharge. For each of these, the physicians were asked to list whatever issues needed to be resolved prior to placing the discharge order (Appendix 1).
The second survey was administered late morning on the same day, typically between 11
The third survey was administered midafternoon, typically around 3 PM similar to the first two surveys, with the exception that the third survey did not attempt to identify new definite or possible discharges.
Sample Size
We stopped collecting data after obtaining a convenience sample of 5% of total discharges at each study site or on the study end date, which was May 31, 2016, whichever came first.
Data Analysis
Data were collected and managed using a secure, web-based application electronic data capture tool (REDCap), hosted at Denver Health. REDCap (Research Electronic Data Capture, Nashville, Tennessee) is designed to support data collection for research studies.27 Data were then analyzed using SAS Enterprise Guide 5.1 (SAS Institute, Inc., Cary, North Carolina). All data entered into REDCap were reviewed by the principal investigator to ensure that data were not missing, and when there were missing data, a query was sent to verify if the data were retrievable. If retrievable, then the data would be entered. The volume of missing data that remained is described in our results.
Continuous variables were described using means and standard deviations (SD) or medians and interquartile ranges (IQR) based on tests of normality. Differences in the time that the discharge orders were placed in the electronic medical record according to morning patient census, teaching versus nonteaching service, and rounding style were compared using the Wilcoxon rank sum test. Linear regression was used to evaluate the effect of patient census on discharge order time. P < .05 was considered as significant.
RESULTS
We conducted 1,584 patient evaluations through surveys of 254 physicians over 156 days. Given surveys coincided with the existing work we had full participation (ie, 100% participation) and no dropout during the study days. Median (IQR) survey time points were 8:30
The characteristics of the five hospitals participating in the study, the patients’ final discharge status, the types of physicians surveyed, the services on which they were working, the rounding styles employed, and the median starting daily census are summarized in Table 1. The majority of the physicians surveyed were housestaff working on teaching services, and only a small minority structured rounds such that patients ready for discharge were seen first.
Over the course of the three surveys, 949 patients were identified as being definite discharges at any time point, and the large majority of these (863, 91%) were discharged on the day of the survey. The median (IQR) time that the discharge orders were written was 11:50
During the initial morning survey, 314 patients were identified as being definite discharges for that day (representing approximately 6% of the total number of patients being cared for, or 33% of the patients identified as definite discharges throughout the day). Of these, the physicians thought that 44 (<1% of the total number of patients being cared for on the services) could have been discharged on the previous day. The most frequent reasons cited for why these patients were not discharged on the previous day were “Patient did not want to leave” (n = 15, 34%), “Too late in the day” (n = 10, 23%), and “No ride” (n = 9, 20%). The remaining 10 patients (23%) had a variety of reasons related to system or social issues (ie, shelter not available, miscommunication).
At the morning time point, the most common barriers to discharge identified were that the physicians had not finished rounding on their team of patients and that the housestaff needed to staff their patients with their attending. At noon, caring for other patients and tending to the discharge processes were most commonly cited, and in the afternoon, the most common barriers were that the physicians were in the process of completing the discharge paperwork for those patients or were discharging other patients (Table 2). When comparing barriers on teaching to nonteaching teams, a higher proportion of teaching teams were still rounding on all patients and were working on discharge paperwork at the second survey. Barriers cited by sites were similar; however, the frequency at which the barriers were mentioned varied (data not shown).
The physicians identified 1,237 patients at any time point as being possible discharges during the day of the survey and these had a mean (±SD) of 1.3 (±0.5) barriers cited for why these patients were possible rather than definite discharges. The most common were that clinical improvement was needed, one or more pending issues related to their care needed to be resolved, and/or awaiting pending test results. The need to see clinical improvement generally decreased throughout the day as did the need to staff patients with an attending physician, but barriers related to consultant recommendations or completing procedures increased (Table 3). Of the 1,237 patients ever identified as possible discharges, 594 (48%) became a definite discharge by the third call and 444 (36%) became a no discharge as their final status. As with definite discharges, barriers cited by sites were similar; however, the frequency at which the barriers were mentioned varied.
Among the 949 and 1,237 patients who were ever identified as definite or possible discharges, respectively, at any time point during the study day, 28 (3%) and 444 (36%), respectively, had their discharge status changed to no discharge, most commonly because their clinical condition either worsened or expected improvements did not occur or that barriers pertaining to social work, physical therapy, or occupational therapy were not resolved.
The median time that the discharge orders were entered into the electronic medical record was 43 minutes earlier if patients were on teams with a lower versus a higher starting census (P = .0003), 48 minutes earlier if they were seen by physicians whose rounding style was to see patients first who potentially could be discharged (P = .0026), and 58 minutes earlier if they were on nonteaching versus teaching services (P < .0001; Table 4). For every one-person increase in census, the discharge order time increased by 6 minutes (β = 5.6, SE = 1.6, P = .0003).
DISCUSSION
The important findings of this study are that (1) the large majority of issues thought to delay discharging patients identified as definite discharges were related to physicians caring for other patients on their team, (2) although 91% of patients ever identified as being definite discharges were discharged on the day of the survey, only 48% of those identified as possible discharges became definite discharges by the afternoon time point, largely because the anticipated clinical improvement did not occur or care being provided by ancillary services had not been completed, and (3) discharge orders on patients identified as definite discharges were written on average 50 minutes earlier by physicians on teams with a smaller starting patient census, on nonteaching services, or when the rounding style was to see patients ready for discharges first.
Previous research has reported that physician-perceived barriers to discharge were extrinsic to providers and even extrinsic to the hospital setting (eg, awaiting subacute nursing placement and transportation).28,29 However, many of the barriers that we identified were related directly to the providers’ workload and rounding styles and whether the patients were on teaching versus nonteaching services. We also found that delays in the ability of hospital services to complete care also contributed to delayed discharges.
Our observational data suggest that delays resulting from caring for other patients might be reduced by changing rounding styles such that patients ready for discharge are seen first and are discharged prior to seeing other patients on the team, as previously reported by Beck et al.30 Intuitively, this would seem to be a straightforward way of freeing up beds earlier in the day, but such a change will, of necessity, lead to delaying care for other patients, which, in turn, could increase their length of stays. Durvasula et al. suggested that discharges could be moved to earlier in the day by completing orders and paperwork the day prior to discharge.25 Such an approach might be effective on an Obstetrical or elective Orthopedic service on which patients predictably are hospitalized for a fixed number of days (or even hours) but may be less relevant to patients on internal medicine services where lengths of stay are less predictable. Interventions to improve discharge times have resulted in earlier discharge times in some studies,2,4 but the overall length of stay either did not decrease25 or increased31 in others. Werthheimer et al.1 did find earlier discharge times, but other interventions also occurred during the study period (eg, extending social work services to include weekends).1,32
We found that discharge times were approximately 50 minutes earlier on teams with a smaller starting census, on nonteaching compared with teaching services, or when the attending’s rounding style was to see patients ready for discharges first. Although 50 minutes may seem like a small change in discharge time, Khanna et al.33 found that when discharges occur even 1 hour earlier, hospital overcrowding is reduced. To have a lower team census would require having more teams and more providers to staff these teams, raising cost-effectiveness concerns. Moving to more nonteaching services could represent a conflict with respect to one of the missions of teaching hospitals and raises a cost-benefit issue as several teaching hospitals receive substantial funding in support of their teaching activities and housestaff would have to be replaced with more expensive providers.
Delays attributable to ancillary services indicate imbalances between demand and availability of these services. Inappropriate demand and inefficiencies could be reduced by systems redesign, but in at least some instances, additional resources will be needed to add staff, increase space, or add additional equipment.
Our study has several limitations. First, we surveyed only physicians working in university-affiliated hospitals, and three of these were public safety-net hospitals. Accordingly, our results may not be generalizable to different patient populations. Second, we surveyed only physicians, and Minichiello et al.29 found that barriers to discharge perceived by physicians were different from those of other staff. Third, our data were observational and were collected only on weekdays. Fourth, we did not differentiate interns from residents, and thus, potentially the level of training could have affected these results. Similarly, the decision for a “possible” and a “definite” discharge is likely dependent on the knowledge base of the participant, such that less experienced participants may have had differing perspectives than someone with more experience. Fifth, the sites did vary based on the infrastructure and support but also had several similarities. All sites had social work and case management involved in care, although at some sites, they were assigned according to team and at others according to geographic location. Similarly, rounding times varied. Most of the services surveyed did not utilize advanced practice providers (the exception was the nonteaching services at Denver Health, and their presence was variable). These differences in staffing models could also have affected these results.
Our study also has a number of strengths. First, we assessed the barriers at five different hospitals. Second, we collected real-time data related to specific barriers at multiple time points throughout the day, allowing us to assess the dynamic nature of identifying patients as being ready or nearly ready for discharge. Third, we assessed the perceptions of barriers to discharge from physicians working on teaching as well as nonteaching services and from physicians utilizing a variety of rounding styles. Fourth, we had a very high participation rate (100%), probably due to the fact that our study was strategically aligned with participants’ daily work activities.
In conclusion, we found two distinct categories of issues that physicians perceived as most commonly delaying writing discharge orders on their patients. The first pertained to patients thought to definitely be ready for discharge and was related to the physicians having to care for other patients on their team. The second pertained to patients identified as possibly ready for discharge and was related to the need for care to be completed by a variety of ancillary services. Addressing each of these barriers would require different interventions and a need to weigh the potential improvements that could be achieved against the increased costs and/or delays in care for other patients that may result.
Disclosures
The authors report no conflicts of interest relevant to this work.
1. Wertheimer B, Jacobs RE, Bailey M, et al. Discharge before noon: an achievable hospital goal. J Hosp Med. 2014;9(4):210-214. doi: 10.1002/jhm.2154. PubMed
2. Kane M, Weinacker A, Arthofer R, et al. A multidisciplinary initiative to increase inpatient discharges before noon. J Nurs Adm. 2016;46(12):630-635. doi: 10.1097/NNA.0000000000000418. PubMed
3. Khanna S, Sier D, Boyle J, Zeitz K. Discharge timeliness and its impact on hospital crowding and emergency department flow performance. Emerg Med Australas. 2016;28(2):164-170. doi: 10.1111/1742-6723.12543. PubMed
4. Kravet SJ, Levine RB, Rubin HR, Wright SM. Discharging patients earlier in the day: a concept worth evaluating. Health Care Manag (Frederick). 2007;26:142-146. doi: 10.1097/01.HCM.0000268617.33491.60. PubMed
5. Khanna S, Boyle J, Good N, Lind J. Impact of admission and discharge peak times on hospital overcrowding. Stud Health Technol Inform. 2011;168:82-88. doi: 10.3233/978-1-60750-791-8-82. PubMed
6. McGowan JE, Truwit JD, Cipriano P, et al. Operating room efficiency and hospital capacity: factors affecting operating room use during maximum hospital census. J Am Coll Surg. 2007;204(5):865-871; discussion 71-72. doi: 10.1016/j.jamcollsurg.2007.01.052 PubMed
7. Khanna S, Boyle J, Good N, Lind J. Early discharge and its effect on ED length of stay and access block. Stud Health Technol Inform. 2012;178:92-98. doi: 10.3233/978-1-61499-078-9-92 PubMed
8. Powell ES, Khare RK, Venkatesh AK, Van Roo BD, Adams JG, Reinhardt G. The relationship between inpatient discharge timing and emergency department boarding. J Emerg Med. 2012;42(2):186-196. doi: 10.1016/j.jemermed.2010.06.028. PubMed
9. Wertheimer B, Jacobs RE, Iturrate E, Bailey M, Hochman K. Discharge before noon: Effect on throughput and sustainability. J Hosp Med. 2015;10(10):664-669. doi: 10.1002/jhm.2412. PubMed
10. Sikka R, Mehta S, Kaucky C, Kulstad EB. ED crowding is associated with an increased time to pneumonia treatment. Am J Emerg Med. 2010;28(7):809-812. doi: 10.1016/j.ajem.2009.06.023. PubMed
11. Coil CJ, Flood JD, Belyeu BM, Young P, Kaji AH, Lewis RJ. The effect of emergency department boarding on order completion. Ann Emerg Med. 2016;67:730-736 e2. doi: 10.1016/j.annemergmed.2015.09.018. PubMed
12. Gaieski DF, Agarwal AK, Mikkelsen ME, et al. The impact of ED crowding on early interventions and mortality in patients with severe sepsis. Am J Emerg Med. 2017;35:953-960. doi: 10.1016/j.ajem.2017.01.061. PubMed
13. Pines JM, Localio AR, Hollander JE, et al. The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia. Ann Emerg Med. 2007;50(5):510-516. doi: 10.1016/j.annemergmed.2007.07.021. PubMed
14. Hwang U, Richardson L, Livote E, Harris B, Spencer N, Sean Morrison R. Emergency department crowding and decreased quality of pain care. Acad Emerg Med. 2008;15:1248-1255. doi: 10.1111/j.1553-2712.2008.00267.x. PubMed
15. Mills AM, Shofer FS, Chen EH, Hollander JE, Pines JM. The association between emergency department crowding and analgesia administration in acute abdominal pain patients. Acad Emerg Med. 2009;16:603-608. doi: 10.1111/j.1553-2712.2009.00441.x. PubMed
16. Pines JM, Shofer FS, Isserman JA, Abbuhl SB, Mills AM. The effect of emergency department crowding on analgesia in patients with back pain in two hospitals. Acad Emerg Med. 2010;17(3):276-283. doi: 10.1111/j.1553-2712.2009.00676.x. PubMed
17. Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. ED overcrowding is associated with an increased frequency of medication errors. Am J Emerg Med. 2010;28:304-309. doi: 10.1016/j.ajem.2008.12.014. PubMed
18. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006;184(5):213-216. PubMed
19. Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52(2):126-136. doi: 10.1016/j.annemergmed.2008.03.014. PubMed
20. Singer AJ, Thode HC, Jr., Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011;18(12):1324-1329. doi: 10.1111/j.1553-2712.2011.01236.x. PubMed
21. White BA, Biddinger PD, Chang Y, Grabowski B, Carignan S, Brown DF. Boarding inpatients in the emergency department increases discharged patient length of stay. J Emerg Med. 2013;44(1):230-235. doi: 10.1016/j.jemermed.2012.05.007. PubMed
22. Forster AJ, Stiell I, Wells G, Lee AJ, van Walraven C. The effect of hospital occupancy on emergency department length of stay and patient disposition. Acad Emerg Med. 2003;10(2):127-133. doi: 10.1197/aemj.10.2.127. PubMed
23. Foley M, Kifaieh N, Mallon WK. Financial impact of emergency department crowding. West J Emerg Med. 2011;12(2):192-197. PubMed
24. Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS, Datner EM. The effect of emergency department crowding on patient satisfaction for admitted patients. Acad Emerg Med. 2008;15(9):825-831. doi: 10.1111/j.1553-2712.2008.00200.x. PubMed
25. Durvasula R, Kayihan A, Del Bene S, et al. A multidisciplinary care pathway significantly increases the number of early morning discharges in a large academic medical center. Qual Manag Health Care. 2015;24:45-51. doi: 10.1097/QMH.0000000000000049. PubMed
26. Cho HJ, Desai N, Florendo A, et al. E-DIP: Early Discharge Project. A Model for Throughput and Early Discharge for 1-Day Admissions. BMJ Qual Improv Rep. 2016;5(1): pii: u210035.w4128. doi: 10.1136/bmjquality.u210035.w4128. PubMed
27. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. doi: 10.1016/j.jbi.2008.08.010. PubMed
28. Patel H, Fang MC, Mourad M, et al. Hospitalist and internal medicine leaders’ perspectives of early discharge challenges at academic medical centers. J Hosp Med. 2018;13(6):388-391. doi: 10.12788/jhm.2885. PubMed
29. Minichiello TM, Auerbach AD, Wachter RM. Caregiver perceptions of the reasons for delayed hospital discharge. Eff Clin Pract. 2001;4(6):250-255. PubMed
30. Beck MJ, Okerblom D, Kumar A, Bandyopadhyay S, Scalzi LV. Lean intervention improves patient discharge times, improves emergency department throughput and reduces congestion. Hosp Pract (1995). 2016;44(5):252-259. doi: 10.1080/21548331.2016.1254559. PubMed
31. Rajkomar A, Valencia V, Novelero M, Mourad M, Auerbach A. The association between discharge before noon and length of stay in medical and surgical patients. J Hosp Med. 2016;11(12):859-861. doi: 10.1002/jhm.2529. PubMed
32. Shine D. Discharge before noon: an urban legend. Am J Med. 2015;128(5):445-446. doi: 10.1016/j.amjmed.2014.12.011. PubMed
33. Khanna S, Boyle J, Good N, Lind J. Unravelling relationships: Hospital occupancy levels, discharge timing and emergency department access block. Emerg Med Australas. 2012;24(5):510-517. doi: 10.1111/j.1742-6723.2012.01587.x. PubMed
Hospital discharges frequently occur in the afternoon or evening hours.1-5 Late discharges can adversely affect patient flow throughout the hospital,3,6-9 which, in turn, can result in delays in care,10-16 more medication errors,17 increased mortality,18-20 longer lengths of stay,20-22 higher costs,23 and lower patient satisfaction.24
Various interventions have been employed in the attempts to find ways of moving discharge times to earlier in the day, including preparing the discharge paperwork and medications the previous night,25 using checklists,1,25 team huddles,2 providing real-time feedback to unit staff,1 and employing multidisciplinary teamwork.1,2,6,25,26
The purpose of this study was to identify and determine the relative frequency of barriers to writing discharge orders in the hopes of identifying issues that might be addressed by targeted interventions. We also assessed the effects of daily team census, patients being on teaching versus nonteaching services, and how daily rounds were structured at the time that the discharge orders were written.
