Trusts have struggled with delivering patient discharge summaries rapidly to GPs. It is hoped that a new interactive toolkit will guide organisations through developing electronic systems that will overcome the problems, says Daloni Carlisle.
The edict that, within 24 hours of a patient’s discharge, all acute trusts should deliver to GPs summaries of the treatment, diagnosis and medications prescribed is obviously a good thing for patient safety. But it has posed enormous problems for trusts.
The target has been a moving one and is currently embodied in the CQUIN (commissioning for quality and innovation) framework, offering a payment to trusts that send at least 85 per cent of discharge summaries to GPs within the time limit.
For trusts to have a realistic chance of claiming the cash, they need an electronic system that cuts out the inherently slow and error prone manual processes such as typing summaries, hand writing prescriptions and putting copies in the post.
Ideally, the system should enable doctors and nurses to start compiling the summary in advance, automate processes such as entering demographic details and medications, and dispatch the summary electronically.
Over the years there have been a number of initiatives to help trusts develop such systems. In 2008, the Royal College of Physicians published professional standards for what should be in a discharge summary. NHS Connecting for Health then developed the interoperability toolkit that was designed to help trusts and suppliers develop solutions that could be re-used, thus bringing down their costs and the time it takes to develop them.
Now this has all come together in a new interactive guide developed by the Department of Health with five NHS trusts. It describes their journeys as they developed electronic solutions and is aimed at helping other trusts trying to do the same.
Newcastle upon Tyne Hospitals Foundation Trust was among the five sites. The trust delivers more than 2,000 discharge summaries a week to GPs in the North Tyne area; today, around 90 per cent get there within 24 hours.
Clinical director of pharmacy and medicines management Neil Watson, who led Newcastle’s work on the project, says: “We have all wrestled with this target for a number of years. We knew we were sending information to GPs that was of dubious quality and timeliness.”
Rachel Cooper, vice chair of Newcastle Bridges Clinical Commissioning Group, agrees. “Having accurate and timely communications from hospital following an admission is essential to safe and efficient primary care,” she says.
“In the past difficulties have occurred when a patient presents to a GP in the surgery requiring a change in medication, follow-up blood tests or to discuss an admission, and we have no information or very scanty details about the admission. This resulted in frustrated doctors and patients, time required chasing up details and the potential of patients taking the wrong medications.”
While the hospital did have an electronic discharge summary system developed in-house this did not include medicines information. As recently as 2010, the hospital was sending summaries in the post containing carbon copies of handwritten prescriptions, often barely readable. They would take days, even weeks, to arrive.
The trust used the introduction of electronic prescribing as a catalyst for change. By integrating electronic prescribing with the electronic discharge summary, the whole process could be made electronic.
“We started to switch to electronic prescribing in December 2009 and it has taken the last 12-14 months to transfer from handwritten medications in discharge summaries to an electronic solution,” says Mr Watson.
An important part of the process was standardising the content of discharge summaries using the Royal College of GPs standards.
“If you do not use standards, you cannot be sure you are all talking about the same thing,” says Mr Watson. “It gives a structure to the discharge summary.”
So within the electronic discharge summary is a series of headings that can be populated – patient details, GP details, admission details, discharge details, medications prescribed and changed and so on.
Once compiled, summaries are dispatched electronically using Sunquest ICE, a web based service for transferring clinical documents between primary and secondary care.
The biggest challenge was understanding the workflows and how they would change on introducing the electronic solution, says Mr Watson.
“One of the key things we did was to bring together a multiprofessional group of medical, nursing, IT, pharmacy and informatics people to work on this,” he says. “We needed to understand how the workflow was going to change, particularly for junior doctors. This is not just an administrative change but something that has clinical relevance.”
For example, it was crucial for junior doctors to complete the summary promptly so the patient was discharged from the hospital patient administration system (Cerner in this case) at the same time as the information was sent to the GP. This required a change in practice as some junior doctors were accustomed to compiling discharge summaries in their own time.
The new system supports clinical staff in starting to compile the summary earlier and update as the patient moves towards discharge.
“That requires a cultural change,” says Mr Watson.
The feedback from GPs has been good, says Mr Watson, although he adds: “This is a very much a journey and we are not there yet.”
Dr Cooper is positive, calling the new discharge summaries “a huge improvement”.
“Thanks to training of junior doctors, the information is appropriate and enables us to manage the patient effectively once they are back in primary care,” she says. “Knowing what has happened to a patient in hospital, their diagnosis, the investigations carried out and follow-up arrangements leads to more seamless management, helpful patient discussions and increased confidence. This should reduce repeat investigations, reattendances and readmissions in the long term.”
The interactive guide is now available for anyone in the NHS to use (see box, below). The DH hopes it will support trusts at whatever stage they have reached towards delivering timely, accurate and legible discharge summaries.
DH national clinical director for informatics Charles Gutteridge says: “The exchange of accurate information is essential to improving patient safety and care. This toolkit builds on existing national standards and was developed with local trusts to help NHS organisations produce key patient information delivered to GPs within 24 hours of discharge.
“We now have a discharge summary that is approved by the Academy of Royal Medical Colleges and can be provided by any hospital or clinic, containing information GPs need to continue care and for patients who need to know which drugs they should take and which procedures they have just had done.
“This information helps patients, it helps healthcare professionals and it makes care better right now and in the future.”
The interactive toolkit
The toolkit is a step by step interactive guide that helps NHS trusts implement an electronic 24 hour discharge summary.
Five trusts have been involved in developing the guide, implementing the outputs and feedback so that others can learn from their successes. The trusts involved were:
- Newcastle upon Tyne Hospitals Foundation Trust
- Chelsea and Westminster Hospital Foundation Trust
- Kent and Medway Hospitals Foundation Trust (Medway)
- South Tees Hospitals Foundation Trust
- Sandwell and West Birmingham Hospitals Trust