Electronic Discharge Summaries Research Articles

Electronic Discharge Summaries: Perspectives on National Implementation from Clinicians in Hospital and Primary Care.

This paper describes clinicians' views on the structure and content of an electronic discharge summary (EDS). A sample EDS template was developed by building on existing Australian guidelines to illustrate some of the proposed elements required for a high-quality clinical document. Surveys were widely disseminated to gather feedback and perspectives of hospital and primary care clinicians. A pragmatic approach to this study was underpinned by a strong evidence base and informed by implementation science methods. Key themes were identified, including variability in workflow and clinical needs, digital maturity, and digital health literacy of the clinical workforce. Understanding different workflows and priorities between hospital and primary care clinicians was a significant barrier to implementing a high-quality EDS. The strong consensus for change from both hospital and primary care clinicians, however, signaled the workforce's readiness as a potential enabler of high-quality EDS documentation.

Lost in Transition: Insights from a Retrospective Chart Audit on Nutrition Care Practices for Older Australians with Malnutrition Transitioning from Hospital to Home.

Care transitions from hospital to home for older adults with malnutrition present a period of elevated risk; however, minimal data exist describing the existing practice. This study aimed to describe the transition of nutrition care processes provided to older adults in a public tertiary hospital in Australia. A retrospective chart audit conducted between July and October 2022 included older (≥65 years), malnourished adults discharged to independent living. Dietetic care practices (from inpatient to six-months post-discharge) were reported descriptively. Of 3466 consecutive admissions, 345 (10%) had a diagnosis of malnutrition documented by the dietitian and were included in the analysis. The median number of dietetic visits per admission was 2.0 (IQR 1.0-4.0). Nutrition-focused discharge plans were inconsistently developed and documented. Only 10% of patients had nutrition care recommendations documented in the electronic discharge summary. Post-discharge oral nutrition supplementation was offered to 46% and accepted by 34% of the patients, while only 23% attended a follow-up appointment with dietetics within six months of hospital discharge. Most patients who are seen by dietitians and diagnosed with malnutrition appear lost in transition from hospital to home. Ongoing work is required to explore determinants of post-discharge nutrition care in this vulnerable population.

A Survey on the Electronic Discharge Summary Process in an Acute Inpatient Ward

A Survey on the Electronic Discharge Summary Process in an Acute Inpatient Ward

#924 Characteristics and outcomes of emergency department patients with acute kidney injury (AKI) stage 2 and 3 electronic alerts at a single UK centre

Abstract Background and Aims The epidemiology of Acute Kidney Injury (AKI) in hospitalized and critically ill populations has been well described but less is known about AKI in the emergency department (ED) patients. Community-acquired AKI represents about a quarter of AKI events observed in the hospital, and its incidence is increasing. Our aim was to look at the characteristics, early management, triage and outcomes of patients with AKI stage 2 and 3 alerts from busy emergency department. Method A retrospective review of patients with AKI 2 and 3 alerts from ED at Doncaster royal Infirmary (DRI) and Bassetlaw sister units in England over a 2 month period from August - September 2022 was conducted. All alerts from Ambulatory/SDEC (Same day emergency care) units have been excluded from this study. Data was gathered from trust electronic health system and patient discharge summaries. Results 158 AKI stage 2 and 3 alerts were received from ED at DRI and Bassetlaw of which 91 (57.5%) were AKI 2 alerts and 67 (42.4%) were AKI 3 alerts. Average age of patients was 73 yrs. Median length of stay in ED was 9hrs (Range 3 hrs–41 hrs). 44 (28%) patients died during this hospital episode of which 28 (64%) died in medical wards, 10 (23%) in critical care unit, 5 died in ED and 1 patient died in surgical ward. Average age of patients who died was 70 yrs and Median length of stay in ED was no different at 9hrs. 23 (52%) had sepsis as primary cause of death. 8 (18%) who died had active malignancy. 9 (20%) had either end stage heart failure/Liver failure or primary lung condition. 8 (18%) had either Frailty, Old age and/or Dementia listed as contributing to death. 8 (18%) patients were discharged home from ED. Discharge diagnosis was Dehydration and/or Falls. Only 4 of the 8 patients had AKI communicated to Primary care on ED discharge letter. 3 of the discharged patients had hospital readmission within 30 days. Looking at the initial intervention in ED, all patients had early warning score and initial resuscitation documented however none of the patients had Fluid balance charted. Bladder scan was performed on 15 (34%) patients where there was high suspicion of obstructive uropathy. Medication as a contributing factor to AKI was commented in 7 (4%) cases. Out of 106 patients who were discharged from hospital wards, sepsis, community acquired pneumonia, urinary tract infection and gastroenteritis were the commonest discharge diagnosis. Median length of Hospital stay was 11 days. Only 2 patients were admitted to specialist Renal ward directly from ED. AKI was communicated to primary care in 70 (62%) patients at discharge. 13 (12%) patients were readmitted to hospital within 30 days of discharge. Conclusion AKI is a marker of severity of illness and we note significant mortality in patients who present to ED with stage 2 and 3 AKI. Sepsis was commonest cause of death but we note a significant proportion of patients had either active malignancy or severe underlying chronic health condition. With increasing waiting times in ED, early recognition and AKI focused management is a priority. AKI education for nursing and medical staff in ED and Pharmacy input for patients who spend long hours in ED might help reduce length of overall hospital stay.

