Discharge

Introduction

A good discharge summary for a patient is an important clinical record that narrates and communicates clinical information about the patient's entire hospitalisation. Discharge communications between healthcare facilities play a pivotal role in the coordination of patient care. As geriatric patients’ physical health is intricately woven into their social circumstances, mobility, and available care facilities, the mention of these parameters becomes quite important as it informs the community medical team of the patient’s condition more comprehensively. Crafting a good summary is challenging and we noted insufficient documentation of geriatric domains.

Methods

A discharge summary QIP was run in the geriatric wards at the Royal Gwent Hospital for 5 cycles. In these 5 cycles, we introduced a poster, electronic MDT, teaching sessions, and discharge summary checklist respectively as our chosen intervention. We collected data prospectively and calculated the percentages of presenting complaints, diagnosis, comorbidities, history, examination findings, investigations, management, mobility, care needs, discharge destination, cognition, resuscitation and escalation plan, whether were documented or not in the summaries.

Results

A total of 20-30 patients’ discharges were included in each cycle. Overall, there was good documentation in general medical domains (95-100%). A remarkable rise in the documentation of care needs (65%), mobility (80%), and discharge destination (50%) amongst other parameters was noted. However, there is a comparatively small improvement in cognition, resuscitation and escalation plans as some of them do not apply to all patients. The improvement is progressing as the physicians are now frequently referring to the checklist for writing the summaries.

Conclusion

These interventional measures showed the quality of discharge summaries has improved dramatically. Hence, we uploaded the discharge checklist to our health board intranet and included it in the induction booklet. We hope to include it in our yearly induction sessions to maintain the level of improvement

Title: Evaluation of Frailty Assessment, Management Practices, and Patient Outcomes in GIM Patients Under 85 Years: A Two-Cycle Audit in GIM Wards at Queen Alexandra Hospital, Portsmouth Hospital University NHS trust.

Introduction:

Frailty significantly affects outcomes like length of stay and readmissions in elderly patients. At Queen Alexandra Hospital, inpatients under 85 are under the care of General Internal Medicine (GIM) wards and they lack regular access to frailty services. This baseline audit evaluated frailty assessment, management practices and patient outcomes, implementing staff education, ward posters, and a frailty Multidisciplinary Team (MDT) between cycles. Methods: Data were retrospectively collected from three GIM wards over two cycles—January and August 2024.

Eligibility criteria:

Patients aged 65-85, admitted to GIM were included. The audit measured frailty assessment using the Clinical Frailty Scale (CFS), Comprehensive Geriatric Assessment (CGA) practices, frailty prevalence (CFS ≥ 5), advance care planning (ACP), and readmission rates.

Results:

Frailty assessment compliance rose from 76.6% to 94.4%. Frailty detection (CFS ≥ 5) increased from 36% to 75%. CFS documentation improved to 34.5%, with better CGA documentation. However, ACP rates remained low at 3.03%, and 56.6% of frail patients were readmitted within the year, indicating ongoing challenges.

Conclusion:

Improvements were seen in frailty assessments and detection, yet ACP remains underutilized, and readmission rates are high. Continued efforts are needed to enhance ACP documentation and frailty management strategies. Recommendations: 1. Implement robust policies for ACP and implement a straightforward pathway for ACP documentation by all doctors. 2. Educate all doctors to practice comprehensive geriatric assessment and participate in frailty MDT meetings. 3. Further audits to specifically investigate the proportion of patients admitted with frailty syndrome and assess their prognosis. 4. Prioritize triage based on CFS scores/frailty over age to enhance targeted care and resource allocation.

Background: Patients triaged as routine, discharged home from Intermediate Care Units (ICUs) in areas of West Sussex wait  approximately 4 weeks or more until rehabilitation continues by the Community Therapy Team (CTT).

Introduction NHS England (2023a) and NHS England (2023b) call for minimal delays, effective coordination processes and sharing of information for timely rehabilitation in intermediate care settings. Local patient feedback indicated poor patient satisfaction and increased clinicians anxiety regarding risk of deterioration due to long waits (Lewis A., 2018).

Aim To improve average wait times for routine ICU patients’ discharge, for ongoing community therapy input, to within 1 week by July 2024, while maintaining patient safety and improving patient satisfaction.

Methodology: Quality improvement methodology, using stakeholder engagement was used to determine the cause for long wait times for home therapy. PDSA cycles were engaged to determine if improvements could be made without a loss of quality of care, or impacting patient safety, while improving patient experience. These involved formal communication channels between teams and using a therapy assistant for an initial home assessment where assessments had already been undertaken by registered therapists on the ICUs. Patient satisfaction surveys were undertaken to understand the experience of transition home.