METHODS
Study Design, Setting, and Participants
We conducted a prospective, cross-sectional survey of house-staff and attending physicians on general medicine teaching and nonteaching services from November 13, 2014, through May 31, 2016. The study was conducted at the following five hospitals: Denver Health Medical Center (DHMC) and Presbyterian/Saint Luke’s Medical Center (PSL) in Denver, Colorado; Ronald Reagan University (UCLA) and Los Angeles County/University of Southern California Medical Center (LAC+USC) in Los Angeles, California; and Harborview Medical Center (HMC) in Seattle, Washington. The study was approved by the Colorado Multi-Institutional Review Board as well as by the review boards of the other participating sites.
Data Collection
The results of the focus groups composed of attending physicians at DHMC were used to develop our initial data collection template. Additional sites joining the study provided feedback, leading to modifications (Appendix 1).
Physicians were surveyed at three different time points on study days that were selected according to the convenience of the investigators. The sampling occurred only on weekdays and was done based on the investigators’ availability. Investigators would attempt to survey as many teams as they were able to but, secondary to feasibility, not all teams could be surveyed on study days. The specific time points varied as a function of physician workflows but were standardized as much as possible to occur in the early morning, around noon, and midafternoon on weekdays. Physicians were contacted either in person or by telephone for verbal consent prior to administering the first survey. All general medicine teams were eligible. For teaching teams, the order of contact was resident, intern, and then attending based on which physician was available at the time of the survey and on which member of the team was thought to know the patients the best. For the nonteaching services, the attending physicians were contacted.
During the initial survey, the investigators assessed the provider role (ie, attending or housestaff), whether the service was a teaching or a nonteaching service, and the starting patient census on that service primarily based on interviewing the provider of record for the team and looking at team census lists. Physicians were asked about their rounding style (ie, sickest patients first, patients likely to be discharged first, room-by-room, most recently admitted patients first, patients on the team the longest, or other) and then to identify all patients they thought would be definite discharges sometime during the day of the survey. Definite discharges were defined as patients whom the provider thought were either currently ready for discharge or who had only minor barriers that, if unresolved, would not prevent same-day discharge. They were asked if the discharge order had been entered and, if not, what was preventing them from doing so, if the discharge could in their opinion have occurred the day prior and, if so, why this did not occur. We also obtained the date and time of the admission and discharge orders, the actual discharge time, as well as the length of stay either through chart review (majority of sites) or from data warehouses (Denver Health and Presbyterian St. Lukes had length of stay data retrieved from their data warehouse).
Physicians were also asked to identify all patients whom they thought might possibly be discharged that day. Possible discharges were defined as patients with barriers to discharge that, if unresolved, would prevent same-day discharge. For each of these, the physicians were asked to list whatever issues needed to be resolved prior to placing the discharge order (Appendix 1).
The second survey was administered late morning on the same day, typically between 11
The third survey was administered midafternoon, typically around 3 PM similar to the first two surveys, with the exception that the third survey did not attempt to identify new definite or possible discharges.
Sample Size
We stopped collecting data after obtaining a convenience sample of 5% of total discharges at each study site or on the study end date, which was May 31, 2016, whichever came first.
Data Analysis
Data were collected and managed using a secure, web-based application electronic data capture tool (REDCap), hosted at Denver Health. REDCap (Research Electronic Data Capture, Nashville, Tennessee) is designed to support data collection for research studies.27 Data were then analyzed using SAS Enterprise Guide 5.1 (SAS Institute, Inc., Cary, North Carolina). All data entered into REDCap were reviewed by the principal investigator to ensure that data were not missing, and when there were missing data, a query was sent to verify if the data were retrievable. If retrievable, then the data would be entered. The volume of missing data that remained is described in our results.
Continuous variables were described using means and standard deviations (SD) or medians and interquartile ranges (IQR) based on tests of normality. Differences in the time that the discharge orders were placed in the electronic medical record according to morning patient census, teaching versus nonteaching service, and rounding style were compared using the Wilcoxon rank sum test. Linear regression was used to evaluate the effect of patient census on discharge order time. P < .05 was considered as significant.
RESULTS
We conducted 1,584 patient evaluations through surveys of 254 physicians over 156 days. Given surveys coincided with the existing work we had full participation (ie, 100% participation) and no dropout during the study days. Median (IQR) survey time points were 8:30
The characteristics of the five hospitals participating in the study, the patients’ final discharge status, the types of physicians surveyed, the services on which they were working, the rounding styles employed, and the median starting daily census are summarized in Table 1. The majority of the physicians surveyed were housestaff working on teaching services, and only a small minority structured rounds such that patients ready for discharge were seen first.
Over the course of the three surveys, 949 patients were identified as being definite discharges at any time point, and the large majority of these (863, 91%) were discharged on the day of the survey. The median (IQR) time that the discharge orders were written was 11:50
During the initial morning survey, 314 patients were identified as being definite discharges for that day (representing approximately 6% of the total number of patients being cared for, or 33% of the patients identified as definite discharges throughout the day). Of these, the physicians thought that 44 (<1% of the total number of patients being cared for on the services) could have been discharged on the previous day. The most frequent reasons cited for why these patients were not discharged on the previous day were “Patient did not want to leave” (n = 15, 34%), “Too late in the day” (n = 10, 23%), and “No ride” (n = 9, 20%). The remaining 10 patients (23%) had a variety of reasons related to system or social issues (ie, shelter not available, miscommunication).
At the morning time point, the most common barriers to discharge identified were that the physicians had not finished rounding on their team of patients and that the housestaff needed to staff their patients with their attending. At noon, caring for other patients and tending to the discharge processes were most commonly cited, and in the afternoon, the most common barriers were that the physicians were in the process of completing the discharge paperwork for those patients or were discharging other patients (Table 2). When comparing barriers on teaching to nonteaching teams, a higher proportion of teaching teams were still rounding on all patients and were working on discharge paperwork at the second survey. Barriers cited by sites were similar; however, the frequency at which the barriers were mentioned varied (data not shown).
The physicians identified 1,237 patients at any time point as being possible discharges during the day of the survey and these had a mean (±SD) of 1.3 (±0.5) barriers cited for why these patients were possible rather than definite discharges. The most common were that clinical improvement was needed, one or more pending issues related to their care needed to be resolved, and/or awaiting pending test results. The need to see clinical improvement generally decreased throughout the day as did the need to staff patients with an attending physician, but barriers related to consultant recommendations or completing procedures increased (Table 3). Of the 1,237 patients ever identified as possible discharges, 594 (48%) became a definite discharge by the third call and 444 (36%) became a no discharge as their final status. As with definite discharges, barriers cited by sites were similar; however, the frequency at which the barriers were mentioned varied.
Among the 949 and 1,237 patients who were ever identified as definite or possible discharges, respectively, at any time point during the study day, 28 (3%) and 444 (36%), respectively, had their discharge status changed to no discharge, most commonly because their clinical condition either worsened or expected improvements did not occur or that barriers pertaining to social work, physical therapy, or occupational therapy were not resolved.
The median time that the discharge orders were entered into the electronic medical record was 43 minutes earlier if patients were on teams with a lower versus a higher starting census (P = .0003), 48 minutes earlier if they were seen by physicians whose rounding style was to see patients first who potentially could be discharged (P = .0026), and 58 minutes earlier if they were on nonteaching versus teaching services (P < .0001; Table 4). For every one-person increase in census, the discharge order time increased by 6 minutes (β = 5.6, SE = 1.6, P = .0003).
DISCUSSION
The important findings of this study are that (1) the large majority of issues thought to delay discharging patients identified as definite discharges were related to physicians caring for other patients on their team, (2) although 91% of patients ever identified as being definite discharges were discharged on the day of the survey, only 48% of those identified as possible discharges became definite discharges by the afternoon time point, largely because the anticipated clinical improvement did not occur or care being provided by ancillary services had not been completed, and (3) discharge orders on patients identified as definite discharges were written on average 50 minutes earlier by physicians on teams with a smaller starting patient census, on nonteaching services, or when the rounding style was to see patients ready for discharges first.
Previous research has reported that physician-perceived barriers to discharge were extrinsic to providers and even extrinsic to the hospital setting (eg, awaiting subacute nursing placement and transportation).28,29 However, many of the barriers that we identified were related directly to the providers’ workload and rounding styles and whether the patients were on teaching versus nonteaching services. We also found that delays in the ability of hospital services to complete care also contributed to delayed discharges.
Our observational data suggest that delays resulting from caring for other patients might be reduced by changing rounding styles such that patients ready for discharge are seen first and are discharged prior to seeing other patients on the team, as previously reported by Beck et al.30 Intuitively, this would seem to be a straightforward way of freeing up beds earlier in the day, but such a change will, of necessity, lead to delaying care for other patients, which, in turn, could increase their length of stays. Durvasula et al. suggested that discharges could be moved to earlier in the day by completing orders and paperwork the day prior to discharge.25 Such an approach might be effective on an Obstetrical or elective Orthopedic service on which patients predictably are hospitalized for a fixed number of days (or even hours) but may be less relevant to patients on internal medicine services where lengths of stay are less predictable. Interventions to improve discharge times have resulted in earlier discharge times in some studies,2,4 but the overall length of stay either did not decrease25 or increased31 in others. Werthheimer et al.1 did find earlier discharge times, but other interventions also occurred during the study period (eg, extending social work services to include weekends).1,32
We found that discharge times were approximately 50 minutes earlier on teams with a smaller starting census, on nonteaching compared with teaching services, or when the attending’s rounding style was to see patients ready for discharges first. Although 50 minutes may seem like a small change in discharge time, Khanna et al.33 found that when discharges occur even 1 hour earlier, hospital overcrowding is reduced. To have a lower team census would require having more teams and more providers to staff these teams, raising cost-effectiveness concerns. Moving to more nonteaching services could represent a conflict with respect to one of the missions of teaching hospitals and raises a cost-benefit issue as several teaching hospitals receive substantial funding in support of their teaching activities and housestaff would have to be replaced with more expensive providers.
