Joseph Feinglass, PhD

The hospitalist movement and increasingly stringent resident work hour restrictions have led to the utilization of shift work in many hospitals.1 Use of nocturnist and night float systems, while often necessary, results in increased patient hand‐offs. Research suggests that hand‐offs in the inpatient setting can adversely affect patient outcomes as lack of continuity may increase the possibility of medical error.2, 3 In 2001, Bell et al.4 found that mortality was higher among patients admitted on weekends as compared to weekdays. Uneven staffing, lack of supervision, and fragmented care were cited as potential contributing factors.4 Similarly, Peberdy et al.5 in 2008 revealed that patients were less likely to survive a cardiac arrest if it occurred at night or on weekends, again attributed in part to fragmented patient care and understaffing.

The results of these studies raise concerns as to whether increased reliance on shift work and resulting handoffs compromises patient care.6, 7 The aim of this study was to evaluate the potential association between night admission and hospitalization‐relevant outcomes (length of stay [LOS], hospital charges, intensive care unit [ICU] transfer during hospitalization, repeat emergency department [ED] visit within 30 days of discharge, readmission within 30 days of discharge, and poor outcome [transfer to the ICU, cardiac arrest, or death] within the first 24 hours of admission) at an institution that exclusively uses nocturnists (night‐shift based hospitalists) and a resident night float system for patients admitted at night to the general medicine service. A secondary aim was to determine the potential association between weekend admission and hospitalization‐relevant outcomes.

Methods

Results

We reviewed 857 records. After excluding 33 records lacking administrative data regarding gender, race and ethnicity, and other demographic variables, there were 824 medical records available for analysis. We reviewed a similar number of records from each time period: 274 from January 2008, 265 from April 2008, and 285 from July 2008. A total of 345 (42%) patients were admitted during the day, and 479 (58%) at night; 641 (78%) were admitted on weekdays, and 183 (22%) on weekends. The 33 excluded charts were similar to the included charts for both time of admission and outcomes. Results for parametric testing and nonparametric testing, as well as for log‐transformation and non‐log‐transformation of the continuous outcomes were similar in both magnitude and statistical significance, so we present the parametric and nonlog‐transformed results below for ease of interpretation.

Interrater reliability among the 3 reviewers was very high. There were no disagreements among the 20 multiple reviews for either poor outcomes within 24 hours of admission or admitting service; the interclass correlation coefficients for 30 day repeat ED visit and 30 day readmission were 0.97 and 0.87, respectively.

Patients admitted at night or on the weekend were similar to patients admitted during the day and week across age, gender, insurance class, MDC, and Charlson Comorbidity Index (Table 1). For unadjusted outcomes, patients admitted at night has a similar LOS, hospital charges, 30 day repeat ED visits, 30 day readmissions, and poor outcome within 24 hours of admission as those patients admitted during the day. They had a potentially lower chance of any ICU transfer during hospitalization though this did not reach statistical significance at P < 0.05 (night admission 6%, day admission 3%, P = 0.06) (Table 2).

Patients admitted to the hospital during the weekend were similar to patients admitted during the week for unadjusted LOS, 30 day repeat ED visit or readmission rate, and poor outcomes within 24 hours of admission as those admitted during the week; however, they had lower hospital charges (weekend admission $22,700, weekday admission $27,200; P = 0.02), and a lower chance of ICU transfer during hospitalization (weekend admission 1%, weekday admission 5%; P = 0.02) (Table 2).

In the multivariable linear and logistic regression models (Tables 3 and 4), we assessed the independent association between night admission or weekend admission and each hospitalization‐relevant outcome except for poor outcome within 24 hours of admission (poor outcome within 24 hours of admission was not modeled to avoid the risk of overfitting because there were only 13 total events). After adjustment for age, gender, race and ethnicity, admitting service (hospitalist or teaching), Medicaid or self‐pay insurance, MDC, and Charlson Comorbidity Index, there was no statistically significant association between night admission and worse outcomes for LOS, hospital charges, 30 day repeat ED visit, or 30 day readmission. Night admission was associated with a decreased chance of ICU transfer during hospitalization, but the difference was not statistically significant (odds ratio, 0.54; 95% confidence interval [CI], 0.26‐1.11, P = 0.09). Weekend admission was not associated with worse outcomes for LOS or 30 day repeat ED visit or readmission; however, weekend admission was associated with a decrease in overall charges ($4400; 95% CI, $8300 to $600) and a decreased chance of ICU transfer during hospitalization (odds ratio, 0.20; 95% CI, 0.050.88).

Our multivariate models explained very little of the variance in patient outcomes. For LOS and hospital charges, adjusted R² values were 0.06 and 0.05, respectively. For ICU transfer during hospitalization, 30 day repeat ED visit, and 30 day readmission, the areas under the receiver operator curves were 0.75, 0.51, and 0.61 respectively.

To assess the robustness of our conclusions regarding night admission, we redefined night to include only patients admitted between the hours of 8 pm and 5:59 am. This did not change our conclusions. We also tested for interaction between night admission and weekend admission for all outcomes to assess whether night admissions on the weekend were in fact at increased risk of worse outcomes; we found no evidence of interaction (P > 0.3 for the interaction terms in each model).

Discussion

Among patients admitted to the medicine services at our academic medical center, night or weekend admission was not associated with worse hospitalization‐relevant outcomes. In some cases, night or weekend admission was associated with better outcomes, particularly in terms of ICU transfer during hospitalization and hospital charges. Prior research indicates worse outcomes during off‐hours,5 but we did not replicate this finding in our study.

The finding that admission at night was not associated with worse outcomes, particularly proximal outcomes such as LOS or ICU transfer during hospitalization, was surprising, though reassuring in view of the fact that more than half of our patients are admitted at night. We believe a few factors may be responsible. First, our general medicine service is staffed during the night (7 pm to 7 am) by in‐house nocturnists and night float residents. Second, our staffing ratio, while lower at night than during the day, remains the same on weekends and may be higher than in other settings. In continuously well‐staffed settings such as the ED12 and ICU,13 night and weekend admissions are only inconsistently associated with worse outcomes, which may be the same phenomena we observed in the current study. Third, the hospital used as the site of this study has received Nursing Magnet recognition and numerous quality awards such as the National Research Corporation's Consumer Choice Award and recognition as a Distinguished Hospital for Clinical Excellence by HealthGrades. Fourth, our integrated electronic medical record, computerized physician order entry system, and automatically generated sign out serve as complements to the morning hand off. Fifth, hospitalists and teaching teams rotate on a weekly, biweekly, or every 4 week basis, which may protect against discontinuity associated with the weekend. We believe that all of these factors may facilitate alert, comprehensive care during the night and weekend as well as safe and efficient transfer of patients from the night to the day providers.

