Discharge Summary

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Discharge Summary MHSD Project 2003
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Discharge Summaries

• Long been recognised as a problem
• Information can be
• Insufficient
• Incorrect
• Arrive too late
• Research confirms this (Local and National - APAC
  and GPAC)

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Discharge Summaries

• Divisions of General Practice
• Director of Clinical Training
• Executive Director of Medical Services
• Initial GP Liaison Meeting
• Discussed several issues - seemed a good forum to
  address this issue
• Idea to try to solve the problems
• Some kind of stop gap measure

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Discharge Summaries

• How could this be achieved ?
• Perhaps an Interim Discharge Summary ?
• Quality Project -
• Continuous Quality Improvement
• What does this mean?

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Continuous Quality Improvement
Quality as defined by Queensland
Health the provision of a high quality health
service whose quality can be demonstrated to its
customers (consumers), its staff, its funders and
the people of Queensland. An organisation which
continually improves its services Source
Queensland Health Quality of Health Services
Framework (Good Health and Better Health
Services) Quality Improvement and Enhancement
Program 1999 2004)
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CQI GUIDING PRINCIPLES
Improvement through change
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What do external customers expect ?

• Quality care
• Friendliness
• Responsiveness
• Communication
• Satisfaction
• Timeliness
• Effective and efficient service
• Fair and reasonable cost
• NO surprises !!

Principles of Continuous Quality Management
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Discharge Summaries

• EXTERNAL CUSTOMERS
• General Practitioners
• Existing document (from 2000)
• Non standard, did not look professional
• No QHealth logo
• GPs were largely dissatisfied (verbal)
• GP Liaison Committee perfect forum
• (GPAC Guidelines)

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Discharge Summaries

• PATIENTS
• Transition from Hospital to Community needs to be
  as smooth as possible
• Medication Errors source of readmission
• Need to be adequately informed of their own
  discharge medications
• About 80,000 medication related hospital
  admissions per year in Australia (This outnumbers
  top DRGs)

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Discharge Summaries

Hospital Patient/clients readiness for discharge
assessed from medical, social, cultural,
emotional and functional perspectives.
Discharge date confirmed. Post-discharge
arrangements are made with community providers.
24-48 hours prior to discharge Patient/client
confirmed as ready for discharge. Medication and
community-based care arranged. Transport booked
at least 24 hours prior to discharge, if
required. Day of discharge Patient/client
discharged with adequate supply of medication,
copy of discharge summary referral and relevant
information. Patient/client and carer role in
patient care clearly explained.
GPAC Guidelines
Hospital Legible,
comprehensive discharge summary referral securely
transmitted to GP and community providers at
discharge or within 24-48 hours of
discharge. GP/Community Community providers
contact patient for follow-up. Identified
practitioner coordinates post-discharge ongoing
care. Maintain regular communication between
hospital, GP, and community services for ongoing
care.
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• Discharge Summary Referral
• Prepared prior to discharge to communicate
  referral information between hospital and GP (and
  other community providers, as needed)
• Patient details
• Carer/primary support person details
• Referring doctor details (GP)
• Consultant name, specialty and contact number
• Hospital unit of discharge
• Admission date, source and reason for admission
• Past medical history
• Discharge date and discharge destination
• Discharge summary referral issue date
• Principal diagnosis and other current conditions
• Procedures and date
• Progress notes/comments
• Specific follow-up advice for referring doctor
  (e.g. further treatment or tests required)
• Discharge medication dose, strength frequency
  
• Medications ceased and new medications
  started,
• including reasons for changes
• Allergies and adverse drug reactions

Discharge Summaries
GPAC Guidelines

• Lists Specific Requirements for Discharge
  Information
• Comprehensive
• Time Consuming to prepare

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Discharge Summaries

• PLAN
• Research required ?
• Draft initial idea for a form
• Think about the existing processes and
  resources available
• Identify the Consumer groups and their needs
• Bring all the consumer groups together in the
  process by liaison and communication

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Discharge Summaries

• Existing Resources
• Pharmacy
• Discharge Medication Record or DMR
• MedProfs
• Created for all discharges on Medical Ward by the
  Medication sheet going down to Pharmacy with
  markers for dispensing of actual drugs required
• Network Computers

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Discharge Medication Record
Doctor only needs this part
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Discharge Summaries

• Idea to keep it all Electronic
• Advantages
• Confidentiality
• Viewing by Consultants for Audit
• Save the Paper wastage
• Access by Pharmacy, Doctors and Medical Records
  (HIU) Staff
• Increase Teamwork

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What do internal customers expect ?