Delays attributable to ancillary services indicate imbalances between demand and availability of these services. Inappropriate demand and inefficiencies could be reduced by systems redesign, but in at least some instances, additional resources will be needed to add staff, increase space, or add additional equipment.
Our study has several limitations. First, we surveyed only physicians working in university-affiliated hospitals, and three of these were public safety-net hospitals. Accordingly, our results may not be generalizable to different patient populations. Second, we surveyed only physicians, and Minichiello et al.29 found that barriers to discharge perceived by physicians were different from those of other staff. Third, our data were observational and were collected only on weekdays. Fourth, we did not differentiate interns from residents, and thus, potentially the level of training could have affected these results. Similarly, the decision for a “possible” and a “definite” discharge is likely dependent on the knowledge base of the participant, such that less experienced participants may have had differing perspectives than someone with more experience. Fifth, the sites did vary based on the infrastructure and support but also had several similarities. All sites had social work and case management involved in care, although at some sites, they were assigned according to team and at others according to geographic location. Similarly, rounding times varied. Most of the services surveyed did not utilize advanced practice providers (the exception was the nonteaching services at Denver Health, and their presence was variable). These differences in staffing models could also have affected these results.
Our study also has a number of strengths. First, we assessed the barriers at five different hospitals. Second, we collected real-time data related to specific barriers at multiple time points throughout the day, allowing us to assess the dynamic nature of identifying patients as being ready or nearly ready for discharge. Third, we assessed the perceptions of barriers to discharge from physicians working on teaching as well as nonteaching services and from physicians utilizing a variety of rounding styles. Fourth, we had a very high participation rate (100%), probably due to the fact that our study was strategically aligned with participants’ daily work activities.
In conclusion, we found two distinct categories of issues that physicians perceived as most commonly delaying writing discharge orders on their patients. The first pertained to patients thought to definitely be ready for discharge and was related to the physicians having to care for other patients on their team. The second pertained to patients identified as possibly ready for discharge and was related to the need for care to be completed by a variety of ancillary services. Addressing each of these barriers would require different interventions and a need to weigh the potential improvements that could be achieved against the increased costs and/or delays in care for other patients that may result.
Disclosures
The authors report no conflicts of interest relevant to this work.
Hospital discharges frequently occur in the afternoon or evening hours.1-5 Late discharges can adversely affect patient flow throughout the hospital,3,6-9 which, in turn, can result in delays in care,10-16 more medication errors,17 increased mortality,18-20 longer lengths of stay,20-22 higher costs,23 and lower patient satisfaction.24
Various interventions have been employed in the attempts to find ways of moving discharge times to earlier in the day, including preparing the discharge paperwork and medications the previous night,25 using checklists,1,25 team huddles,2 providing real-time feedback to unit staff,1 and employing multidisciplinary teamwork.1,2,6,25,26
The purpose of this study was to identify and determine the relative frequency of barriers to writing discharge orders in the hopes of identifying issues that might be addressed by targeted interventions. We also assessed the effects of daily team census, patients being on teaching versus nonteaching services, and how daily rounds were structured at the time that the discharge orders were written.
METHODS
Study Design, Setting, and Participants
We conducted a prospective, cross-sectional survey of house-staff and attending physicians on general medicine teaching and nonteaching services from November 13, 2014, through May 31, 2016. The study was conducted at the following five hospitals: Denver Health Medical Center (DHMC) and Presbyterian/Saint Luke’s Medical Center (PSL) in Denver, Colorado; Ronald Reagan University (UCLA) and Los Angeles County/University of Southern California Medical Center (LAC+USC) in Los Angeles, California; and Harborview Medical Center (HMC) in Seattle, Washington. The study was approved by the Colorado Multi-Institutional Review Board as well as by the review boards of the other participating sites.
Data Collection
The results of the focus groups composed of attending physicians at DHMC were used to develop our initial data collection template. Additional sites joining the study provided feedback, leading to modifications (Appendix 1).
Physicians were surveyed at three different time points on study days that were selected according to the convenience of the investigators. The sampling occurred only on weekdays and was done based on the investigators’ availability. Investigators would attempt to survey as many teams as they were able to but, secondary to feasibility, not all teams could be surveyed on study days. The specific time points varied as a function of physician workflows but were standardized as much as possible to occur in the early morning, around noon, and midafternoon on weekdays. Physicians were contacted either in person or by telephone for verbal consent prior to administering the first survey. All general medicine teams were eligible. For teaching teams, the order of contact was resident, intern, and then attending based on which physician was available at the time of the survey and on which member of the team was thought to know the patients the best. For the nonteaching services, the attending physicians were contacted.
During the initial survey, the investigators assessed the provider role (ie, attending or housestaff), whether the service was a teaching or a nonteaching service, and the starting patient census on that service primarily based on interviewing the provider of record for the team and looking at team census lists. Physicians were asked about their rounding style (ie, sickest patients first, patients likely to be discharged first, room-by-room, most recently admitted patients first, patients on the team the longest, or other) and then to identify all patients they thought would be definite discharges sometime during the day of the survey. Definite discharges were defined as patients whom the provider thought were either currently ready for discharge or who had only minor barriers that, if unresolved, would not prevent same-day discharge. They were asked if the discharge order had been entered and, if not, what was preventing them from doing so, if the discharge could in their opinion have occurred the day prior and, if so, why this did not occur. We also obtained the date and time of the admission and discharge orders, the actual discharge time, as well as the length of stay either through chart review (majority of sites) or from data warehouses (Denver Health and Presbyterian St. Lukes had length of stay data retrieved from their data warehouse).
Physicians were also asked to identify all patients whom they thought might possibly be discharged that day. Possible discharges were defined as patients with barriers to discharge that, if unresolved, would prevent same-day discharge. For each of these, the physicians were asked to list whatever issues needed to be resolved prior to placing the discharge order (Appendix 1).
The second survey was administered late morning on the same day, typically between 11
The third survey was administered midafternoon, typically around 3 PM similar to the first two surveys, with the exception that the third survey did not attempt to identify new definite or possible discharges.
Sample Size
We stopped collecting data after obtaining a convenience sample of 5% of total discharges at each study site or on the study end date, which was May 31, 2016, whichever came first.
Data Analysis
Data were collected and managed using a secure, web-based application electronic data capture tool (REDCap), hosted at Denver Health. REDCap (Research Electronic Data Capture, Nashville, Tennessee) is designed to support data collection for research studies.27 Data were then analyzed using SAS Enterprise Guide 5.1 (SAS Institute, Inc., Cary, North Carolina). All data entered into REDCap were reviewed by the principal investigator to ensure that data were not missing, and when there were missing data, a query was sent to verify if the data were retrievable. If retrievable, then the data would be entered. The volume of missing data that remained is described in our results.
Continuous variables were described using means and standard deviations (SD) or medians and interquartile ranges (IQR) based on tests of normality. Differences in the time that the discharge orders were placed in the electronic medical record according to morning patient census, teaching versus nonteaching service, and rounding style were compared using the Wilcoxon rank sum test. Linear regression was used to evaluate the effect of patient census on discharge order time. P < .05 was considered as significant.
RESULTS
We conducted 1,584 patient evaluations through surveys of 254 physicians over 156 days. Given surveys coincided with the existing work we had full participation (ie, 100% participation) and no dropout during the study days. Median (IQR) survey time points were 8:30
The characteristics of the five hospitals participating in the study, the patients’ final discharge status, the types of physicians surveyed, the services on which they were working, the rounding styles employed, and the median starting daily census are summarized in Table 1. The majority of the physicians surveyed were housestaff working on teaching services, and only a small minority structured rounds such that patients ready for discharge were seen first.
Over the course of the three surveys, 949 patients were identified as being definite discharges at any time point, and the large majority of these (863, 91%) were discharged on the day of the survey. The median (IQR) time that the discharge orders were written was 11:50
During the initial morning survey, 314 patients were identified as being definite discharges for that day (representing approximately 6% of the total number of patients being cared for, or 33% of the patients identified as definite discharges throughout the day). Of these, the physicians thought that 44 (<1% of the total number of patients being cared for on the services) could have been discharged on the previous day. The most frequent reasons cited for why these patients were not discharged on the previous day were “Patient did not want to leave” (n = 15, 34%), “Too late in the day” (n = 10, 23%), and “No ride” (n = 9, 20%). The remaining 10 patients (23%) had a variety of reasons related to system or social issues (ie, shelter not available, miscommunication).
At the morning time point, the most common barriers to discharge identified were that the physicians had not finished rounding on their team of patients and that the housestaff needed to staff their patients with their attending. At noon, caring for other patients and tending to the discharge processes were most commonly cited, and in the afternoon, the most common barriers were that the physicians were in the process of completing the discharge paperwork for those patients or were discharging other patients (Table 2). When comparing barriers on teaching to nonteaching teams, a higher proportion of teaching teams were still rounding on all patients and were working on discharge paperwork at the second survey. Barriers cited by sites were similar; however, the frequency at which the barriers were mentioned varied (data not shown).
The physicians identified 1,237 patients at any time point as being possible discharges during the day of the survey and these had a mean (±SD) of 1.3 (±0.5) barriers cited for why these patients were possible rather than definite discharges. The most common were that clinical improvement was needed, one or more pending issues related to their care needed to be resolved, and/or awaiting pending test results. The need to see clinical improvement generally decreased throughout the day as did the need to staff patients with an attending physician, but barriers related to consultant recommendations or completing procedures increased (Table 3). Of the 1,237 patients ever identified as possible discharges, 594 (48%) became a definite discharge by the third call and 444 (36%) became a no discharge as their final status. As with definite discharges, barriers cited by sites were similar; however, the frequency at which the barriers were mentioned varied.
Among the 949 and 1,237 patients who were ever identified as definite or possible discharges, respectively, at any time point during the study day, 28 (3%) and 444 (36%), respectively, had their discharge status changed to no discharge, most commonly because their clinical condition either worsened or expected improvements did not occur or that barriers pertaining to social work, physical therapy, or occupational therapy were not resolved.
The median time that the discharge orders were entered into the electronic medical record was 43 minutes earlier if patients were on teams with a lower versus a higher starting census (P = .0003), 48 minutes earlier if they were seen by physicians whose rounding style was to see patients first who potentially could be discharged (P = .0026), and 58 minutes earlier if they were on nonteaching versus teaching services (P < .0001; Table 4). For every one-person increase in census, the discharge order time increased by 6 minutes (β = 5.6, SE = 1.6, P = .0003).
DISCUSSION
The important findings of this study are that (1) the large majority of issues thought to delay discharging patients identified as definite discharges were related to physicians caring for other patients on their team, (2) although 91% of patients ever identified as being definite discharges were discharged on the day of the survey, only 48% of those identified as possible discharges became definite discharges by the afternoon time point, largely because the anticipated clinical improvement did not occur or care being provided by ancillary services had not been completed, and (3) discharge orders on patients identified as definite discharges were written on average 50 minutes earlier by physicians on teams with a smaller starting patient census, on nonteaching services, or when the rounding style was to see patients ready for discharges first.
Previous research has reported that physician-perceived barriers to discharge were extrinsic to providers and even extrinsic to the hospital setting (eg, awaiting subacute nursing placement and transportation).28,29 However, many of the barriers that we identified were related directly to the providers’ workload and rounding styles and whether the patients were on teaching versus nonteaching services. We also found that delays in the ability of hospital services to complete care also contributed to delayed discharges.
Our observational data suggest that delays resulting from caring for other patients might be reduced by changing rounding styles such that patients ready for discharge are seen first and are discharged prior to seeing other patients on the team, as previously reported by Beck et al.30 Intuitively, this would seem to be a straightforward way of freeing up beds earlier in the day, but such a change will, of necessity, lead to delaying care for other patients, which, in turn, could increase their length of stays. Durvasula et al. suggested that discharges could be moved to earlier in the day by completing orders and paperwork the day prior to discharge.25 Such an approach might be effective on an Obstetrical or elective Orthopedic service on which patients predictably are hospitalized for a fixed number of days (or even hours) but may be less relevant to patients on internal medicine services where lengths of stay are less predictable. Interventions to improve discharge times have resulted in earlier discharge times in some studies,2,4 but the overall length of stay either did not decrease25 or increased31 in others. Werthheimer et al.1 did find earlier discharge times, but other interventions also occurred during the study period (eg, extending social work services to include weekends).1,32
We found that discharge times were approximately 50 minutes earlier on teams with a smaller starting census, on nonteaching compared with teaching services, or when the attending’s rounding style was to see patients ready for discharges first. Although 50 minutes may seem like a small change in discharge time, Khanna et al.33 found that when discharges occur even 1 hour earlier, hospital overcrowding is reduced. To have a lower team census would require having more teams and more providers to staff these teams, raising cost-effectiveness concerns. Moving to more nonteaching services could represent a conflict with respect to one of the missions of teaching hospitals and raises a cost-benefit issue as several teaching hospitals receive substantial funding in support of their teaching activities and housestaff would have to be replaced with more expensive providers.
Delays attributable to ancillary services indicate imbalances between demand and availability of these services. Inappropriate demand and inefficiencies could be reduced by systems redesign, but in at least some instances, additional resources will be needed to add staff, increase space, or add additional equipment.
Our study has several limitations. First, we surveyed only physicians working in university-affiliated hospitals, and three of these were public safety-net hospitals. Accordingly, our results may not be generalizable to different patient populations. Second, we surveyed only physicians, and Minichiello et al.29 found that barriers to discharge perceived by physicians were different from those of other staff. Third, our data were observational and were collected only on weekdays. Fourth, we did not differentiate interns from residents, and thus, potentially the level of training could have affected these results. Similarly, the decision for a “possible” and a “definite” discharge is likely dependent on the knowledge base of the participant, such that less experienced participants may have had differing perspectives than someone with more experience. Fifth, the sites did vary based on the infrastructure and support but also had several similarities. All sites had social work and case management involved in care, although at some sites, they were assigned according to team and at others according to geographic location. Similarly, rounding times varied. Most of the services surveyed did not utilize advanced practice providers (the exception was the nonteaching services at Denver Health, and their presence was variable). These differences in staffing models could also have affected these results.