We were also surprised by the association between weekend admission and lower charges and a lower chance of ICU transfer during hospitalization. We believe many of the same factors noted above may have played a role in these findings. In terms of hospital charges, it is possible that some workups were completed outside of the hospital rather than during the hospitalization, and that some tests were not ordered at all due to unavailability on weekends. The decreased chance of ICU transfer is unexplained. We hypothesize that there may have been a more conservative admission strategy within the ED, such that patients with high baseline severity were admitted directly to the ICU on the weekend rather than being admitted first to the general medicine floor. This hypothesis requires further study.

Our study had important limitations. It was a retrospective study from a single academic hospital. The sample size lacked sufficient power to detect differences in the low frequency of certain outcomes such as poor outcomes within 24 hours of admission (2% vs. 1%), and also for more frequent outcomes such as 30 day readmission; it is possible that with a larger sample there would have been statistically significant differences. Further, we recognize that the Charlson Comorbidity Index, which was developed to predict 1‐year mortality for medicine service patients, does not adjust for severity of illness at presentation, particularly for outcomes such as readmission. If patients admitted at night and during the weekend were less acutely ill despite having similar comorbidities and MDCs at admission, true associations between time of admission and worse outcomes could have been masked. Furthermore, the multivariable modeling explained very little of the variance in patient outcomes such that significant unmeasured confounding may still be present, and consequently our results cannot be interpreted in a causal way. Data was collected from electronic records, so it is possible that some adverse events were not recorded. However, it seems unlikely that major events such as death and transfer to an ICU would have been missed.

Several aspects of the study strengthen our confidence in the findings, including a large sample size, relevance of the outcomes, the adjustment for confounders, and an assessment for robustness of the conclusions based on restricting the definition of night and also testing for interaction between night and weekend admission. Our patient demographics and insurance mix resemble that of other academic hospitals,10 and perhaps our results may be generalizable to these settings, if not to non‐urban or community hospitals. Furthermore, the Charlson Comorbidity Index was associated with all 5 of the modeled outcomes we chose for our study, reaffirming their utility in assessing the quality of hospital care. Future directions for investigation may include examining the association of night admission with hospitalization‐relevant outcomes in nonacademic, nonurban settings, and examining whether the lack of association between night and weekend admission and worse outcomes persists with adjustment for initial severity of illness.

In summary, at a large, well‐staffed urban academic hospital, day or time of admission were not associated with worse hospitalization‐relevant outcomes. The use of nocturnists and night float teams for night admissions and continuity across weekends appears to be a safe approach to handling the increased volume of patients admitted at night, and a viable alternative to overnight call in the era of work hour restrictions.

The hospitalist movement and increasingly stringent resident work hour restrictions have led to the utilization of shift work in many hospitals.1 Use of nocturnist and night float systems, while often necessary, results in increased patient hand‐offs. Research suggests that hand‐offs in the inpatient setting can adversely affect patient outcomes as lack of continuity may increase the possibility of medical error.2, 3 In 2001, Bell et al.4 found that mortality was higher among patients admitted on weekends as compared to weekdays. Uneven staffing, lack of supervision, and fragmented care were cited as potential contributing factors.4 Similarly, Peberdy et al.5 in 2008 revealed that patients were less likely to survive a cardiac arrest if it occurred at night or on weekends, again attributed in part to fragmented patient care and understaffing.

The results of these studies raise concerns as to whether increased reliance on shift work and resulting handoffs compromises patient care.6, 7 The aim of this study was to evaluate the potential association between night admission and hospitalization‐relevant outcomes (length of stay [LOS], hospital charges, intensive care unit [ICU] transfer during hospitalization, repeat emergency department [ED] visit within 30 days of discharge, readmission within 30 days of discharge, and poor outcome [transfer to the ICU, cardiac arrest, or death] within the first 24 hours of admission) at an institution that exclusively uses nocturnists (night‐shift based hospitalists) and a resident night float system for patients admitted at night to the general medicine service. A secondary aim was to determine the potential association between weekend admission and hospitalization‐relevant outcomes.

Methods

Results

We reviewed 857 records. After excluding 33 records lacking administrative data regarding gender, race and ethnicity, and other demographic variables, there were 824 medical records available for analysis. We reviewed a similar number of records from each time period: 274 from January 2008, 265 from April 2008, and 285 from July 2008. A total of 345 (42%) patients were admitted during the day, and 479 (58%) at night; 641 (78%) were admitted on weekdays, and 183 (22%) on weekends. The 33 excluded charts were similar to the included charts for both time of admission and outcomes. Results for parametric testing and nonparametric testing, as well as for log‐transformation and non‐log‐transformation of the continuous outcomes were similar in both magnitude and statistical significance, so we present the parametric and nonlog‐transformed results below for ease of interpretation.

Interrater reliability among the 3 reviewers was very high. There were no disagreements among the 20 multiple reviews for either poor outcomes within 24 hours of admission or admitting service; the interclass correlation coefficients for 30 day repeat ED visit and 30 day readmission were 0.97 and 0.87, respectively.

Patients admitted at night or on the weekend were similar to patients admitted during the day and week across age, gender, insurance class, MDC, and Charlson Comorbidity Index (Table 1). For unadjusted outcomes, patients admitted at night has a similar LOS, hospital charges, 30 day repeat ED visits, 30 day readmissions, and poor outcome within 24 hours of admission as those patients admitted during the day. They had a potentially lower chance of any ICU transfer during hospitalization though this did not reach statistical significance at P < 0.05 (night admission 6%, day admission 3%, P = 0.06) (Table 2).

Patients admitted to the hospital during the weekend were similar to patients admitted during the week for unadjusted LOS, 30 day repeat ED visit or readmission rate, and poor outcomes within 24 hours of admission as those admitted during the week; however, they had lower hospital charges (weekend admission $22,700, weekday admission $27,200; P = 0.02), and a lower chance of ICU transfer during hospitalization (weekend admission 1%, weekday admission 5%; P = 0.02) (Table 2).

In the multivariable linear and logistic regression models (Tables 3 and 4), we assessed the independent association between night admission or weekend admission and each hospitalization‐relevant outcome except for poor outcome within 24 hours of admission (poor outcome within 24 hours of admission was not modeled to avoid the risk of overfitting because there were only 13 total events). After adjustment for age, gender, race and ethnicity, admitting service (hospitalist or teaching), Medicaid or self‐pay insurance, MDC, and Charlson Comorbidity Index, there was no statistically significant association between night admission and worse outcomes for LOS, hospital charges, 30 day repeat ED visit, or 30 day readmission. Night admission was associated with a decreased chance of ICU transfer during hospitalization, but the difference was not statistically significant (odds ratio, 0.54; 95% confidence interval [CI], 0.26‐1.11, P = 0.09). Weekend admission was not associated with worse outcomes for LOS or 30 day repeat ED visit or readmission; however, weekend admission was associated with a decrease in overall charges ($4400; 95% CI, $8300 to $600) and a decreased chance of ICU transfer during hospitalization (odds ratio, 0.20; 95% CI, 0.050.88).

