EP.TU.281Mind the Gap: Improving the Quality of Neurosurgical Discharge Summaries

Abstract

Abstract Aims A discharge summary is a permanent record of a patient’s hospital visit and the primary means of handover between care providers. Studies show they often lack precision and omit important information. This may compromise quality and continuity of care yet they are frequently written by the most junior clinicians on a ward with little guidance or formal education on how to write one. The aim of this study was to develop some specific guidelines to improve the quality of discharge summaries in a busy neurosurgical unit. Methods A survey was designed to identify the challenges faced by junior medical staff in writing discharge summaries. The essential components of a good neurosurgical discharge summary were identified by group of senior neurosurgeons. Summaries were retrospectively audited against these components. We then designed a simple visual aid and placed it above computer stations in the junior doctors’ offices. Formal departmental teaching session followed. After three months we re-audited the discharge summaries retrospectively to measure any effect of our intervention. Results Half of the neurosurgical team rated summaries as below expectations. Challenges included poor ward round documentation and a lack of clear expectations regarding structure and essential components. After the intervention, ward round documentation and discharge summary quality improved dramatically. Conclusions Although various recommendations about writing good discharge summaries exist, they are generally vague and not specific to neurosurgical practice. The development of a simple specialty specific discharge summary guide can improve discharge summary quality and should be encouraged in all specialties.