Our study also has a number of strengths. First, we assessed the barriers at five different hospitals. Second, we collected real-time data related to specific barriers at multiple time points throughout the day, allowing us to assess the dynamic nature of identifying patients as being ready or nearly ready for discharge. Third, we assessed the perceptions of barriers to discharge from physicians working on teaching as well as nonteaching services and from physicians utilizing a variety of rounding styles. Fourth, we had a very high participation rate (100%), probably due to the fact that our study was strategically aligned with participants’ daily work activities.
In conclusion, we found two distinct categories of issues that physicians perceived as most commonly delaying writing discharge orders on their patients. The first pertained to patients thought to definitely be ready for discharge and was related to the physicians having to care for other patients on their team. The second pertained to patients identified as possibly ready for discharge and was related to the need for care to be completed by a variety of ancillary services. Addressing each of these barriers would require different interventions and a need to weigh the potential improvements that could be achieved against the increased costs and/or delays in care for other patients that may result.
Disclosures
The authors report no conflicts of interest relevant to this work.
1. Wertheimer B, Jacobs RE, Bailey M, et al. Discharge before noon: an achievable hospital goal. J Hosp Med. 2014;9(4):210-214. doi: 10.1002/jhm.2154. PubMed
2. Kane M, Weinacker A, Arthofer R, et al. A multidisciplinary initiative to increase inpatient discharges before noon. J Nurs Adm. 2016;46(12):630-635. doi: 10.1097/NNA.0000000000000418. PubMed
3. Khanna S, Sier D, Boyle J, Zeitz K. Discharge timeliness and its impact on hospital crowding and emergency department flow performance. Emerg Med Australas. 2016;28(2):164-170. doi: 10.1111/1742-6723.12543. PubMed
4. Kravet SJ, Levine RB, Rubin HR, Wright SM. Discharging patients earlier in the day: a concept worth evaluating. Health Care Manag (Frederick). 2007;26:142-146. doi: 10.1097/01.HCM.0000268617.33491.60. PubMed
5. Khanna S, Boyle J, Good N, Lind J. Impact of admission and discharge peak times on hospital overcrowding. Stud Health Technol Inform. 2011;168:82-88. doi: 10.3233/978-1-60750-791-8-82. PubMed
6. McGowan JE, Truwit JD, Cipriano P, et al. Operating room efficiency and hospital capacity: factors affecting operating room use during maximum hospital census. J Am Coll Surg. 2007;204(5):865-871; discussion 71-72. doi: 10.1016/j.jamcollsurg.2007.01.052 PubMed
7. Khanna S, Boyle J, Good N, Lind J. Early discharge and its effect on ED length of stay and access block. Stud Health Technol Inform. 2012;178:92-98. doi: 10.3233/978-1-61499-078-9-92 PubMed
8. Powell ES, Khare RK, Venkatesh AK, Van Roo BD, Adams JG, Reinhardt G. The relationship between inpatient discharge timing and emergency department boarding. J Emerg Med. 2012;42(2):186-196. doi: 10.1016/j.jemermed.2010.06.028. PubMed
9. Wertheimer B, Jacobs RE, Iturrate E, Bailey M, Hochman K. Discharge before noon: Effect on throughput and sustainability. J Hosp Med. 2015;10(10):664-669. doi: 10.1002/jhm.2412. PubMed
10. Sikka R, Mehta S, Kaucky C, Kulstad EB. ED crowding is associated with an increased time to pneumonia treatment. Am J Emerg Med. 2010;28(7):809-812. doi: 10.1016/j.ajem.2009.06.023. PubMed
11. Coil CJ, Flood JD, Belyeu BM, Young P, Kaji AH, Lewis RJ. The effect of emergency department boarding on order completion. Ann Emerg Med. 2016;67:730-736 e2. doi: 10.1016/j.annemergmed.2015.09.018. PubMed
12. Gaieski DF, Agarwal AK, Mikkelsen ME, et al. The impact of ED crowding on early interventions and mortality in patients with severe sepsis. Am J Emerg Med. 2017;35:953-960. doi: 10.1016/j.ajem.2017.01.061. PubMed
13. Pines JM, Localio AR, Hollander JE, et al. The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia. Ann Emerg Med. 2007;50(5):510-516. doi: 10.1016/j.annemergmed.2007.07.021. PubMed
14. Hwang U, Richardson L, Livote E, Harris B, Spencer N, Sean Morrison R. Emergency department crowding and decreased quality of pain care. Acad Emerg Med. 2008;15:1248-1255. doi: 10.1111/j.1553-2712.2008.00267.x. PubMed
15. Mills AM, Shofer FS, Chen EH, Hollander JE, Pines JM. The association between emergency department crowding and analgesia administration in acute abdominal pain patients. Acad Emerg Med. 2009;16:603-608. doi: 10.1111/j.1553-2712.2009.00441.x. PubMed
16. Pines JM, Shofer FS, Isserman JA, Abbuhl SB, Mills AM. The effect of emergency department crowding on analgesia in patients with back pain in two hospitals. Acad Emerg Med. 2010;17(3):276-283. doi: 10.1111/j.1553-2712.2009.00676.x. PubMed
17. Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. ED overcrowding is associated with an increased frequency of medication errors. Am J Emerg Med. 2010;28:304-309. doi: 10.1016/j.ajem.2008.12.014. PubMed
18. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006;184(5):213-216. PubMed
19. Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52(2):126-136. doi: 10.1016/j.annemergmed.2008.03.014. PubMed
20. Singer AJ, Thode HC, Jr., Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011;18(12):1324-1329. doi: 10.1111/j.1553-2712.2011.01236.x. PubMed
21. White BA, Biddinger PD, Chang Y, Grabowski B, Carignan S, Brown DF. Boarding inpatients in the emergency department increases discharged patient length of stay. J Emerg Med. 2013;44(1):230-235. doi: 10.1016/j.jemermed.2012.05.007. PubMed
22. Forster AJ, Stiell I, Wells G, Lee AJ, van Walraven C. The effect of hospital occupancy on emergency department length of stay and patient disposition. Acad Emerg Med. 2003;10(2):127-133. doi: 10.1197/aemj.10.2.127. PubMed
23. Foley M, Kifaieh N, Mallon WK. Financial impact of emergency department crowding. West J Emerg Med. 2011;12(2):192-197. PubMed
24. Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS, Datner EM. The effect of emergency department crowding on patient satisfaction for admitted patients. Acad Emerg Med. 2008;15(9):825-831. doi: 10.1111/j.1553-2712.2008.00200.x. PubMed
25. Durvasula R, Kayihan A, Del Bene S, et al. A multidisciplinary care pathway significantly increases the number of early morning discharges in a large academic medical center. Qual Manag Health Care. 2015;24:45-51. doi: 10.1097/QMH.0000000000000049. PubMed
26. Cho HJ, Desai N, Florendo A, et al. E-DIP: Early Discharge Project. A Model for Throughput and Early Discharge for 1-Day Admissions. BMJ Qual Improv Rep. 2016;5(1): pii: u210035.w4128. doi: 10.1136/bmjquality.u210035.w4128. PubMed
27. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. doi: 10.1016/j.jbi.2008.08.010. PubMed
28. Patel H, Fang MC, Mourad M, et al. Hospitalist and internal medicine leaders’ perspectives of early discharge challenges at academic medical centers. J Hosp Med. 2018;13(6):388-391. doi: 10.12788/jhm.2885. PubMed
29. Minichiello TM, Auerbach AD, Wachter RM. Caregiver perceptions of the reasons for delayed hospital discharge. Eff Clin Pract. 2001;4(6):250-255. PubMed
30. Beck MJ, Okerblom D, Kumar A, Bandyopadhyay S, Scalzi LV. Lean intervention improves patient discharge times, improves emergency department throughput and reduces congestion. Hosp Pract (1995). 2016;44(5):252-259. doi: 10.1080/21548331.2016.1254559. PubMed
31. Rajkomar A, Valencia V, Novelero M, Mourad M, Auerbach A. The association between discharge before noon and length of stay in medical and surgical patients. J Hosp Med. 2016;11(12):859-861. doi: 10.1002/jhm.2529. PubMed
32. Shine D. Discharge before noon: an urban legend. Am J Med. 2015;128(5):445-446. doi: 10.1016/j.amjmed.2014.12.011. PubMed33. Khanna S, Boyle J, Good N, Lind J. Unravelling relationships: Hospital occupancy levels, discharge timing and emergency department access block. Emerg Med Australas. 2012;24(5):510-517. doi: 10.1111/j.1742-6723.2012.01587.x. PubMed
1. Wertheimer B, Jacobs RE, Bailey M, et al. Discharge before noon: an achievable hospital goal. J Hosp Med. 2014;9(4):210-214. doi: 10.1002/jhm.2154. PubMed
2. Kane M, Weinacker A, Arthofer R, et al. A multidisciplinary initiative to increase inpatient discharges before noon. J Nurs Adm. 2016;46(12):630-635. doi: 10.1097/NNA.0000000000000418. PubMed
3. Khanna S, Sier D, Boyle J, Zeitz K. Discharge timeliness and its impact on hospital crowding and emergency department flow performance. Emerg Med Australas. 2016;28(2):164-170. doi: 10.1111/1742-6723.12543. PubMed
4. Kravet SJ, Levine RB, Rubin HR, Wright SM. Discharging patients earlier in the day: a concept worth evaluating. Health Care Manag (Frederick). 2007;26:142-146. doi: 10.1097/01.HCM.0000268617.33491.60. PubMed
5. Khanna S, Boyle J, Good N, Lind J. Impact of admission and discharge peak times on hospital overcrowding. Stud Health Technol Inform. 2011;168:82-88. doi: 10.3233/978-1-60750-791-8-82. PubMed
6. McGowan JE, Truwit JD, Cipriano P, et al. Operating room efficiency and hospital capacity: factors affecting operating room use during maximum hospital census. J Am Coll Surg. 2007;204(5):865-871; discussion 71-72. doi: 10.1016/j.jamcollsurg.2007.01.052 PubMed
7. Khanna S, Boyle J, Good N, Lind J. Early discharge and its effect on ED length of stay and access block. Stud Health Technol Inform. 2012;178:92-98. doi: 10.3233/978-1-61499-078-9-92 PubMed
8. Powell ES, Khare RK, Venkatesh AK, Van Roo BD, Adams JG, Reinhardt G. The relationship between inpatient discharge timing and emergency department boarding. J Emerg Med. 2012;42(2):186-196. doi: 10.1016/j.jemermed.2010.06.028. PubMed
9. Wertheimer B, Jacobs RE, Iturrate E, Bailey M, Hochman K. Discharge before noon: Effect on throughput and sustainability. J Hosp Med. 2015;10(10):664-669. doi: 10.1002/jhm.2412. PubMed
10. Sikka R, Mehta S, Kaucky C, Kulstad EB. ED crowding is associated with an increased time to pneumonia treatment. Am J Emerg Med. 2010;28(7):809-812. doi: 10.1016/j.ajem.2009.06.023. PubMed
11. Coil CJ, Flood JD, Belyeu BM, Young P, Kaji AH, Lewis RJ. The effect of emergency department boarding on order completion. Ann Emerg Med. 2016;67:730-736 e2. doi: 10.1016/j.annemergmed.2015.09.018. PubMed
12. Gaieski DF, Agarwal AK, Mikkelsen ME, et al. The impact of ED crowding on early interventions and mortality in patients with severe sepsis. Am J Emerg Med. 2017;35:953-960. doi: 10.1016/j.ajem.2017.01.061. PubMed
13. Pines JM, Localio AR, Hollander JE, et al. The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia. Ann Emerg Med. 2007;50(5):510-516. doi: 10.1016/j.annemergmed.2007.07.021. PubMed
14. Hwang U, Richardson L, Livote E, Harris B, Spencer N, Sean Morrison R. Emergency department crowding and decreased quality of pain care. Acad Emerg Med. 2008;15:1248-1255. doi: 10.1111/j.1553-2712.2008.00267.x. PubMed
15. Mills AM, Shofer FS, Chen EH, Hollander JE, Pines JM. The association between emergency department crowding and analgesia administration in acute abdominal pain patients. Acad Emerg Med. 2009;16:603-608. doi: 10.1111/j.1553-2712.2009.00441.x. PubMed
16. Pines JM, Shofer FS, Isserman JA, Abbuhl SB, Mills AM. The effect of emergency department crowding on analgesia in patients with back pain in two hospitals. Acad Emerg Med. 2010;17(3):276-283. doi: 10.1111/j.1553-2712.2009.00676.x. PubMed
17. Kulstad EB, Sikka R, Sweis RT, Kelley KM, Rzechula KH. ED overcrowding is associated with an increased frequency of medication errors. Am J Emerg Med. 2010;28:304-309. doi: 10.1016/j.ajem.2008.12.014. PubMed
18. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006;184(5):213-216. PubMed
19. Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52(2):126-136. doi: 10.1016/j.annemergmed.2008.03.014. PubMed
20. Singer AJ, Thode HC, Jr., Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011;18(12):1324-1329. doi: 10.1111/j.1553-2712.2011.01236.x. PubMed
21. White BA, Biddinger PD, Chang Y, Grabowski B, Carignan S, Brown DF. Boarding inpatients in the emergency department increases discharged patient length of stay. J Emerg Med. 2013;44(1):230-235. doi: 10.1016/j.jemermed.2012.05.007. PubMed
22. Forster AJ, Stiell I, Wells G, Lee AJ, van Walraven C. The effect of hospital occupancy on emergency department length of stay and patient disposition. Acad Emerg Med. 2003;10(2):127-133. doi: 10.1197/aemj.10.2.127. PubMed
23. Foley M, Kifaieh N, Mallon WK. Financial impact of emergency department crowding. West J Emerg Med. 2011;12(2):192-197. PubMed
24. Pines JM, Iyer S, Disbot M, Hollander JE, Shofer FS, Datner EM. The effect of emergency department crowding on patient satisfaction for admitted patients. Acad Emerg Med. 2008;15(9):825-831. doi: 10.1111/j.1553-2712.2008.00200.x. PubMed
25. Durvasula R, Kayihan A, Del Bene S, et al. A multidisciplinary care pathway significantly increases the number of early morning discharges in a large academic medical center. Qual Manag Health Care. 2015;24:45-51. doi: 10.1097/QMH.0000000000000049. PubMed
26. Cho HJ, Desai N, Florendo A, et al. E-DIP: Early Discharge Project. A Model for Throughput and Early Discharge for 1-Day Admissions. BMJ Qual Improv Rep. 2016;5(1): pii: u210035.w4128. doi: 10.1136/bmjquality.u210035.w4128. PubMed
27. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. doi: 10.1016/j.jbi.2008.08.010. PubMed
28. Patel H, Fang MC, Mourad M, et al. Hospitalist and internal medicine leaders’ perspectives of early discharge challenges at academic medical centers. J Hosp Med. 2018;13(6):388-391. doi: 10.12788/jhm.2885. PubMed
29. Minichiello TM, Auerbach AD, Wachter RM. Caregiver perceptions of the reasons for delayed hospital discharge. Eff Clin Pract. 2001;4(6):250-255. PubMed
30. Beck MJ, Okerblom D, Kumar A, Bandyopadhyay S, Scalzi LV. Lean intervention improves patient discharge times, improves emergency department throughput and reduces congestion. Hosp Pract (1995). 2016;44(5):252-259. doi: 10.1080/21548331.2016.1254559. PubMed
31. Rajkomar A, Valencia V, Novelero M, Mourad M, Auerbach A. The association between discharge before noon and length of stay in medical and surgical patients. J Hosp Med. 2016;11(12):859-861. doi: 10.1002/jhm.2529. PubMed
32. Shine D. Discharge before noon: an urban legend. Am J Med. 2015;128(5):445-446. doi: 10.1016/j.amjmed.2014.12.011. PubMed33. Khanna S, Boyle J, Good N, Lind J. Unravelling relationships: Hospital occupancy levels, discharge timing and emergency department access block. Emerg Med Australas. 2012;24(5):510-517. doi: 10.1111/j.1742-6723.2012.01587.x. PubMed
Safety of MRI in patients with implantable cardiac devices
Clinical question: Is MRI safe for patients who have implanted ICD or pacemakers that have not been deemed to be “MRI conditional” by the Food and Drug Administration?