Our multivariate models explained very little of the variance in patient outcomes. For LOS and hospital charges, adjusted R² values were 0.06 and 0.05, respectively. For ICU transfer during hospitalization, 30 day repeat ED visit, and 30 day readmission, the areas under the receiver operator curves were 0.75, 0.51, and 0.61 respectively.

To assess the robustness of our conclusions regarding night admission, we redefined night to include only patients admitted between the hours of 8 pm and 5:59 am. This did not change our conclusions. We also tested for interaction between night admission and weekend admission for all outcomes to assess whether night admissions on the weekend were in fact at increased risk of worse outcomes; we found no evidence of interaction (P > 0.3 for the interaction terms in each model).

Discussion

Among patients admitted to the medicine services at our academic medical center, night or weekend admission was not associated with worse hospitalization‐relevant outcomes. In some cases, night or weekend admission was associated with better outcomes, particularly in terms of ICU transfer during hospitalization and hospital charges. Prior research indicates worse outcomes during off‐hours,5 but we did not replicate this finding in our study.

The finding that admission at night was not associated with worse outcomes, particularly proximal outcomes such as LOS or ICU transfer during hospitalization, was surprising, though reassuring in view of the fact that more than half of our patients are admitted at night. We believe a few factors may be responsible. First, our general medicine service is staffed during the night (7 pm to 7 am) by in‐house nocturnists and night float residents. Second, our staffing ratio, while lower at night than during the day, remains the same on weekends and may be higher than in other settings. In continuously well‐staffed settings such as the ED12 and ICU,13 night and weekend admissions are only inconsistently associated with worse outcomes, which may be the same phenomena we observed in the current study. Third, the hospital used as the site of this study has received Nursing Magnet recognition and numerous quality awards such as the National Research Corporation's Consumer Choice Award and recognition as a Distinguished Hospital for Clinical Excellence by HealthGrades. Fourth, our integrated electronic medical record, computerized physician order entry system, and automatically generated sign out serve as complements to the morning hand off. Fifth, hospitalists and teaching teams rotate on a weekly, biweekly, or every 4 week basis, which may protect against discontinuity associated with the weekend. We believe that all of these factors may facilitate alert, comprehensive care during the night and weekend as well as safe and efficient transfer of patients from the night to the day providers.

We were also surprised by the association between weekend admission and lower charges and a lower chance of ICU transfer during hospitalization. We believe many of the same factors noted above may have played a role in these findings. In terms of hospital charges, it is possible that some workups were completed outside of the hospital rather than during the hospitalization, and that some tests were not ordered at all due to unavailability on weekends. The decreased chance of ICU transfer is unexplained. We hypothesize that there may have been a more conservative admission strategy within the ED, such that patients with high baseline severity were admitted directly to the ICU on the weekend rather than being admitted first to the general medicine floor. This hypothesis requires further study.

Our study had important limitations. It was a retrospective study from a single academic hospital. The sample size lacked sufficient power to detect differences in the low frequency of certain outcomes such as poor outcomes within 24 hours of admission (2% vs. 1%), and also for more frequent outcomes such as 30 day readmission; it is possible that with a larger sample there would have been statistically significant differences. Further, we recognize that the Charlson Comorbidity Index, which was developed to predict 1‐year mortality for medicine service patients, does not adjust for severity of illness at presentation, particularly for outcomes such as readmission. If patients admitted at night and during the weekend were less acutely ill despite having similar comorbidities and MDCs at admission, true associations between time of admission and worse outcomes could have been masked. Furthermore, the multivariable modeling explained very little of the variance in patient outcomes such that significant unmeasured confounding may still be present, and consequently our results cannot be interpreted in a causal way. Data was collected from electronic records, so it is possible that some adverse events were not recorded. However, it seems unlikely that major events such as death and transfer to an ICU would have been missed.

Several aspects of the study strengthen our confidence in the findings, including a large sample size, relevance of the outcomes, the adjustment for confounders, and an assessment for robustness of the conclusions based on restricting the definition of night and also testing for interaction between night and weekend admission. Our patient demographics and insurance mix resemble that of other academic hospitals,10 and perhaps our results may be generalizable to these settings, if not to non‐urban or community hospitals. Furthermore, the Charlson Comorbidity Index was associated with all 5 of the modeled outcomes we chose for our study, reaffirming their utility in assessing the quality of hospital care. Future directions for investigation may include examining the association of night admission with hospitalization‐relevant outcomes in nonacademic, nonurban settings, and examining whether the lack of association between night and weekend admission and worse outcomes persists with adjustment for initial severity of illness.

In summary, at a large, well‐staffed urban academic hospital, day or time of admission were not associated with worse hospitalization‐relevant outcomes. The use of nocturnists and night float teams for night admissions and continuity across weekends appears to be a safe approach to handling the increased volume of patients admitted at night, and a viable alternative to overnight call in the era of work hour restrictions.

The hospitalist movement and increasingly stringent resident work hour restrictions have led to the utilization of shift work in many hospitals.1 Use of nocturnist and night float systems, while often necessary, results in increased patient hand‐offs. Research suggests that hand‐offs in the inpatient setting can adversely affect patient outcomes as lack of continuity may increase the possibility of medical error.2, 3 In 2001, Bell et al.4 found that mortality was higher among patients admitted on weekends as compared to weekdays. Uneven staffing, lack of supervision, and fragmented care were cited as potential contributing factors.4 Similarly, Peberdy et al.5 in 2008 revealed that patients were less likely to survive a cardiac arrest if it occurred at night or on weekends, again attributed in part to fragmented patient care and understaffing.

The results of these studies raise concerns as to whether increased reliance on shift work and resulting handoffs compromises patient care.6, 7 The aim of this study was to evaluate the potential association between night admission and hospitalization‐relevant outcomes (length of stay [LOS], hospital charges, intensive care unit [ICU] transfer during hospitalization, repeat emergency department [ED] visit within 30 days of discharge, readmission within 30 days of discharge, and poor outcome [transfer to the ICU, cardiac arrest, or death] within the first 24 hours of admission) at an institution that exclusively uses nocturnists (night‐shift based hospitalists) and a resident night float system for patients admitted at night to the general medicine service. A secondary aim was to determine the potential association between weekend admission and hospitalization‐relevant outcomes.