Results: Baseline data indicated that waiting time for home therapy varied between 18 - 59 days, from discharge. After the initial PDSA cycle, waiting time reduced to between 4 - 10 days, and after the second cycle waits reduced further to between 3 - 7 days. Patients’ satisfaction improved significantly with shorter waiting times for therapy once home.

Conclusion: Therapy assistant initial visits at home reduced waiting times to within a week, and patients’ satisfaction improved with shorter waiting times. Patient safety was not compromised as there were clear protocols for appropriate escalations for unregistered staff.

Introduction: Hospital-Associated Deconditioning Syndrome (HADS) can lead to prolonged length of stay (LOS). Evidence indicates that early intervention may reduce HADS and LOS. (British Geriatrics Society, Deconditioning, Healthy Ageing, 11 May 2017, Dr Amit Arora, NHS England, 24 January 2017, Time to Move). The Acute Frailty Team (AFT) at Eastbourne District General Hospital piloted a Frailty Early Discharge Scheme (FEDS) in the Frailty Unit for 8 weeks between May-June 2023 with the aim of providing early mobilisation and discharge planning to reduce LOS.

Methods: Patients were admitted to either FEDS or Non-FEDS (NFEDS) beds depending on the bed availability. FEDS patients were provided with additional early assessments and interventions including discharge plans from day 1 after admission, offering early, continuous and active mobilisation by a trained FEDS team of a registered Nurse and Health Care Assistant. The FEDS team worked in conjunction with the medical team to actively promote discharge planning while patients were still receiving acute medical treatment, before patients becoming medically fit for discharge (MFFD). NFEDS followed the standard care plan, usually initiated after patients were declared MFFD. Data was collected for all patients, comparing FEDS 12 beds with NFEDS 12 beds.

Results: 83 patients were enrolled 45 FEDS, 38 NFEDS Discharged within 48hrs FEDS 11.11%, NFEDS 2.63% Discharged within 7 days FEDS 44.44%, NFEDS 28.94% LOS 8.07 days FEDS, 11.36 days NFEDS (30 day trim point).

Conclusions: 1. Increased rate of discharge within 48 hrs and 7 days. 2. Reduced LOS within 30 days. 3. The benefit is mostly noticed within the first 7 days indicating the need to apply the intervention early 4. The adoption of a FEDS-project in all frailty wards could be beneficial for elderly patients.

Introduction

There is limited understanding of long-term delirium care after discharge from hospital for older people. A realist approach was used to investigate the contextual factors and mechanisms of care that influence recovery from delirium. Realist evaluation is fundamentally theory-driven. A preliminary programme theory was used as the foundation for theory testing and refinement, in order to develop the RecoverED intervention.

Method

Realist interviewing techniques were used to obtain real-world and lived experiences of delirium recovery and service use in the community for theory-building and testing. Semi-structured interviews were conducted with a purposive sample of people with delirium (N=7), informal carers (N=14), and healthcare professionals (N=24). Data from the interviews were analysed using a deductive codebook of Context-Mechanism-Outcome (CMO) configurations. Open coding was also performed to identify inductive themes, which were then aggregated to elicit explanatory statements.

Results

There was support for a multicomponent delirium intervention including cognitive and physical rehabilitation, and psychosocial support. The analysis revealed the need for an additional component which focused on improving awareness and understanding about delirium amongst those with lived experience. In the context of insufficient knowledge about delirium, people experienced increased fear and anxiety among other negative outcomes. Offering a focused educational component as part of the intervention is expected to contribute to recovery outcomes. This was associated with CMOs identifying the need for positive relationships with staff, improving communication with staff and sense-making through staff emotional support.

Conclusion(s)

The preliminary programme theory was refined based on the realist analysis data. Additional components were included, one of which was targeted education for people with delirium and carers. Following a consultation with an expert panel, the intervention is being tested in a feasibility trial and process evaluation, which will analyse data from multiple sources using realist methods to further refine the intervention

Introduction

In 2022, 293 hip fractures had been admitted to the Bristol Royal Infirmary. As recommended by National Osteoporosis Guideline Group ( NOGG ) intravenous zoledronate is the first line treatment option following a hip fracture.

Aims

We wanted to improve bone health summaries on discharge summaries for the benefit of the General practitioner ( GP ), Fracture liaison service and patient.