Background: The majority of patients with implantable cardiac devices have a clinical indication for MRI within 10 years. Devices that meet certain criteria specified by the Food and Drug Administration are not felt to pose any safety hazards and are deemed “MRI conditional.” Those that do not meet these criteria are referred to as “legacy” devices and are considered to be a contraindication to MRI by the FDA and device manufacturers. The majority of ICDs and pacemakers currently in use are legacy devices and access to MRI for patients who have these devices has been very limited. This study is the first large prospective study to evaluate the safety of an MRI protocol in patients with legacy ICDs and pacemakers.
Study design: Prospective nonrandomized study.
Setting: Single academic medical center.
Synopsis: During 2003-2015, 1,509 patients with ICDs (629 patients) and pacemakers (880 patients) were enrolled and underwent 2,103 MRI examinations supervised by either an electrophysiologist or a registered nurse with cardiac device programming experience.
Study outcomes included safety and device function immediately after MRI and change in device parameters both immediately after MRI and at long-term follow-up. The most important clinical adverse event that occurred was a reset of device to backup settings referred to as “power on reset” that occurred in nine examinations. Of these nine events, one was associated with mild physical discomfort, one led to device replacement, and one was associated with transient inhibition of pacing. Small changes in P- or R-wave amplitude and atrial or ventricular capture were noted at long-term follow-up. However, none of these were large enough to result in lead revision or device reprogramming. Notable limitations of this study include that it is a single-center study limiting its ability to be generalized and that nearly 20% of patients were lost to long term follow up.
Bottom line: When performed at an institution with an established safety protocol, MRI examinations in patients with legacy devices are not associated with clinically significant adverse safety events or changes in device function that require reprogramming. Multicenter studies are necessary to determine if these results can be generalizable.
Citation: Nazarian S et al. Safety of magnetic resonance imaging in patients with cardiac devices. N Engl J Med. 2017 Dec 28;377(26):2555-64.
Dr. Scaletta is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.
Clinical question: Is MRI safe for patients who have implanted ICD or pacemakers that have not been deemed to be “MRI conditional” by the Food and Drug Administration?
Background: The majority of patients with implantable cardiac devices have a clinical indication for MRI within 10 years. Devices that meet certain criteria specified by the Food and Drug Administration are not felt to pose any safety hazards and are deemed “MRI conditional.” Those that do not meet these criteria are referred to as “legacy” devices and are considered to be a contraindication to MRI by the FDA and device manufacturers. The majority of ICDs and pacemakers currently in use are legacy devices and access to MRI for patients who have these devices has been very limited. This study is the first large prospective study to evaluate the safety of an MRI protocol in patients with legacy ICDs and pacemakers.
Study design: Prospective nonrandomized study.
Setting: Single academic medical center.
Synopsis: During 2003-2015, 1,509 patients with ICDs (629 patients) and pacemakers (880 patients) were enrolled and underwent 2,103 MRI examinations supervised by either an electrophysiologist or a registered nurse with cardiac device programming experience.
Study outcomes included safety and device function immediately after MRI and change in device parameters both immediately after MRI and at long-term follow-up. The most important clinical adverse event that occurred was a reset of device to backup settings referred to as “power on reset” that occurred in nine examinations. Of these nine events, one was associated with mild physical discomfort, one led to device replacement, and one was associated with transient inhibition of pacing. Small changes in P- or R-wave amplitude and atrial or ventricular capture were noted at long-term follow-up. However, none of these were large enough to result in lead revision or device reprogramming. Notable limitations of this study include that it is a single-center study limiting its ability to be generalized and that nearly 20% of patients were lost to long term follow up.
Bottom line: When performed at an institution with an established safety protocol, MRI examinations in patients with legacy devices are not associated with clinically significant adverse safety events or changes in device function that require reprogramming. Multicenter studies are necessary to determine if these results can be generalizable.
Citation: Nazarian S et al. Safety of magnetic resonance imaging in patients with cardiac devices. N Engl J Med. 2017 Dec 28;377(26):2555-64.
Dr. Scaletta is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.
Clinical question: Is MRI safe for patients who have implanted ICD or pacemakers that have not been deemed to be “MRI conditional” by the Food and Drug Administration?
Background: The majority of patients with implantable cardiac devices have a clinical indication for MRI within 10 years. Devices that meet certain criteria specified by the Food and Drug Administration are not felt to pose any safety hazards and are deemed “MRI conditional.” Those that do not meet these criteria are referred to as “legacy” devices and are considered to be a contraindication to MRI by the FDA and device manufacturers. The majority of ICDs and pacemakers currently in use are legacy devices and access to MRI for patients who have these devices has been very limited. This study is the first large prospective study to evaluate the safety of an MRI protocol in patients with legacy ICDs and pacemakers.
Study design: Prospective nonrandomized study.
Setting: Single academic medical center.
Synopsis: During 2003-2015, 1,509 patients with ICDs (629 patients) and pacemakers (880 patients) were enrolled and underwent 2,103 MRI examinations supervised by either an electrophysiologist or a registered nurse with cardiac device programming experience.
Study outcomes included safety and device function immediately after MRI and change in device parameters both immediately after MRI and at long-term follow-up. The most important clinical adverse event that occurred was a reset of device to backup settings referred to as “power on reset” that occurred in nine examinations. Of these nine events, one was associated with mild physical discomfort, one led to device replacement, and one was associated with transient inhibition of pacing. Small changes in P- or R-wave amplitude and atrial or ventricular capture were noted at long-term follow-up. However, none of these were large enough to result in lead revision or device reprogramming. Notable limitations of this study include that it is a single-center study limiting its ability to be generalized and that nearly 20% of patients were lost to long term follow up.
Bottom line: When performed at an institution with an established safety protocol, MRI examinations in patients with legacy devices are not associated with clinically significant adverse safety events or changes in device function that require reprogramming. Multicenter studies are necessary to determine if these results can be generalizable.
Citation: Nazarian S et al. Safety of magnetic resonance imaging in patients with cardiac devices. N Engl J Med. 2017 Dec 28;377(26):2555-64.
Dr. Scaletta is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.
Curbside vs Formal Consultation
A curbside consultation is an informal process whereby a consultant is asked to provide information or advice about a patient's care without doing a formal assessment of the patient.14 Curbside consultations are common in the practice of medicine2, 3, 5 and are frequently requested by physicians caring for hospitalized patients. Several surveys have documented the quantity of curbside consultations requested of various subspecialties, the types of questions asked, the time it takes to respond, and physicians' perceptions about the quality of the information exchanged.111 While curbside consultations have a number of advantages, physicians' perceptions are that the information conveyed may be inaccurate or incomplete and that the advice offered may be erroneous.13, 5, 10, 12, 13
Cartmill and White14 performed a random audit of 10% of the telephone referrals they received for neurosurgical consultation over a 1‐year period and noted discrepancies between the Glascow Coma Scores reported during the telephone referrals and those noted in the medical records, but the frequency of these discrepancies was not reported. To our knowledge, no studies have compared the quality of the information provided in curbside consultations with that obtained in formal consultations that included direct face‐to‐face patient evaluations and primary data collection, and whether the advice provided in curbside and formal consultations on the same patient differed.
We performed a prospective cohort study to compare the information received by hospitalists during curbside consultations on hospitalized patients, with that obtained from formal consultations done the same day on the same patients, by different hospitalists who were unaware of any details regarding the curbside consultation. We also compared the advice provided by the 2 hospitalists following their curbside and formal consultations. Our hypotheses were that the information received during curbside consultations was frequently inaccurate or incomplete, that the recommendations made after the formal consultation would frequently differ from those made in the curbside consultation, and that these differences would have important implications on patient care.
METHODS
This was a quality improvement study conducted at Denver Health, a 500‐bed university‐affiliated urban safety net hospital from January 10, 2011 to January 9, 2012. The study design was a prospective cohort that included all curbside consultations on hospitalized patients received between 7 AM and 3 PM, on intermittently selected weekdays, by the Internal Medicine Consultation Service that was staffed by 18 hospitalists. Data were collected intermittently based upon hospitalist availability and was done to limit potential alterations in the consulting practices of the providers requesting consultations.
Consultations were defined as being curbside when the consulting provider asked for advice, suggestions, or opinions about a patient's care but did not ask the hospitalist to see the patient.15, 15 Consultations pertaining to administrative issues (eg, whether a patient should be admitted to an intensive care bed as opposed to an acute care floor bed) or on patients who were already being followed by a hospitalist were excluded.
The hospitalist receiving the curbside consultation was allowed to ask questions as they normally would, but could not verify the accuracy of the information received (eg, could not review any portion of the patient's medical record, such as notes or lab data). A standardized data collection sheet was used to record the service and level of training of the requesting provider, the medical issue(s) of concern, all clinical data offered by the provider, the number of questions asked by the hospitalist of the provider, and whether, on the basis of the information provided, the hospitalist felt that the question(s) being asked was (were) of sufficient complexity that a formal consultation should occur. The hospitalist then offered advice based upon the information given during the curbside consultation.
After completing the curbside consultation, the hospitalist requested verbal permission from the requesting provider to perform a formal consultation. If the request was approved, the hospitalist performing the curbside consultation contacted a different hospitalist who performed the formal consultation within the next few hours. The only information given to the second hospitalist was the patient's identifiers and the clinical question(s) being asked. The formal consultation included a complete face‐to‐face history and physical examination, a review of the patient's medical record, documentation of the provider's findings, and recommendations for care.
Upon completion of the formal consultation, the hospitalists who performed the curbside and the formal consultations met to review the advice each gave to the requesting provider and the information on which this advice was based. The 2 hospitalists jointly determined the following: (a) whether the information received during the curbside consultation was correct and complete, (b) whether the advice provided in the formal consultation differed from that provided in the curbside consultation, (c) whether the advice provided in the formal consultation dealt with issues other than one(s) leading to the curbside consultation, (d) whether differences in the recommendations given in the curbside versus the formal consultation changed patient management in a meaningful way, and (e) whether the curbside consultation alone was felt to be sufficient.
Information obtained by the hospitalist performing the formal consultation that was different from, or not included in, the information recorded during the curbside consultation was considered to be incorrect or incomplete, respectively. A change in management was defined as an alteration in the direction or type of care that the patient would have received as a result of the advice being given. A pulmonary and critical care physician, with >35 years of experience in inpatient medicine, reviewed the information provided in the curbside and formal consultations, and independently assessed whether the curbside consultation alone would have been sufficient and whether the formal consultation changed management.
Curbside consultations were neither solicited nor discouraged during the course of the study. The provider requesting the curbside consultation was not informed or debriefed about the study in an attempt to avoid affecting future consultation practices from that provider or service.
Associations were sought between the frequency of inaccurate or incomplete data and the requesting service and provider, the consultative category and medical issue, the number of questions asked by the hospitalist during the curbside consultation, and whether the hospitalist doing the curbside consultation thought that formal consultation was needed. A chi‐square test was used to analyze all associations. A P value of <0.05 was considered significant. All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc, Cary, NC) software. The study was approved by the Colorado Multiple Institutional Review Board.
