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Discharge Planning and Transitions of Care

Transitions of care refer to the movement of patients between different healthcare settings such as from an ambulance to the emergency department, an intensive care unit to a medical ward, and the hospital to home. The transition from hospital to home can be challenging as patients and families become responsible for care coordination. Hospital discharges are complicated and often lack standardization. Patients receive an onslaught of new information, medications, and follow-up tasks such as scheduling appointments with primary care providers.

Suboptimal transitions of care increase the risk of readmissions and adverse drug events after discharge. 1 The discharge process can be influenced by characteristics and activities of the health system, patient, and clinician. 2 Discharge instructions may differ between providers, or may not be tailored to a patient’s level of health literacy or current health status. 3 Prior studies have shown that an early discharge preparation process can significantly decrease hospital length of stay (LOS), readmission risk, and mortality risk. 4

As such, discharge planning should begin as soon as possible. However, studies show it is often difficult to predict the day of discharge accurately, 5 which may contribute to the practice of communicating important information on the day of discharge 6 and patients and caregivers feeling that the discharge process is rushed. Healthcare professionals may overestimate the time spent on providing discharge instructions as well as their patients’ understanding. 7 In addition, healthcare professionals and patients use different wording to describe health-related terms. 6 All of these factors can play a role in the patient’s ability to state their diagnosis, medication name, indication, or side effects. 8 Furthermore, discharge instructions oftentimes instruct patients or caregivers to schedule follow-up appointments with their primary care provider or specialty providers after discharge. However, up to half of the patients instructed to make the appointment may not understand the reasons or mechanism for doing so, and therefore do not make the appointment. 6

Identifying Risk Factors for Poor Transitions

In one seminal study, patients who understood their post-discharge plan had a lower rate of subsequent hospital utilization (ED visits or hospitalizations) than those who did not. 9 Challenges to understanding discharge instructions include patients’ lack of physical or emotional readiness to learn and the fact that family members or patient caregivers may not be consistently involved with the educational and discharge planning efforts. Discharge instructions may be unclear and may not be tailored to patient’s individual learning style, social determinants, or health literacy needs. Furthermore, education provided from different healthcare providers may include conflicting or confusing information. Discharge information should be written clearly in patient-friendly terminology and be tailored to the patient’s learning style, social determinants, and health literacy needs. 10

Assessment of patient and caregiver concerns and risk factors associated with nonadherence should be addressed throughout the hospitalization, including lack of engagement, poor continuity of care, and complex treatment regimens. 11  Oftentimes, patients may be non-adherent because of poor understanding or confusion about needed care, transportation, and how to schedule appointments. 12  Lack of follow-up appointment coordination prior to discharge results in patient and family caregivers not knowing who and when to follow up with when there are multiple providers. 3 In addition, there can be a lack of clear communication of the post-discharge care plan between the physician and the home health care team following the home health orders.

A systematic review of nine studies grouped factors for medication nonadherence into patient-related factors (i.e. disease-state knowledge, health literacy, cognitive function), drug-related factors (i.e. adverse effects, polypharmacy), patient-provider relationship, and logistical factors (i.e. transportation and medication access). 14 Proactively assessing these factors may streamline the discharge process.

Improvements in Discharge Planning and Transitions of Care

Discharge education should be provided throughout the hospitalization and then understanding confirmed on the day of discharge. There are tools available to help facilitate discharge education such as “teach-back” which assesses the key learner’s understanding of the discharge instructions. 15  Another strategy is to incorporate a discharge checklist. Some studies demonstrate the value of discharge checklists to document required components for a safe discharge. 16,17   One study found that 1 in 10 discharges include errors in discharge instructions, incorrect discharge medications, or a good catch and approximately a third of patients may need additional education prior to discharge. 18 While checklists may be helpful, they do not replace appropriate training or clinical competence. 19   Resources such as the AHRQ Re-Engineered Discharge ( RED) Toolkit can help provide evidence-based training for staff as well as outline processes to improve the discharge process and reduce readmissions. 9

Nurses play an integral role in the discharge process by coordinating care and providing timely communication with key stakeholders including families and community providers to ensure smooth transitions of care.  Additionally, pharmacists can play a crucial role in medication safety during transitions of care through medication reconciliation and discharge education. 20 Pharmacists can ensure patients understand their medications and can obtain them after leaving the hospital. Furthermore, since the majority of post-discharge adverse events involve medications, pharmacists can assist with post-discharge telephone follow-up to check in with patients and proactively address any medication related issues. 21

