GPs call for higher quality discharge summaries

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.’

Dr 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’.

clinical handover discharge summaries health data