Results

We used our local National Hip Fracture database to identify the patients who had had a fractured hip in September 2023. We then introduced our changes as part of the PDSA cycle. The change was copying and pasting a blank bone health paragraph into every discharge summary on day 1 of the patient's admission to make it easier for the Trauma and Orthopaedic (T&O) junior doctor completing the discharge summary pre discharge. We then used an excel spreadsheet to collect results in September and October 2023 and analyse them and display them using pie charts. In September , 28.3% of discharge summaries did not have a bone health plan, compared to 25% in October. Not mentioning of Vitamin D levels in discharge summaries has increased from 57.1% to 59.4%. Mentioning of administration of inpatient zoledronic acid post fracture decreased from 32.1% to 25%.

Conclusion

Despite the intervention,The bone health plans are poorly communicated to the GP and the Fracture Liaison service, which leads to delay in administering bone health medication in a timely manner to prevent a second fracture.

Next step

Teaching Session with the T&O juniors to find out if they think it’s a good idea and discuss why they have not found the current standardised paragraph helpful. Then we can work together to make a further change (s) and start another PDSA cycle.

References

National Osteoporosis Guideline Group.UK ( NOGG ),2021

Background

Fragility fractures, defined as fractures resulting from low energy trauma (1), are consistent with a diagnosis of osteoporosis. When a patient is discharged from hospital, guidelines recommend principal and additional diagnoses, relevant co-morbidities contributing to primary diagnosis, medications and relevant investigations are recorded (2).

Methods

This audit reviewed discharge summaries of all patients discharged from a rehabilitation unit over two months, in accordance with the Health Information and Quality Authority’s (HIQA) National Standard for Patient Discharge Summary Information (2). Patients with fragility fractures were identified through medical record review. Principal and additional diagnoses were reviewed, with cause and mechanism of falls considered relevant co-morbidities. Discharge prescriptions for anti-resorptive medications were noted. Dual-energy x-ray absorptiometry (DXA) was recorded as a relevant investigation (3).

Results

33 discharge summaries met inclusion criteria. 12 patients were admitted with fragility fractures with a mean age of 81 years (69-90). 83.3% (n=10) were female. Osteoporosis was mentioned in 50% (n=6) of discharge summaries of patients with fragility fractures. On review of relevant co-morbidities, likely cause of the fall was documented in 58.3% (n=7) and mechanism in 75.0% (n=9). Bone protection was planned in 83.3% (n=10). Plan for DXA was documented in 8.3% (n=1)

Conclusion

This audit demonstrates suboptimal communication between hospital and community teams, despite chronic disease being predominantly managed in the community. In Europe, Ireland has one of the largest disease burdens relating to osteoporosis and the largest increase predicted in the next ten years (4) . It is of utmost importance we improve communication to minimise disease burden.

References

1. International Osteoporosis Foundation (2023) Fragility Fractures. https://www.osteoporosis.foundation/health-professionals/fragility-frac… (Accessed on 30 August 2023).

2. Health Information and Quality Authority (2013) ‘National Standard for Patient Discharge Summary Information’. Dublin: Health Information and Quality Authority. https://www.hiqa.ie/reports-and-publications/health-information/nationa…- patient-discharge-summary-information (Accessed on 30 August 2023).

3. Irish Osteoporosis Society (2023) About Osteoporosis. https://www.irishosteoporosis.ie/information-support/about- osteoporosis/#accordion-0-10 (Accessed 30 August 2023).

4.Carey, J.J., Erjiang, E., Wang, T., Yang, L., Dempsey, M., Brennan, A., Yu, M., Chan, W.P., Whelan, B., Silke, C., O'Sullivan, M., Rooney, B., McPartland, A. and O'Malley, G. (2023), Prevalence of Low Bone Mass and Osteoporosis in Ireland: the Dual-Energy X-Ray Absorptiometry (DXA) Health Informatics Prediction (HIP) Project. JBMR Plus, pp. 1-10.

Introduction                                                                                                                                                                        High number of clinically optimised patients in a DGH were having daily clinical input. RAAC clinical incident resulted in movement of clinically optimised patients from the district general hospital to a community hospital increasing the community bed base from 32 to 72. This gave the opportunity to review how these patients were managed.             

Method                                                                                                                                                                                    It was recognised that a daily medical ward round for clinically optimised patients was neither necessary or optimal and potentially perpetuated the impression that patients required in hospital care. National guidance supports delegation of daily review to other members of the Multidisciplinary Team. All clinically optimised were planned to be seen once a week on a medical ward round. All patients were discussed on the daily multidisciplinary board round and if needed were changed on the board to not clinically optimised which prompted review. Nurses could also ask for review outside of the board round.                                                                                                                                                                             

Results                                                                                                                                                                            During four weeks period one third ( 24/72 ) of patients needed review outside of the weekly planned review. Of these 79.2% required only one review. Junior doctors reported that they previously spent 5-15 minutes per day per clinically optimised patient. Therefore time saving of 16-48 hours per week was estimated. Balancing measures of falls, mortality, pressure sores and complaints showed no change in the four months after implementation of the change. Patients, family and staff qualitative feed back was gathered. Stage two of the project offered clinically optimised patients a ' What Matters to Me' meeting with their family utilising the time saved by reduced ward rounds to improve communication, medication review and future care planning.                                                                                            Conclusion                                                                                                                                                                          Data suggested no adverse impact of change in practice. Staff were redeployed to the front door frailty team rather than community hospital to improve access to Comprehensive Geriatric Assessment at admission in the Emergency Department and Acute Frailty Unit.