• Support
• Cooperation
• Communication
• Reliability
• Responsiveness
• Training

• Courtesy
• Loyalty
• Recognition
• To be informed
• No surprises

Principles of Continuous Quality Management
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Discharge Summaries

• INTERNAL CUSTOMERS
• Pharmacy
• APAC Project Officer
• Information Services
• Health Information Unit
• Release of Information Officer
• Junior Doctors
• Supervising Clinicians

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Internal Customers

• Pharmacy
• MedProfs DMR
• Could use same information by Pharmacists
  cutting and pasting and saving to the
  Confidential folder
• Keen to assist
• Interest in Discharge Medications

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Internal Customers

• APAC Implementation Project Officer
• Kaylene Wadd
• QIEP QUM (Quality Improvement and Enhancement
  Program - Quality Use of Medicines)
• National Guidelines to achieve the continuum of
  QUM between hospital and community
• Australian Pharmaceutical Advisory Council
  January 1998
• APAC Milestones for PBS Implementation Project in
  Queensland Health Hospitals Feb 03 (Being
  expanded on Revision)

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APAC Guidelines

• Statewide project to coordinate implementation of
  best practice activities outlined in
• Australian Pharmaceutical Advisory Councils
  National Guidelines to achieve the continuum of
  quality use of medicines between hospital and
  community

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APAC Guidelines
1.Medication Discharge Pathway/Coordinator 2.
Medication History 3. Medication Review during
admission 4. Medication Action Plan/Patient
Consultation 5. Checklist for Discharge 6.
Discharge Medication Folio 7. Community Liaison ?
7 Principles - We addressed Principles 1 , 6 and
7 ? In process, we determined the need to include
Principle 2 and as a result Principle 3 followed
on.(Principle 5 with PBS)
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APAC Guidelines - Principle 1
Medication discharge plan/discharge
coordinator (Relates to Schedule F, clause 28) It
is the responsibility of the admitting
institution to ensure the development and
coordination of a medication discharge plan for
each patient. The person responsible for
coordinating the development, implementation, and
monitoring of the medication discharge plan,
including medication supply and medication
information, should be identified as soon as
practicable after admission ? Coordinated
Approach
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APAC Guidelines - Principle 5

• Pre discharge review
• (Relates to Schedule F, clause 32)
• Prior to discharge, pre-discharge medication
  review and dispensing of adequate medication
  should take place in a planned and timely
  fashion. Supply of the medication must be
  adequate to ensure continuity of medication is
  not interrupted by the inability to obtain
  further ongoing supplies if required, within a
  reasonable timeframe.
• ? Will come with PBS Implementation

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APAC Guidelines - Principle 6

• Discharge Medication Folio(Relates to Schedule
  F, clause 33)
• At the time of discharge, patients should be
  provided with adequate information in an
  appropriate language to assist them following
  discharge. This information should include the
  purpose of the medicines specific for that
  patient and may include consumer medicine
  information, the availability and source of
  future supplies and arrangements for follow up
  care.
• ? Addressed through MedProfs

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APAC Guidelines - Principle 7

• Medication liaison
• Relates to Schedule F, clause 34
• On discharge, or as soon as practicable after
  discharge, information regarding the patients
  admission, medication changes (including
  additions/deletions) and arrangements for follow
  up should be communicated to the health care
  provider(s) nominated by the patient as being
  responsible for his or her ongoing care. Health
  care providers may include general practitioner,
  community pharmacists, district nurses etc.?
  Electronic Discharge Summary Process and
  Webster Pack Process

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Internal Customers - Contd

• Information Services
• Create File called Discharge Summary
• Access for only specified people via Novell
  Password
• Junior Doctors
• Pharmacy
• Release of Information Officer
• Supervisors

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Internal Customers - Contd

• Information Services
• Transfer all the pre-existing files over to
  Archive (Take off Common Drive)
• Improves Patient Confidentiality
• Provide sufficient disc space
• Consider alternatives for archiving
• Update the Doctors Codes in HBSCIS in liaison
  with the Divisions of GP

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Internal Customers - Contd
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Internal Customers - Contd

• Health Information Unit
• Needed to identify one person who could be
  source of Information for GPs
• Available and Interested, (will inc workload)
  Computer literate
• Current list of General Practitioners Names and
  Fax numbers
• Faxes sent to correct numbers in the interests
  of Confidentiality and Security

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Internal Customers - Contd

• Release of Information Officer
• Starts work at 0700
• Checks the file and faxes the Summaries at
  0700 each dayand again at 1500
• Keen and Interested
• Aim To streamline the process and reduce
  time-lines
• Aim to fax within 24 hours of Discharge

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Internal Customers - Contd

• Junior Doctors
• Appreciated the assistance
• Prefer Electronic
• Like to have it all standardised
• Some not computer proficient
• All required Novell Log on and Passwords

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Internal Customers - Contd

• SUPERVISORS
• Director of Medicine, Consultants
• Auditing
• Executive Director of Medical Services
• Director of Clinical Training
• Audits, Feedback
• Clinical Risk Management Committee Informed
• Reporting as Project Aim Reduce Transcription
  errors in Discharge Scripts

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Discharge Summaries

• Templates
• QHealth Forms Design Rules
• QHealth logo and MHSD Address
• Can be used at all MHSD Hospitals
• Used Header as place to adhere label
• Ensures all the printed out information had
  patient identification information on each
  individual sheet but data is only entered once