Effective discharge planning can help reduce medical errors during transitions of care, which is known to be a time during which patients are particularly vulnerable. Planning for discharge should involve the patient and caregiver and begin as soon as possible during the hospitalization. The IDEAL discharge planning strategy is one approach emphasizing patient and family engagement in discharge planning and discharge education. 22 Additionally, AHRQ houses a library of evidence-based resources and tools to improve the discharge process and care transitions. 23

Sarah A. Bajorek, PharmD, BCACP Pharmacy Supervisor, Transitions of Care and Medication Reconciliation University of California, Davis Health [email protected]

Vanessa McElroy, RN, BSN, PHN, ACM-RN IQCI Director, Care Transition Management University of California, Davis Health [email protected]

• Agency for Healthcare Research and Quality. Readmissions and Adverse Events After Discharge. https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
• Greenwald JL, Denham CR, Jack BW. The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process. J Patient Saf . 2007;(3):97-106. 
• HSAG Coordination Toolkit. Care Coordination Best Practices Toolkit: an overview of care coordination best practices to avert hospital readmission. Accessed April 12, 2024. [ Free full text ]
• Gabriel S, Gaddis J, Mariga NN, et al. Use of a daily discharge goals checklist for timely discharge and patient satisfaction.  MedSurg Nursing . 2017;(4):236.
• Sullivan B, Ming D, Boggan JC, et al. An evaluation of physician predictions of discharge on a general medicine service. J Hosp Med . 2015;(12):808-810. [ Free full text ]
• Horwitz LI, Moriarty JP, Chen C, et al. Quality of discharge practices and patient understanding at an academic medical center.  JAMA Intern Med . 2013;(18):1715-1722. [ Free full text ]
• Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients' understanding of the postdischarge treatment plan.  Arch Intern Med . 1997;(157):1026-1030. [ Available at ]
• Mayakarus AN, Friedman EA. Patients' understanding of their treatment plans and diagnosis at discharge.  Mayo Clin Proc . 2005;(8):991-994. [ Available at ]
• Agency for Healthcare Research and Quality. Re-Engineered Discharged (RED) Toolkit. https://www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/index.html
• Peter D, Robinson P, Jordan M, et al. Reducing readmissions using teach-back: enhancing patient and family education.  J Nurs Adm . 2015;45(1):35-42. [ Available at ]
• Naylor MD, Shaid EC, Carpenter D, et al. Components of comprehensive and effective transitional care. J Am Geriatr Soc . 2017;(65):1119-1125. [ Free full text ]
• Agency for Healthcare Research and Quality. Patient Engagement and Safety. https://psnet.ahrq.gov/primer/patient-engagement-and-safety
• Albrecht JS, Gruber-Baldini AL, Hirshon JM, et al. Hospital discharge instructions: comprehension and compliance among older adults.  J Gen Intern Med . 2014;29(11):1491-1498. [ Free full text ]
• Gellad WF, Grenard JL, Marcum ZA. A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity.  Am J Geriatr Pharmacother . 2011;9(1):11-23. [ Free full text ]
• Agency for Healthcare Research and Quality. Health Literacy universal Precautions Toolkit, 3 rd edition. Use the Teach-Back Method: Tool #5. Accessed April 12, 2024. [ Free full text ]
• Soong C, Daub S, Lee J, et al. Development of a checklist of safe discharge practices for hospital patients.  J Hosp Med . 2013;8(8):444-449. [ Free full text ]
• Flaster R. Four strategies cut newborn readmissions.  Contemporary Pediatrics. 2017;(7):10. [ Free full text ]
• Gao MC, Martin PB, Motal J, et al. A multidisciplinary discharge timeout checklist improves patient education and captures discharge process errors. Q Manage Health Care . 2018;(27):63-68. [ Available at ]
• Agency for Healthcare Research and Quality. Checklists. https://psnet.ahrq.gov/primer/checklists
• Agency for Healthcare Research and Quality. The Pharmacist’s Role in Medication Safety. https://psnet.ahrq.gov/primer/pharmacists-role-medication-safety
• Agency for Healthcare Research and Quality. Postdischarge Follow-Up Phone Call. https://psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
• Agency for Healthcare Research and Quality. Strategy 4: Care Transitions From Hospital to Home: IDEAL Discharge Planning. https://www.ahrq.gov/professionals/systems/hospital/engagingfamilies/strategy4/index.html
• Agency for Healthcare Research and Quality. Resources and Tools to Improve Discharge and Transitions of Care and Reduce Readmissions. https://www.ahrq.gov/patient-safety/resources/improve-discharge/index.html

