Abstract
Background
The emergence of the COVID-19 pandemic has placed increased demands on the NHS workforce, especially in medical and intensive care units. The subsequent redistribution of surgical house officers to accommodate this in a single-centre NHS hospital has possibly negatively impacted on the effective discharge notification of acute surgical patients.
Methods
Discharge summaries of all patients directly discharged from a Surgical Assessment Unit were collected on the day of discharge and analysed to identify the date of completion and staff grade of the responsible clinician. Data collection was carried out before the initiation of lockdown measures and continued for a further three weeks during the peak of the COVID-19 pandemic with an interventional period in between. A poster was created and displayed in areas where discharge software could be accessed.
Results
In the initial audit, 36.2% of the 246 patients had delayed discharge summaries with an average of 7 days to complete. On re-evaluation, 45.3% of the 223 patients had delayed discharge summaries, taking an average of 12 days to complete. A survey conducted post-re-audit identified that the most common reason for delayed discharge summaries was due to time constraints associated with the increased workload.
Conclusion
The reallocation of surgical staff in response to the COVID-19 pandemic has affected communication between primary and secondary care, with a rise in delayed discharge letters of acute surgical patients. Given the potential repercussions of these delays, healthcare systems should be aware of this consequence of the pandemic, especially in preparation for any resurgences.
Introduction
Since the emergence of COVID-19 (SARS-CoV-2 virus) in the UK, and initiation of the subsequent lockdown, there has been a redistribution of medical staff in NHS hospitals to prepare for and accommodate increased demand in medical and intensive care units.1–4 In surgical units in Wales, many elective procedures have been postponed or cancelled, and several surgical wards have been transformed into medical wards to accommodate the sudden increase in Coronavirus-suspected and Coronavirus-infected patients.3,4 In a single-centre NHS hospital, surgical house officers (HO) were relocated to medical specialties to meet this high demand from Coronavirus patients.1–4 Consequently, the remaining surgical staff (primarily core surgical trainees and registrars) were left filling the gap made by the sudden decrease in junior grades. This meant that surgical trainees not only had to fulfil their existing emergency surgical requirements but were also responsible for completing discharge summaries for patients. Usually, this is the responsibility of surgical house officers.
Since the absence of surgical house officers’ support on acute surgical wards, ward staff have noticed that there has been an increase in incomplete/delayed discharges of acute surgical patients. This study aims to identify the impact of the Coronavirus (SARS-CoV-2 virus) pandemic on the completion of discharges of acute surgical patients and to educate staff on improving compliance of completing discharge summaries as per the local guidelines.
Methods and materials
According to the Guidance of Audit and Implementation Network 2011, it is recommended that patients should receive an immediate discharge summary upon discharge from the hospital and a final discharge document within the next five days. 5 However, local Health Board guidelines dictate that it is best practice to complete discharge summaries within a day of discharge. 6 Discharge summaries were completed online and there were a total of four computers on SAU for doctors to use.
The study involved discharge summaries of all patients who were discharged from the Surgical Assessment Unit (SAU) of a single, district general hospital with a catchment area of 600,000 people. Discharge summaries were collected on the day of discharge and analysed to identify the date of completion and grade of the responsible clinician. Clinicians captured in the study included surgical house officers and surgical trainees ranging from senior house officers, core surgical trainees, registrars, and consultants. A surgical house officer is defined as a junior doctor who is in their first year of practice after graduation. Surgical trainees are doctors who are currently in surgical training comprising various stages/grades.
Delayed discharge summaries have been an ongoing issue at the local centre. An initial audit carried out over three weeks between the 12th February to the 5th March 2020 was chosen as a measure of current practice before the initiation of lockdown measures. An interventional poster was placed strategically around surgical workstations to raise awareness highlighting the failings in current practice and illustrating the potential consequences of these in anticipation of staff shortages at the peak of the Coronavirus pandemic. A re-audit was later carried out for a further three weeks between the 30th of March to the 24th of April 2020 to demonstrate the impact of junior staff redistribution to medical wards at the peak of the Coronavirus pandemic.
To reduce the Hawthorne effect, surgical trainees and surgical house officers were notified that an audit of incomplete/delayed discharge summaries would be carried out across three months but were not told when data collection would take place. The data collected was then compared to the local Health Board guidelines. The anonymity of clinicians was maintained throughout too. Following the results of the re-audit, a survey in regard to the completion of discharge summaries was distributed to surgical clinicians of all grades to assess the general perception. Data were analysed using background statistics (i.e. mean, median and range in days) on Excel. A Chi-squared test was used to compare and identify any significant improvement between the initial audit and the re-audit.
This study did not require the approval from the Human Subjects Review Committee as all data were analysed anonymously, information obtained was not acquired through intervention or interaction with patients and the results do not contain identifiable private information.
Results
A total of 469 discharge summaries were reviewed in this study over two periods.
Before the peak of the SARS-CoV-2 virus pandemic – 12th February till 5th March 2020
In the initial audit, 246 patients attended SAU. Of these, 36.2% (n = 89) had incomplete/delayed discharges. In order to quantify whether a discharge summary was incomplete, a cut-off date of 10 days after the initial audit was used. Of the delayed/incomplete discharge summaries, it took an average number of 7 days for the discharge summary to be completed, a median of 4 days, and with a range of 2 to 58 days. Ten days following the close of the re-audit, the longest delay for a pending discharge was 77 days (still pending). By staff grade, house officers were responsible for 77.5% (n = 69) of still pending discharge summaries, and senior house officers were responsible for 19.1% (n = 17).