Standardized Hospital Guidelines for Paracetamol Overdose - fewer prescription and drug administration Errors?

Introduction: Paracetamol overdose is one of the most common drug overdoses in the UK. The standard treatment is intravenous N-acetylcysteine (NAC) which is usually administered as a 21-hour infusion in UK hospitals. A 12-hour infusion known as the "SNAP" regimen has been implemented in some centres and appears on the TOXBASE database (UK Poisons Information). The availability of two treatment options has caused confusion in our centre resulting in an increased number of prescribing and administration errors. Aims/Objectives: To produce a standardized guideline and prescription chart in two District General Hospital Emergency Departments within the same NHS Trust as part of a Quality Improvement Project (QIP) in an effort to reduce prescribing and administration errors for NAC. Methods: Trust guidelines for Paracetamol overdose were revised using the 12-hour regimen for adults only. A retrospective review of patient notes and electronic discharge summaries was performed prior to and following the implementation of the new guidelines to identify patients that received NAC. The Trust electronic incident reporting system (DATIX) was reviewed for incidents relating to NAC prescription or administration. Results: We had four incidents over three months prior to the introduction of the new guidelines and pre-filled prescription charts. Following the introduction of our new guidelines and prescription charts there were no incidents reported of errors related to NAC. One incident reported was a 16-year-old patient incorrectly receiving the SNAP regimen (without adverse effect) rather than the 21-hour infusion for paediatric patients. Discussion: Use of pre-filled charts reduced the potential human factors in prescription mistakes especially in inaccurate dose calculations and drawing up errors. The charts also prevented confusion between the 21-hour and SNAP NAC Protocols. The standardized guidelines along with the pre-filled charts have reduced the rate of prescription and administration errors of NAC.

Usability Evaluation Methods Used in Electronic Discharge Summaries: Literature Review.

With the widespread adoption of digital health records, including electronic discharge summaries (eDS), it is important to assess their usability in order to understand whether they meet the needs of the end users. While there are established approaches for evaluating the usability of electronic health records, there is a lack of knowledge regarding suitable evaluation methods specifically for eDS. This literature review aims to identify the usability evaluation approaches used in eDS. We conducted a comprehensive search of PubMed, CINAHL, Web of Science, ACM Digital Library, MEDLINE, and ProQuest databases from their inception until July 2023. The study information was extracted and reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). We included studies that assessed the usability of eDS, and the systems used to display eDS. A total of 12 records, including 11 studies and 1 thesis, met the inclusion criteria. The included studies used qualitative, quantitative, or mixed methods approaches and reported the use of various usability evaluation methods. Heuristic evaluation was the most used method to assess the usability of eDS systems (n=7), followed by the think-aloud approach (n=5) and laboratory testing (n=3). These methods were used either individually or in combination with usability questionnaires (n=3) and qualitative semistructured interviews (n=4) for evaluating eDS usability issues. The evaluation processes incorporated usability metrics such as user performance, satisfaction, efficiency, and impact rating. There are a limited number of studies focusing on usability evaluations of eDS. The identified studies used expert-based and user-centered approaches, which can be used either individually or in combination to identify usability issues. However, further research is needed to determine the most appropriate evaluation method which can assess the fitness for purpose of discharge summaries.