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers

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• Research article
• Open access
• Published: 05 September 2017

Assessing the impact of the introduction of an electronic hospital discharge system on the completeness and timeliness of discharge communication: a before and after study

• Rajnikant L. Mehta 1 ,
• Bryn Baxendale 2 ,
• Katie Roth 1 ,
• Victoria Caswell 1 ,
• Ivan Le Jeune 2 ,
• Jack Hawkins 3 ,
• Haya Zedan 4 &
• Anthony J. Avery 1  

BMC Health Services Research volume  17 , Article number:  624 ( 2017 ) Cite this article

3985 Accesses

17 Citations

Metrics details

Hospital discharge summaries are a key communication tool ensuring continuity of care between primary and secondary care. Incomplete or untimely communication of information increases risk of hospital readmission and associated complications. The aim of this study was to evaluate whether the introduction of a new electronic discharge system (NewEDS) was associated with improvements in the completeness and timeliness of discharge information, in Nottingham University Hospitals NHS Trust, England.

A before and after longitudinal study design was used. Data were collected using the gold standard auditing tool from the Royal College of Physicians (RCP). This tool contains a checklist of 57 items grouped into seven categories, 28 of which are classified as mandatory by RCP. Percentage completeness (out of the 28 mandatory items) was considered to be the primary outcome measure. Data from 773 patients discharged directly from the acute medical unit over eight-week long time periods (four before and four after the change to the NewEDS) from August 2010 to May 2012 were extracted and evaluated. Results were summarised by effect size on completeness before and after changeover to NewEDS respectively. The primary outcome variable was represented with percentage of completeness score and a non-parametric technique was used to compare pre-NewEDS and post-NewEDS scores.

The changeover to the NewEDS resulted in an increased completeness of discharge summaries from 60.7% to 75.0% ( p  < 0.001) and the proportion of summaries created under 24 h from discharge increased significantly from 78.0% to 93.0% ( p  < 0.001). Furthermore, five of the seven grouped checklist categories also showed significant improvements in levels of completeness ( p  < 0.001), although there were reduced levels of completeness for three items (p < 0.001).

The introduction of a NewEDS was associated with a significant improvement in the completeness and timeliness of hospital discharge communication.

Peer Review reports

Hospital discharge summaries are a key communication tool for patient safety issues [ 1 ] as incomplete or untimely communication of information can lead to increased risk of hospital readmission and other associated complications. Admission to hospital often leads to new diagnoses, important investigation results and changes to treatment plans. Hence, it is very important that hospital discharge communications are accurate, complete and reach primary care teams in a timely manner [ 2 , 3 , 4 ].

Incomplete discharge summaries can have an adverse impact on patient safety [ 1 ], potentially causing increased avoidable hospital readmission, unnecessary complications and at the most extreme, patient mortality [ 4 , 5 , 6 ]. As the patient is particularly vulnerable during the period immediately after discharge, it is essential that discharge summaries are not only completed to a high standard but also that they are communicated to General Practitioners (GPs) in a timely manner. The lack of timeliness can also lead to an increased likelihood of unfavourable outcomes [ 2 ] and inappropriate utilization of health care resources. Re-admission is a major problem in hospitals, particularly in acute medical units where there is often a waiting list for beds and patients needing immediate medical attention. Re-admission of patients as a result of an incomplete discharge summary is avoidable and unnecessary [ 6 , 7 ].

Hospital doctors sometimes view discharge summaries as a chore and can rush the completion of these communications, taking shortcuts which can lead to important information being overlooked and omitted either intentionally or otherwise [ 8 ]. The level of completion of each summary can vary and Grimes et al., found that one of the most common pieces of information being left off discharge summaries was ‘medication changes’, either what medications had actually been changed or the reason why [ 9 , 10 ]. Changes to medication regimens is crucial information that must be forwarded to primary care. This is especially a concern in more complex patients with multiple morbidities who take multiple medications.

In 2008, the Royal College of Physicians (RCP) produced guidelines designed to improve the quality of discharge summaries and standardise their format for transmission between care sectors [ 11 ]. The template was designed to contain all the information necessary to correctly inform the GPs of the hospital episode and thus maintain continuity of care [ 11 , 12 ].