During the peak of the SARS-CoV-2 virus pandemic – 30th March till 24th April 2020
During the re-audit, 223 patients presented to SAU, of which 45.3% (n = 101) had incomplete/delayed discharges. In order to quantify whether a discharge summary was incomplete, a cut-off date of 10 days after the re-audit was used. It took an average of 12 days for delayed discharges to be completed, a median of 12 days, and the range was 2 to 30 days. In comparison to the initial audit, 41.6% (n = 42) of pending discharges were from senior house officers and 57.4% (n = 58) from registrars. A Chi-squared test proved that there was significant improvement (p = 0.0447) between the initial and re-audit data, supporting the use of the interventional poster.
Survey
A total of 16 (50%) surgical staff members completed the survey; 50% (n = 8) were from Colorectal Surgery, 25% (4) from Upper Gastrointestinal Surgery, and 25% (n = 4) from Vascular Surgery. Over a third of responses were by house officers, 31.3% (n = 5) were by consultants, 18.8% (n = 3) were by registrars, 12.5% (n = 2) were by senior house officers. Of those who completed the survey, 43.8% (n = 7) responded that discharge summaries should be completed immediately with a further 43.8% (n = 7) within one day. The majority, 93.8% (n = 15) of participants stated they were aware of the impact of delayed discharges. The most common reason (80%, n = 12) for not completing discharge summaries within one day was due to time constraints associated with the job. All of the respondents were aware of the impact of delayed discharges such as its effect on continuity of patient care in the community, General Practitioner’s awareness to continue/stop/change medication prescriptions, the expedition of booking/referral of scans, clinics, and procedures, the summary of recent admission and medicolegal implications.
Discussion
Statement of principal findings
Delayed discharge summaries are a recurring problem across multiple tertiary hospitals.7–11 The study shows that 45.3% (n = 101) of acute surgical patients had a delayed discharge summary as a result of the pandemic. Despite the majority (93.8%, n = 15) of surgical trainees and junior doctors being aware of the impact of delayed discharges, there was an increasing number of incomplete or delayed discharges due to the time constraints associated with the increased workload.
Strengths and limitations
To the knowledge of the authors, this study is the first study reporting the effect of the COVID-19 pandemic on the completion of discharge summaries for acute surgical patients. As discharge summaries play a key communicative role between primary and secondary care, the findings of the study raise a red flag to surgical units in other hospitals nationally.
However, some limitations should be noted. The cancellation and postponement of many elective surgical procedures and several surgical wards being transformed into medical wards to accommodate the sudden increase in Coronavirus-suspected and Coronavirus- infected patients3,4 resulted in a relatively small study (n = 469). The interventional poster proved effective in making a significant improvement (p = 0.0447), despite the multiple changes made to the staff rota and uncertainty of staff availability (i.e. in self-isolation or working). This further emphasises the impact of the Coronavirus pandemic on the completion of discharge summaries of acute surgical patients.
Besides that, the study did not take into consideration the length of stay or complexity of patients in both the initial audit and re-audit. Nevertheless, the authors do not consider this to be a significant cause of delayed discharge summaries. Clinicians are responsible for completing discharge summaries within respectable time frames and should be given priority to avoid potential medicolegal implications. Furthermore, the study only covered the surgical assessment unit of a single-centre institution, albeit being the worst-hit COVID- 19 hospital outside of London.12,13 Hence, the findings may not be applicable to all hospitals in the UK. The authors also acknowledge that the time frame and protocols for completing discharge summaries may also differ in other hospitals.
Interpretation within the context of the wider literature
Discharge summaries remain an essential part of communication between primary and secondary care in relaying important information not only on inpatient events, but also essential follow-up and medication reconciliation.5–10 Furthermore, discharge summaries are also valued by patients and can help improve their understanding of their clinical condition, hence, improving patient autonomy.11,14 Several studies have also identified that delays in submission of discharge summaries have caused significant consequences such as an increased rate of readmission 7 and inappropriate restarting of medications, resulting in readmission and risk of medication errors.15,16
Implications for policy, practice and research
The authors hope that the findings of the study raise awareness, among policymakers, on the importance of allocating time for discharge summaries to be completed at the end of each shift. Moreover, departmental leaders should ensure that doctors are equipped with the necessary training on how to complete discharge summaries comprehensively, highlighting the importance of discharge summaries in promoting safe practice. The authors too recommend trainees to carry out regular audits and to present their findings at departmental ‘Quality and Safety’ meetings. This is to ensure that discharge summaries are completed promptly to prevent further delays in communication between primary and secondary care. Most importantly, trainees need to be aware of the consequences of delayed and incomplete discharge summaries on patient safety and risk management, to improve current practice and enhance patient care.
Conclusion
Overall, this study demonstrated that, despite clinicians’ perception of discharge summaries and its importance, there is still room for improvement. The COVID-19 pandemic has affected communication between primary and secondary care with the rise in incomplete or delayed discharge summaries of acute surgical patients. As mentioned previously, there are several potentially harmful consequences resulting from delayed completion of discharge summaries. Therefore, surgical units should be aware of the effect of the COVID-19 pandemic on safe patient discharge, especially in preparation for any further disruption to the workforce, and also to avoid any medicolegal implications caused by resurgences of the pandemic.
Footnotes
Contributorship
RO created the concept and design of the study. RO and IBS collected and analysed the data. RO and IBS critically appraised current literature and contributed to the write up of the paper. GW supervised the study and was involved in the write up of the paper. All authors approved the final version of the manuscript for submission. RO is the guarantor of the study.
Acknowledgements
The authors would like to thank all staff on the Surgical Assessment Unit, Royal Gwent Hospital for collecting relevant documentation. The authors would also like to thank Catherine Price, Helen Slater and Bethan Benger for their assistance with data collection.
Data availability
The authors confirm that all supporting information and data are available from the authors on request.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