RESULTS
Fifty curbside consultations were requested on a total of 215 study days. The requesting service declined formal consultation in 3 instances, leaving 47 curbside consultations that had a formal consultation. Curbside consultations came from a variety of services and providers, and addressed a variety of issues and concerns (Table 1).
| Curbside Consultations, N (%) | |
|---|---|
| 47 (100) | |
| |
| Requesting service | |
| Psychiatry | 21 (45) |
| Emergency Department | 9 (19) |
| Obstetrics/Gynecology | 5 (11) |
| Neurology | 4 (8) |
| Other (Orthopedics, Anesthesia, General Surgery, Neurosurgery, and Interventional Radiology) | 8 (17) |
| Requesting provider | |
| Resident | 25 (53) |
| Intern | 8 (17) |
| Attending | 9 (19) |
| Other | 5 (11) |
| Consultative issue* | |
| Diagnosis | 10 (21) |
| Treatment | 29 (62) |
| Evaluation | 20 (43) |
| Discharge | 13 (28) |
| Lab interpretation | 4 (9) |
| Medical concern* | |
| Cardiac | 27 (57) |
| Endocrine | 17 (36) |
| Infectious disease | 9 (19) |
| Pulmonary | 8 (17) |
| Gastroenterology | 6 (13) |
| Fluid and electrolyte | 6 (13) |
| Others | 23 (49) |
The hospitalists asked 0 to 2 questions during 8/47 (17%) of the curbside consultations, 3 to 5 questions during 26/47 (55%) consultations, and more than 5 questions during 13/47 (28%). Based on the information received during the curbside consultations, the hospitalists thought that the curbside consultations were insufficient for 18/47 (38%) of patients. In all instances, the opinions of the 2 hospitalists concurred with respect to this conclusion, and the independent reviewer agreed with this assessment in 17 of these 18 (94%).
The advice rendered in the formal consultations differed from that provided in 26/47 (55%) of the curbside consultations, and the formal consultation was thought to have changed management for 28/47 (60%) of patients (Table 2). The independent reviewer thought that the advice provided in the formal consultations changed management in 29/47 (62%) of the cases, and in 24/28 cases (86%) where the hospitalist felt that the formal consult changed management.
| Curbside Consultations, N (%) | |||
|---|---|---|---|
| Total | Accurate and Complete | Inaccurate or Incomplete | |
| 47 (100) | 23 (49) | 24 (51) | |
| |||
| Advice in formal consultation differed from advice in curbside consultation | 26 (55) | 7 (30) | 19 (79)* |
| Formal consultation changed management | 28 (60) | 6 (26) | 22 (92) |
| Minor change | 18 (64) | 6 (100) | 12 (55) |
| Major change | 10 (36) | 0 (0) | 10 (45) |
| Curbside consultation insufficient | 18 (38) | 2 (9) | 16 (67) |
Information was felt to be inaccurate or incomplete in 24/47 (51%) of the curbside consultations (13/47 inaccurate, 16/47 incomplete, 5/47 both inaccurate and incomplete), and when inaccurate or incomplete information was obtained, the advice given in the formal consultations more commonly differed from that provided in the curbside consultation (19/24, 79% vs 7/23, 30%; P < 0.001), and was more commonly felt to change management (22/24, 92% vs 6/23, 26%; P < 0.0001) (Table 2). No association was found between whether the curbside consultation contained complete or accurate information and the consulting service from which the curbside originated, the consulting provider, the consultative aspect(s) or medical issue(s) addressed, the number of questions asked by the hospitalist during the curbside consultation, nor whether the hospitalists felt that a formal consultation was needed.
DISCUSSION
The important findings of this study are that (a) the recommendations made by hospitalists in curbside versus formal consultations on the same patient frequently differ, (b) these differences frequently result in changes in clinical management, (c) the information presented in curbside consultations by providers is frequently inaccurate or incomplete, regardless of the providers specialty or seniority, (d) when inaccurate or incomplete information is received, the recommendations made in curbside and formal consultations differ more frequently, and (e) we found no way to predict whether the information provided in a curbside consultation was likely to be inaccurate or incomplete.
Our hospitalists thought that 38% of the curbside consultations they received should have had formal consultations. Manian and McKinsey7 reported that as many as 53% of questions asked of infectious disease consultants were thought to be too complex to be addressed in an informal consultation. Others, however, report that only 11%33% of curbside consultations were thought to require formal consultation.1, 9, 10, 16 Our hospitalists asked 3 or more questions of the consulting providers in more than 80% of the curbside consultations, suggesting that the curbside consultations we received might have had a higher complexity than those seen by others.
Our finding that information provided in curbside consultation was frequently inaccurate or incomplete is consistent with a number of previous studies reporting physicians' perceptions of the accuracy of curbside consultations.2, 3 Hospital medicine is not likely to be the only discipline affected by inaccurate curbside consultation practices, as surveys of specialists in infectious disease, gynecology, and neurosurgery report that practitioners in these disciplines have similar concerns.1, 10, 14 In a survey returned by 34 physicians, Myers1 found that 50% thought the information exchanged during curbside consultations was inaccurate, leading him to conclude that inaccuracies presented during curbside consultations required further study.
We found no way of predicting whether curbside consultations were likely to include inaccurate or incomplete information. This observation is consistent with the results of Bergus et al16 who found that the frequency of curbside consultations being converted to formal consultations was independent of the training status of the consulting physician, and with the data of Myers1 who found no way of predicting the likelihood that a curbside consultation should be converted to a formal consultation.
We found that formal consultations resulted in management changes more often than differences in recommendations (ie, 60% vs 55%, respectively). This small difference occurred because, on occasion, the formal consultations found issues to address other than the one(s) for which the curbside consultation was requested. In the majority of these instances, the management changes were minor and the curbside consultation was still felt to be sufficient.
In some instances, the advice given after the curbside and the formal consultations differed to only a minor extent (eg, varying recommendations for oral diabetes management). In other instances, however, the advice differed substantially (eg, change in antibiotic management in a septic patient with a multidrug resistant organism, when the original curbside question was for when to order a follow‐up chest roentgenogram for hypoxia; see Supporting Information, Appendix, in the online version of this article). In 26 patients (55%), formal consultation resulted in different medications being started or stopped, additional tests being performed, or different decisions being made about admission versus discharge.
Our study has a number of strengths. First, while a number of reports document that physicians' perceptions are that curbside consultations frequently contain errors,2, 3, 5, 12 to our knowledge this is the first study that prospectively compared the information collected and advice given in curbside versus formal consultation. Second, while this study was conducted as a quality improvement project, thereby requiring us to conclude that the results are not generalizable, the data presented were collected by 18 different hospitalists, reducing the potential of bias from an individual provider's knowledge base or practice. Third, there was excellent agreement between the independent reviewer and the 2 hospitalists who performed the curbside and formal consultations regarding whether a curbside consultation would have been sufficient, and whether the formal consultation changed patient management. Fourth, the study was conducted over a 1‐year period, which should have reduced potential bias arising from the increasing experience of residents requesting consultations as their training progressed.
Our study has several limitations. First, the number of curbside consultations we received during the study period (50 over 215 days) was lower than anticipated, and lower than the rates of consultation reported by others.1, 7, 9 This likely relates to the fact that, prior to beginning the study, Denver Health hospitalists already provided mandatory consultations for several surgical services (thereby reducing the number of curbside consultations received from these services), because curbside consultations received during evenings, nights, and weekends were not included in the study for reasons of convenience, and because we excluded all administrative curbside consultations. Our hospitalist service also provides consultative services 24 hours a day, thereby reducing the number of consultations received during daytime hours. Second, the frequency with which curbside consultations included inaccurate or incomplete information might be higher than what occurs in other hospitals, as Denver Health is an urban, university‐affiliated public hospital and the patients encountered may be more complex and trainees may be less adept at recognizing the information that would facilitate accurate curbside consultations (although we found no difference in the frequency with which inaccurate or incomplete information was provided as a function of the seniority of the requesting physician). Third, the disparity between curbside and formal consultations that we observed could have been biased by the Hawthorne effect. We attempted to address this by not providing the hospitalists who did the formal consultation with any information collected by the hospitalist involved with the curbside consultation, and by comparing the conclusions reached by the hospitalists performing the curbside and formal consultations with those of a third party reviewer. Fourth, while we found no association between the frequency of curbside consultations in which information was inaccurate or incomplete and the consulting service, there could be a selection bias of the consulting service requesting the curbside consultations as a result of the mandatory consultations already provided by our hospitalists. Finally, our study was not designed or adequately powered to determine why curbside consultations frequently have inaccurate or incomplete information.
In summary, we found that the information provided to hospitalists during a curbside consultation was often inaccurate and incomplete, and that these problems with information exchange adversely affected the accuracy of the resulting recommendations. While there are a number of advantages to curbside consultations,1, 3, 7, 10, 12, 13 our findings indicate that the risk associated with this practice is substantial.
Acknowledgements
Disclosure: Nothing to report.
- .Curbside consultation in infectious diseases: a prospective study.J Infect Dis.1984;150:797–802.
- ,,.Physicians' experiences and beliefs regarding informal consultation.JAMA.1998;280:900–904.
- ,,.Curbside consultation practices and attitudes among primary care physicians and medical subspecialists.JAMA.1998;280:905–909.
- ,,,,,.The complexity, relative value, and financial worth of curbside consultations in an academic infectious diseases unit.Clin Infect Dis.2010;51:651–655.
- ,.Curbside consultations. A closer look at a common practice.JAMA.1996;275:145–147.
- ,,,.Informal advice‐ and information‐seeking between physicians.J Med Educ.1981;56;174–180.
- ,.A prospective study of 2,092 “curbside” questions asked of two infectious disease consultants in private practice in the midwest.Clin Infect Dis.1996;22:303–307.
- ,,,,.Curbside consultation in endocrine practice: a prospective observational study.Endocrinologist.1996;6:328–331.
- ,,.Informal consultations provided to general internists by the gastroenterology department of an HMO.J Gen Intern Med.1998;13:435–438.
- .“Curbside” consultations in gynecologic oncology: a closer look at a common practice.Gynecol Oncol.1999;74:456–459.
- ,,, et al.Informal consultations in infectious diseases and clinical microbiology practice.Clin Microbiol Infect.2003;9:724–726.
- .Curbside consultations and the viaduct effect.JAMA.1998;280:929–930.
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- ,,,.Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues?Arch Fam Med.2000;9:541–547.
A curbside consultation is an informal process whereby a consultant is asked to provide information or advice about a patient's care without doing a formal assessment of the patient.14 Curbside consultations are common in the practice of medicine2, 3, 5 and are frequently requested by physicians caring for hospitalized patients. Several surveys have documented the quantity of curbside consultations requested of various subspecialties, the types of questions asked, the time it takes to respond, and physicians' perceptions about the quality of the information exchanged.111 While curbside consultations have a number of advantages, physicians' perceptions are that the information conveyed may be inaccurate or incomplete and that the advice offered may be erroneous.13, 5, 10, 12, 13
Cartmill and White14 performed a random audit of 10% of the telephone referrals they received for neurosurgical consultation over a 1‐year period and noted discrepancies between the Glascow Coma Scores reported during the telephone referrals and those noted in the medical records, but the frequency of these discrepancies was not reported. To our knowledge, no studies have compared the quality of the information provided in curbside consultations with that obtained in formal consultations that included direct face‐to‐face patient evaluations and primary data collection, and whether the advice provided in curbside and formal consultations on the same patient differed.
We performed a prospective cohort study to compare the information received by hospitalists during curbside consultations on hospitalized patients, with that obtained from formal consultations done the same day on the same patients, by different hospitalists who were unaware of any details regarding the curbside consultation. We also compared the advice provided by the 2 hospitalists following their curbside and formal consultations. Our hypotheses were that the information received during curbside consultations was frequently inaccurate or incomplete, that the recommendations made after the formal consultation would frequently differ from those made in the curbside consultation, and that these differences would have important implications on patient care.
METHODS
This was a quality improvement study conducted at Denver Health, a 500‐bed university‐affiliated urban safety net hospital from January 10, 2011 to January 9, 2012. The study design was a prospective cohort that included all curbside consultations on hospitalized patients received between 7 AM and 3 PM, on intermittently selected weekdays, by the Internal Medicine Consultation Service that was staffed by 18 hospitalists. Data were collected intermittently based upon hospitalist availability and was done to limit potential alterations in the consulting practices of the providers requesting consultations.
Consultations were defined as being curbside when the consulting provider asked for advice, suggestions, or opinions about a patient's care but did not ask the hospitalist to see the patient.15, 15 Consultations pertaining to administrative issues (eg, whether a patient should be admitted to an intensive care bed as opposed to an acute care floor bed) or on patients who were already being followed by a hospitalist were excluded.
The hospitalist receiving the curbside consultation was allowed to ask questions as they normally would, but could not verify the accuracy of the information received (eg, could not review any portion of the patient's medical record, such as notes or lab data). A standardized data collection sheet was used to record the service and level of training of the requesting provider, the medical issue(s) of concern, all clinical data offered by the provider, the number of questions asked by the hospitalist of the provider, and whether, on the basis of the information provided, the hospitalist felt that the question(s) being asked was (were) of sufficient complexity that a formal consultation should occur. The hospitalist then offered advice based upon the information given during the curbside consultation.
After completing the curbside consultation, the hospitalist requested verbal permission from the requesting provider to perform a formal consultation. If the request was approved, the hospitalist performing the curbside consultation contacted a different hospitalist who performed the formal consultation within the next few hours. The only information given to the second hospitalist was the patient's identifiers and the clinical question(s) being asked. The formal consultation included a complete face‐to‐face history and physical examination, a review of the patient's medical record, documentation of the provider's findings, and recommendations for care.
Upon completion of the formal consultation, the hospitalists who performed the curbside and the formal consultations met to review the advice each gave to the requesting provider and the information on which this advice was based. The 2 hospitalists jointly determined the following: (a) whether the information received during the curbside consultation was correct and complete, (b) whether the advice provided in the formal consultation differed from that provided in the curbside consultation, (c) whether the advice provided in the formal consultation dealt with issues other than one(s) leading to the curbside consultation, (d) whether differences in the recommendations given in the curbside versus the formal consultation changed patient management in a meaningful way, and (e) whether the curbside consultation alone was felt to be sufficient.