An audit of electronic discharge summaries of neonates admitted with hypoxic ischaemic encephalopathy to tertiary hospitals in [City], 2018–2019.

Background. A discharge summary may be the only available health record for a patient, especially in resource-limited settings with suboptimal record-keeping. Considering the risk of adverse neurodevelopmental outcomes secondary to hypoxic ischaemic encephalopathy (HIE) and litigation, the quality of summaries for neonates with HIE is particularly important. 
 Objectives. To audit electronic discharge summaries of neonates admitted with HIE to two tertiary hospitals in [City], South Africa. 
 Methods. A retrospective, quantitative study was conducted. Electronic discharge summaries of late preterm and term neonates with HIE, admitted in 2018 and 2019 were audited for relevant information: final diagnosis, birth history, clinical evaluation, management, investigations, plan at discharge, and counselling of parents. 
 Results. Of the 165 identified cases, 34 (20.6%) were excluded. Ten patients did not have electronic discharge summaries. Details of the other 24 cases in admission registers were incomplete. The final diagnosis of HIE appeared in 87 (66.4%) of 131 audited summaries. More than half (52.7%) lacked correct ICD-10 coding for HIE. Information on foetal distress and sentinel events was absent in 61.1% and 42.0%. Requirement for resuscitation was recorded in 90.8% of summaries. Performance of cardiac compressions and adrenaline administration were not specified in 46.6% and 54.2%. Admission blood gas results, particularly base deficit, lactate and glucose, were absent in 42.7%, 63.4% and 90.8% of summaries. Eligibility for therapeutic hypothermia was not captured in 41.2%. Cranial ultrasound, neuro-imaging, exclusion of meningitis, or multisystem involvement was not mentioned in 80.9%, 99.2%, 80.2% and 96.2%, respectively. Notes on counselling of parents were lacking (83.2%). Final cause of death was unspecified in 12 of 14 (85.7%) patients who died. 
 Conclusion. Discharge summaries of neonates at risk of adverse neurodevelopmental outcomes secondary to HIE lacked essential information. Quality improvement and regular auditing of patient records must be prioritised.

Inappropriate requests for cranial CT scans in emergency departments increase overuse and reduce test performance.

The number of non-traumatic urgent cranial computed tomography (NT-UCCT) is exponentially increasing but limited research has been conducted on the quality of clinical justification. Accordingly, we aimed (1) to assess how clinical information in the electronic NT-UCCT request agreed with that provided in the patient's emergency department discharge summary and (2) to analyze the potential effect of those discrepancies on the NT-UCCT overload. Patients undergoing NT-UCCT in 2017-2021 were randomly selected for this retrospective research-board-approved study. Signs and symptoms (S/S) in electronic request and emergency department discharge summary, acute and relevant computed tomography (CT) findings (acute ischemia or hemorrhage, masses, brain edema, or previously undetected hydrocephalus), and final diagnosis at emergency department discharge summary were collected. Concordance between digital request and emergency department discharge summary and their association with both acute and relevant CT findings and final diagnosis were analyzed. We recruited 156 patients: 80 men; mean age, 55. Acute, relevant CT findings were detected in 28 cases (17.9%). The final diagnosis was neurological disease, non-neurological disease, and no definitive diagnosis in 46 (29.5%), 58 (37.2%), and 51 (32.7%) cases, respectively. Full agreement between the electronic request and emergency department discharge summary occurred in only 36 patients (23.1%). Motor deficit was the most frequent false positive electronic request S/S (18; 11.54%), having low positive predictive value (30.30%; 95%CI 15.59-48.71%) andworst association with acute relevant CT findings than when true positive (OR 2.54; 95%CI 0.04-6.21 vs. OR 6.26, 95%CI 2.21-17.78). Nausea/vomiting was the third most common false negative electronic request S/S (13; 10.26%) and reduced the likelihood of acute and relevant CT findings (OR 0.126; 95%CI 0.016-0.971; p = 0.020). False S/S in electronic request predominated in non-neurological diseases (50-60.2% vs. 33-39.8%; p = 0.068). Discrepancies between electronic request and emergency department discharge summary were observed in >75% of patients, leading to unnecessary NT-UCCT tests.

