Development and Evaluation of an Electronic Health Record–Based Best-Practice Discharge Checklist for Hospital Patients

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Article-at-a-Glance

Background

Checklists may help reduce discharge errors; however, current paper checklists have limited functionality. In 2013 a best-practice discharge checklist using the electronic health record (EHR) was developed and evaluated at Stanford University Medical Center (Stanford, California) in a cluster randomized trial to evaluate its usage, user satisfaction, and impact on physicians’ work flow.

Methods

The study was divided into four phases.

Results

In Phase I, on the survey (N = 76), most of the participants (54.0%) reported using memory to remember discharge tasks. On a 0–100 scale, perception of checklists as being useful was strong (mean, 66.4; standard deviation [SD], 21.2), as was interest in EHR checklists (64.5, 26.6). In Phase II, the checklist consisted of 15 tasks categorized by admission, hospitalization, and discharge-planning. In Phase III, the checklist was implemented as an EHR “smart-phrase” allowing for automatic insertion. In Phase IV, in a trial with 60 participating physicians, 23 EHR checklist users reported higher usage than 12 paper users (28.5 versus 7.67, p = .019), as well as higher checklist integration with work flow (22.6 versus 1.67, p = .014), usefulness of checklist (33.7 versus. 8.92, p = .041), discharge confidence (30.8 versus 5.00, p = .029), and discharge efficiency (25.5 versus 6.67, p = .056). Increasing EHR checklist use was correlated with usefulness (r = .85, p < .001), confidence (r = .81, p < .001), and efficiency (r = .87, p < .001).

Conclusions

The EHR checklist reminded physicians to complete discharge tasks, improved confidence, and increased process efficiency. This is the first study to show that medicine residents use “memory” as the most common method for remembering discharge tasks. These data reinforce the need for a formalized tool, such as a checklist, that residents can rely on to complete important discharge tasks.

Section snippets

Setting

This study was conducted at Stanford University Medical Center (Stanford, California), an academic medical center with more than 25,000 inpatient admissions per year and approximately 2,100 medical staff and 700 interns and residents. Our Institutional Review Board considered the study as quality improvement and therefore “exempt.”

Phase I. Determining the Need and Modality of Checklist (January–March 2013)

Before this study, we had anecdotal evidence that there was considerable variation in discharge practices at our hospital, in part because of variation in methods of

Phase I. Determining the Need and Modality of Checklist

The internal medicine survey was sent to 109 residents and had 76 participants (response rate, 69.7%), of which 25 (32.9%) were first-year residents, 26 (34.2%) were second-year, and 25 (32.9%) were third-year. Participants’ perceived usefulness of checklists in standardizing and improving the patient care process was reported on an ascending scale from 1 (low) to 100 (high) and had a mean of 66.4, which did not differ by year of resident (p = .92). Currently used methods for remembering

Discussion

The objective of this study was to develop, implement, and evaluate an EHR best-practice discharge checklist for hospital patients. Best-practice discharge checklists have been described previously, and our checklist items are consistent with those previously proposed.8., 9. To our knowledge, there are no previous studies that have characterized physicians’ methods for remembering discharge tasks, their perceived value of checklists, and their preferred modality of checklists. Few studies have

Conclusions

We describe the need for a best-practice discharge checklist and propose that an EHR smart-phrase tool is a novel and physician-supported mechanism for checklist delivery. Using an EHR checklist improves physicians’ perceived confidence in discharge, reminds them to complete necessary discharge tasssssks, and increases the perceived efficiency of the discharge process.

References (27)

  • S. Kripalani

    Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care

    JAMA

    (2007 Feb 28)
  • E.A. Coleman et al.

    Lost in transition: Challenges and opportunities for improving the quality of transitional care

    Ann Intern Med.

    (2004 Oct 5)
  • A.J. Forster

    The incidence and severity of adverse events affecting patients after discharge from the hospital

    Ann Intern Med.

    (2003 Feb 4)
  • C. van Walraven

    Continuity of care and patient outcomes after hospital discharge

    J Gen Intern Med.

    (2004)
  • B.W. Jack

    A reengineered hospital discharge program to decrease rehospitalization: A randomized trial

    Ann Intern Med.

    (2009 Feb 3)
  • M. VanSuch

    Effect of discharge instructions on readmission of hospitalised patients with heart failure: Do all of the Joint Commission on Accreditation of Healthcare Organization’s heart failure core measures reflect better care?

    Qual Saf Health Care

    (2006)
  • L.I. Horwitz

    Quality of discharge practices and patient understanding at an academic medical center

    JAMA Intern Med.

    (2013 Oct 14)
  • L. Halasyamani

    Transition of care for hospitalized elderly patients—Development of a discharge checklist for hospitalists

    J Hosp Med.

    (2006)
  • C. Soong

    Development of a checklist of safe discharge practices for hospital patients

    J Hosp Med.

    (2013)
  • A.B. Haynes

    A surgical safety checklist to reduce morbidity and mortality in a global population

    N Engl J Med.

    (2009 Jan 29)
  • P. Pronovost

    Interventions to decrease catheter-related bloodstream infections in the ICU: The Keystone Intensive Care Unit Project

    Am J Infect Control

    (2008)
  • H.C. Ko et al.

    Systematic review of safety checklists for use by medical care teams in acute hospital settings—Limited evidence of effectiveness

    BMC Health Serv Res.

    (2011 Sep 2)
  • A. Fourcade

    Barriers to staff adoption of a surgical safety checklist

    BMJ Qual Saf.

    (2012)
  • Cited by (0)

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