Dear TBCH

[J-Rad]

---

Members don't see this ad.

Dear TBCH. I hate you. I would have sent my patient to anybody but you. I tried, but you are only one of the only two in the state with that particular service (and the other one has its own shiz going on). And this family could use as close to home as possible. Because we lobbed an F'n bombshell at them. And your institutional arrogance continues. A phone call. Just a phone call. But we've, on more than one occasion, had to wait until the family called to know that our patient DIED. DIED...FU. Why would I not expect that you wouldn't keep me in the loop as to what's going on with the patient with potentially devastating disease. And you want to send them to the local carpetbaggers-that offer not a whit more than what they can already get to make a buck for your sh**ty program? Yeah, you know what...I don't think so. It was our people that saved the child from possible sudden, unexpected death due to their index of suspicion and heroic follow up. So, again,I offer my most heartfelt: F You. Any. One. But. You.
Rant over


Sent from my iPhone using SDN mobile

 

[calvnandhobbs68]

Dear TBCH. I hate you. I would have sent my patient to anybody but you. I tried, but you are only one of the only two in the state with that particular service (and the other one has its own shiz going on). And this family could use as close to home as possible. Because we lobbed an F'n bombshell at them. And your institutional arrogance continues. A phone call. Just a phone call. But we've, on more than one occasion, had to wait until the family called to know that our patient DIED. DIED...FU. Why would I not expect that you wouldn't keep me in the loop as to what's going on with the patient with potentially devastating disease. And you want to send them to the local carpetbaggers-that offer not a whit more than what they can already get to make a buck for your sh**ty program? Yeah, you know what...I don't think so. It was our people that saved the child from possible sudden, unexpected death due to their index of suspicion and heroic follow up. So, again,I offer my most heartfelt: F You. Any. One. But. You.
Rant over


Sent from my iPhone using SDN mobile

Texas Baptist Children's Home?

 

[J-Rad]

🙂
"The Big Children's Hospital"

 

[Stitch]

This is sadly all too common. I don't understand why.

 

[J-Rad]

I thought this would make for an interesting start to a discussion of what people are being taught about communication with referring providers, especially in the tertiary and quarternary care centers.
The approach was radically different where I trained for fellowship (ironically, in residency, my QIP was trying to shed the program's reputation for being a black hole in which PCPs lost all sight of their patients until they showed up in the office without much in the way of records).

 

[SurfingDoctor]

I suppose not having worked in private practice or the community, I can't say I know exactly where you are coming from. However, I think every referral center has issues with communication with community providers. I'm not going to make specific excuses, but I will be honest, calling community providers to tell them that their patient is sick is a low priority. Granted, this is solely from my own experience and I don't want to speak for others, but after rounding for 3 to 4 hours on 20 critically ill patients, examining all the patients, synthesizing the data, making up plans, talking to families, admitting new patients, completing necessary procedures, providing teaching to fellows and residents and going to divisional meetings, patient care conferences, etc and going home to see my family and often finishing notes that I didn't get to finish at the hospital, calling to tell a community provider that their patient is sick, getting better, has a terminal prognosis, what have you... I don't view it as a priority. I will try to have residents or fellows make calls, especially for follow up care, but I don't honestly double check to make sure it happened. I'm probably wrong in my approach, or I probably don't do it as I should, but that is the reality.

To the point of calling the providers to which you referred the patient too and them not returning a call, well I don't think that is very professional on their part. Most often, I never get calls from referring providers (PCPs or other hospitals) but when I do, I always make sure I answer or respond to their call. I don't consider my time more valuable then theirs in any way and not returning a courtesy is again not professional (that is a ACGME training goal, after all).

Again, I don't know the specifics of the situation you are referring to, but I thought I would give a perspective from the other side. Usually, communication requires 2 or more people, and in my experience, if communication breaks down, rarely is it the fault of a single person.

 

[Perrotfish]

I suppose not having worked in private practice or the community, I can't say I know exactly where you are coming from. However, I think every referral center has issues with communication with community providers. I'm not going to make specific excuses, but I will be honest, calling community providers to tell them that their patient is sick is a low priority. Granted, this is solely from my own experience and I don't want to speak for others, but after rounding for 3 to 4 hours on 20 critically ill patients, examining all the patients, synthesizing the data, making up plans, talking to families, admitting new patients, completing necessary procedures, providing teaching to fellows and residents and going to divisional meetings, patient care conferences, etc and going home to see my family and often finishing notes that I didn't get to finish at the hospital, calling to tell a community provider that their patient is sick, getting better, has a terminal prognosis, what have you... I don't view it as a priority. I will try to have residents or fellows make calls, especially for follow up care, but I don't honestly double check to make sure it happened. I'm probably wrong in my approach, or I probably don't do it as I should, but that is the reality.

