GPs call for higher quality discharge summaries

Doug Hendrie

11/12/2018 2:58:13 PM

Frustrated GPs want a major improvement to the quality and timeliness of hospital discharge summaries.

GPs believe one of the issues is the fact summaries are often handed to people who did not directly treat the patient.
GPs believe one of the issues is the fact summaries are often handed to people who did not directly treat the patient.

Discharge summaries with low-quality information or arriving weeks late are a perennial bugbear for GPs treating patients who have recently been hospitalised.
Incorrect information in summaries has led to adverse events, such as re-admission, in almost half of patients discharged from hospital, according to a 2003 US study.
Dr Carl Mahfouz, GP and University of Wollongong academic told newsGP there is no easy fix for what he describes as a worldwide problem.
‘Discharge summaries are very important documents; a patient’s health can depend on it,’ he said. ‘Deaths, re-admissions, morbidity – that’s been documented.
‘There’s no question about the negative impact of poorly written or poorly timed summaries. Everyone agrees on that. The question is how to solve it.
‘It’s not easy to summarise [clinical information] in a relevant and succinct manner, trying to filter what you think is important from what is not. It’s not an easy job, especially for the intern who just came to the ward.’
Dr Mahfouz observed the situation first hand when he was hospitalised several years ago, as the responsibility for writing his summary was handed to a medical intern who had not directly treated him.
‘I didn’t recognise myself in my own discharge summary. Consultants and registrars have to take some responsibility – it can’t just be dumped on a poor junior doctor,’ Dr Mahfouz said.
‘Most of these interns are the last one in the chain to have something to do with that patient, and they have to write the summary. Registrars are too busy and don’t want to take ownership of it.
‘In my day, the consultant had to look at it to correct or adjust it. But I don’t believe that happens these days, even at registrar level.’

Dr Mahfouz was lead author on a 2017 article in Australian Family Physician that developed a pilot tool to assess the quality of discharge summaries. A first step to improving the situation, he said, would be teaching medical students about discharge summaries.
‘Nobody trains medical students how to write them. They’re just expected to know how to do it,’ Dr Mahfouz said. ‘But it also has to trickle from the top down [in hospitals].’
The key skill, according to Dr Mahfouz, is how to condense copious medical detail into a paragraph, outlining the essence of the hospital stay and what GPs could do to continue the care.
‘The most important feedback I get [as a GP] is the handwritten summary – the patient presented with this, we found that, please do this,’ he said.
‘It’s the most useful section in a discharge summary, but it’s often missed because it’s computerised or people just copy and paste. You have to know the patient to be able to do a three-line summary.
‘I don’t need a 10-page discharge summary with pasted surgical notes. As a GP, I just need the relevant information. It needs to be succinct and relevant. But that’s not something that comes naturally to doctors. You have to develop it.’

Carl-Mahfouz-(hero-and-tile)-(1).jpgDr Carl Mahfouz is calling for urgent improvement to discharge summaries.
Australia’s My Health Record electronic system was pitched, in part, as a way to improve communication among hospitals, specialists and GPs, with discharge summaries vital to that effort.
But Dr Mahfouz believes it will only be a partial fix.
‘Uploading [discharge summaries] will help with timeliness, but doesn’t help with the quality of information or including a plan for what needs to be done,’ he said. ‘So it’s brilliant that it eliminates one aspect of the problem, but it doesn’t help the others.’
Dr Mahfouz first became passionate about the issue after working in hospitals in the Illawarra region in NSW and often finding that the information included in a clinical handover between hospitals was close to ‘useless’.
‘We’d get patients from other hospitals after hours, and the only thing that linked me was the summary,’ he said.
‘Often they just had absolutely useless information. I’d often go and see a patient at 11.00 pm, read the summary and have no idea why they were there.’
Canberra women’s health GP Dr Gillian Riley said the issue is that discharge summaries are not considered important. She called for it to become a key performance indicator (KPI) for consultants.
‘They’re delegated to already busy junior staff, and often not completed in a timely manner,’ she said. ‘I’m sure we all remember working through discharge summary boxes or equivalent with incentives to “just finish”.
‘The “get the paperwork done” attitude isn’t helpful when you’re the doctor on the other end in need of a clinical handover.
‘I would argue this is how it should be improved. Make it the responsibility of the consultant. Make it a reportable KPI. 
‘My Health Record might improve the system, but only in terms of how rapidly the document is transmitted.
‘If it’s not being completed, then we still have all the same issues. It’s a cultural problem.’ 
Kangaroo Island GP Dr Tim Leeuwenberg made similar observations while commenting on Twitter.
‘We have to change the acceptance of “discharge summar[ies]” as a routine chore for [junior medical officers and] re-frame as a clinical handover,’ he wrote.
‘It’s a safety issue. Failure to handover negates care.’
Earlier this year, Gold Coast GP Dr Katrina Mclean and two colleagues sounded the alarm.
‘It is apparent that the impacts from delayed or poor clinical handover on patient care across the country are significant, under-reported, and have a profoundly negative effect on the care patients receive,’ they wrote on MJA Insight.
‘Hospitals are incredible places, but the aim is for patients to return home to their communities and trusted GPs. They come home. Their GPs are waiting, willing and able. We can do better, and we will. We extend an open hand to our amazing hospitals. Pass us the baton – we won’t drop it.’
Discharge summaries are one form of clinical handover, which is defined as a key plank of Australia’s healthcare safety and quality guidelines.
The Australian Commission on Safety and Quality in Health Care defines a clinical handover as ‘the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis’.

