Evaluation of Immediate Discharge Documents – Room for improvement?

Dr. Duncan S Foster MB ChB MRCGP

General Practitioner, Glover St Medical Centre, 133 Glover St, Perth PH2 OJB

dfoster@gloverhc.finix.org.uk

Caroline Paterson RGN, Reg. Midwife, BSc

Clinical Audit Facilitator Tayside Audit Resource for Primary Care, Ward 4, Srathmartine Hospital, Dundee DD3 0PG

caroline.paterson@tpct.scot.nhs.co.uk

Geraldine Fairfield BA

IT Manager, Tayside Audit Resource for Primary Care, Ward 4, Srathmartine Hospital, Dundee DD3 0PG

geraldine.fairfield@tpct.scot.nhs.co.uk

Abstract

Background .The Immediate Discharge Document is a tool used to communicate patient discharge information between hospitals and General Practitioners. The standard of information provided may be variable, and sometimes delayed in arriving at the GP practice. Typed communication from the hospital can also be slow. This can result in difficulty managing patients in the community following their discharge.

Aim. This was to assess the quantity of information provided on Immediate Discharge Documents, and to assess the time scale taken for GPs to receive written communications from hospitals regarding patient discharges.

Design. An audit was initiated using a tool devised from Scottish Intercollegiate Guidelines Network Publication no 5

Setting. 4 General Practices within City of Perth, Scotland

Method. Data was collected over a 28-day period June/July 2001, by examining Immediate Discharge Documents relevant to each practice population received during this period, and by noting the time of arrival of a final typed summary. Data was analysed by Tayside Audit Resource for Primary Care.

Results. 244 Documents were audited. Most significant results include basic administrative detail lacking in up to 30%. 13% failed to record a main condition or diagnosis. 93% recorded drug information, but only in 28% were follow up plans clear. 60% were received within 5 days of discharge, whilst final typed summaries were received from the hospitals within 4 weeks only in 51%.

Conclusion These results show there to be room for improvement with regard communication of patient discharge information, in regard to both the content of information provided and the time it takes to arrive. We require to raise awareness of this problem amongst hospital colleagues involving clinical governance and audit staff, with the objective to improve the quality and timescale of information transfer.  ‘Where this piece fits’ It is known that effective information transfer between health professionals is vital to optimise patient care. This work gives further impetus to improve the current standard of communication, and confirms a significant time delay that it takes information to reach GPs from the hospital setting.

  Introduction

Good communication between primary and secondary care is vital to ensure a smooth transition of care for ill patients when they leave hospital. The Scottish Executive Health Department reports that we must “improve communications and break down barriers”, and “improve the patients journey of care”¹. Regarding discharge arrangements, the Clinical Standards Board for Scotland report “communication and transfer of information among healthcare professionals is essential to a seamless process.” ² Currently when a patient leaves hospital a hand-written document is produced by medical staff detailing relevant information necessary for the General Practitioner to continue patient care- “The Immediate Discharge Document”. This is followed subsequently by a more detailed, usually typewritten letter, “The Final Discharge Summary”. During daily clinical practice some Perth General Practitioners suspected that there was a wide range in quantity and quality of information provided in Immediate Discharge Documents, in addition to delays in receipt of the Final Discharge Summaries. On occasion by local critical incident analysis it was considered that poor communication compromised patient care. It is known that audit can be an effective method of changing clinical practice when seeking to improve the standard of hospital discharge letters.³ In June 1996 the Scottish Intercollegiate Guidelines Network circulated a minimum data set recommended for use in Scotland, entitled “Interface Between the Hospital and the Community. The Immediate Discharge Document” (SIGN 5)⁴. Using this recommendation as a framework, it was thus decided to proceed with audit to clarify the scale of the problem and to subsequently enable improvements to be made.

Aims/Methods

The aim of the audit was to assess the quantity of information provided on Immediate Discharge Documents, to clarify which items of information were missing, and to record the dates of receipt of the Immediate Discharge Document and the Final Typed Summary. Results were to be used to enable the development of an action plan to address areas of poor performance prior to further data collection in 1 year.

