Systems of care | Efficiency and Access

A Discharge Summary on Discharge

Walsall Healthcare NHS Trust
Dr Diana Toma
The initial problem and its impact

Children attending the paediatrics assessment unit (PAU) for less than 4 hours were not receiving a copy of their discharge summary (DS) before going home. This was not in line with the organisational target for this group of patients, which aimed to provide a DS for more than 95% of them within two working days. This meant that most of the time information was passed verbally to the patient and their family, with no written support to prevent misundersanding and act as a memory aid.There were also significant delays in getting important information sent to GP surgeries. This was due the fact that discharge summaries were often completed several days after the attendance date. They were written by doctors who did not see the patient, using the patient's notes - which made the process more time consuming (reading the notes to become familiar with the case) and more prone to mistakes (unintelligible handwriting). This situation frequently led to stress built up among the staff, as there was a constant pile of discharge summaries waiting to be completed.The discharge summaries were also difficult to access if needed: the only hard copy was in the patients' file and no digital copy was available.

Causes of the problem
  • The decision that every patient should have a discharge summary within two working days was not enforced: patients were not asked to wait until the discharge summary was ready and PAU staff were not reminded that discharge summaries need to be done promptly.
  • Difficult process: for every PAU patient with a <4 hour stay, there were two manual paper forms that had to be completed: a nursing discharge form and a form filled in by a doctor. Both forms were handwritten, each took 3-5 minutes to complete and they contained a good amount of duplicated information.
Project aim statement

All PAU patient with a <4 hour stay should go home with a copy of the discharge summary. (Note: this was more ambitious than the original organisational target, but more in keeping with patients' needs and those of GPs.) 

Stakeholders

Patients and their families, medical (doctors, nurses) and non medical staff (ward clarks), health visitors, GPs.

PDSA Cycles / solution(s) tested

Collection of baseline (qualitative and quantitative) data: how long it takes to complete the old paper forms, how may patients were going home with a DS.

  • PDSA 1: Devise new model unifying the nurses' and the doctors' discharge form into a single page paper form. Implement new form. Continue gathering data on how long it takes to complete the new form and the percentage of patients going home with a DS. Collect feedback from nurses, doctors and patients. 
  • PDSA 2-4: Adjust unified form and optimise process to reflect feedback.  Implement updated versions of the form. Changes included: increase in size for some of the boxes, adding new boxes (name of the most senior doctor who reviewed the patient), adding more information (PAU phone number for patients who had open access). Ammendments to the process included: installing a photocopier on PAU so that staff wouldn't have to leave the ward in order to copy the form, getting a double plug so that staff wouldn't have to unplug a computer monitor in order to plug in the photocopier. Continue monitoring percentage of patients going home with a DS and continue collecting feedback from nurses, doctors and patients. 
  • PDSA 5: Replace paper form with identical PDF digital form. Develop step-by-step procedure of completing the form and offer training to all staff involved.  Continue monitoring percentage of patients going home with a DS and continue collecting feedback from nurses, doctors and patients. 
  • PDSA 6: Update PDF form to reflect feedack. Implement new form. Obtain tablets for easier access to the digital form.
Data results
  • Baseline data collection showed that 0% of the patients were going home with a DS on discharge. Doctors reported that it took them between 3 and 5 minutes to complete the old discharge form. Similar times were reported for nurses.
  • Two weeks after implementing the unified form we have achieved levels of 60-100%. The variation reflects the process of refining the form and the process. Doctors reported that they needed between 2-3 minutes to fill in the new form and nurses, between 1-2 minutes.
  • Afterwards levels of 96-100% have been constantly maintained. This continued after the implementation of the PDF form (approximately 5 weeks after commencing the project). The fact that this process is now easier means that even during times of increasing patient attendances we have seen levels sustained.
  • Occasional dips were caused by speciality teams, which were not familiar with the new process or were not aware of the organisational target. 
  • We stopped collecting data in mid-August, when the new process was considered ingrained.
How this improvement will be sustained
  • Doctors' induction will cover the procedure for completing the new digital form.
  • Maintaining awareness among doctors, PAU nurses and non-medical staff that patients should receive a copy of the discharge summary before going home.
Challenges and Learnings

Challenges: explaining the importance of giving patients a copy of the discharge form; data collection (especially the time needed to complete a form, which proved to be difficult to asses objectively); obtaining the necessary equipment for PAU; designing the digital form (finding someone capabe of creating a functional form).Learnings: involve the right people (admin staff, doctors, nurses, ward clerks), keep everyone motivated by presenting the progress of the project.

Suggestions for further implementation

Integrate the current stand alone digital form into the local patient data system: Our current PDF form saves the DS in our departmental shared drive. The file name is not standardised, which makes it difficult to find a particular DS. Integrating the form into the local system will make it significantly easier to access previous discharge summaries for a given patient. In addition, GPs will be automatically notified when a new DS has been uploaded, in this way saving the ward clark from having to post paper discharge summaries. We are currently testing a new program developed by the local IT department which could replace the current PDF form and upload the DS as described. We are hoping to implement this program beginning of October 2019.