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Daniel Byrne   14/12/2018 7:54:04 AM

Time for the RACGP to start an award for the best and worst performing hospital networks in Australia for timeliness and quality of discharge summaries.

Praveen   14/12/2018 11:05:18 AM

Such an article featuring in a magazine for GPs doesnt mean anything. It is a problem we are well aware of and can relate to. What would be important is definitive action points which we need to think of or the RACGP has to come with to address the problem.

Dr RG   14/12/2018 11:09:14 AM

One of the best skills I ever learned as an intern, while doing a geriatric medical term, was that of writing a concise and useful discharge summary. Unit policy was that it could be no longer than 1 page and had to go out on the same day the patient was discharged, and we were given feedback on the quality of our work by the consultants. It is a vital skill, but one which does need to be specifically taught - don't expect junior doctors to just stumble through and pick it up by trial and error.

Dr AF   14/12/2018 12:16:00 PM

Why dont we get GPs to go speak with final year medical students and interns during orientation week. Give them some real life examples of what GPs want in a discharge summary. Hospital doctors (even registrars and consultants) dont always understand what information is crucial to GPs and therefore hard for that to trickle down.

Pradeep Jayasuriya   14/12/2018 12:36:28 PM

Hospitals unilaterally impose criteria for referrals perhaps we can have criteria before we accept a discharge summaries . I agree with Daniel Byrne its time we named and shamed hospitals . We know this works. Perhaps the RACGP and the ACSQHC could joint do some work in developing standards that hospitals can be measured against .

Mark   14/12/2018 10:32:36 PM

The discharge summary is currently expected to fill too many roles.

Hospitals use the discharge summary as the primary document from which they calculate the activity based funding (WEIS). They therefore teach their interns to be overly thorough, including small transient problems such as electrolyte disturbances, constipation and mild AKIs in order to attract extra money. In some hospitals the summary is also expected to contain the definitive list of a patients comorbidities and the relevant investigations and prior treatments for each of them. This is primarily to save time and repetition in case of re-admission to the same hospital, but is likely irrelevant to the GP as it should already be known to them. This all impacts readability and takes the focus away from providing a succinct summary for the GP.

The discharge summary should serve the exclusive purpose of clinical handover to the GP. Activity based funding should be calculated from the more extensive progress notes and an up to date list of comorbidities will hopefully be one of the main outcomes of the My Health Record.

Dr Robert Menz   17/12/2018 3:25:49 PM

I agree with many of the comments above. I wonder if one of the ways forward is to set the example, by writing concise and useful referrals when our patients are handed over to hospitals. And is there a role for quality awards for referral letters?

Oliver Frank   1/01/2019 9:28:45 AM

It is vital to understand dumping the summary into the patient's My Health Record without sending it directly to the GP is not acceptable.

To its credit, the Australian Digital Health Agency got it right when it said:

"When a healthcare provider creates a discharge summary, it will be sent directly to the intended recipient, as per current practices. When a hospital is connected to the My Health Record system, a copy of the Discharge Summary can also be sent to the patient's My Health Record."

Note the important word 'also', not 'instead', in that last sentence.

Unfortunately, what you have quoted Dr Gillian Riley as saying muddies the waters: "‘My Health Record might improve the system, but only in terms of how rapidly the document is transmitted." 'Transmitted' is not an appropriate word here - it implies that the summary was sent to the GP, when that is not the case.

Miss norr   6/07/2019 12:58:53 AM

In my opinion more accurate discharge sumaries is what
australians need as a patient I have had more than one discharge summary that has been almost entirely incorrect and it has affected my health in the sense that nobody can treat me effectively. I've been hospitalised repetitively as a result. These admissions have also been extremely serious. With apparent pnuemonia and haert failure