Abstract
According to the World Health Organization, the global population of elderly people aged 60 years or more was 600 000 000 in 2000 and is expected to rise to around 2 billion by 2050 (Buckinx et al., 2015). Around 10% of people aged over 65 years have frailty, rising to between a quarter and a half of those aged over 85 years (Turner, 2014). Given the increasing number of hospitalised frailty patients, a better adapted discharge summary to improve communication between primary and secondary care is necessary to protect the most vulnerable when returning to the community.
The discharge summary is a communication tool vital to continuity of care, provided the information in the summary is reliable, relevant and received within a reasonable time frame. Improving junior doctor knowledge on social care and therapy terminology is essential to avoid inaccuracies on discharge summaries, poor care continuity, duplication of consultations or community assessments and multiple hospital admissions.
Currently within our trust we have no set standardised guideline of what essential information to include in the discharge summary for patients, and there is variation between the content of letters based upon the clinician who writes them. With regards to frailty, we felt there was a lack of specific information which would be useful to update the patient’s GP upon discharge. A holistic approach to patient care is essential in elderly care, and it is vital for the community healthcare professionals to know if a patient’s mobility status has declined or if they now require a care package at home (Dutta, 2015).
Key items to include in the frailty-specific discharge summary.
Aims
The aims of this audit can be split into two parts in order to improve the interface between primary and secondary care for the vulnerable frail, older patients:
Create a frailty-specific discharge summary to transmit relevant information to the GP to improve the quality of information transfer from secondary care to primary care To improve the knowledge of junior doctors working in elderly care on relevant social care and therapy team terminology, in order to improve the content on the discharge summaries regarding care in the community
Design and intervention
Aim 1
The key criteria seen in Box 1 were utilised as a data collection tool when gathering the initial data. We collated retrospective data of ward discharges in February 2019 utilising the Lorenzo database to access the discharge summaries. Out of a total of 67 admissions in February (total of 28 days), 46 were discharged and their discharge summaries were reviewed. We analysed the discharge letters that were written by the junior doctors working on the frailty ward, to identify if the frailty-specific questions within our data tool were recorded.
After our initial data collection, we discussed our results and the frailty-specific discharge summary questions with junior doctors and consultants in the clinical governance meetings and the weekly elderly-care teaching sessions to highlight the issue. We also printed out the discharge summary key criteria items and placed it next to each computer on the frailty wards, to act as a prompt and reference for junior doctors when writing the discharge summaries. In the future, the frailty-specific discharge summary will be discussed during the induction of each cohort of junior doctors every 4 months when starting their placements on elderly care.
Re-audit of the March admissions was then undertaken utilising the same methodology. Analysis was undertaken for the first 28 days of March to make it an equal comparison to the month of February. Out of a total of 45 admissions in March, 27 were discharged and their discharge summaries were reviewed and audited against the same data collection tool described above.
Aim 2
To explore the knowledge of junior doctors on social care and therapy terminology, a survey was created and distributed during the weekly elderly-care teaching sessions (see Fig. 1 for the results). It was designed to assess whether we could identify gaps in their knowledge that we could address, in order to improve the accuracy of the discharge summaries and their knowledge about continued care into the community.
Social and therapy terms questionnaire accumulated results (n = 15).
After collating the results from the survey, we created posters containing a glossary of the social and therapy terms and definitions for junior doctors to act as a reference. These posters have been distributed across the elderly care wards with the aim of improving junior doctor’s knowledge on these aspects of care, to ensure that accurate information can be used in the discharge summaries. In the future, these posters will be discussed during the induction of each cohort of junior doctors every 4 months when starting their placements on elderly care.
Findings and re-audit results
Percentage increase of each item within the discharge letter pre and post implementation of the frailty-specific discharge summary.
Discussion
Aim 1
Frailty is a distinctive health state related to the ageing process, in which multiple body systems gradually lose their in-built reserves (Turner, 2014). Frail patients often present with an increased burden of symptoms, medical complexity, and reduced tolerance for medical interventions. Awareness of frailty and associated risks for adverse outcomes, and an understanding of its biological basis, can improve care for this most vulnerable subset of patients (Walston, 2019). Continuity of care between secondary and primary services is essential, and the reason why we developed this frailty-specific discharge letter.
As can be seen in Table 1, our interventions between February and March made a drastic impact in all of the frailty-specific items, except for the escalation plan (Gold Standard Framework/palliative care). We believe this is due to it not being applicable to the majority of patients discharged, so the junior doctors did not comment on it in the letter.
The Edmonton Frailty Score (EFS) helps to quantify frailty status and consists of nine domains. A total score of: 0 to 3 indicates no frailty; 4 to 5 indicates pre-frailty; 6 to 8 indicates frailty; and 9 to 17 a severe state of frailty (GPNotebook, 2016). It is routinely measured when frail older patients are admitted to the elderly care ward and compromises the initial part of the clerking proforma. This provides valuable information, as it helps identify patients who may need specialist frailty input and provides an assessment that can be used over time to monitor the progression of a patient’s health. Zero percent of discharge letters in February contained this information, which means valuable assessments undertaken on admission were failing to be communicated to the GPs. Following our intervention, 100% of the discharge summaries in March contained the EFS, which will provide GPs with vital information and if a patient was re-admitted, provide our frailty multi-disciplinary team with a baseline measurement.
Aim 2
Our results showed that 83% of doctors felt unfamiliar with social care and therapy terms on starting their placements in elderly care. This could lead to inaccuracies on the discharge summaries, and therefore, the transfer of wrong information to GPs. An awareness of the social and therapy aspects of patient care is fundamentally important in the elderly population as they often contribute to the reason for the admission and are one of the reasons that delay the discharge once a patient is deemed medically fit. Having a better understanding of these terms would not only help doctors follow multi-disciplinary team) discussions, but also assist when updating patients and family members. Discussing the posters during the induction process when a new team of doctors joins the ward, proactively targets the gaps in knowledge from the start, and we believe this will make a continual positive impact. It optimises patient care and improves the interface between primary and secondary care.
Conclusion
Population demographics have been shifting for the past few centuries and with an ageing population with increasing physical and mental multi-morbidities we are faced with a 21st-century health challenge. The template could be further improved by consultation with colleagues in general practice. However, we believe that there is scope to extend our discharge summary template beyond our hospital trust and implement it nationally, to help the interface between primary and secondary care for frail patients.