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Discharge Summaries

• Interim Discharge Summary
• Discharge Information and Discharge Medication
  for Primary Care Giver
• Created to fill the gap
• Final - Medical
• Final - Surgical

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Header
Discharge Summaries
Interim Summary
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Discharge Summaries - Interim

• Name and Address of General Practitioner
• Primary Diagnosis
• Major Procedure Performed
• Management Plan
• Specific Medication Changes (and why)
• Follow Up Instructions
• Hospital Medical Officer
• Consultant Date
• 5 lines of Vital Information to fill in the gap
  until a Final Summary can be completed
  FAX Within 24 - 48 hours

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Discharge Summaries - Interim

• Interim Summary ADVANTAGES
• All patients can leave Hospital with some
  Information
• Pharmacy uses the DMR to cut and paste the
  Medication Information
• Decreases transcription errors
• Saves Medical Staff Time
• Improves timeliness of information availability
  

Increased Safety
Increased Teamwork
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Header
Discharge Summaries Final

• Thorough
• Includes all but 4 of the principles from the
  GPAC guidelines (Has now been altered to include
  all but two of these)

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CQI GUIDING PRINCIPLES
Improvement through change
PLAN Identify - document
ACT refine standardise
DO do it
FEEDBACK
CHECK monitor progress
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How did we do it?
EDUCATION
Flow charts
Power Point Presentations
Flyers
Individual Interviews
Regular E-mails
Meetings
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Discharge Summaries

• CQI DO
• Start the Trial
• April 14th - May 26th
• Medical Ward
• Inform all the Internal Customers
• Survey the End Users (External and Internal
  Customers)

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FEEDBACK
Discharge Summaries
FEEDBACK

• Process
• Audit
• FEEDBACK
• Continual Process
• Audit
• FEEDBACK

FEEDBACK
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Internal Customers
Reduced Drug Transcription Errors

• SURVEY
• Pharmacy
• Increased workload but good system and happy to
  continue
• Release of Information Officer
• Very happy
• More efficient if Computer had modem and could
  fax directly (Looking into this option)

Increased Job Satisfaction
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Internal Customers
Increased Teamwork

• SURVEY
• Junior Doctors
• Liked the system BUT Missed the point
• Half were not aware of the benchmark of 24 -48
  hours to supply discharge summary
• Most felt workload too great
• Most felt Discharge Summary was second priority
  to acute care

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External Customers
Generally Positive Response

• SURVEY
• General Practitioners
• 106 Surveys, (45 response)
• 41 Not received any,(58 not received Interim)
• 58 had received and 56 Liked new format
• Including tabulated medication information (58)
• Felt table would decrease transcription errors
  (50) in transition from hospital to community

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External Customers
Generally Positive Response

• SURVEY
• General Practitioners
• Still poor time frames (35 Unacceptable)
• Prefer Final Discharge Summary (56)
• FAXED (73)
• Within 24 hours

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CQI GUIDING PRINCIPLES
Improvement through change
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Discharge Summaries

• CQI - ACT
• Report Recommendations
• Alter the Discharge Summary Template to include
  GPAC Guidelines (done for 2 of 4)
• Alter the Computer filing system to make it
  easier (done)
• REINFORCE to Medical staff the benchmarks and
  the importance of providing adequate information
  in a timely manner
• Executive to endorse the use of the Interim
  Report
• Roll out Hospital wide

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Discharge Summaries
FEEDBACK

• CQI - ACT
• Continue to review
• Continue to Audit
• Repeat surveys in six months
• Research further developments

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Discharge Summaries

• Thank you to all the participants
• Divisions of General Practice
• Pharmacy
• APAC Project Officer
• Information Services
• Health Information Unit
• Release of Information Officer
• Junior Doctors
• Supervising Clinicians
• Executive Director of Medical Services
  Helping People to Better Health and
  Well-Being

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Discharge Summaries

• Thank you to all the participants
• Dr Rachel Harvey
• Director of Clinical Training
• Mackay Health Service District
• Kaylene Wadd
• Project Officer, APAC Implementation Officer
• QIEP Quality Use of Medicines
• June 2003

Helping People to Better Health and Well-Being
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Discharge Summaries

• References
• 1 Compliance with Guidelines for Continuity
  of care in Therapeutics from hospital to
  community MJA 2001174277 - 280
• 2 The Quality of Communication between
  Hospitals and general practitioners An
  assessment J.Qual. Clin.Practice (1998)18,
  241-247
• 3 Improving the Continuity of Care between
  general practitioners and public hospitals Med
  J Aust 1994 161 656 - 659
• 4 Pharmacist integration into the discharge
  process a qualitative and quantitative impact
  assessmentInt J Pharm Pract 2001 9 59 - 64
• 5 Problems with Medicines Following Hospital
  Discharge Not Always the Patients
  Fault?Journal of Social and Administrative
  Pharmacy Vol 16, No 3/4 , 1999
• 6 A Quality Use of Medicines program for
  continuity of care in therapeutics from hospital
  to communityMJA 2002 177 32 - 34