Information obtained by the hospitalist performing the formal consultation that was different from, or not included in, the information recorded during the curbside consultation was considered to be incorrect or incomplete, respectively. A change in management was defined as an alteration in the direction or type of care that the patient would have received as a result of the advice being given. A pulmonary and critical care physician, with >35 years of experience in inpatient medicine, reviewed the information provided in the curbside and formal consultations, and independently assessed whether the curbside consultation alone would have been sufficient and whether the formal consultation changed management.
Curbside consultations were neither solicited nor discouraged during the course of the study. The provider requesting the curbside consultation was not informed or debriefed about the study in an attempt to avoid affecting future consultation practices from that provider or service.
Associations were sought between the frequency of inaccurate or incomplete data and the requesting service and provider, the consultative category and medical issue, the number of questions asked by the hospitalist during the curbside consultation, and whether the hospitalist doing the curbside consultation thought that formal consultation was needed. A chi‐square test was used to analyze all associations. A P value of <0.05 was considered significant. All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc, Cary, NC) software. The study was approved by the Colorado Multiple Institutional Review Board.
RESULTS
Fifty curbside consultations were requested on a total of 215 study days. The requesting service declined formal consultation in 3 instances, leaving 47 curbside consultations that had a formal consultation. Curbside consultations came from a variety of services and providers, and addressed a variety of issues and concerns (Table 1).
| Curbside Consultations, N (%) | |
|---|---|
| 47 (100) | |
| |
| Requesting service | |
| Psychiatry | 21 (45) |
| Emergency Department | 9 (19) |
| Obstetrics/Gynecology | 5 (11) |
| Neurology | 4 (8) |
| Other (Orthopedics, Anesthesia, General Surgery, Neurosurgery, and Interventional Radiology) | 8 (17) |
| Requesting provider | |
| Resident | 25 (53) |
| Intern | 8 (17) |
| Attending | 9 (19) |
| Other | 5 (11) |
| Consultative issue* | |
| Diagnosis | 10 (21) |
| Treatment | 29 (62) |
| Evaluation | 20 (43) |
| Discharge | 13 (28) |
| Lab interpretation | 4 (9) |
| Medical concern* | |
| Cardiac | 27 (57) |
| Endocrine | 17 (36) |
| Infectious disease | 9 (19) |
| Pulmonary | 8 (17) |
| Gastroenterology | 6 (13) |
| Fluid and electrolyte | 6 (13) |
| Others | 23 (49) |
The hospitalists asked 0 to 2 questions during 8/47 (17%) of the curbside consultations, 3 to 5 questions during 26/47 (55%) consultations, and more than 5 questions during 13/47 (28%). Based on the information received during the curbside consultations, the hospitalists thought that the curbside consultations were insufficient for 18/47 (38%) of patients. In all instances, the opinions of the 2 hospitalists concurred with respect to this conclusion, and the independent reviewer agreed with this assessment in 17 of these 18 (94%).
The advice rendered in the formal consultations differed from that provided in 26/47 (55%) of the curbside consultations, and the formal consultation was thought to have changed management for 28/47 (60%) of patients (Table 2). The independent reviewer thought that the advice provided in the formal consultations changed management in 29/47 (62%) of the cases, and in 24/28 cases (86%) where the hospitalist felt that the formal consult changed management.
| Curbside Consultations, N (%) | |||
|---|---|---|---|
| Total | Accurate and Complete | Inaccurate or Incomplete | |
| 47 (100) | 23 (49) | 24 (51) | |
| |||
| Advice in formal consultation differed from advice in curbside consultation | 26 (55) | 7 (30) | 19 (79)* |
| Formal consultation changed management | 28 (60) | 6 (26) | 22 (92) |
| Minor change | 18 (64) | 6 (100) | 12 (55) |
| Major change | 10 (36) | 0 (0) | 10 (45) |
| Curbside consultation insufficient | 18 (38) | 2 (9) | 16 (67) |
Information was felt to be inaccurate or incomplete in 24/47 (51%) of the curbside consultations (13/47 inaccurate, 16/47 incomplete, 5/47 both inaccurate and incomplete), and when inaccurate or incomplete information was obtained, the advice given in the formal consultations more commonly differed from that provided in the curbside consultation (19/24, 79% vs 7/23, 30%; P < 0.001), and was more commonly felt to change management (22/24, 92% vs 6/23, 26%; P < 0.0001) (Table 2). No association was found between whether the curbside consultation contained complete or accurate information and the consulting service from which the curbside originated, the consulting provider, the consultative aspect(s) or medical issue(s) addressed, the number of questions asked by the hospitalist during the curbside consultation, nor whether the hospitalists felt that a formal consultation was needed.
DISCUSSION
The important findings of this study are that (a) the recommendations made by hospitalists in curbside versus formal consultations on the same patient frequently differ, (b) these differences frequently result in changes in clinical management, (c) the information presented in curbside consultations by providers is frequently inaccurate or incomplete, regardless of the providers specialty or seniority, (d) when inaccurate or incomplete information is received, the recommendations made in curbside and formal consultations differ more frequently, and (e) we found no way to predict whether the information provided in a curbside consultation was likely to be inaccurate or incomplete.
Our hospitalists thought that 38% of the curbside consultations they received should have had formal consultations. Manian and McKinsey7 reported that as many as 53% of questions asked of infectious disease consultants were thought to be too complex to be addressed in an informal consultation. Others, however, report that only 11%33% of curbside consultations were thought to require formal consultation.1, 9, 10, 16 Our hospitalists asked 3 or more questions of the consulting providers in more than 80% of the curbside consultations, suggesting that the curbside consultations we received might have had a higher complexity than those seen by others.
Our finding that information provided in curbside consultation was frequently inaccurate or incomplete is consistent with a number of previous studies reporting physicians' perceptions of the accuracy of curbside consultations.2, 3 Hospital medicine is not likely to be the only discipline affected by inaccurate curbside consultation practices, as surveys of specialists in infectious disease, gynecology, and neurosurgery report that practitioners in these disciplines have similar concerns.1, 10, 14 In a survey returned by 34 physicians, Myers1 found that 50% thought the information exchanged during curbside consultations was inaccurate, leading him to conclude that inaccuracies presented during curbside consultations required further study.
We found no way of predicting whether curbside consultations were likely to include inaccurate or incomplete information. This observation is consistent with the results of Bergus et al16 who found that the frequency of curbside consultations being converted to formal consultations was independent of the training status of the consulting physician, and with the data of Myers1 who found no way of predicting the likelihood that a curbside consultation should be converted to a formal consultation.
We found that formal consultations resulted in management changes more often than differences in recommendations (ie, 60% vs 55%, respectively). This small difference occurred because, on occasion, the formal consultations found issues to address other than the one(s) for which the curbside consultation was requested. In the majority of these instances, the management changes were minor and the curbside consultation was still felt to be sufficient.
In some instances, the advice given after the curbside and the formal consultations differed to only a minor extent (eg, varying recommendations for oral diabetes management). In other instances, however, the advice differed substantially (eg, change in antibiotic management in a septic patient with a multidrug resistant organism, when the original curbside question was for when to order a follow‐up chest roentgenogram for hypoxia; see Supporting Information, Appendix, in the online version of this article). In 26 patients (55%), formal consultation resulted in different medications being started or stopped, additional tests being performed, or different decisions being made about admission versus discharge.
Our study has a number of strengths. First, while a number of reports document that physicians' perceptions are that curbside consultations frequently contain errors,2, 3, 5, 12 to our knowledge this is the first study that prospectively compared the information collected and advice given in curbside versus formal consultation. Second, while this study was conducted as a quality improvement project, thereby requiring us to conclude that the results are not generalizable, the data presented were collected by 18 different hospitalists, reducing the potential of bias from an individual provider's knowledge base or practice. Third, there was excellent agreement between the independent reviewer and the 2 hospitalists who performed the curbside and formal consultations regarding whether a curbside consultation would have been sufficient, and whether the formal consultation changed patient management. Fourth, the study was conducted over a 1‐year period, which should have reduced potential bias arising from the increasing experience of residents requesting consultations as their training progressed.
Our study has several limitations. First, the number of curbside consultations we received during the study period (50 over 215 days) was lower than anticipated, and lower than the rates of consultation reported by others.1, 7, 9 This likely relates to the fact that, prior to beginning the study, Denver Health hospitalists already provided mandatory consultations for several surgical services (thereby reducing the number of curbside consultations received from these services), because curbside consultations received during evenings, nights, and weekends were not included in the study for reasons of convenience, and because we excluded all administrative curbside consultations. Our hospitalist service also provides consultative services 24 hours a day, thereby reducing the number of consultations received during daytime hours. Second, the frequency with which curbside consultations included inaccurate or incomplete information might be higher than what occurs in other hospitals, as Denver Health is an urban, university‐affiliated public hospital and the patients encountered may be more complex and trainees may be less adept at recognizing the information that would facilitate accurate curbside consultations (although we found no difference in the frequency with which inaccurate or incomplete information was provided as a function of the seniority of the requesting physician). Third, the disparity between curbside and formal consultations that we observed could have been biased by the Hawthorne effect. We attempted to address this by not providing the hospitalists who did the formal consultation with any information collected by the hospitalist involved with the curbside consultation, and by comparing the conclusions reached by the hospitalists performing the curbside and formal consultations with those of a third party reviewer. Fourth, while we found no association between the frequency of curbside consultations in which information was inaccurate or incomplete and the consulting service, there could be a selection bias of the consulting service requesting the curbside consultations as a result of the mandatory consultations already provided by our hospitalists. Finally, our study was not designed or adequately powered to determine why curbside consultations frequently have inaccurate or incomplete information.
In summary, we found that the information provided to hospitalists during a curbside consultation was often inaccurate and incomplete, and that these problems with information exchange adversely affected the accuracy of the resulting recommendations. While there are a number of advantages to curbside consultations,1, 3, 7, 10, 12, 13 our findings indicate that the risk associated with this practice is substantial.
Acknowledgements
Disclosure: Nothing to report.
A curbside consultation is an informal process whereby a consultant is asked to provide information or advice about a patient's care without doing a formal assessment of the patient.14 Curbside consultations are common in the practice of medicine2, 3, 5 and are frequently requested by physicians caring for hospitalized patients. Several surveys have documented the quantity of curbside consultations requested of various subspecialties, the types of questions asked, the time it takes to respond, and physicians' perceptions about the quality of the information exchanged.111 While curbside consultations have a number of advantages, physicians' perceptions are that the information conveyed may be inaccurate or incomplete and that the advice offered may be erroneous.13, 5, 10, 12, 13
Cartmill and White14 performed a random audit of 10% of the telephone referrals they received for neurosurgical consultation over a 1‐year period and noted discrepancies between the Glascow Coma Scores reported during the telephone referrals and those noted in the medical records, but the frequency of these discrepancies was not reported. To our knowledge, no studies have compared the quality of the information provided in curbside consultations with that obtained in formal consultations that included direct face‐to‐face patient evaluations and primary data collection, and whether the advice provided in curbside and formal consultations on the same patient differed.
We performed a prospective cohort study to compare the information received by hospitalists during curbside consultations on hospitalized patients, with that obtained from formal consultations done the same day on the same patients, by different hospitalists who were unaware of any details regarding the curbside consultation. We also compared the advice provided by the 2 hospitalists following their curbside and formal consultations. Our hypotheses were that the information received during curbside consultations was frequently inaccurate or incomplete, that the recommendations made after the formal consultation would frequently differ from those made in the curbside consultation, and that these differences would have important implications on patient care.
METHODS
This was a quality improvement study conducted at Denver Health, a 500‐bed university‐affiliated urban safety net hospital from January 10, 2011 to January 9, 2012. The study design was a prospective cohort that included all curbside consultations on hospitalized patients received between 7 AM and 3 PM, on intermittently selected weekdays, by the Internal Medicine Consultation Service that was staffed by 18 hospitalists. Data were collected intermittently based upon hospitalist availability and was done to limit potential alterations in the consulting practices of the providers requesting consultations.
Consultations were defined as being curbside when the consulting provider asked for advice, suggestions, or opinions about a patient's care but did not ask the hospitalist to see the patient.15, 15 Consultations pertaining to administrative issues (eg, whether a patient should be admitted to an intensive care bed as opposed to an acute care floor bed) or on patients who were already being followed by a hospitalist were excluded.
The hospitalist receiving the curbside consultation was allowed to ask questions as they normally would, but could not verify the accuracy of the information received (eg, could not review any portion of the patient's medical record, such as notes or lab data). A standardized data collection sheet was used to record the service and level of training of the requesting provider, the medical issue(s) of concern, all clinical data offered by the provider, the number of questions asked by the hospitalist of the provider, and whether, on the basis of the information provided, the hospitalist felt that the question(s) being asked was (were) of sufficient complexity that a formal consultation should occur. The hospitalist then offered advice based upon the information given during the curbside consultation.
After completing the curbside consultation, the hospitalist requested verbal permission from the requesting provider to perform a formal consultation. If the request was approved, the hospitalist performing the curbside consultation contacted a different hospitalist who performed the formal consultation within the next few hours. The only information given to the second hospitalist was the patient's identifiers and the clinical question(s) being asked. The formal consultation included a complete face‐to‐face history and physical examination, a review of the patient's medical record, documentation of the provider's findings, and recommendations for care.
Upon completion of the formal consultation, the hospitalists who performed the curbside and the formal consultations met to review the advice each gave to the requesting provider and the information on which this advice was based. The 2 hospitalists jointly determined the following: (a) whether the information received during the curbside consultation was correct and complete, (b) whether the advice provided in the formal consultation differed from that provided in the curbside consultation, (c) whether the advice provided in the formal consultation dealt with issues other than one(s) leading to the curbside consultation, (d) whether differences in the recommendations given in the curbside versus the formal consultation changed patient management in a meaningful way, and (e) whether the curbside consultation alone was felt to be sufficient.
