Uses and Potential Adverse Effects of Level Iii (L3) Nicu Discharge Summary (Ds) in Level Ii (L2) Nicu

Abstract

Background: DS forms the single most important means of communication during interfacility transfer, especially when the recipient physician was not involved in the initial care. Objective: To determine (1) the uses and potential adverse effects of L3 NICU DS in L2 NICU; (2) L2 physicians' workflow in relation to L3 DS. Design/Methods: A qualitative study was conducted from 2006 to 2009. Based on literature review, document analysis (30 L3 DSs) and participant observation (12 months in 3 L3) a questionnaire was designed. Semi-structured interviews (n=3) and a focus group (n=5) with L2 physicians were conducted. Audiotapes were transcribed, analyzed qualitatively and results were triangulated to identify emerging themes. Results: Three overarching themes emerged for the use of L3 NICU DS within the L2 NICU; understanding patient in-depth and providing optimal care, understanding family to plan interactions and institute support, and empowering L2 physicians to perform their role with confidence. L2 physicians considered the psychosocial transition of parents was more challenging and complex than the transition of infant care. Relevant information in L3 DS allowed L2 physicians to meet parents' expectations and align L2 care plans with L3. Physicians' workflow after receiving DS had a consistent pattern; reading, interpretation, gaining insight, physical examination of infant, order entry, care planning, writing admission note, leaving DS in patient chart for future reference, interacting with family, revisiting DS when necessary during L2 stay and finally in L2 DS preparation. Several potential adverse effects affecting the infants' care (vulnerability for under/over investigations and treatment, generic rather than personalized care, missing opportunities for early diagnosis and treatment); family (aggravation of emotional problems and hurt feelings, negative attitude on health care system, suboptimal family support) and physicians (inefficiency, negative feeling and predisposition for committing errors) emerged. Adverse effects were mostly attributable to deficits in content and format of L3 DS. Conclusions: Understanding patient and family, followed by decision making and care planning are the major uses of L3 DS. Careful consideration of L2 physicians' workflow and attention to their information content and formatting needs in a L3 DS may have a role in minimizing potential adverse effects and improving patient safety.