Methods

Results

We reviewed 857 records. After excluding 33 records lacking administrative data regarding gender, race and ethnicity, and other demographic variables, there were 824 medical records available for analysis. We reviewed a similar number of records from each time period: 274 from January 2008, 265 from April 2008, and 285 from July 2008. A total of 345 (42%) patients were admitted during the day, and 479 (58%) at night; 641 (78%) were admitted on weekdays, and 183 (22%) on weekends. The 33 excluded charts were similar to the included charts for both time of admission and outcomes. Results for parametric testing and nonparametric testing, as well as for log‐transformation and non‐log‐transformation of the continuous outcomes were similar in both magnitude and statistical significance, so we present the parametric and nonlog‐transformed results below for ease of interpretation.

Interrater reliability among the 3 reviewers was very high. There were no disagreements among the 20 multiple reviews for either poor outcomes within 24 hours of admission or admitting service; the interclass correlation coefficients for 30 day repeat ED visit and 30 day readmission were 0.97 and 0.87, respectively.

Patients admitted at night or on the weekend were similar to patients admitted during the day and week across age, gender, insurance class, MDC, and Charlson Comorbidity Index (Table 1). For unadjusted outcomes, patients admitted at night has a similar LOS, hospital charges, 30 day repeat ED visits, 30 day readmissions, and poor outcome within 24 hours of admission as those patients admitted during the day. They had a potentially lower chance of any ICU transfer during hospitalization though this did not reach statistical significance at P < 0.05 (night admission 6%, day admission 3%, P = 0.06) (Table 2).

Patients admitted to the hospital during the weekend were similar to patients admitted during the week for unadjusted LOS, 30 day repeat ED visit or readmission rate, and poor outcomes within 24 hours of admission as those admitted during the week; however, they had lower hospital charges (weekend admission $22,700, weekday admission $27,200; P = 0.02), and a lower chance of ICU transfer during hospitalization (weekend admission 1%, weekday admission 5%; P = 0.02) (Table 2).

In the multivariable linear and logistic regression models (Tables 3 and 4), we assessed the independent association between night admission or weekend admission and each hospitalization‐relevant outcome except for poor outcome within 24 hours of admission (poor outcome within 24 hours of admission was not modeled to avoid the risk of overfitting because there were only 13 total events). After adjustment for age, gender, race and ethnicity, admitting service (hospitalist or teaching), Medicaid or self‐pay insurance, MDC, and Charlson Comorbidity Index, there was no statistically significant association between night admission and worse outcomes for LOS, hospital charges, 30 day repeat ED visit, or 30 day readmission. Night admission was associated with a decreased chance of ICU transfer during hospitalization, but the difference was not statistically significant (odds ratio, 0.54; 95% confidence interval [CI], 0.26‐1.11, P = 0.09). Weekend admission was not associated with worse outcomes for LOS or 30 day repeat ED visit or readmission; however, weekend admission was associated with a decrease in overall charges ($4400; 95% CI, $8300 to $600) and a decreased chance of ICU transfer during hospitalization (odds ratio, 0.20; 95% CI, 0.050.88).

Our multivariate models explained very little of the variance in patient outcomes. For LOS and hospital charges, adjusted R² values were 0.06 and 0.05, respectively. For ICU transfer during hospitalization, 30 day repeat ED visit, and 30 day readmission, the areas under the receiver operator curves were 0.75, 0.51, and 0.61 respectively.

To assess the robustness of our conclusions regarding night admission, we redefined night to include only patients admitted between the hours of 8 pm and 5:59 am. This did not change our conclusions. We also tested for interaction between night admission and weekend admission for all outcomes to assess whether night admissions on the weekend were in fact at increased risk of worse outcomes; we found no evidence of interaction (P > 0.3 for the interaction terms in each model).

Discussion

Among patients admitted to the medicine services at our academic medical center, night or weekend admission was not associated with worse hospitalization‐relevant outcomes. In some cases, night or weekend admission was associated with better outcomes, particularly in terms of ICU transfer during hospitalization and hospital charges. Prior research indicates worse outcomes during off‐hours,5 but we did not replicate this finding in our study.

The finding that admission at night was not associated with worse outcomes, particularly proximal outcomes such as LOS or ICU transfer during hospitalization, was surprising, though reassuring in view of the fact that more than half of our patients are admitted at night. We believe a few factors may be responsible. First, our general medicine service is staffed during the night (7 pm to 7 am) by in‐house nocturnists and night float residents. Second, our staffing ratio, while lower at night than during the day, remains the same on weekends and may be higher than in other settings. In continuously well‐staffed settings such as the ED12 and ICU,13 night and weekend admissions are only inconsistently associated with worse outcomes, which may be the same phenomena we observed in the current study. Third, the hospital used as the site of this study has received Nursing Magnet recognition and numerous quality awards such as the National Research Corporation's Consumer Choice Award and recognition as a Distinguished Hospital for Clinical Excellence by HealthGrades. Fourth, our integrated electronic medical record, computerized physician order entry system, and automatically generated sign out serve as complements to the morning hand off. Fifth, hospitalists and teaching teams rotate on a weekly, biweekly, or every 4 week basis, which may protect against discontinuity associated with the weekend. We believe that all of these factors may facilitate alert, comprehensive care during the night and weekend as well as safe and efficient transfer of patients from the night to the day providers.

We were also surprised by the association between weekend admission and lower charges and a lower chance of ICU transfer during hospitalization. We believe many of the same factors noted above may have played a role in these findings. In terms of hospital charges, it is possible that some workups were completed outside of the hospital rather than during the hospitalization, and that some tests were not ordered at all due to unavailability on weekends. The decreased chance of ICU transfer is unexplained. We hypothesize that there may have been a more conservative admission strategy within the ED, such that patients with high baseline severity were admitted directly to the ICU on the weekend rather than being admitted first to the general medicine floor. This hypothesis requires further study.

Our study had important limitations. It was a retrospective study from a single academic hospital. The sample size lacked sufficient power to detect differences in the low frequency of certain outcomes such as poor outcomes within 24 hours of admission (2% vs. 1%), and also for more frequent outcomes such as 30 day readmission; it is possible that with a larger sample there would have been statistically significant differences. Further, we recognize that the Charlson Comorbidity Index, which was developed to predict 1‐year mortality for medicine service patients, does not adjust for severity of illness at presentation, particularly for outcomes such as readmission. If patients admitted at night and during the weekend were less acutely ill despite having similar comorbidities and MDCs at admission, true associations between time of admission and worse outcomes could have been masked. Furthermore, the multivariable modeling explained very little of the variance in patient outcomes such that significant unmeasured confounding may still be present, and consequently our results cannot be interpreted in a causal way. Data was collected from electronic records, so it is possible that some adverse events were not recorded. However, it seems unlikely that major events such as death and transfer to an ICU would have been missed.

