Interventions to improve discharge summary systems

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pending test results were actionable, or required follow up, but neither the GPs nor outpatient the consultant were likely to be aware of the results when they became available. This presented serious medical risks to the patients. The deficits in discharge summaries impacted negatively on patient’s and clinician’s satisfaction, and caused suboptimal use of clinical resources, including unnecessary repetition of tests by GPs (Coleman and Berenson, 2004; Poon et al., 2004; Van Walraven et al., 2004; Wills et al., 2011).

2.5 Interventions to improve discharge summary systems

The division of labour and discontinuity of care between secondary and primary care means the deficits associated with discharge summaries are serious issues which need immediate solutions (Watcher and Goldman, 2002; Kripalani et al., 2007). Previous research on interventions to improve discharge summary systems has focused using computer-generated discharge summaries, changing the mode of delivery, and changing the structure and format of the records (Van Walraven et al., 1999; Mant et al., 2002; Rao et al., 2005). Moving to a centralised EHR system was seen as an alternative to rectify the many problems associated with paper based discharge summaries (Pullen and Loudon, 2006). EHR systems were often believed to unleash the capability of information and communication technology to support healthcare services.

A systematic review by Kripalani et al. (2007) on discharge communication concluded with the following recommendations: (1) ensuring the completeness with agreed content structure, (2) using proper structuring and formatting, (3) ensuring accuracy and faster data entry by using computer-generated data from the patient’s medical record, (4) giving a copy of the discharge summary to patients and asking them to bring it with them on the follow up visits. Some studies suggested that introducing a formal education and training programme, and undertaking audits, with feedback, can help junior doctors to improve the quality and completeness of their discharge summaries (Myers et al., 2006;

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Dinescu et al., 2011).

A more recent national initiative “nurse-led discharge” (Department of Health, 2004a) was proposed as a solution to cut the unnecessary delays in the patient discharge process, and to produce timely discharge summary for the patient with simple medical problems. The implementations by early adopters showed that NHS Hospital Trusts tended to interpret this initiative as the total transfer of responsibility for patient discharge from doctors to nurses (Rooney, 2010). The implementations showed mixed clinical outcomes (Office for Public Management, 2010). For example, some implementations reported an increase in the length of inpatient stay, while other implementations reported the reverse.

Within the context of NPfIT, there were two majors initiatives to improve discharge summary systems in England. In line with the NPfIT plan to reform NHS IT systems, NHS Hospital Trusts in England are now obliged to deliver discharge summaries to GPs within 24 hours after a patient discharge (Department of Health, 2008). The policy essentially requires NHS Hospital Trusts to

implement an electronic discharge summary system with connectivity to the GP system. The original NPfIT plan was to encourage NHS Hospital Trusts to participate in the NPfIT programme in order to update their IT systems.

Unfortunately, many NHS Hospital Trusts lost confidence with the NPfIT agenda due to failures/delays to deliver the promised IT systems. This has caused many NHS Hospital Trusts to commence the implementation of their own programmes, in order to comply with NHS policy.

The second initiative to improve discharge summary systems was the

development of standard content structure for discharge summary records by the RCP, as part of NPfIT programme. In 2007, the Health Informatics Unit (HIU) of the RCP developed generic standards for medical record keeping (see Table 2.1).

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Table 2.1 Generic medical record keeping standards by RCP Standards Description

1 The patient’s complete medical record should be available at all times during their stay in hospital

2 Every page in the medical record should include the patient’s name, identification number (NHS number) and location in the hospital 3 The contents of the medical record should have a standardised

structure and layout.

4 Documentation within the medical record should reflect the

continuum of patient care and should be viewable in chronological order

5 Data recorded or communicated on admission, handover and discharge should be recorded using a standardised proforma 6 Every entry in the medical record should be dated, timed (24 hour

clock), legible and signed by the person making the entry. The name and designation of the person making the entry should be legibly printed against their signature. Deletions and alterations should be countersigned, dated and timed.

7 Entries to the medical record should be made as soon as possible after the event to be documented (e.g change in clinical state, ward round, investigation) and before the relevant staff member goes off duty, If there is a delay, the times of the event and the delay should be recorded.

8 Every entry in the medical record should indentify the most senior healthcare professional present (who is responsible for decision making) at the time the entry is made.

9 On each occasion the consultant responsible for the patient’s care changes, the name of the new responsible consultant, and the date and time of the agreed transfer of care, should be recorded.

10 An entry should be made in the medical record whenever a patient is seen by a doctor. When there is no entry in the hospital record for more than four (4) days for acute medical care or seven (7) days for long stay continuing care, the next entry should explain why.

11 The discharge record/discharge summary should be commenced at the time a patient is admitted to hospital.

12 Advance Decision to Refuse Treatment, Consent, Cardio

Pulmonary Resuscitation decisions must be clearly recorded in the medical record. In circumstances where the patient is not the decision maker, that person should be identified, e.g Lasting Power of Attorney.

Source: Carpenter et al. (2007)

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The development of the standard was based on a review of published standards and wide consultations with health practitioners. The generic standards are applicable to any operational clinical records relating to hospital care, including discharge summary records; the standards can be applied to both paper and electronic records.

The subsequent work by HIU produced a list of approved headings/subheadings for structuring the content of discharge summaries (see Appendix 1). This development was based on an initial literature review and expert consultation which was then validated using a survey (n=1454) administered to hospital doctors and GPs (Royal College of Physicians, 2008b). The initiative also developed a paper proforma template for discharge summary records (see Appendix 2), which was piloted by hospital doctors (n=67) and GPs (n=20).

The work from the initiative also produced additional raw data that was worthy of further analysis. The headings such as “patient detail”, “source of admission”,

“destination address”, “advance directives”, “functional measures” were more likely to be seen as significant by practitioners from mental health specialities rather than those from medicine or surgery. Interestingly, there was a significant gap in the level of agreement between the hospital doctor and GP participants in regard to the importance of headings such as “source of admission”, “destination address”, “information given to patients”, and “past medical history”. The score for usability (76%) and clarity (61%) of the discharge summary proforma was the lowest when compared to other criteria, such as appropriateness and sufficiency.

Most strikingly, there was a significant gap between hospital doctors and the GP participants about the prospect of the proforma improving data recording, quality of care and patient safety in current practice. Most GP participants were optimistic about the prospect, while hospital doctor participants were divided.

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