To the point of calling the providers to which you referred the patient too and them not returning a call, well I don't think that is very professional on their part. Most often, I never get calls from referring providers (PCPs or other hospitals) but when I do, I always make sure I answer or respond to their call. I don't consider my time more valuable then theirs in any way and not returning a courtesy is again not professional (that is a ACGME training goal, after all).

Again, I don't know the specifics of the situation you are referring to, but I thought I would give a perspective from the other side. Usually, communication requires 2 or more people, and in my experience, if communication breaks down, rarely is it the fault of a single person.

How I think it should work:

1) The referring PCM's information, including their fax, is gathered by a clerk as part of check in

2) Discharge summaries should be done, completely, before a patient can be discharged from the hospital

3) One copy of the patient's discharge summaries should go with the patient, and a clerk faxes the other copy to the provider.

You're right that any push to make residents actually call referring providers won't happen. Beyond the fact that hospitalists are too busy for this, there's also the logistical impossibility of successfully calling someone who is turning over a clinic patient every 15 minutes. On the other hand the d/c summary has to be done anyway, so its very reasonable to push for an institutional change where they are done prior to the bed being turned over.

 

[SurfingDoctor]

2) Discharge summaries should be done, completely, before a patient can be discharged from the hospital

3) One copy of the patient's discharge summaries should go with the patient, and a clerk faxes the other copy to the provider.

I think this is generally true, at least at my institution. I get nasty emails if a discharge summary hasn't been signed by me 2 days after discharge. Granted, me signing it and it actually getting to a provider are 2 whole separate things, one of which I have no control over, but again, at least at my institution, generally discharge summaries get done.

 

[J-Rad]

I can understand where my vague vent may have left a bit of vagueness; nevertheless, other than venting, I did want to start a discussion. Thanks to those participating.
So here's the thing: I'm not a community pediatrician (not that they don't deserve a reasonable level of communication bout their patients). I'm a subspecialist. When I need to send out of my facility it is for a procedure that I can't provide (surgery or intervention). The only time I send out of the local area it is because they provide on of the very few (actually only) services that aren't available locally. It's not sh**-hit-the fan even, because most of the time, that situation can be ameliorated locally. BUT, if I send out it is because it's really bad.
The recent "bad" was an incidental finding..an afternoon favor to another subs service. I eventually sent the pt. to a facility that we've never had a good experience with sending to. A "top 5" facility if rankings are to be respected. Over the last four days I've asked the service pager to be called three times. No call back. The family asked the service doc to call me. No call back. I finally got a call back this morning (with the number blocked. Ironically, I have the direct numbers of two people who aren't on service right now). This is going to have to be a collaborative care arrangement, and I'm fighting to have them communicate with me.
Commentary on residency later.

 

[Perrotfish]

I think this is generally true, at least at my institution. I get nasty emails if a discharge summary hasn't been signed by me 2 days after discharge. Granted, me signing it and it actually getting to a provider are 2 whole separate things, one of which I have no control over, but again, at least at my institution, generally discharge summaries get done.

Getting in done within 48 hours of discharge is not the same as making a finished d/c summary a requirement for discharge. I have rotated through 3 children's hospitals to date, and I work with a 4th as a community Pediatrician, and they all do discharge summaries within 72 hours and can get them to me if I have the unit clerk call and ask for it. Only one of the 4 children's hospitals had any system in place to send me the summary without a request, and that usually happened a week or so after discharge. I have at only worked at one hospital that made a signed d/c summary a requirement for discharge. I think this is a shame for several reasons:
1) The best way to make sure the d/c summary gets to the PCM is to send it twice: by fax AND with the patient. At least the 4 children's hospitals I have worked with send their patients home with basically no information about their hospital stay.
2) Its much harder to set up a system where the summary actually gets to the patient's PCM once they're off the floor. The unit clerk is usually a better option for making this happen than someone in the bowels of the hospital
AND
3) I'm likely to see a patient almost immediately after they're discharged, so later is often too for it to be really helpful.

 

[mvenus929]

Re: Discharge summaries.

Our large children's hospital doesn't require full discharge summaries prior to discharge, except in the NICU where they are most likely to follow-up in 1-2 days. They are technically required within 48 hours of discharge, but our residents are particularly bad at meeting that deadline. I've seen some patients readmitted a month or so later and still don't have discharge summaries from the first admission completed. It's remarkably annoying as the admit resident. We also don't require discharge summaries if the patient has been admitted less than 48 hours. The reason being that we still hand write a discharge note that gets copied and sent with the patient, which includes a brief overview of what happened during the hospitalization. I think once we fully transition to EMR, that requirement will change.