Several aspects of the study strengthen our confidence in the findings, including a large sample size, relevance of the outcomes, the adjustment for confounders, and an assessment for robustness of the conclusions based on restricting the definition of night and also testing for interaction between night and weekend admission. Our patient demographics and insurance mix resemble that of other academic hospitals,10 and perhaps our results may be generalizable to these settings, if not to non‐urban or community hospitals. Furthermore, the Charlson Comorbidity Index was associated with all 5 of the modeled outcomes we chose for our study, reaffirming their utility in assessing the quality of hospital care. Future directions for investigation may include examining the association of night admission with hospitalization‐relevant outcomes in nonacademic, nonurban settings, and examining whether the lack of association between night and weekend admission and worse outcomes persists with adjustment for initial severity of illness.

In summary, at a large, well‐staffed urban academic hospital, day or time of admission were not associated with worse hospitalization‐relevant outcomes. The use of nocturnists and night float teams for night admissions and continuity across weekends appears to be a safe approach to handling the increased volume of patients admitted at night, and a viable alternative to overnight call in the era of work hour restrictions.

Preventable or ameliorable adverse events have been reported to occur in 12% of patients in the period immediately following hospital discharge.1, 2 A potential contributor to this is the inadequate transfer of clinical information at hospital discharge. The discharge summary comprises a vital component of the information transfer between the inpatient and outpatient settings. Unfortunately, discharge summaries are often unavailable at the time of follow‐up care and often lack important content.37

A growing number of hospitals are implementing electronic medical records (EMR). This creates the opportunity to standardize the content of clinical documentation and creates the potential to assemble, immediately at the time of hospital discharge, major components of a discharge summary. With enhanced communication systems, this information can be delivered in a variety of ways with minimal delay. Previously, we reported the results of a survey of medicine faculty at an urban academic medical center evaluating the timeliness and quality of discharge summaries, the perceived incidence of preventable adverse events related to suboptimal information transfer at discharge, and a needs assessment for an electronically generated discharge summary that we planned to design.8 We now report the results of the follow‐up survey of outpatient physicians and an evaluation of the quality and timeliness of the electronic discharge summary we created.

Materials and Methods

Results

Discussion

Our study found that an electronic discharge summary was well accepted by inpatient physicians and significantly improved the quality and timeliness of discharge summaries. Prior studies have shown that the use of electronically entered discharge summaries improved the timeliness of discharge summaries.1416 However, the discharge summaries used in these studies required manual input of data into a computer system separate from the patient's medical record. To our knowledge, this is the first study to report the impact of discharge summaries generated from an EMR. Leveraging the EMR, we were able to automate the insertion of specific patient data elements, streamline delivery, and create an electronic reminder system to inpatient physicians for summaries not completed 24 hours after discharge.

Prior research has shown that the quality of discharges summaries is improved with the use of standardized content.10, 17 Using a standardized template for the electronic discharge summary, we likewise demonstrated improved quality of discharge summaries. Key discharge summary elements, specifically discussion of follow‐up issues, pending test results, and information provided to the patient and/or family, were present more reliably after the implementation of the electronic discharge summary. The importance of identifying pending test results is underscored by a recent study showing that many patients are discharged from hospitals with test results still pending, and that physicians are often unaware when results are abnormal.18 One discharge summary element, significant laboratory findings, was present less often after the implementation of the electronic discharge summary. Our template did not designate significant laboratory findings under a separate heading. Instead, we used a heading entitled Key Results (labs, imaging, pathology). Physicians completing the discharge summaries may have prioritized the report of imaging and pathology results in this section. A simple revision of our discharge summary template to include a separate heading for significant laboratory findings may result in improvement in this regard.

Timeliness of discharge summaries was improved in our study, but remained less than optimal. Although nearly three‐quarters of electronic discharge summaries were completed within 3 days of discharge, our ultimate goal is to have 100% of discharge summaries completed within 3 days. This is especially important for complicated patients requiring outpatient follow‐up soon after discharge. We are currently in the process of designing further modifications to the electronic discharge summary completion process. One modification that may be beneficial is the automation of additional patient specific data elements into the discharge summary. We also plan to link performance of medication reconciliation, completion of patient discharge instructions, and completion of the discharge summary into an integrated set of activities performed in the EMR prior to patient discharge.

We found that fewer outpatient physicians reported 1 or more of their patients having a preventable adverse event or near miss as a result of suboptimal transfer of information at discharge after the implementation of the electronic discharge summary. Although we did not measure preventable adverse events directly in our study, this is an important finding in light of the large number of patients who sustain preventable adverse events after hospital discharge1, 2 and prior research showing that the absence of discharge summaries at postdischarge follow‐up visits increased the risk for hospital readmission.19

We had wondered what effect the electronic discharge summary would have on the length and clarity of discharge summaries. A published commentary suggested that notes performed in EMRs were inordinately long and often difficult to read.20 We were pleased to discover that electronic discharge summaries were similar in length to previous discharge summaries and were rated higher with regard to clarity.

Our study has several limitations. First, many inpatient physicians began to use electronic discharge summaries prior to our creation of the final electronic discharge summary product. We had explicitly instructed physicians to continue to dictate discharge summaries in the first phase of our study. The fact that physicians quickly adopted the practice of completing discharge summaries electronically suggests that they preferred this method for completion and may help to explain the improvement in timeliness. A second limitation, as previously mentioned, is that our study did not measure adverse events directly. Instead, we asked outpatient physicians to estimate the number of their patients discharged in the last 6 months who had sustained a preventable adverse event or near miss related to suboptimal information transfer at discharge. We had limited space in the survey to define the meaning of a preventable adverse event; therefore, the description in the survey does not exactly match previous definitions.1, 2 Finally, the ordinal scale used to assess clarity of discharge summaries has not been previously validated.

In conclusion, the use of an electronic discharge summary significantly improved the quality and timeliness of discharge summaries. The discharge summary comprises a vital component of the information transfer between the inpatient and outpatient settings during the vulnerable period following hospital discharge. As hospitals expand their use of EMRs, they should take advantage of opportunities to leverage functionality to improve quality and timeliness of discharge summaries.