Introduction

Information-sharing between primary and secondary care is vital for patient safety and reducing duplication. The Electronic Discharge Summary (EDS) enables this but is often incomplete due to time pressures and poor team continuity. Information from the Comprehensive Geriatric Assessment (CGA) by the Perioperative care of Older People undergoing Surgery (POPS) team is often omitted, leading to queries from primary care colleagues and duplication of work on readmission to hospital.

Methods

Eight core CGA components were determined for inclusion in the EDS. Twenty EDS were reviewed to for each PDSA cycle to assess compliance. Various strategies were trialled to increase compliance including junior doctor education (attendance at induction plus separate teaching), a checklist poster, the POPS team directly entering information into the EDS and a separate CGA summary.

Results

Baseline data demonstrated poor compliance with core CGA components (mean 25%, range 0-62.5%). PDSA 1 demonstrated improvement after junior doctor education and introduction of a checklist poster (mean 35%, range 12.5-87.5%). Mean compliance increased to 53% during PDSA 2 with the POPS team directly entering information into the EDS, but with continued wide variation (range 12.5 – 100%). The introduction of a POPS CGA summary to complement the EDS in PDSA 3 increased compliance with reduced variation in practice (mean 99%, range 87.5-100%).

Conclusions

Sharing information gleaned from a CGA was marginally improved with education, but is challenging due to the rotational nature of staff completing the EDS. The improvement seen with the POPS team entering EDS information was limited by the lack of 7-day working and the ‘locking’ of the completed EDS by the parent team. A separate CGA summary markedly improves information-sharing, with reduced variation in practice. This has benefitted primary and secondary care colleagues, as well as the POPS team when patients are readmitted or attend clinic.

The Psychological Impact of Hospital Discharge on the Older Person

Hussein Y ¹, Edwards S ², Patel HP ^2,3,4

¹ Undergraduate Medicine, Faculty of Medicine, University of Southampton, UK;       

² Department of Medicine for Older People, University Hospital Southampton NHS Foundation Trust, UK; ³Academic Geriatric Medicine, University of Southampton, UK; ⁴NIHR Southampton Biomedical Research Centre, University of Southampton & University Hospital Southampton NHS Foundation Trust, UK

Background

The number of older people at risk of health-related morbidity is growing at an unprecedented rate. Older people often require hospitalisation but prolonged length of stay and deconditioning in the acute setting is associated with multiple adverse outcomes. On average, 35% of older people do not recover functionally after hospital discharge. Less is known on the psychological impact and coping mechanisms after hospital discharge for vulnerable older people. Our aim was to explore factors signalling psychological vulnerability in older patients post-discharge to inform better discharge planning.

Methods

A systematic search for studies reporting poor discharge outcomes in older people were performed in the databases Medline, CINAHL, PsycInfo between 2010-2022. The search terms were ’older patients >65 year’, ‘post-discharge’, ’psychological distress’, ’loneliness’, ‘anxiety’, ‘depression’, and ‘length of hospital stay’. Exclusion criteria included COVID-19 disease, dementia (+/- severe cognitive impairment), individuals aged <65 and those under palliative care services.

Results

1,666 records were identified of which 878 were excluded as they were outside of our date limits or were not in English Language. 681 were excluded after application of exclusion criteria and 699 were excluded because of insufficient details. 31 duplicates were removed leaving 38 articles that were assessed for eligibility. 7 of these reports were found suitable, comprising of 1,131 patients. Three highly relevant themes identified relating to post-discharge outcomes across all studies were social isolation, lack of support, depression, apathy and fear, which led to further psychological distress. Older patients with tendency toward depressive symptoms had an increase likelihood of death.

Conclusion

It appears discharge processes fail to address psychological factors that permit successful transition from hospital. Pre-discharge screening of psychological symptoms and coping ability may assist in identifying older patients who are at risk of mental as well as subsequent physical deterioration. Better knowledge of positive and negative predictors of a successful transition from hospital to home would enable more holistic, effective, and inclusive discharge planning processes for older people.