Our policy for our level 2 nursery (in a different hospital) is that discharge summaries have to be signed by the resident prior to the patient leaving, so the nurse can print out a copy for the parents to take home. But this is run by the same group as our NICU, so I think it is their general policy.

 

[ProfMD]

I would absolutely agree that communication from the referral center back to the referring physician needs to be better. I would fully support my hospital requiring d/c summaries at discharge. As it is, they are supposed to be done within a couple of days and then auto-faxed.

At the risk of stirring controversy, I would also say that communication from the referring physician to the referral center needs to improve. In my own practice, when patients are sent to the ED, the usually arrive without physician documentation. Even when patients are referred to my clinic, I receive little or no clinical information from the referring physician.

 

[SurfingDoctor]

I would absolutely agree that communication from the referral center back to the referring physician needs to be better. I would fully support my hospital requiring d/c summaries at discharge. As it is, they are supposed to be done within a couple of days and then auto-faxed.

I am not opposed to this in anyway, however I think the reality of this is easier said than done. Certainly during slower times or lower patient census, it would be feasible to make sure every document is finished, signed and faxed prior to discharge, however in high acuity, high census times, paperwork is always secondary to patient flow and patient care as it should be (neither of which are mutually inclusive). Especially, in today's world of medicine, where reimbursements are low and the only way to offset that is to discharge patients quickly to get more in, the need to maximize patient volume is one of the most important factors to keep a hospital profitable. Add to that, that discharge summaries are not billable documentation, well you can see why little emphasize is put on them. So in slower times, I could see a readily available discharge summary available, however considering slower times are bad times for hospital profit, I doubt there will ever be significant emphasis on them but the emphasis is on patient volume and inpatient outcomes. I'm not saying it is right or wrong, but the reality is medicine is a business (even in academic centers) and thus, work is focused on items that maximize profit and inpatient care, not outpatient follow up.

I can understand where my vague vent may have left a bit of vagueness; nevertheless, other than venting, I did want to start a discussion. Thanks to those participating.
So here's the thing: I'm not a community pediatrician (not that they don't deserve a reasonable level of communication bout their patients). I'm a subspecialist. When I need to send out of my facility it is for a procedure that I can't provide (surgery or intervention). The only time I send out of the local area it is because they provide on of the very few (actually only) services that aren't available locally. It's not sh**-hit-the fan even, because most of the time, that situation can be ameliorated locally. BUT, if I send out it is because it's really bad.
The recent "bad" was an incidental finding..an afternoon favor to another subs service. I eventually sent the pt. to a facility that we've never had a good experience with sending to. A "top 5" facility if rankings are to be respected. Over the last four days I've asked the service pager to be called three times. No call back. The family asked the service doc to call me. No call back. I finally got a call back this morning (with the number blocked. Ironically, I have the direct numbers of two people who aren't on service right now). This is going to have to be a collaborative care arrangement, and I'm fighting to have them communicate with me.
Commentary on residency later.

Hmm, some of the deals are lacking, an "incidental finding" that is "really bad"; so maybe they didn't see it as an emergency, but I see your point and yeah, there's no real excuse for that. Again, being too busy may have delayed the call, but it shouldn't prevent a call, especially if you paged them. I do wonder, some services are going towards cell phones or variations of them for in-hospital and out-of-hospital communication. Is that a possible reason? Despite me carrying the hospital cell phone when I'm service, people still page me (though I leave my pager on vibrate and sometimes miss their pages). I know personally, the lack of unified technology for communication has led me to "miss"-communicate from time to time.

 

[Dr. Wexler]

Historically discharge summaries did not have to be completed before the patient left the hospital. I've worked at places where it had to be complete prior to discharge and places were it didn't

In the age when the same physician saw the patient in the office, admitted the patient, rounded on the patient, discharged the patient, and followed-up the patient, it didn't matter much. He knew the whole history. That age is ending for many in primary care (see the emergence of pediatric hospital medicine as a sub-specialty).

With more patients being admitted under the care of a pediatric hospital medicine specialist and then followed up by an outpatient primary care physician, I will argue that to have a patient discharged without a discharge summary is unacceptable. That discharge summary becomes the most recent, important part of their medical record on the most dangerous day of hospitalization...the day of discharge. The same groups that are advocating pediatric hospital medicine and pediatric outpatient practice as mutually exclusive really need to take responsibility for the paradigm shift that will be necessary to change current accepted practice with discharge summary.

Am I giving good care when I see a patient in follow-up without a discharge summary? No way to know, since I don't know the patient's most recent medical history. It's probably better than nothing. But that's not saying much.