More than a third of residents unsure who's responsible for patient education at discharge

Many residents didn't know who is primarily responsible for providing patient education at discharge, a survey study found.

Researchers emailed the survey to internal medicine residents at seven academic centers between March and May 2019 to assess who they perceive to be primarily responsible for discharge education, how these perceptions affect their own communication with patients, and how they envision improving multidisciplinary communication around discharges. The survey also asked how frequently they engaged in six discharge communication practices: explaining the purpose of medication changes, discussing red flags, explaining the purpose of follow-up appointments, outlining symptom expectations, discussing self-management of disease, and asking the patient to teach back the discharge plan. Results were published online Feb. 2 by the Journal of General Internal Medicine.

Of 966 residents invited to participate, 613 (63%) responded. The most common response (35%) was that residents were not sure who was primarily responsible for patient education at discharge, followed by the intern (27%), the resident (17%), the nurse (16%), and the attending (4%). About half (45%) pointed to the senior resident as best suited to be primarily responsible for discharge education. Of the discharge communication practices, 71% reported frequently addressing the purpose of medication changes, 69% said they discussed red flags, 52% reported explaining the purpose of follow-up appointments, 47% said they outlined symptom expectations, 39% said they discussed self-management of disease, and 17% said they ask patients to teach back the discharge plan. Compared to residents who were not sure who was responsible for discharge education, those who believed it was either the intern's or the resident's primary responsibility had 4.28 (95% CI, 2.51 to 7.30) and 3.01 (95% CI, 1.66 to 5.71) times the odds, respectively, of reporting frequent use of discharge communication practices.

When invited to provide open-ended comments on improving multidisciplinary discharge communication, residents called for team members to clarify roles and responsibilities for communicating with patients, to set expectations for communication among team members, and to redefine the culture around discharges. With regard to this last point, residents suggested a need to change the environment that shapes the transition to outpatient care. As one resident wrote, “Unfortunately, multidisciplinary rounds have become quite stressful for residents. I believe this comes from such a push to get patients out earlier and earlier.”

Among other limitations, resident responses were self-reported and thus subject to social desirability bias, the study authors noted. They added that there was a lack of input from other interdisciplinary team members or patients involved in the discharge process.

“Developing proficiency in team collaboration to discharge patients effectively and safely is a critical skill in hospital medicine,” the authors concluded. “This study demonstrates that normative beliefs of discharge education responsibility may influence reported discharge communication practices.”