Information obtained by the hospitalist performing the formal consultation that was different from, or not included in, the information recorded during the curbside consultation was considered to be incorrect or incomplete, respectively. A change in management was defined as an alteration in the direction or type of care that the patient would have received as a result of the advice being given. A pulmonary and critical care physician, with >35 years of experience in inpatient medicine, reviewed the information provided in the curbside and formal consultations, and independently assessed whether the curbside consultation alone would have been sufficient and whether the formal consultation changed management.
Curbside consultations were neither solicited nor discouraged during the course of the study. The provider requesting the curbside consultation was not informed or debriefed about the study in an attempt to avoid affecting future consultation practices from that provider or service.
Associations were sought between the frequency of inaccurate or incomplete data and the requesting service and provider, the consultative category and medical issue, the number of questions asked by the hospitalist during the curbside consultation, and whether the hospitalist doing the curbside consultation thought that formal consultation was needed. A chi‐square test was used to analyze all associations. A P value of <0.05 was considered significant. All analyses were performed using SAS Enterprise Guide 4.3 (SAS Institute, Inc, Cary, NC) software. The study was approved by the Colorado Multiple Institutional Review Board.
RESULTS
Fifty curbside consultations were requested on a total of 215 study days. The requesting service declined formal consultation in 3 instances, leaving 47 curbside consultations that had a formal consultation. Curbside consultations came from a variety of services and providers, and addressed a variety of issues and concerns (Table 1).
| Curbside Consultations, N (%) | |
|---|---|
| 47 (100) | |
| |
| Requesting service | |
| Psychiatry | 21 (45) |
| Emergency Department | 9 (19) |
| Obstetrics/Gynecology | 5 (11) |
| Neurology | 4 (8) |
| Other (Orthopedics, Anesthesia, General Surgery, Neurosurgery, and Interventional Radiology) | 8 (17) |
| Requesting provider | |
| Resident | 25 (53) |
| Intern | 8 (17) |
| Attending | 9 (19) |
| Other | 5 (11) |
| Consultative issue* | |
| Diagnosis | 10 (21) |
| Treatment | 29 (62) |
| Evaluation | 20 (43) |
| Discharge | 13 (28) |
| Lab interpretation | 4 (9) |
| Medical concern* | |
| Cardiac | 27 (57) |
| Endocrine | 17 (36) |
| Infectious disease | 9 (19) |
| Pulmonary | 8 (17) |
| Gastroenterology | 6 (13) |
| Fluid and electrolyte | 6 (13) |
| Others | 23 (49) |
The hospitalists asked 0 to 2 questions during 8/47 (17%) of the curbside consultations, 3 to 5 questions during 26/47 (55%) consultations, and more than 5 questions during 13/47 (28%). Based on the information received during the curbside consultations, the hospitalists thought that the curbside consultations were insufficient for 18/47 (38%) of patients. In all instances, the opinions of the 2 hospitalists concurred with respect to this conclusion, and the independent reviewer agreed with this assessment in 17 of these 18 (94%).
The advice rendered in the formal consultations differed from that provided in 26/47 (55%) of the curbside consultations, and the formal consultation was thought to have changed management for 28/47 (60%) of patients (Table 2). The independent reviewer thought that the advice provided in the formal consultations changed management in 29/47 (62%) of the cases, and in 24/28 cases (86%) where the hospitalist felt that the formal consult changed management.
| Curbside Consultations, N (%) | |||
|---|---|---|---|
| Total | Accurate and Complete | Inaccurate or Incomplete | |
| 47 (100) | 23 (49) | 24 (51) | |
| |||
| Advice in formal consultation differed from advice in curbside consultation | 26 (55) | 7 (30) | 19 (79)* |
| Formal consultation changed management | 28 (60) | 6 (26) | 22 (92) |
| Minor change | 18 (64) | 6 (100) | 12 (55) |
| Major change | 10 (36) | 0 (0) | 10 (45) |
| Curbside consultation insufficient | 18 (38) | 2 (9) | 16 (67) |
Information was felt to be inaccurate or incomplete in 24/47 (51%) of the curbside consultations (13/47 inaccurate, 16/47 incomplete, 5/47 both inaccurate and incomplete), and when inaccurate or incomplete information was obtained, the advice given in the formal consultations more commonly differed from that provided in the curbside consultation (19/24, 79% vs 7/23, 30%; P < 0.001), and was more commonly felt to change management (22/24, 92% vs 6/23, 26%; P < 0.0001) (Table 2). No association was found between whether the curbside consultation contained complete or accurate information and the consulting service from which the curbside originated, the consulting provider, the consultative aspect(s) or medical issue(s) addressed, the number of questions asked by the hospitalist during the curbside consultation, nor whether the hospitalists felt that a formal consultation was needed.
DISCUSSION
The important findings of this study are that (a) the recommendations made by hospitalists in curbside versus formal consultations on the same patient frequently differ, (b) these differences frequently result in changes in clinical management, (c) the information presented in curbside consultations by providers is frequently inaccurate or incomplete, regardless of the providers specialty or seniority, (d) when inaccurate or incomplete information is received, the recommendations made in curbside and formal consultations differ more frequently, and (e) we found no way to predict whether the information provided in a curbside consultation was likely to be inaccurate or incomplete.
Our hospitalists thought that 38% of the curbside consultations they received should have had formal consultations. Manian and McKinsey7 reported that as many as 53% of questions asked of infectious disease consultants were thought to be too complex to be addressed in an informal consultation. Others, however, report that only 11%33% of curbside consultations were thought to require formal consultation.1, 9, 10, 16 Our hospitalists asked 3 or more questions of the consulting providers in more than 80% of the curbside consultations, suggesting that the curbside consultations we received might have had a higher complexity than those seen by others.
Our finding that information provided in curbside consultation was frequently inaccurate or incomplete is consistent with a number of previous studies reporting physicians' perceptions of the accuracy of curbside consultations.2, 3 Hospital medicine is not likely to be the only discipline affected by inaccurate curbside consultation practices, as surveys of specialists in infectious disease, gynecology, and neurosurgery report that practitioners in these disciplines have similar concerns.1, 10, 14 In a survey returned by 34 physicians, Myers1 found that 50% thought the information exchanged during curbside consultations was inaccurate, leading him to conclude that inaccuracies presented during curbside consultations required further study.
We found no way of predicting whether curbside consultations were likely to include inaccurate or incomplete information. This observation is consistent with the results of Bergus et al16 who found that the frequency of curbside consultations being converted to formal consultations was independent of the training status of the consulting physician, and with the data of Myers1 who found no way of predicting the likelihood that a curbside consultation should be converted to a formal consultation.
We found that formal consultations resulted in management changes more often than differences in recommendations (ie, 60% vs 55%, respectively). This small difference occurred because, on occasion, the formal consultations found issues to address other than the one(s) for which the curbside consultation was requested. In the majority of these instances, the management changes were minor and the curbside consultation was still felt to be sufficient.
In some instances, the advice given after the curbside and the formal consultations differed to only a minor extent (eg, varying recommendations for oral diabetes management). In other instances, however, the advice differed substantially (eg, change in antibiotic management in a septic patient with a multidrug resistant organism, when the original curbside question was for when to order a follow‐up chest roentgenogram for hypoxia; see Supporting Information, Appendix, in the online version of this article). In 26 patients (55%), formal consultation resulted in different medications being started or stopped, additional tests being performed, or different decisions being made about admission versus discharge.
Our study has a number of strengths. First, while a number of reports document that physicians' perceptions are that curbside consultations frequently contain errors,2, 3, 5, 12 to our knowledge this is the first study that prospectively compared the information collected and advice given in curbside versus formal consultation. Second, while this study was conducted as a quality improvement project, thereby requiring us to conclude that the results are not generalizable, the data presented were collected by 18 different hospitalists, reducing the potential of bias from an individual provider's knowledge base or practice. Third, there was excellent agreement between the independent reviewer and the 2 hospitalists who performed the curbside and formal consultations regarding whether a curbside consultation would have been sufficient, and whether the formal consultation changed patient management. Fourth, the study was conducted over a 1‐year period, which should have reduced potential bias arising from the increasing experience of residents requesting consultations as their training progressed.
Our study has several limitations. First, the number of curbside consultations we received during the study period (50 over 215 days) was lower than anticipated, and lower than the rates of consultation reported by others.1, 7, 9 This likely relates to the fact that, prior to beginning the study, Denver Health hospitalists already provided mandatory consultations for several surgical services (thereby reducing the number of curbside consultations received from these services), because curbside consultations received during evenings, nights, and weekends were not included in the study for reasons of convenience, and because we excluded all administrative curbside consultations. Our hospitalist service also provides consultative services 24 hours a day, thereby reducing the number of consultations received during daytime hours. Second, the frequency with which curbside consultations included inaccurate or incomplete information might be higher than what occurs in other hospitals, as Denver Health is an urban, university‐affiliated public hospital and the patients encountered may be more complex and trainees may be less adept at recognizing the information that would facilitate accurate curbside consultations (although we found no difference in the frequency with which inaccurate or incomplete information was provided as a function of the seniority of the requesting physician). Third, the disparity between curbside and formal consultations that we observed could have been biased by the Hawthorne effect. We attempted to address this by not providing the hospitalists who did the formal consultation with any information collected by the hospitalist involved with the curbside consultation, and by comparing the conclusions reached by the hospitalists performing the curbside and formal consultations with those of a third party reviewer. Fourth, while we found no association between the frequency of curbside consultations in which information was inaccurate or incomplete and the consulting service, there could be a selection bias of the consulting service requesting the curbside consultations as a result of the mandatory consultations already provided by our hospitalists. Finally, our study was not designed or adequately powered to determine why curbside consultations frequently have inaccurate or incomplete information.
In summary, we found that the information provided to hospitalists during a curbside consultation was often inaccurate and incomplete, and that these problems with information exchange adversely affected the accuracy of the resulting recommendations. While there are a number of advantages to curbside consultations,1, 3, 7, 10, 12, 13 our findings indicate that the risk associated with this practice is substantial.
Acknowledgements
Disclosure: Nothing to report.
- .Curbside consultation in infectious diseases: a prospective study.J Infect Dis.1984;150:797–802.
- ,,.Physicians' experiences and beliefs regarding informal consultation.JAMA.1998;280:900–904.
- ,,.Curbside consultation practices and attitudes among primary care physicians and medical subspecialists.JAMA.1998;280:905–909.
- ,,,,,.The complexity, relative value, and financial worth of curbside consultations in an academic infectious diseases unit.Clin Infect Dis.2010;51:651–655.
- ,.Curbside consultations. A closer look at a common practice.JAMA.1996;275:145–147.
- ,,,.Informal advice‐ and information‐seeking between physicians.J Med Educ.1981;56;174–180.
- ,.A prospective study of 2,092 “curbside” questions asked of two infectious disease consultants in private practice in the midwest.Clin Infect Dis.1996;22:303–307.
- ,,,,.Curbside consultation in endocrine practice: a prospective observational study.Endocrinologist.1996;6:328–331.
- ,,.Informal consultations provided to general internists by the gastroenterology department of an HMO.J Gen Intern Med.1998;13:435–438.
- .“Curbside” consultations in gynecologic oncology: a closer look at a common practice.Gynecol Oncol.1999;74:456–459.
- ,,, et al.Informal consultations in infectious diseases and clinical microbiology practice.Clin Microbiol Infect.2003;9:724–726.
- .Curbside consultations and the viaduct effect.JAMA.1998;280:929–930.
- .What do we really need to know about consultation and referral?J Gen Intern Med.1998;13:497–498.
- ,.Telephone advice for neurosurgical referrals. Who assumes duty of care?Br J Neurosurg.2001;15:453–455.
- ,.Malpractice liability for informal consultations.Fam Med.2003;35:476–481.
- ,,,.Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues?Arch Fam Med.2000;9:541–547.
- .Curbside consultation in infectious diseases: a prospective study.J Infect Dis.1984;150:797–802.
- ,,.Physicians' experiences and beliefs regarding informal consultation.JAMA.1998;280:900–904.
- ,,.Curbside consultation practices and attitudes among primary care physicians and medical subspecialists.JAMA.1998;280:905–909.
- ,,,,,.The complexity, relative value, and financial worth of curbside consultations in an academic infectious diseases unit.Clin Infect Dis.2010;51:651–655.
- ,.Curbside consultations. A closer look at a common practice.JAMA.1996;275:145–147.
- ,,,.Informal advice‐ and information‐seeking between physicians.J Med Educ.1981;56;174–180.
- ,.A prospective study of 2,092 “curbside” questions asked of two infectious disease consultants in private practice in the midwest.Clin Infect Dis.1996;22:303–307.
- ,,,,.Curbside consultation in endocrine practice: a prospective observational study.Endocrinologist.1996;6:328–331.
- ,,.Informal consultations provided to general internists by the gastroenterology department of an HMO.J Gen Intern Med.1998;13:435–438.
- .“Curbside” consultations in gynecologic oncology: a closer look at a common practice.Gynecol Oncol.1999;74:456–459.
- ,,, et al.Informal consultations in infectious diseases and clinical microbiology practice.Clin Microbiol Infect.2003;9:724–726.
- .Curbside consultations and the viaduct effect.JAMA.1998;280:929–930.
- .What do we really need to know about consultation and referral?J Gen Intern Med.1998;13:497–498.
- ,.Telephone advice for neurosurgical referrals. Who assumes duty of care?Br J Neurosurg.2001;15:453–455.
- ,.Malpractice liability for informal consultations.Fam Med.2003;35:476–481.
- ,,,.Does the structure of clinical questions affect the outcome of curbside consultations with specialty colleagues?Arch Fam Med.2000;9:541–547.
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