Causes and outcome of infants admitted with respiratory distress in a tertiary care neonatal unit: A five year review

Background: Respiratory distress is a common cause for admission of infants to a neonatal unit. The aim of this study was to analyze the causes of respiratory distress leading to admission in a neonatal unit.
 Method: This is a 5 year retrospective review of neonates admitted initially with diagnosis of respiratory distress in the neonatal unit of a tertiary care hospital from November 2017 to October 2022. Cases were identified and analyzed using electronic database maintained in the neonatal unit and were cross checked with electronic discharge summaries where necessary.
 Results: Respiratory distress was found to be the most common cause for admission to the neonatal unit almost comprising of 46% of total admissions. The commonest cause for respiratory distress on admission was found to be transient tachypnoea of newborn (TTN) in term infants and surfactant deficiency respiratory distress syndrome (RDS) in preterm infants. As compared to babies with TTN, who were all discharged home, 18.4% of those with RDS did not survive. The overall mortality of infants presenting initially as respiratory distress was 9.1%. Other common causes for respiratory distress on admission were sepsis, birth asphyxia, shock, congenital heart disease, seizure and polycythemia.
 Conclusion: Respiratory distress is a common cause for admission to a neonatal unit in both term and preterm infants. Although TTN in term and RDS in preterm are common causes for respiratory distress in newborns, the underlying cause for respiratory distress is diverse and not just limited to the lungs and heart.

285 ‘To communicate or not, that is not the question!’

Abstract Background Safe patient care necessitates accurate and timely patient communication between acute, community, and primary care services. Given the complexities of care of older adults, including polypharmacy and deprescribing, reliable communication between all services is essential. This has been identified as a requirement prior to discharge. This audit aimed to assess compliance with discharge communication across the Geriatrics Service. Methods This audit was carried out from 10th–17th April 2023. Consecutive patient discharges across Stroke and Acute Geriatrics Services were assessed for data including age, gender, date of admission, date of discharge, discharge summary completion, and date and time of validation of the discharge summary. The Electronic Discharge Summary (EDS) and Inpatient Patient Management Systems (IPMS) systems were used for data collection. Data was analysed descriptively. Standards used were The Integrated Care Guidance: A Practical Guide To Discharge And Transfer From Hospital (HSE), and the National Standard For Patient Discharge Summary Information (HIQA). Results 107 patient records were assessed, median age 72.2 years (IQR 29.1), 48.6% female (n = 52). 91.5% (n = 98) patients had discharge summaries completed, 86.7% (n = 85) of which were validated. When including all validated discharge summaries, the median time to validation was 0.4 hours (IQR 79.43) post discharge. Median time to validation pre-discharge was 1.5 hours (IQR 3.1) and represented 54.2% (n = 58) of patients. Median time to validation post discharge was 21.8 hours (IQR 149.76) and represented 31.7% (n = 27) of patients. Conclusion This audit highlights a high level of compliance with discharge summary completion. Areas for improvement include higher levels of completion prior to discharge, and ensuring that all summaries are validated to allow for printing and distribution. This will help ensure seamless and safe communication between all levels of care of older adults.