In 2011, Nottingham University Hospitals NHS Trust (NUHT) implemented a new electronic discharge system (NewEDS) based on this gold standard template, having already moved away from traditional forms of writing discharge summaries (hand-written or dictated). The new system was developed ‘in house’ and is not commercially available. It was designed to incorporate the fields recommended in the RCP guidelines. Demographic information was auto-imported, but the hospital did not have an Electronic Health Record at the time and so clinical data and medications had to be manually recorded.

The new system replaced a single sheet of paper on which was written the patient’s details, diagnoses, medications and follow up arrangements. The NewEDS discharge summaries were transferred electronically to the relevant general practice computer systems using the NHS Spine, which provides a secure data connection.

Our objective was to evaluate whether the introduction of the NewEDS brought about improvements in the completeness and timeliness of discharge communication. In terms of ‘completeness’ we focused on the RCP mandatory clinical and administrative data.

We retrospectively studied patient discharge summaries records from two wards (named B3 and D57) which comprised part of the acute medical unit at NUHT in the UK. These wards were selected as they managed a full range of acute medical adult patients in a high-pressure environment with a high patient turnover. Ward B3 is focused on short-stay patients with an anticipated length of stay of less than 48 h. The average length of stay in B3 to direct discharge is 15 h. Ward D57 patients were more likely to require longer admissions. Most patients transferred from ward D57 to the base wards of other specialities leading to fewer direct discharges, however the patients discharged from this ward tended to be older and have more complex medical background.

Selecting cases

The NewEDS was established on the 5th July 2011. Four (equally distanced) time periods were chosen before this date and four after to collect a sample of discharge summaries in order to address the aims of the study.

The periods examined were the weeks commencing 16th August 2010, 15th November 2010, 14th February 2011, 16th May 2011, 15th August 2011, 14th November 2011, 13th February 2012, and 14th May 2012. These dates were chosen as they did not cover any bank holidays or any other significant event that was felt might affect the level of completion and timeliness of the discharge summaries. Furthermore, one of the collection periods before and after NewEDS introduction was selected to include a week in mid-August close to the changeover period for new junior doctors to give a fair reflection of the potential effect of inexperience on the findings. Full weeks were looked at in order to assess a variety of inpatients as well as multiple doctors completing the summaries.

For each of the eight weeks in this study a random sample of 50 patients from each of the wards was created. Where there were fewer than 50 discharges, all were included. The list of patients contained basic demographic information (e.g. gender, date of birth), and admission and discharge dates and times were recorded from this source. Patient data were accessed using the Nottingham Information System (NotIS) database by two medical researchers (KR, VC), who received training in its use for purposes of data abstraction. Patients were identified on the system using their ‘K number’ (a unique number assigned to each patient treated at NUHT) and the discharge summary from the particular inpatient stay was then located.

Recording the data

The two trained medical researchers inspected both the pre-NewEDS and post-NewEDS discharge summaries and recorded the data contained within them using a data collection tool that had previously been used in a PhD project [ 13 ]. This data collection tool was developed by HZ in 2009 in consultation with the RCP using their standards, summary headings and definitions. [ 11 ]

The data collection tool took the form of a checklist, with two columns for items to be recorded as present or not present; the checklist contained 57 items under 7 headings (GP Information, Patient Information, Admission Information, Discharge Information, Clinical Information, Advice Recommendations and Future Plan, and Person Completing Summary).

To ensure the two medical researchers were assessing the data in the same way, agreement was analysed throughout the study. To assess agreement, discharge summaries sampled were crossed over and checked independently by the other medical researcher. This process was conducted for 50 discharge summaries before and after changeover respectively implying 100 summaries crossed over and re-analysed (Fig.  1 ). Agreement between the 2 medical researchers was found to be 99.23%. It was not possible to ‘blind’ the researchers as to which discharge summaries were completed before, and which were completed after, the introduction of the NewEDS.

Flow chart depicting process and assessing agreement

Inclusion and exclusion criteria

To be included in the study, patients had to have been discharged from hospital, from either ward, during the eight weeks examined. Patients were excluded if they were transferred to a different ward, had a missing discharge summary or if the researchers were not authorized to access the summary (this occurred if the summary contained sensitive information).

Data analysis

There were two primary outcome variables. The first was the percentage completeness score of the discharge summaries in relation to 28 items of information considered mandatory by the RCP [ 11 , 12 ]. The second was the percentage of discharge summaries created within 24 h of a hospital discharge [ 12 ].