A working group was formed from 4 Perth City General Practices, with a combined list size of approximately 35000 patients. Using an audit tool based on SIGN 5, all Immediate Discharge Documents received by the Practices during a 4-week period in June/July 2001 were analysed for the presence or absence of key information. The only exclusions were maternity and day case discharges as their discharge documents were of a different format. All other discharge documents received within this period were analysed. All discharge communication received from hospitals during this period was date stamped on receipt by practices allowing accurate data collection. Four weeks after discharge GP mail and patient records were searched to determine whether Final Typed Summaries had been received from the hospitals relevant to the patients’ discharges. Data was collected by practice audit co-ordinators from 3 Practices and by the project lead GP from the other practice. Data was subsequently analysed by Tayside Audit Resource for Primary Care using Microsoft Excel.

Results

4 practices participated in the study.  Data was collected for 244 patients.  The results of this report refer to these 244 patients.

Table 1            Breakdown of Results

Discussion

Current Immediate Discharge Documents received by Perth GP Practices are frequently inadequate, with 95% of such documents originating from Tayside NHS Hospitals. 27% are not addressed to a named GP, and 16% fail to state a consultant in charge. Basic administrative detail e.g. their address is lacking in 30%. Dates of admission and discharge are often required for social security forms, insurance claims and for audit purposes, but are lacking one fifth of the time resulting in administrative difficulties.

A previous study has raised doubts concerning the accuracy of diagnosis provided in discharge communication ⁵. A limitation of this audit remains that non-medically qualified audit co-ordinators could not be expected to discriminate between true diagnoses and symptom descriptions e.g. migraines and headaches. Any entry in the section concerning main condition/diagnosis was thus considered to be acceptable. However in a surprising 13% no information was recorded at all, a basic failing in one of the major uses of the Immediate Discharge Document.

The quality of recording of discharge medication was better, with 93% of patients having discharge medication recorded. This may reflect the activity of hospital pharmacists in using the Document as a tool to allow discharge medication to be dispensed. However informal discussions suggest that for this reason there is time pressure on clinicians to complete the Documents early, perhaps compromising the other information that should be contained within.

Recording of discharge planning remains poor, patient location on discharge unspecified in 48%, and significantly only 28% recording a review date. In this latter regard a review date specified by date or by time period e.g. 2 weeks was acceptable. If there was uncertainty, the relevant section being left blank or recorded as “to be posted” then it was regarded as unacceptable. Patients are often unclear on follow-up plans, and GPs are often asked for advice in this regard. A failure to relay such information does little to empower the GP to co-ordinate appropriate management plans.

SIGN 5 recommends an unlimited comment section to allow expansion on any area regarding the patients admission. It was of some value, an entry being made in 28%. Only 12% of letters stated whether further test results were awaited. Knowledge of outstanding tests may help avoid duplication of investigations within the community. The Fountain system⁶ has developed computerised relay of laboratory test results between hospitals and General Practitioners, but there still can remain uncertainty especially when on a home visit away from computer terminals. Additionally radiology investigation results from Perth Royal Infirmary are likely to remain unavailable to GPs on the Fountain system for a further 12 months.

SIGN 5 records: “This document should be read and approved by the consultant or a member of the intermediate grade staff only and not by the resident” Yet in only 43% was it indicated that the letter had been written or approved by a fully registered GMC practitioner (i.e. SHO or above). Communication with hospital colleagues confirms this is not done as routine, perhaps not considering this to be important, perhaps having insufficient time with competing pressures of clinical workload or perhaps not being allowed time with pressure from pharmacy to have the Document prepared early, or patients wanting early discharge. Further discussion and change of working practice is required.

Only 41% of letters specified the name of a person to be contacted if further clinical detail were needed. This is likely to become more important in future years, as when junior doctors’ working hours are reduced, continuity of care may be compromised⁷. This may make it more difficult to identify the key doctor whom would be likely to be able to provide GPs with further clinical information when needed. On this point, whilst 83% of letters were signed, this signature was legible in only 39% and undated in 21%. Poor handwriting is certainly not a new phenomenon, but it obviously does make it unnecessarily difficult to contact a doctor whose name is illegible.