759 Electronic Discharge Summary Audit

Abstract Aim Electronic discharge summaries (EDS) in General Surgery were found to be lacking adequate clinical information. The Professional Records Standards Body (PRSB) released guidance, endorsed by NICE, with the information required in an electronic discharge summary. The aim of the study was to monitor and record how many EDS’s have been completed with all the relevant/required sections completed. Method A retrospective analysis of EDS of 50 patients admitted under general surgery at Worcestershire Royal Hospital was conducted. Yes, No or N/A were marked against 13 categories based on PRSB guidelines. 4 cycles were carried out between 2020 to 2022. After cycle 1, a poster was introduced outlining the criteria for electronic discharge summaries (Figure 1). A printed version of the poster was placed in the doctor’s office. After cycle 2, feedback was collected from junior doctors who suggested a teaching session on how to write electronic discharge summaries. A teaching session was delivered to junior doctors prior to cycle 3 and 4. Results The overall level of compliance for each cycle was as follows-Cycle 1- 8% complianceCycle 2- 22% complianceCycle 3- 34% complianceCycle 4- 69% compliance Conclusions The poster and teaching session proved effective at improving compliance.It was found there was poor compliance in completing the comorbidities section in the EDS. Acknowledging feedback from the junior doctors helped provide useful teaching sessions so we will continue regular teaching sessions. Continue annual audit of EDS' to increase compliance.

463 Adherence to Extended Venous Thromboembolism Prophylaxis for Post Operative Resection of Colorectal Malignancies

Abstract Aim Patients undergoing cancer resection abdominal surgery are at high risk of developing venous thrombo-embolism (VTE) in the post-operative period. To reduce this risk, these patients should be considered for extended pharmacological VTE prophylaxis for 28 days post-surgery as per NICE guidelines (NICE NG89). In our surgical department, we give all colorectal cancer resection patients 5000 units of Deltaparin for 28 days post resection unless it is contraindicated. We aimed to evaluate adherence to this guideline. Method This is a single-centre retrospective audit study. We included 100 colorectal cancer resection cases between 1st October 2021 and 28th February 2022 (n = 100). Retrospective data was collected including the type of procedure, histology and whether post-operative Deltaparin was prescribed for 28 days. All consecutive colorectal cancer resections were included in the study. The data was collected from the patient electronic records, electronic prescribing system and the electronic discharge summaries. Results The most common operation was anterior resection of the rectum (42%) followed by right hemicolectomy (40%). The Adherence to the NICE guidelines for extended VTE prophylaxis was 87%. Conclusions The adherence to the NICE guidelines in our department falls below the national target of 90% adherence. To improve the compliance, we will carry out staff education on appropriate anticoagulation prescribing and also display informative posters in the surgical wards to increase the awareness. We will aim to re-audit the adherence to the guidelines after implementing these measures.

WTP6.13 A closed loop audit on the Quality of Electronic Discharge Summaries within General Surgery

Abstract Aim Following surgical admissions, Electronic Discharge Summaries (EDS) are vital to ensure patient safety through continuity of care to the primary care setting. It is also an official record to the patient about the treatment and care they received including any further treatment or follow up appointments they require and is therefore important they are not only accurate but detailed with all the relevant information included. Methods An audit of Electronic Discharge Summaries within a busy Emergency General Surgery department was undertaken using a gold standard which was established by using the 20 most important parameters within the standardized proforma. If a discharge summary had 80% or more parameters sufficiently completed it was deemed to be adequate. A first and second cycle of data collection of 100 EDS’s were undertaken and analysed using the gold standard criteria. Results A first cycle data collection of 100 EDS’s were analysed, it was found only 55% of these were adequate following the standard set. An educational teaching session to doctors at a local meeting was carried out to explain why 45% of the discharge summaries were not complaint with the standard set. The second cycle showed 91% of EDS’s to be of adequate standard. Conclusion This audit has shown that adhering to a gold standard template can significantly improve the quality of discharge summaries. A re-audit in 12 months should be carried out to ensure standards have been maintained.