The mean percentage completeness score before and after introduction of NewEDS was compared using an independent t-test. For categorical data, percentages were used and the chi-squared test was used to determine statistical significance. Where continuous variables like completeness and timeliness were not normally distributed non-parametric methods (Mann-Whitney U-test) were applied and the median with quartile ranges were presented. Statistical results pertaining to normally distributed continuous variables are presented with mean and standard deviation (SD), non-normally distributed variables with medians and quartile and categorical variables with percentages respectively. Data were analysed using STATA 13 and results were considered as statistically significant if p  < 0.05 (two-sided). When pertinent, 95% confidence intervals (95% CI) were calculated.

Sample size

A sample size calculation was conducted showing that, given a minimum 5% disagreement and assuming a 95% confidence interval width of 5%, a minimum of 292 discharge summaries needed to be analysed.

Description of sample

During the study period 773 hospital discharge summaries were found to be eligible for inclusion. The discharge summaries were extracted from two wards (B3:400(51.7%) and D57:373(48.3%)) pre and post-NewEDS (pre-NewEDS:386(49.9%) and post-NewEDS:387(50.1%)) (Table  1 ). It can be seen in Table 1 that 50 were sampled for each time period for B3. There were fewer than 50 patients for some of the time periods for D57. Appendix 1 displays in more detail the number of discharge summaries excluded for each reason, per time point and ward. We found that the number of Total excluded discharge summaries decreased during Post-NewEDS compared to Pre-NewEDS period respectively.

The recording of gender was present in all discharge summaries. The proportions of male and female were similar in each ward (B3(49.5% vs 50.5%) and D57(45.6% vs 54.4%); p  = 0.275). However, patients age differed between the two wards and was significantly higher in D57 compared to B3 (mean(SD): 64.2(23.2) vs 57.2(21.2); p  < 0.001).

• Completeness

The percentage completeness scores are illustrated in Fig.  2 . The median percentage completeness score of RCP mandatory data pre and post-NewEDS was significantly higher post-NewEDS compared to Pre-NewEDS (Median (quartiles): 75.0%(75.0,75.0) vs 60.7%(57.1,64.3), p < 0.001(Mann-Whitney)). This demonstrates that completeness of RCP mandatory fields increased by 14.3% after implementation of the NewEDS.

In relation to the timeliness of the discharge summaries score being completed, there was a significant decrease in days for completion after the introduction of the NewEDS (mean number of days: 4.2 vs 2.7, p  < 0.001 (Mann Whitney)). Summarising the scores of both wards (B3 and D57) a significant increase was found in the post-NewEDS timeliness of discharge summaries completed within one day compared to pre-NewEDS (93.0% vs 78.0%, p < 0.001). Results pertaining to both wards also show that for the final four time-points, the proportion of timely discharge summaries were approximately 90% and above, reaching a peak of 97.6% in May 2012 (Fig.  3 ).

RCP grouping and mandatory list

The RCP checklist had 56 items (signature was excluded) that could be marked as either ‘present’ or ‘not present’; these items were then grouped into seven categories: 1) GP details; 2) Patient details; 3) Admission details; 4) Discharge details; 5) Clinical information; 6) Advice, recommendations and future plan; 7) Person completing summary. For each category a tally of the number of items completed was calculated. Analyses were performed on each category and to assess whether there was a significant change in completeness between pre-NewEDS and post-NewEDS.

The completeness of categories 1–5 significantly increased after the change in EDS, while the completeness of categories 6 and 7 significantly decreased (Table  2 ).

Of the 56 RCP items, 28 items were RCP mandatory fields and 12 items showed highly statistically significant ( p  < 0.001) differences in completeness between the two systems: nine items showed improvements using the NewEDS and of these three were related to medication measures; three items showed decreased levels of completeness when using the NewEDS (Table  3 ). Table 3 also shows four non-mandatory items that demonstrated improvements when using the NewEDS and four items which showed decreased levels of completeness.

Our study has demonstrated that the implementation of a NewEDS summary was associated with a 14.3% absolute increase in completeness of the RCP recommended handover information and a 15% absolute increase in the number of discharge summaries completed within 24 h of discharge.

Our finding also show a highly significant improvement in the quality of the discharge summaries being produced after the change in NewEDS. The likely mechanism for the improvements was, in part, due to the development of mandatory fields within the new electronic discharge summary which required the discharging doctor to input at least some information into specific parts of the form. However, this feature can still be bypassed by typing any characters such as “.” or “None” into the form and therefore does not ensure 100% completeness but has helped to make significant gains. Nevertheless, we recognise that there is still room for further improvement in the completeness of several of the data items.