Preventable or ameliorable adverse events have been reported to occur in 12% of patients in the period immediately following hospital discharge.1, 2 A potential contributor to this is the inadequate transfer of clinical information at hospital discharge. The discharge summary comprises a vital component of the information transfer between the inpatient and outpatient settings. Unfortunately, discharge summaries are often unavailable at the time of follow‐up care and often lack important content.37

A growing number of hospitals are implementing electronic medical records (EMR). This creates the opportunity to standardize the content of clinical documentation and creates the potential to assemble, immediately at the time of hospital discharge, major components of a discharge summary. With enhanced communication systems, this information can be delivered in a variety of ways with minimal delay. Previously, we reported the results of a survey of medicine faculty at an urban academic medical center evaluating the timeliness and quality of discharge summaries, the perceived incidence of preventable adverse events related to suboptimal information transfer at discharge, and a needs assessment for an electronically generated discharge summary that we planned to design.8 We now report the results of the follow‐up survey of outpatient physicians and an evaluation of the quality and timeliness of the electronic discharge summary we created.

Materials and Methods

Results

Discussion

Our study found that an electronic discharge summary was well accepted by inpatient physicians and significantly improved the quality and timeliness of discharge summaries. Prior studies have shown that the use of electronically entered discharge summaries improved the timeliness of discharge summaries.1416 However, the discharge summaries used in these studies required manual input of data into a computer system separate from the patient's medical record. To our knowledge, this is the first study to report the impact of discharge summaries generated from an EMR. Leveraging the EMR, we were able to automate the insertion of specific patient data elements, streamline delivery, and create an electronic reminder system to inpatient physicians for summaries not completed 24 hours after discharge.

Prior research has shown that the quality of discharges summaries is improved with the use of standardized content.10, 17 Using a standardized template for the electronic discharge summary, we likewise demonstrated improved quality of discharge summaries. Key discharge summary elements, specifically discussion of follow‐up issues, pending test results, and information provided to the patient and/or family, were present more reliably after the implementation of the electronic discharge summary. The importance of identifying pending test results is underscored by a recent study showing that many patients are discharged from hospitals with test results still pending, and that physicians are often unaware when results are abnormal.18 One discharge summary element, significant laboratory findings, was present less often after the implementation of the electronic discharge summary. Our template did not designate significant laboratory findings under a separate heading. Instead, we used a heading entitled Key Results (labs, imaging, pathology). Physicians completing the discharge summaries may have prioritized the report of imaging and pathology results in this section. A simple revision of our discharge summary template to include a separate heading for significant laboratory findings may result in improvement in this regard.

Timeliness of discharge summaries was improved in our study, but remained less than optimal. Although nearly three‐quarters of electronic discharge summaries were completed within 3 days of discharge, our ultimate goal is to have 100% of discharge summaries completed within 3 days. This is especially important for complicated patients requiring outpatient follow‐up soon after discharge. We are currently in the process of designing further modifications to the electronic discharge summary completion process. One modification that may be beneficial is the automation of additional patient specific data elements into the discharge summary. We also plan to link performance of medication reconciliation, completion of patient discharge instructions, and completion of the discharge summary into an integrated set of activities performed in the EMR prior to patient discharge.

We found that fewer outpatient physicians reported 1 or more of their patients having a preventable adverse event or near miss as a result of suboptimal transfer of information at discharge after the implementation of the electronic discharge summary. Although we did not measure preventable adverse events directly in our study, this is an important finding in light of the large number of patients who sustain preventable adverse events after hospital discharge1, 2 and prior research showing that the absence of discharge summaries at postdischarge follow‐up visits increased the risk for hospital readmission.19

We had wondered what effect the electronic discharge summary would have on the length and clarity of discharge summaries. A published commentary suggested that notes performed in EMRs were inordinately long and often difficult to read.20 We were pleased to discover that electronic discharge summaries were similar in length to previous discharge summaries and were rated higher with regard to clarity.

Our study has several limitations. First, many inpatient physicians began to use electronic discharge summaries prior to our creation of the final electronic discharge summary product. We had explicitly instructed physicians to continue to dictate discharge summaries in the first phase of our study. The fact that physicians quickly adopted the practice of completing discharge summaries electronically suggests that they preferred this method for completion and may help to explain the improvement in timeliness. A second limitation, as previously mentioned, is that our study did not measure adverse events directly. Instead, we asked outpatient physicians to estimate the number of their patients discharged in the last 6 months who had sustained a preventable adverse event or near miss related to suboptimal information transfer at discharge. We had limited space in the survey to define the meaning of a preventable adverse event; therefore, the description in the survey does not exactly match previous definitions.1, 2 Finally, the ordinal scale used to assess clarity of discharge summaries has not been previously validated.

In conclusion, the use of an electronic discharge summary significantly improved the quality and timeliness of discharge summaries. The discharge summary comprises a vital component of the information transfer between the inpatient and outpatient settings during the vulnerable period following hospital discharge. As hospitals expand their use of EMRs, they should take advantage of opportunities to leverage functionality to improve quality and timeliness of discharge summaries.

Preventable or ameliorable adverse events have been reported to occur in 12% of patients in the period immediately following hospital discharge.1, 2 A potential contributor to this is the inadequate transfer of clinical information at hospital discharge. The discharge summary comprises a vital component of the information transfer between the inpatient and outpatient settings. Unfortunately, discharge summaries are often unavailable at the time of follow‐up care and often lack important content.37

A growing number of hospitals are implementing electronic medical records (EMR). This creates the opportunity to standardize the content of clinical documentation and creates the potential to assemble, immediately at the time of hospital discharge, major components of a discharge summary. With enhanced communication systems, this information can be delivered in a variety of ways with minimal delay. Previously, we reported the results of a survey of medicine faculty at an urban academic medical center evaluating the timeliness and quality of discharge summaries, the perceived incidence of preventable adverse events related to suboptimal information transfer at discharge, and a needs assessment for an electronically generated discharge summary that we planned to design.8 We now report the results of the follow‐up survey of outpatient physicians and an evaluation of the quality and timeliness of the electronic discharge summary we created.

Materials and Methods

Results

Discussion

Our study found that an electronic discharge summary was well accepted by inpatient physicians and significantly improved the quality and timeliness of discharge summaries. Prior studies have shown that the use of electronically entered discharge summaries improved the timeliness of discharge summaries.1416 However, the discharge summaries used in these studies required manual input of data into a computer system separate from the patient's medical record. To our knowledge, this is the first study to report the impact of discharge summaries generated from an EMR. Leveraging the EMR, we were able to automate the insertion of specific patient data elements, streamline delivery, and create an electronic reminder system to inpatient physicians for summaries not completed 24 hours after discharge.