ThTP4.9 Adherence to extended venous thrombo-embolism prophylaxis for post operative resection of colorectal malignancies

Abstract Aim Patients undergoing cancer resection abdominal surgery are at high risk of developing venous thrombo-embolism (VTE) in the post-operative period. To reduce this risk, these patients should be considered for extended pharmacological VTE prophylaxis for 28 days post-surgery as per NICE guidelines (NICE NG89). In our surgical department, we give all colorectal cancer resection patients 5000 units of Deltaparin for 28 days post resection unless it is contraindicated. We aimed to evaluate adherence to this guideline. Method This is a single-centre retrospective audit study. We included 100 colorectal cancer resection cases between 1st October 2021 and 28th February 2022 (n=100). Retrospective data was collected including the type of procedure, histology and whether post-operative Deltaparin was prescribed for 28 days. All consecutive colorectal cancer resections were included in the study. The data was collected from the patient electronic records, electronic prescribing system and the electronic discharge summaries. Results The most common operation was anterior resection of the rectum (42%) followed by right hemicolectomy (40%). The Adherence to the NICE guidelines for extended VTE prophylaxis was 87%. Conclusion The adherence to the NICE guidelines in our department falls below the national target of 90% adherence. To improve the compliance, we will carry out staff education on appropriate anticoagulation prescribing and also display informative posters in the surgical wards to increase the awareness. We will aim to re-audit the adherence to the guidelines after implementing these measures.

Improving Resident Hospital Discharge Communication by Changing Electronic Health Record Templates to Enhance Primary Care Provider Satisfaction.

Despite use of standardized electronic health record templates, the structure of discharge summaries may hinder communication from inpatient settings to primary care providers (PCPs). We developed an enhanced electronic discharge summary template to improve PCP satisfaction with written discharge summaries targeting diagnoses, medication reconciliation, laboratory test results, specialist follow-up, and recommendations. Resident template usage was measured using statistical process control charts. PCP reviewers' discharge summary satisfaction was surveyed using 5-point Likert scales analyzed using the Mann-Whitney U test. Residents were surveyed for satisfaction. Resident template usage increased from 61% initially to 72% of discharge summaries at 6 months. The PCP reviewers reported increased satisfaction for summaries using the template compared with those without (4.3 vs 3.9, P = .003). Surveyed residents desired template inclusion in the default electronic discharge summary (93%). This system-level resident-initiated quality improvement initiative created a novel discharge summary template that achieved widespread usage among residents and significantly increased outpatient PCP satisfaction.

An Audit of Inpatient Management of Acute Decompensated Heart Failure With Reduced Ejection Fraction in General Medicine

This audit aimed to describe the use of guideline-directed medical therapies (GDMT) in patients with heart failure with reduced ejection fraction who have been hospitalised with decompensated heart failure in a tertiary hospital. Patients not on GDMT due to medical contraindications are termed to be on “rationalised medical therapy” (RMT). The primary objective was to assess the percentage of patients discharged on GDMT, RMT, or suboptimal therapy. Secondary outcomes were the prevalence of sodium-glucose transport protein 2 inhibitors (SGLT2I) use and inpatient venous thromboembolism (VTE) prophylaxis. Patients aged ≥18 years, with a left ventricular ejection fraction of <40% and admitted under General Medicine at Middlemore with an ICD-10 diagnosis of acute decompensated heart failure between 30 September 2021 and 30 March 2022 were identified. Sixty-two patients were randomly selected from an eligible population of 339 patients. Data collection was performed using the Electronic-Prescribing and Electronic Discharge Summary applications. Twenty-seven patients (44%) were discharged on GDMT, 17 (27%) were discharged on RMT, and 18 (29%) were discharged on suboptimal therapy; 8% of patients were discharged on SGLT2I, while 80% did not meet PHARMAC Special Authority criteria. A total of 69% of patients received VTE prophylaxis. Eighteen patients (29%) were on suboptimal heart failure therapy at discharge and almost 31% did not have VTE prophylaxis. This may lead to suboptimal outcomes in mortality and morbidity. A total of 80% of patients could benefit from SGLT2I therapy but did not meet special authority criteria.