We acknowledge that completeness of categories 6 and 7 (Table 2 ) including three RCP mandatory items relating to ‘person completing the summary’ (Table 3 ) showed a statistically significant decrease in the level of completeness after the implementation of NewEDS. This is because these items were not included as fields on the NewEDS system. This is why, for example, the inclusion of the ‘date that the discharge record was completed’ decreased from 99% to 3%. Furthermore the reduction in completeness for four non-mandatory items, was also probably because they were not included as explicit fields in the newEDS. Three of these related to hospital responsibility for future care of the patient and arguably these items should have been included in the NewEDS to give adequate information for primary care clinicians.

The improvements in timeliness may, in part, be attributed to the fact that the new electronic discharge summary is simpler to complete giving the increased number of automated fields where data is imported from the hospital database and thus does not require the clinician to input as much information manually. In addition there has been a strong focus within the NHS on timely completion of discharge summaries and an increased awareness of the need for discharge summaries to be completed within 24 h as a direct result of the introduction of the new electronic discharge summary [ 12 ].

It is worth noting that, despite the system change, some discharge summaries remained significantly delayed. In examining such cases individually it became apparent that there were two reasons for this: the first is that certain patients undergoing a complex period of care requiring multiple hospital attendances did not have clinical notes available at the time of discharge. The second may be attributed to periods of high intensity activity on the ward where these discharge summaries may be left to be completed in the next quieter period. In these cases, often concentrated at weekends and nights, it appears that clinical staff continued to prioritise other aspects of their work. This may also relate to relatively low staffing levels during these out-of-hours periods.

Implications

Previous similar work that concentrated on the changes brought about by moving to an electronic discharge summary system from hand written communication was systematically reviewed by Motamedi et al. [ 14 ]. This showed a clear improvement in completeness of discharge summaries when electronic systems we used. Comparison of studies is, however, difficult as previous work does not have a definitive “gold standard” checklist to compare against. The advantage of this study is that we were able to use the carefully developed Royal College of Physicians checklist as an agreed standard [ 13 ].

Despite the fact that GPs have stated that they regard information about a patient’s medication as vitally important to facilitate appropriate onward care [ 2 , 9 , 15 , 16 ] it has been noted by previous studies that this aspect of the discharge summary was often lacking. Kripalani et al. found that 21% to discharge summaries were missing discharge medications and Grimes et al. noted that the majority of failed medication reconciliation was due to missing information on discharge summaries. Kripalani et al. also showed significant increases in documentation of medication changes, discharge medications and medication recommendations when moving from a traditional to an electronic discharge summary. Our study would have demonstrated 100% completeness in all of these ‘medication’ categories had it not been for the fact that 12 of the summaries in the post implementation period were completed using the old forms. This occurred because in the early days of implementation some of the old forms were still available. We included these forms in our post implementation analysis as this reflects the reality that a small minority of these discharge summaries were not done using NewEDS.

Previous authors have demonstrated improvements and timeliness with the change to electronic discharge summary systems. Motamedi et al. showed 90.1% were sent out on or before the day of discharge but other authors including Kripalani et al. and Chen et al.[ 17 ], whilst demonstrating an improvement in timeliness with electronic systems, did not report this change in a comparable way.

This study demonstrates that it is possible to further refine and improve electronic discharge summaries addressing both completeness of information through the use of automated and required fields and also timeliness through a combination of easy completion of forms and a focus on the importance of this task. Furthermore, if these discharge summaries had been linked to Electronic Health Records (EHR) this would have provided opportunities for auto-importing of clinical information. This might have led to even more marked improvements in the completeness of the summaries.

This study demonstrates that both completeness and timeliness have increased when using the NewEDS.

Strengths and limitations

This study has several strengths. Firstly it was conducted using a large sample size (773 summaries analysed in total) meaning the likelihood of the occurrence of a type II error is greatly reduced. This is important as much of the research conducted in this area has used only small sample sizes which impact on the reliability of the results. [ 2 , 5 , 15 ] In addition, the fact that data collection was spread over eight time points in a two year period demonstrated that the improvements brought about by the introduction of the new electronic discharge summary were sustainable and not just due to a short-term focus on a new system. Most importantly, we based the assessment of what information was deemed clinically important on a well validated piece of work carried out by the RCP. Although some items on this checklist may be viewed as subjective, we demonstrated a high level of agreement (99.23%) between two independent medical researchers when using this checklist to comparison sets of discharge summaries.

