Development and pilot implementation of a patient-oriented discharge summary for critically Ill patients

BACKGROUND

Patients leaving the intensive care unit (ICU) often experience gaps in care due to deficiencies in discharge communication, leaving them vulnerable to increased stress, adverse events, readmission to ICU, and death. To facilitate discharge communication, written summaries have been implemented to provide patients and their families with information on medications, activity and diet restrictions, follow-up appointments, symptoms to expect, and who to call if there are questions. While written discharge summaries for patients and their families are utilized frequently in surgical, rehabilitation, and pediatric settings, few have been utilized in ICU settings.

AIM

To develop an ICU specific patient-oriented discharge summary tool (PODS-ICU), and pilot test the tool to determine acceptability and feasibility.

METHODS

Patient-partners (i.e., individuals with lived experience as an ICU patient or family member of an ICU patient), ICU clinicians (i.e., physicians, nurses), and researchers met to discuss ICU patients' specific informational needs and design the PODS-ICU through several cycles of discussion and iterative revisions. Research team nurses piloted the PODS-ICU with patient and family participants in two ICUs in Calgary, Canada. Follow-up surveys on the PODS-ICU and its impact on discharge were administered to patients, family participants, and ICU nurses.

RESULTS

Most participants felt that their discharge from the ICU was good or better (n = 13; 87.0%), and some (n = 9; 60.0%) participants reported a good understanding of why the patient was in ICU. Most participants (n = 12; 80.0%) reported that they understood ICU events and impacts on the patient's health. While many patients and family participants indicated the PODS-ICU was informative and useful, ICU nurses reported that the PODS-ICU was "not reasonable" in their daily clinical workflow due to "time constraint".

CONCLUSION

The PODS-ICU tool provides patients and their families with essential information as they discharge from the ICU. This tool has the potential to engage and empower patients and their families in ensuring continuity of care beyond ICU discharge. However, the PODS-ICU requires pairing with earlier discharge practices and integration with electronic clinical information systems to fit better into the clinical workflow for ICU nurses. Further refinement and testing of the PODS-ICU tool in diverse critical care settings is needed to better assess its feasibility and its effects on patient health outcomes.

Structure, content, unsafe abbreviations, and completeness of discharge summaries: A retrospective analysis in a University Hospital in Austria

RATIONALE AND OBJECTIVE

The discharge summary (DS) is one of the most important instruments to transmit information to the treating general physician (GP). The objective of this study was to analyse important components of DS, structural characteristics as well as medical and general abbreviations.

METHOD

One hundred randomly selected DS from five different clinics were evaluated by five independent reviewers regarding content, structure, abbreviations and conformity to the Austrian Electronic Health Records (ELGA) using a structured case report form. Abbreviations of all 100 DS were extracted. All items were scored on a 4-point Likert-type scale ranging from "strongly agree" to "strongly disagree" (or "not relevant"). Subsequently, the results were discussed among reviewers to achieve a consensus decision.

RESULTS

The mandatory fields, reason for admission and diagnosis at discharge were present in 80% and 98% of DS. The last medication was fully scored in 48% and the recommended medication in 94% of 100 DS. There were significant overall differences among clinics for nine mandatory items. In total, 750 unexplained abbreviations were found in 100 DS.

CONCLUSIONS

In conclusion, DS are often lacking important items. Particularly important are a detailed medication history and recommendations for further medication that should always be listed in each DS. It is thus necessary to design and implement changes that improve the completeness of DS. An important quality improvement can be achieved by avoiding the use of ambiguous abbreviations.

Review of electronic discharge summaries from the general medicine, general surgery and mental health streams at a tertiary hospital: retrospective analysis of timeliness, brevity and completeness

Objective This retrospective study identified and compared the performance of electronic discharge summaries (EDSs) from three hospital in-patient streams (surgical, medical and mental health) with Australian standards. Methods An audit was performed of 120 EDSs extracted from a tertiary hospital. Auditors evaluated each EDS using an adaptation of the Australian Commission on Safety and Quality in Health Care's EDS toolkit. Results EDSs from all in-patient streams were lengthy and most did not include information regarding discharge destination, patient education or recommendations. General Medicine EDSs were most timely, averaging within 1 day of discharge. Conclusions Key areas of improvement remain for improving the timeliness, brevity and completeness of EDSs. Key areas identified for improvement include page length, discharge destination, alerts, patient education and recommendations. Variability in audit results between streams suggests the need for speciality-specific templates, standards and medical officer training. What is known about the topic? The literature suggests that an EDS is timely if it is completed within 2 days of discharge. A complete and brief EDS should also include key details of the care in two (or fewer) pages. What does this paper add? This paper evaluated 120 EDSs, compared them against a standard and stratified the EDSs according to three core clinical in-patient streams that produced them (surgical, medical and mental health). What are the implications for practitioners? Although broad guidelines for timeliness, brevity and completeness have been established for EDSs, each in-patient stream will require different standards. A hospital or health service should have established standards relevant to each in-patient stream. Before commencing a term in any of the three in-patient streams, medical officers who are to generate EDSs should be trained in the required standard. Training should highlight critical elements of a speciality stream to ensure EDS authors are aware of the nuances of the stream in which they are rotating. In addition, general practitioners should liaise with local hospitals to ensure ongoing dialogue and improvement of clinical handover documents.