Evaluating an implementation of the Australian National Guidelines for the On-Screen Display of Discharge Summaries.

ObjectiveThe objective of this study was to evaluate changes in the inclusion of pertinent information on electronic discharge summaries (eDS) after implementation of a revised template and electronic medical record (EMR) workflow.MethodsA retrospective medical record audit of eDS at three metropolitan hospitals was undertaken for adult inpatient encounters in June 2021 (pre-intervention, n = 100) and June 2022 (post-intervention, n = 100). The eDS were evaluated against 16 components listed in the Australian National Guidelines for the On-Screen Display of Discharge Summaries. Nine components were further broken down to between two and 11 sub-components. Sub-analysis compared a hospital with full EMR to pooled results from hospitals with hybrid EMRs. Components and sub-components were evaluated for inclusion only; accuracy or relevance of the information was not assessed.ResultsInclusion of three out of 16 components (presentation details: 47% vs 62%, problems and diagnosis: 61% vs 86% and recipient details: 82% vs 93%) and eight out of 36 sub-components (discharge destination, principal diagnosis, history of presenting complaint, infection risk, pressure injury, screening and/or diagnosis of delirium and GP phone number and address) was higher in the post-intervention group (all P < 0.05). Reduced eDS information inclusion in the post-intervention group was observed for discharge date and falls risk only (both P < 0.05). Reporting of falls history decreased at the hospital with full EMR (71% vs 20% P < 0.001) but not at hospitals utilising hybrid EMRs (24% vs 30% P = 0.5).ConclusionThe intervention was associated with improved inclusion of pertinent information as described in the Australian National Guidelines for the On-Screen Display of Discharge Summaries.

Evaluation of a pilot community pharmacy-led discharge medicines service

Abstract Introduction The risk of miscommunication and unintended changes to medicines is a significant problem when patients transfer between care settings.1 Medicines reconciliation is recommended at each transfer of care to reduce the risk of these errors occurring.2 Whilst common practice on admission to hospital, medicines reconciliation was not routinely undertaken for patients after discharge. One local pharmaceutical committee piloted a discharge medicines service (DMS) provided by community pharmacists within the area. The pilot took place prior to commissioning of the essential service, NHS DMS3. It involved a person-centred consultation with each patient and reconciliation of the patient’s post-discharge medicines using the electronic discharge summary received via PharmOutcomes. Any issues were resolved by the community pharmacist where possible, or the GP surgery if necessary. Aim This study aimed to evaluate the impact of the pilot DMS. Methods A mixed-methods approach was taken to comprehensively evaluate the service. Nine community pharmacies provided DMS for patients discharged from hospital. Quantitative data were collected by community pharmacists for each DMS, then collated and analysed using descriptive statistics by an independent researcher. Qualitative, semi-structured telephone interviews based on the quantitative findings were conducted after the pilot with pharmacists from each of the pilot pharmacies. Interview recordings were transcribed and used to contextualise the quantitative findings. Ethical approval was granted by LJMU research ethics committee. Results 56 DMS were carried out a four-month period. 43% (24/56) of patients had at least one medicines-related discrepancy. A total of 40 discrepancies were identified by community pharmacists, 50% (20/40) of which involved high-risk medicines known to cause hospital readmission. 63% (25/40) of the discrepancies identified prevented the dispensing of unnecessary medicines requested, and consequently reduced medicines wastage with an estimated cost saving of £229.06. Community pharmacists from each of the pilot pharmacies found the service worthwhile, perceiving that it helped to improve communication between healthcare professionals, increase patient involvement in their care and cut the medicines waste associated with unnecessary dispensing and returned medicines. Whilst overall beneficial, community pharmacists did report some difficulties, including examples of unclear discharge information documented by hospitals and the time spent trying to contact GP surgeries to resolve some prescribing discrepancies. Discussion/Conclusion This small-scale pilot demonstrated that the impact of DMS could be wide-reaching. A reduction in medicines waste was seen, resulting in a positive impact on sustainability and cost savings for the NHS. The savings reported are due to medicines waste alone and do not take into account any other potential cost savings incurred, for example preventing the costs associated patient harm from medication errors, re-admission to hospital or wasted healthcare professionals’ time. Whilst lessons can be learned from the pharmacists’ feedback to improve efficiency, DMS has a positive impact on various healthcare providers in terms of efficiency and cost savings: GPs, hospitals and pharmacists. Patients will benefit from the efficient provision of appropriate post-discharge medicines and reduced risk of medicines-related issues or hospital readmission. The person-centred approach involves patients throughout to highlight any issues and supports them to more effectively manage their own care.