The major limitation of study methodology was that it was not possible to effectively blind the researchers and therefore it is possible that their reporting may have been subject to bias. The study design attempted to mitigate this risk by the use of two independent researchers with no involvement in the introduction of new electronic discharge summary system. There was also a potential for transcription error from the original paper collection to the Excel spreadsheet used in further analysis, however we calculated the data inputting error as 0.34% and therefore are confident that this would not have had an important influence on findings.

As our data collection defined only discharge summaries done on or before the day of discharge as timely, it is possible that we have under-estimated the number which were completed within the recommended 24 h period. A discharge summary done at 8 am for a patient discharged at 9 pm the previous day would not have been classed as timely in our study but would have met the recommendations. In addition, though most GP practices receive the discharge summaries via automatic e-mail with no time delay, some still need to be sent out by post and there was no way of measuring the delay brought about by this process or indeed the internal processes within GP practices which bring the discharge summaries to the attention of the relevant GP. In addition the study looked at implementation and effect on two busy, high turnover wards where the number of discharge summaries completed is very high. We have shown that the NewEDS was successful despite this service pressure but we have not formally tested other wards to demonstrate similar benefits.

Further limitations include the fact that we did not record data on the time needed to complete the discharge summaries; we did not include subjective assessments of the quality of discharge summaries by GPs who need to use them, and at least some of the improvement in the completeness score was driven by large changes in the rates of completion of administrative data such as GP practice code, gender, and method of admission.

Future work should be targeted at assessment of the accuracy of discharge summary information when compared to clinical notes and, importantly, to look for a link to an objective marker of improved patient outcomes such as reduction in avoidable readmissions.

This research study shows that a structured, partially automated, electronic discharge system designed according to RCP standards improved the timeliness and completeness of discharge summaries. This should have a positive impact on safe transfer of care.

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Acknowledgements

We would like to thank Annette Freyer for initiating this study, and staff on wards B3 and D57 for their support throughout the study.

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Rajnikant L. Mehta, Katie Roth, Victoria Caswell & Anthony J. Avery

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Contributions

This study was conceived and designed by RLM, AJA and BB. KR, VC and ILJ extracted the data. Statistical analysis was conducted by RLM; all authors contributed to the interpretation of the results. The paper was written by RLM with contributions from all authors. All the authors have read and approved the final version of the manuscript.

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Mehta, R.L., Baxendale, B., Roth, K. et al. Assessing the impact of the introduction of an electronic hospital discharge system on the completeness and timeliness of discharge communication: a before and after study. BMC Health Serv Res 17 , 624 (2017). https://doi.org/10.1186/s12913-017-2579-3

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Early palliative care for adults with advanced cancer

Review question

What is the evidence for the effects of early palliative care on quality of life, survival, depression, and symptom intensity in people with advanced cancer?

Frequently, cancer is diagnosed at a late stage, and the disease might have progressed through anticancer treatment. Patients can choose to start or continue anticancer treatment at the potential cost of side effects. Standard care means that all patients are offered palliative care towards the end of life. However, patients may be able to receive palliative care a lot earlier. This approach, which is known as early palliative care, begins at the time of, or shortly after, the diagnosis of advanced cancer. Often, early palliative care is combined with anticancer treatment such as chemotherapy or radiotherapy. Early palliative care, whether provided by the attending oncologist or by specialist teams, involves empathetic communication with patients about their prognosis, advance care planning, and symptom assessment and control.

Study characteristics

In October 2016, we searched for clinical trials on early palliative care in adults with advanced cancer. We included seven studies and found 20 ongoing studies. Most of the studies included participants older than 65 years of age on average, diagnosed with different tumour types and receiving treatment in tertiary care centres in North America. Most of these studies compared early palliative care with standard oncological (cancer) care. All studies were funded by government agencies.

Key results

When evaluated together in a meta-analysis, studies showed that in patients with advanced cancer, early palliative care may slightly increase quality of life. It may also decrease symptom intensity to a small degree. Effects on survival and depression are uncertain. A single study reported side effects (adverse events), for example, more pain and reduced appetite. For the remaining six studies, information about side effects was not published, but trial authors told us they had not observed any.

