Dr Marissa Minns, a former chief registrar and now a consultant in stroke and geriatrics at Leeds Teaching Hospitals NHS Trust, describes a series of steps to improve the quality of discharge summaries.
Completing e-discharge summaries is a big challenge for junior doctors. During the busy winter period of 2016/17, Leeds Teaching Hospital (LTH) NHS Trust received feedback from local GPs that the content in the summaries they received was of poor quality, with the most relevant information lacking, preventing a patient’s ongoing care.
As a chief registrar I held a senior leadership role that focused on delivering high-quality, safe care. Through this role I recognised the challenge for junior doctors of completing quality discharge summaries and investigated what could be done about this.
Poor quality summaries were often triggered by bed pressures. This led to patients being discharged more quickly, sometimes without paperwork, or, more often, with hastily completed discharge summaries. Aspects of patient history, or important actions for GPs, were often missing. When discharge summaries were received and completed, there was sometimes too much information provided, rather than the details most relevant for a patient’s ongoing care.
With no training provided, junior doctors, sifting through huge sets of notes, were unsure what to include in their summaries. Frequently, doctors would be required to complete summaries for patients they had not treated, and whose follow-up arrangements were unclear.
There was a need for a culture change to prioritise discharge summary completion, and I helped to set up the junior doctor body to create links between trainee doctors and the senior management team. I facilitated brainstorming sessions, frequently attended by the chief medical officer, to come up with a problem list and suggestions for solutions.
An electronic discharge advice note (eDAN) working group was created, with key stakeholders from other professions also involved, so the trust could attempt to address the issues identified by the junior doctor body.
The output from these meetings included:
- an overhaul of the trust’s intranet pages that described how to complete electronic discharge summaries
- a trust-wide screensaver, highlighting the importance of timely discharge summary completion
- a video explaining the importance of the discharge summary from a GP’s perspective, which was played at the trust-wide junior doctor induction
- creating a new, more defined and instructive eDAN template, using the record headings in the Professional Record Standards Body eDischarge Summary Standard.
In addition, non-medical prescribers were identified to help with medications input, saving time so that junior doctors only needed to enter the salient clinical points. The trust also employed non-medical prescribers and junior doctors for locum shifts in the busy winter period, with the sole purpose of eDAN completion.
When creating the new template, it was challenging to strike the right balance between keeping the headings generic but also including important areas.
One problem identified by the junior doctor body was the simple lack of sufficient junior doctors to complete the eDANs in a timely fashion. A much wider problem was the structuring of medical teams, with the effect that shift work and compliance with contracts has on continuity of care, and doctors actually knowing the patient they are discharging.
The training received good feedback from junior doctors, but they mentioned they would have liked to receive it at the start of their rotation. This has now been integrated into the foundation years teaching programme, where we provide a joint session with pharmacy. The 2018 junior doctor cohort will be trained in discharge summary completion at their induction.
In mid-2017, LTH began the widespread rolling out of electronic prescribing across the trust, which has positively impacted on the ease of completion and accuracy of prescribing in discharge summaries.
There have been a number of other initiatives in the trust. For example, some teams now identify patients who need a discharge summary during safety huddles and morning ward rounds. Generally, this project has raised the profile of this issue, but ongoing work is needed to bring about a culture change.
Dr Marissa Minns, consultant in stroke and geriatrics at Leeds Teaching Hospitals NHS Trust
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