Prevalence and Risk Factors for Dangerous Abbreviations in Malaysian Electronic Clinical Notes.

Medical abbreviations can be misinterpreted and endanger patients' lives. This research is the first to investigate the prevalence of abbreviations in Malaysian electronic discharge summaries, where English is widely used, and elicit the risk factors associated with dangerous abbreviations. We randomly sampled and manually annotated 1102 electronic discharge summaries for abbreviations and their senses. Three medical doctors assigned a danger level to ambiguous abbreviations based on their potential to cause patient harm if misinterpreted. The predictors for dangerous abbreviations were determined using binary logistic regression. Abbreviations accounted for 19% (33,824) of total words; 22.6% (7640) of those abbreviations were ambiguous; and 52.3% (115) of the ambiguous abbreviations were labelled dangerous. Increased risk of danger occurs when abbreviations have more than two senses (OR = 2.991; 95% CI 1.586, 5.641), they are medication-related (OR = 6.240; 95% CI 2.674, 14.558), they are disorders (OR = 7.771; 95% CI 2.054, 29.409) and procedures (OR = 3.492; 95% CI 1.376, 8.860). Reduced risk of danger occurs when abbreviations are confined to a single discipline (OR = 0.519; 95% CI 0.278, 0.967). Managing abbreviations through awareness and implementing automated abbreviation detection and expansion would improve the quality of clinical documentation, patient safety, and the information extracted for secondary purposes.

87 VERTEBRAL FRACTURES IN OLDER PATIENTS WITH COPD: AN UNDER-DIAGNOSED AND UNDER-TREATED ENTITY

Abstract Background Patients with Chronic Obstructive Pulmonary Disease (COPD) are at increased risk of osteoporosis. Vertebral Fractures (VF) are the most common manifestation of osteoporosis. Only one fourth to one third of incident radiographically identified VF are clinically diagnosed. The aim of this study is to evaluate patients the prevalence of VF in a cohort of patients admitted with Acute Exacerbation of COPD (AECOPD). Methods A retrospective review of AECOPD admissions over a four-month period was performed. Information on baseline characteristics, prescribed medications and reports of radiological imaging were obtained from Electronic Healthcare Records, discharge summaries and clinic letters. Results In total 116 patients were included over the study period. In 24% (n=28), VF was present on imaging. In those with VF, females accounted for 64.3% (n=18). Median age was 80 (76-85) and median CFS was 6. In 12 cases a single VF was present, in 9 two VFs and in 7 patients 3+ VF were present. There was no documented diagnosis of osteoporosis in 67.8% (n=19). VF were initially detected on CT thorax imaging performed to assess for pulmonary pathology in 35.7% (n=10) cases. Vitamin D3 was prescribed in 60.7% (n=17), concurrently with calcium in 28.6% (n=8). Antiresorptive therapy was prescribed in 39.3% (n=11), oral bisphosphonates in 4 patients and denosumab in 7. Vitamin D (OH) level was measured in 78.6% (n= 22) patients and was insufficient (&amp;lt;50mmol) in 25% (n=7). Conclusion Almost one-quarter of patients who were admitted with an AECOPD had vertebral insufficiency fracture on imaging. Identification and treatment of VF was suboptimal. Most were not identified as having osteoporosis nor prescribed antiresorptive therapy. CT imaging should be routinely reviewed for the presence of insufficiency fractures as part of case finding initiatives. Bone health assessment should be routinely performed in patients with COPD, particularly those with frequent corticosteroid usage.