Rates and predictors of general practitioner (GP) follow-up postdischarge from a tertiary hospital cardiology unit: a retrospective cohort study

OBJECTIVE

Previous studies in cardiac patients noted that early patient follow-up with general practitioners (GPs) after hospital discharge was associated with reduced rates of hospital readmissions. We aimed to identify patient, clinical and hospital factors that may influence GP follow-up of patients discharged from a tertiary cardiology unit.

DESIGN

Single centre retrospective cohort study.

SETTING

Australian metropolitan tertiary hospital cardiology unit.

PARTICIPANTS

1079 patients discharged from the hospital cardiology unit within 3 months from May to July 2016.

OUTCOME MEASURES

GP follow-up rates (assessed by telephone communication with patients' nominated GP practices), demographic, clinical and hospital factors predicting GP follow-up.

RESULTS

We obtained GP follow-up data on 983 out of 1079 (91.1%) discharges in the study period. Overall, 7, 14 and 30-day GP follow rates were 50.3%, 66.5% and 79.1%, respectively. A number of patient, clinical and hospital factors were associated with early GP follow-up, including pacemaker and defibrillator implantation, older age and having never smoked. Documented recommendation for follow-up in discharge summary was the strongest predictor for 7-day follow-up (p<0.001).

CONCLUSION

After discharge from a cardiology admission, half of the patients followed up with their GP within 7 days and most patients followed up within 30 days. Patient and hospital factors were associated with GP follow-up rates. Identification of these factors may facilitate prospective interventions to improve early GP follow-up rates.

Supporting continuity of care between prison and the community for women in prison: a medical record review

Objectives The aim of the present study was to examine health information transfer and continuity of care arrangements between prison and community health care providers (HCPs) for women in prison. Methods Medical records of women released from New South Wales prisons in 2013-14 were reviewed. Variables included health status, health care in prison and documented continuity of care arrangements, including information transfer between prison and community. Associations were measured by adjusted odds ratios (AORs) using a logistic regression model. Text from the records was collected as qualitative data and analysed to provide explanatory detail. Results In all, 212 medical records were systematically sampled and reviewed. On prison entry, information was requested from community HCPs in 53% of cases, mainly from general practitioners (GPs, 39%), and was more likely to have occurred for those on medication (AOR 7.08; 95% confidence interval (CI) 3.71, 13.50) or with schizophrenia or other psychotic disorders (AOR 4.20; 95% CI 1.46, 12.11). At release, continuity of care arrangements and health information transfer to GPs were usually linked to formal pre-release healthcare linkage programs. Outside these programs, only 20% of records had evidence of such continuity of care at release, with the odds higher for those on medication (AOR 8.28; 95% CI 1.85, 37.04) and lower for women with problematic substance misuse (AOR 0.32; 95% CI 0.14, 0.72). Few requests for information were received after individuals had been released from custody (5/212; two from GPs). Conclusion Increased health information transfer to community HCPs is needed to improve continuity of care between prison and community. What is known about the topic? Many women in prison have high health needs. Health and well being are at further risk at the time of transition between prison and community. What does this paper add? This study provides evidence that outside formal programs, which are currently available only for a minority of women, continuity of care arrangements and transfer of health information do not usually occur when women leave prison. Pragmatic choices about continuity of care at the interface between prison and community may have been made, particularly focusing on medication continuity. Barriers to continuity of care and ways forward are suggested. What are the implications for practitioners? Siloing of health care delivered within prison health services through lack of continuity of care at release is wasteful, both in terms of healthcare costs and lost opportunities to achieve health outcomes in a vulnerable population with high health needs. There is need for an increased focus on continuity of care between prison and community health services, HCP support and training and expansion of pre-release planning and healthcare linkage programs to assist larger numbers of women in prison.