Comparison with a previous audit in Perth⁸ reveals some improvement regarding the receipt of the Immediate Discharge Document. In 1993, when 611 patient discharges were analysed, 54% of such documents were received by Practices within 5 days. In our study 60% were received within the 5-day time period, with a further 20% not known- the result of a failure to record discharge dates on the document hindering full analysis. There is thus some improvement, but this is still well below even the 1993 audit’s target of 95%.

The value of the Immediate Discharge Document is confirmed by the finding that only 51 % of the Final Discharge Summaries were received by Practices within the 4-week period post discharge. In this regard a clinic letter subsequent to, and relevant to the patients discharge was considered to be acceptable communication. The 1993 audit reported that 58% of typed Final Discharge Summaries were received within 2 weeks of discharge. Further detailed analysis of our study reveals that a comparative figure of 35% was received within 2 weeks. There may be reasons for this deterioration, possibly delay in dictation, typing, signing or posting. This may reflect workload, staffing and time-management issues for medical and secretarial staff. Future developments may include the use of electronic information transfer, which could further reduce the delay in receipt of information from the hospital setting. Indeed “Our National Health”¹ promotes the use of information and telecommunications technology to supply “timely discharge information”.

SIGN 5 was used as a framework upon which this audit was based. In 2002 there is to be a review of this guideline, which, when updated may result in clinical improvement However whilst SIGN guidelines are widely circulated and available on the internet, they in common with other guidelines, may not be read by all relevant individuals nor complied with⁹. It is thus important to maximise awareness of this problem amongst primary and secondary care practitioners

The Immediate Discharge Document continues to transfer valuable information between hospital and community settings, but this audit confirms that there is a problem with the standard of information included. It also shows delay in receipt of the Immediate Discharge Document, and of the Final Discharge Summary. It is hoped that awareness and understanding of the relevant issues will result in improvement, better information transfer between GPs and hospital colleagues, with resulting patient benefit. In this regard we shall circulate the results of this audit to our colleagues in local hospitals and more widely by publication. We are liasing with clinical governance facilitators and clinical audit staff locally to stimulate improvements with the current system and to stimulate further development particularly in the field of electronic communication. A contribution was also made in January 2002 at the SIGN  Immediate Discharge Document review meeting prior to the anticipated publication of  an updated guidline later this year.

Re-audit is planned following discussion of the content of a local Information

Technology framework and its subsequent implementation.

References

1)      Our National Health. A Plan for Action, a Plan for Change. Scottish Executive Health Department December 2000

2)      Clinical Standards Board for Scotland. Promoting Public Confidence in the NHS. January 2001. www.clinical standards.org

3)      Mathur R, Clark RA, Dhillon DP, Winter JH, Lipwoth BJ. . A repeat Audit of Hospital Discharge Letters in Patients Admitted with Acute Asthma. Scottish Medical Journal 1997;42:019-021

4)      Scottish Intercollegiate Guidelines Network. Publication Number 5. Interface between the Hospital and the Community. The Immediate Discharge Document.

5)      Adhiyaman V, Oke A, White AD, Shah IU. Diagnoses in Discharge Communications: How far are they reliable? International Journal of Clinical Practice 2000 Vol. 54(7) :457-458

6)      Fountain Information Service, Medical Computing Unit, University of Dundee.

7)      British Medical Association. Annual Report of Council 2000-2001

8)      Audit of Discharge Notification. Perth Audit Group. August 1993 Unpublished.

9)      Professor Richard Baker. Is it Time to Review the Idea of Compliance with Guidelines? British Journal of General Practice January 2001 Vol.51 No.462 p7

Acknowledgements

Thanks are due to the practices, and to their audit co-ordinators that participated in this audit.

Dr. Reid and Partners, Glover St Medical Centre, Perth

Dr. McWilliam and Partners, Taymount Surgery, Perth

Dr. Dutton and Partners, Whitefriars Surgery, Perth

Dr.Priestley and Partners, Caledonian Road Medical Centre, Perth

Thanks are also due to Caroline Paterson, Clinical Audit Facilitator, and staff at Tayside Audit Resource for Primary Care for guidance and administrative support

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