Prior research has shown that the quality of discharges summaries is improved with the use of standardized content.10, 17 Using a standardized template for the electronic discharge summary, we likewise demonstrated improved quality of discharge summaries. Key discharge summary elements, specifically discussion of follow‐up issues, pending test results, and information provided to the patient and/or family, were present more reliably after the implementation of the electronic discharge summary. The importance of identifying pending test results is underscored by a recent study showing that many patients are discharged from hospitals with test results still pending, and that physicians are often unaware when results are abnormal.18 One discharge summary element, significant laboratory findings, was present less often after the implementation of the electronic discharge summary. Our template did not designate significant laboratory findings under a separate heading. Instead, we used a heading entitled Key Results (labs, imaging, pathology). Physicians completing the discharge summaries may have prioritized the report of imaging and pathology results in this section. A simple revision of our discharge summary template to include a separate heading for significant laboratory findings may result in improvement in this regard.

Timeliness of discharge summaries was improved in our study, but remained less than optimal. Although nearly three‐quarters of electronic discharge summaries were completed within 3 days of discharge, our ultimate goal is to have 100% of discharge summaries completed within 3 days. This is especially important for complicated patients requiring outpatient follow‐up soon after discharge. We are currently in the process of designing further modifications to the electronic discharge summary completion process. One modification that may be beneficial is the automation of additional patient specific data elements into the discharge summary. We also plan to link performance of medication reconciliation, completion of patient discharge instructions, and completion of the discharge summary into an integrated set of activities performed in the EMR prior to patient discharge.

We found that fewer outpatient physicians reported 1 or more of their patients having a preventable adverse event or near miss as a result of suboptimal transfer of information at discharge after the implementation of the electronic discharge summary. Although we did not measure preventable adverse events directly in our study, this is an important finding in light of the large number of patients who sustain preventable adverse events after hospital discharge1, 2 and prior research showing that the absence of discharge summaries at postdischarge follow‐up visits increased the risk for hospital readmission.19

We had wondered what effect the electronic discharge summary would have on the length and clarity of discharge summaries. A published commentary suggested that notes performed in EMRs were inordinately long and often difficult to read.20 We were pleased to discover that electronic discharge summaries were similar in length to previous discharge summaries and were rated higher with regard to clarity.

Our study has several limitations. First, many inpatient physicians began to use electronic discharge summaries prior to our creation of the final electronic discharge summary product. We had explicitly instructed physicians to continue to dictate discharge summaries in the first phase of our study. The fact that physicians quickly adopted the practice of completing discharge summaries electronically suggests that they preferred this method for completion and may help to explain the improvement in timeliness. A second limitation, as previously mentioned, is that our study did not measure adverse events directly. Instead, we asked outpatient physicians to estimate the number of their patients discharged in the last 6 months who had sustained a preventable adverse event or near miss related to suboptimal information transfer at discharge. We had limited space in the survey to define the meaning of a preventable adverse event; therefore, the description in the survey does not exactly match previous definitions.1, 2 Finally, the ordinal scale used to assess clarity of discharge summaries has not been previously validated.

In conclusion, the use of an electronic discharge summary significantly improved the quality and timeliness of discharge summaries. The discharge summary comprises a vital component of the information transfer between the inpatient and outpatient settings during the vulnerable period following hospital discharge. As hospitals expand their use of EMRs, they should take advantage of opportunities to leverage functionality to improve quality and timeliness of discharge summaries.

Twelve percent of patients have been reported to have preventable or ameliorable adverse events in the period immediately following hospital discharge.1, 2 A potential contributor to the number of adverse events is inadequate transfer of clinical information at hospital discharge. The discharge summary is a vital component of the transfer of information from the inpatient to the outpatient setting. Unfortunately, discharge summaries are often unavailable when follow‐up care occurs and often lack important content.36

Many hospitals are implementing an electronic medical record systems. This creates the opportunity at hospital discharge to immediately assemble the major components of a discharge summary. With enhanced communication systems, this information can be delivered in a variety of ways with minimal delay. We report the results and evaluation of a survey of medicine faculty at an urban academic medical center about the timeliness and quality of discharge summaries, the perceived incidence of adverse events related to suboptimal information transfer at discharge, and the need for the electronically generated discharge summary we plan to design.

METHODS

RESULTS

DISCUSSION

Our study found that outpatient physicians were not satisfied with the timeliness or the quality of current discharge summaries. Our findings are in agreement with previous studies demonstrating that discharge summaries were often not available to outpatient physicians^3,4 and were often of poor quality.5, 6

Preventable or ameliorable adverse events have been reported to occur in 12% of patients in the period immediately following hospital discharge.1, 2 No studies have evaluated the relationship between discharge summaries and preventable adverse events following discharge. Our study found that 41% of outpatient physicians believed that at least one of their patients in the 6 months prior to the survey had sustained a preventable adverse event related to the suboptimal transfer of information at hospital discharge. In addition, the likelihood of physicians reporting one or more preventable adverse events increased with the frequency of seeing patients for follow‐up prior to discharge summary arrival.

In preparation for revising the discharge summary, we asked outpatient physicians to rate the importance of discharge summary content and their preference for method of delivery of discharge summaries. As in previous studies, the outpatient physicians rated discharge medications, discharge diagnosis, test results, and follow‐up plans as highly important.7, 8 Much of this clinical data is now available in the electronic medical record. Therefore, it is possible to electronically assemble much, if not all, of discharge summary content. One recent study demonstrated that database‐generated discharge summaries significantly increased the likelihood that a discharge summary was generated within 4 weeks of hospital discharge.9 The database used in that study required manual data input from a handwritten form. To our knowledge, no study has reported the experience of discharge summaries generated from an electronic medical record.

Our study had several limitations. First, our study used physician survey to assess the timeliness of receiving discharge summaries. Measuring the time to actual receipt of discharge summaries by physicians was beyond the scope of our study. Second, our study did not measure adverse events directly. Instead, we asked outpatient physicians to estimate how many of their patients discharged in the last 6 months had sustained a preventable adverse event related to suboptimal information transfer at discharge. We had limited space in the questionnaire to define the meaning of a preventable adverse event; therefore, the description in the survey does not exactly match previous definitions.1, 2 Our study had a response rate of 54%. It is possible that nonresponders may have been more satisfied with the quality and timeliness of discharge summaries and may have believed fewer patients experienced preventable adverse events related to suboptimal information transfer at discharge.

The results of our study suggest that the use of systems to improve the quality and delivery of discharge summaries has the potential to improve outpatient physician satisfaction and to reduce the number of preventable adverse events that occur during the vulnerable period following hospital discharge. With the use of electronic medical records, we now have the potential to automate the process of assembling and delivering clinical information with minimal delay. We are now using the information from this study to design a partially automated, high‐quality discharge summary that can be delivered to outpatient physicians immediately on discharge.

