In this study, we use a method that is more rigorous than that used in earlier studies to identify tests with pending results at hospital discharge. Whereas prior studies have used the number of pending tests noted in the discharge summary to determine how often test results are followed up, we identified pending tests at discharge as all tests ordered during hospitalization whose results were not final until after discharge. Identification of pending tests using our criteria was achieved by querying an electronic medical record system. We demonstrate that large quality-gaps exist in documenting both laboratory tests with pending results at discharge and the appropriate follow-up provider for the tests in discharge summaries. All study patients had pending test results at the time of discharge, but discharge summaries for 75% of these patients did not mention any pending tests, and only 13% of all summaries accurately incorporated all pending tests.
Our findings highlight several points, namely: (1) that current discharge summaries cannot be relied on to comprehensively reflect tests that have results pending at discharge, (2) that deficiencies in documentation are likely due to more complex and possibly systemic reasons and should not be attributed simply to provider experience, patient characteristics, or test characteristics, and (3) that strategies are needed to improve incorporation of both pending tests and the follow-up provider(s) into the discharge summary. The fact that there was no statistical difference in documentation rates among the various types of providers suggests that there is room for improvement by all providers from students to attending physicians.
Any test with a pending result at discharge holds within it the potential for an error due to a missed action. Steps must therefore be taken to ensure that the appropriate follow-up provider is made aware of these pending tests and that the results (as they return) are consistently communicated to that provider. Some strategies that might be adopted to improve the incorporation of pending tests into the discharge summary include: (1) using a checklist that contains a reminder to list pending tests at the time the summary is being created, (2) enforcing documentation of pending tests, either by having a dedicated space for putting this information (which cannot be left blank) or by linking documentation rates to performance evaluation for providers, and (3) automatically identifying the pending tests by querying the admission-discharge-transfer system, the order entry system, and the laboratory information system, and displaying these tests to the discharging provider so that she can choose which ones to place in the summary.
Most of the above strategies can also be employed to improve documentation of information about the follow-up provider into the discharge summary. It could also be possible in an EMR (which contains patient-provider encounter information) to automatically display details of outpatient providers who have previously taken care of the patient. As the follow-up provider will in most cases be someone who has seen the patient previously, this approach should make it easier to document and thereby transmit information for follow-up. In some cases, the decision of who is to be the follow-up provider will need to be resolved before the summary is finalized, so that the information can be appropriately recorded in the summary.
Several limitations of our study deserve mention. The study was done in two tertiary care centers in teams led by hospitalists, and our findings may not be generalizable to institutions without these characteristics. Not all institutions have EMRs, and thus our method of determining pending tests through queries of the EMRs might not be easily translatable to other institutions. We used implicit review and judgments by investigators to categorize actionable test results, and this approach could have introduced bias.