Certainty of the evidence

We rated the certainty of the evidence using four levels: very low, low, moderate, and high. Evidence of very low certainty means that we have little confidence in the results. Evidence of high certainty means that we are very confident in the results. We found that certainty of the evidence was low for health-related quality of life and symptom intensity, and was very low for depression and survival. We downgraded certainty of the evidence for various reasons, for example, problems in the way studies were carried out, differences between studies, and the small number of studies. We remain uncertain about the effects of early palliative care; therefore we have to interpret the results with caution. When published, ongoing studies may provide more evidence, and this may affect the certainty of the results.

This systematic review of a small number of trials indicates that early palliative care interventions may have more beneficial effects on quality of life and symptom intensity among patients with advanced cancer than among those given usual/standard cancer care alone. Although we found only small effect sizes, these may be clinically relevant at an advanced disease stage with limited prognosis, at which time further decline in quality of life is very common. At this point, effects on mortality and depression are uncertain. We have to interpret current results with caution owing to very low to low certainty of current evidence and between-study differences regarding participant populations, interventions, and methods. Additional research now under way will present a clearer picture of the effect and specific indication of early palliative care. Upcoming results from several ongoing studies (N = 20) and studies awaiting assessment (N = 10) may increase the certainty of study results and may lead to improved decision making. In perspective, early palliative care is a newly emerging field, and well-conducted studies are needed to explicitly describe the components of early palliative care and control treatments, after blinding of participants and outcome assessors, and to report on possible adverse events.

Incurable cancer, which often constitutes an enormous challenge for patients, their families, and medical professionals, profoundly affects the patient's physical and psychosocial well-being. In standard cancer care, palliative measures generally are initiated when it is evident that disease-modifying treatments have been unsuccessful, no treatments can be offered, or death is anticipated. In contrast, early palliative care is initiated much earlier in the disease trajectory and closer to the diagnosis of incurable cancer.

To compare effects of early palliative care interventions versus treatment as usual/standard cancer care on health-related quality of life, depression, symptom intensity, and survival among adults with a diagnosis of advanced cancer.

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, OpenGrey (a database for grey literature), and three clinical trial registers to October 2016. We checked reference lists, searched citations, and contacted study authors to identify additional studies.

Randomised controlled trials (RCTs) and cluster-randomised controlled trials (cRCTs) on professional palliative care services that provided or co-ordinated comprehensive care for adults at early advanced stages of cancer.

We used standard methodological procedures as expected by Cochrane. We assessed risk of bias, extracted data, and collected information on adverse events. For quantitative synthesis, we combined respective results on our primary outcomes of health-related quality of life, survival (death hazard ratio), depression, and symptom intensity across studies in meta-analyses using an inverse variance random-effects model. We expressed pooled effects as standardised mean differences (SMDs, or Hedges' adjusted g ). We assessed certainty of evidence at the outcome level using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) and created a 'Summary of findings' table.

We included seven randomised and cluster-randomised controlled trials that together recruited 1614 participants. Four studies evaluated interventions delivered by specialised palliative care teams, and the remaining studies assessed models of co-ordinated care. Overall, risk of bias at the study level was mostly low, apart from possible selection bias in three studies and attrition bias in one study, along with insufficient information on blinding of participants and outcome assessment in six studies.

Compared with usual/standard cancer care alone, early palliative care significantly improved health-related quality of life at a small effect size (SMD 0.27, 95% confidence interval (CI) 0.15 to 0.38; participants analysed at post treatment = 1028; evidence of low certainty). As re-expressed in natural units (absolute change in Functional Assessment of Cancer Therapy-General (FACT-G) score), health-related quality of life scores increased on average by 4.59 (95% CI 2.55 to 6.46) points more among participants given early palliative care than among control participants. Data on survival, available from four studies enrolling a total of 800 participants, did not indicate differences in efficacy (death hazard ratio 0.85, 95% CI 0.56 to 1.28; evidence of very low certainty). Levels of depressive symptoms among those receiving early palliative care did not differ significantly from levels among those receiving usual/standard cancer care (five studies; SMD -0.11, 95% CI -0.26 to 0.03; participants analysed at post treatment = 762; evidence of very low certainty). Results from seven studies that analysed 1054 participants post treatment suggest a small effect for significantly lower symptom intensity in early palliative care compared with the control condition (SMD -0.23, 95% CI -0.35 to -0.10; evidence of low certainty). The type of model used to provide early palliative care did not affect study results. One RCT reported potential adverse events of early palliative care, such as a higher percentage of participants with severe scores for pain and poor appetite; the remaining six studies did not report adverse events in study publications. For these six studies, principal investigators stated upon request that they had not observed any adverse events.