Twelve percent of patients have been reported to have preventable or ameliorable adverse events in the period immediately following hospital discharge.1, 2 A potential contributor to the number of adverse events is inadequate transfer of clinical information at hospital discharge. The discharge summary is a vital component of the transfer of information from the inpatient to the outpatient setting. Unfortunately, discharge summaries are often unavailable when follow‐up care occurs and often lack important content.36

Many hospitals are implementing an electronic medical record systems. This creates the opportunity at hospital discharge to immediately assemble the major components of a discharge summary. With enhanced communication systems, this information can be delivered in a variety of ways with minimal delay. We report the results and evaluation of a survey of medicine faculty at an urban academic medical center about the timeliness and quality of discharge summaries, the perceived incidence of adverse events related to suboptimal information transfer at discharge, and the need for the electronically generated discharge summary we plan to design.

METHODS

RESULTS

DISCUSSION

Our study found that outpatient physicians were not satisfied with the timeliness or the quality of current discharge summaries. Our findings are in agreement with previous studies demonstrating that discharge summaries were often not available to outpatient physicians^3,4 and were often of poor quality.5, 6

Preventable or ameliorable adverse events have been reported to occur in 12% of patients in the period immediately following hospital discharge.1, 2 No studies have evaluated the relationship between discharge summaries and preventable adverse events following discharge. Our study found that 41% of outpatient physicians believed that at least one of their patients in the 6 months prior to the survey had sustained a preventable adverse event related to the suboptimal transfer of information at hospital discharge. In addition, the likelihood of physicians reporting one or more preventable adverse events increased with the frequency of seeing patients for follow‐up prior to discharge summary arrival.

In preparation for revising the discharge summary, we asked outpatient physicians to rate the importance of discharge summary content and their preference for method of delivery of discharge summaries. As in previous studies, the outpatient physicians rated discharge medications, discharge diagnosis, test results, and follow‐up plans as highly important.7, 8 Much of this clinical data is now available in the electronic medical record. Therefore, it is possible to electronically assemble much, if not all, of discharge summary content. One recent study demonstrated that database‐generated discharge summaries significantly increased the likelihood that a discharge summary was generated within 4 weeks of hospital discharge.9 The database used in that study required manual data input from a handwritten form. To our knowledge, no study has reported the experience of discharge summaries generated from an electronic medical record.

Our study had several limitations. First, our study used physician survey to assess the timeliness of receiving discharge summaries. Measuring the time to actual receipt of discharge summaries by physicians was beyond the scope of our study. Second, our study did not measure adverse events directly. Instead, we asked outpatient physicians to estimate how many of their patients discharged in the last 6 months had sustained a preventable adverse event related to suboptimal information transfer at discharge. We had limited space in the questionnaire to define the meaning of a preventable adverse event; therefore, the description in the survey does not exactly match previous definitions.1, 2 Our study had a response rate of 54%. It is possible that nonresponders may have been more satisfied with the quality and timeliness of discharge summaries and may have believed fewer patients experienced preventable adverse events related to suboptimal information transfer at discharge.

The results of our study suggest that the use of systems to improve the quality and delivery of discharge summaries has the potential to improve outpatient physician satisfaction and to reduce the number of preventable adverse events that occur during the vulnerable period following hospital discharge. With the use of electronic medical records, we now have the potential to automate the process of assembling and delivering clinical information with minimal delay. We are now using the information from this study to design a partially automated, high‐quality discharge summary that can be delivered to outpatient physicians immediately on discharge.

Twelve percent of patients have been reported to have preventable or ameliorable adverse events in the period immediately following hospital discharge.1, 2 A potential contributor to the number of adverse events is inadequate transfer of clinical information at hospital discharge. The discharge summary is a vital component of the transfer of information from the inpatient to the outpatient setting. Unfortunately, discharge summaries are often unavailable when follow‐up care occurs and often lack important content.36

Many hospitals are implementing an electronic medical record systems. This creates the opportunity at hospital discharge to immediately assemble the major components of a discharge summary. With enhanced communication systems, this information can be delivered in a variety of ways with minimal delay. We report the results and evaluation of a survey of medicine faculty at an urban academic medical center about the timeliness and quality of discharge summaries, the perceived incidence of adverse events related to suboptimal information transfer at discharge, and the need for the electronically generated discharge summary we plan to design.

METHODS

RESULTS

DISCUSSION

Our study found that outpatient physicians were not satisfied with the timeliness or the quality of current discharge summaries. Our findings are in agreement with previous studies demonstrating that discharge summaries were often not available to outpatient physicians^3,4 and were often of poor quality.5, 6

Preventable or ameliorable adverse events have been reported to occur in 12% of patients in the period immediately following hospital discharge.1, 2 No studies have evaluated the relationship between discharge summaries and preventable adverse events following discharge. Our study found that 41% of outpatient physicians believed that at least one of their patients in the 6 months prior to the survey had sustained a preventable adverse event related to the suboptimal transfer of information at hospital discharge. In addition, the likelihood of physicians reporting one or more preventable adverse events increased with the frequency of seeing patients for follow‐up prior to discharge summary arrival.

In preparation for revising the discharge summary, we asked outpatient physicians to rate the importance of discharge summary content and their preference for method of delivery of discharge summaries. As in previous studies, the outpatient physicians rated discharge medications, discharge diagnosis, test results, and follow‐up plans as highly important.7, 8 Much of this clinical data is now available in the electronic medical record. Therefore, it is possible to electronically assemble much, if not all, of discharge summary content. One recent study demonstrated that database‐generated discharge summaries significantly increased the likelihood that a discharge summary was generated within 4 weeks of hospital discharge.9 The database used in that study required manual data input from a handwritten form. To our knowledge, no study has reported the experience of discharge summaries generated from an electronic medical record.

Our study had several limitations. First, our study used physician survey to assess the timeliness of receiving discharge summaries. Measuring the time to actual receipt of discharge summaries by physicians was beyond the scope of our study. Second, our study did not measure adverse events directly. Instead, we asked outpatient physicians to estimate how many of their patients discharged in the last 6 months had sustained a preventable adverse event related to suboptimal information transfer at discharge. We had limited space in the questionnaire to define the meaning of a preventable adverse event; therefore, the description in the survey does not exactly match previous definitions.1, 2 Our study had a response rate of 54%. It is possible that nonresponders may have been more satisfied with the quality and timeliness of discharge summaries and may have believed fewer patients experienced preventable adverse events related to suboptimal information transfer at discharge.

The results of our study suggest that the use of systems to improve the quality and delivery of discharge summaries has the potential to improve outpatient physician satisfaction and to reduce the number of preventable adverse events that occur during the vulnerable period following hospital discharge. With the use of electronic medical records, we now have the potential to automate the process of assembling and delivering clinical information with minimal delay. We are now using the information from this study to design a partially automated, high‐quality discharge summary that can be delivered to outpatient physicians immediately on discharge.