TU5.11 Do surgical discharge summaries meet national standards? A closed loop clinical audit

Abstract

Abstract Background High quality health care is information reliant. Access to high quality information in a timely manner is imperative in provision of quality patient care. A national standard for discharge summaries has been developed by the Health Information and Quality Authority (HIQA). A standard for surgical discharge letters is needed to avoid patient readmission, unnecessary presentation to primary care and to ensure continuity of care in the community. The aim is to assess the quality of surgical discharge summaries using the HIQA national Standard. To implement quality improvement strategies recommended by current research. To reassess the quality and close the audit loop. Methods For cycle one of audit, one month of discharge summaries in 2020 were generated across four consultant surgeons at the University Hospital Limerick. 33% of those were sampled evenly across consultants. 60 patient discharge summaries were audited. Training was implemented virtually. For cycle two of audit the same methodology was used, 43 discharge summaries were audited. Results Overall performance was 49%, improved to 69% following training. The worst performing category was future management, 20%, improved to 45%. The best performing categories were auto-populated, patient details 97% and primary care details, 100%. Patient medications were compliant in 25%, improving to 59%. Admission and discharge details were complete in 36% improving to 59%. Clinical narrative was present in 37% improving to 64%. Consultants had not signed off on any letters. Conclusions Surgical discharge summaries audited remain non-compliant with the national standard however, as research shows, NCHD training has improved performance across categories.