Aneurin Bevan Health Board Discharge Summaries 1 Introduction The timeliness of transfer of care communication between hospital clinicians and GPs at the point of discharge has been a constant issue for many years. The conversion of paper based discharge summaries into electronic discharge notifications allied with the ability to transmit those notifications directly to GP practices electronically has provided the opportunity to tighten clinical operational processes and, with effective performance management, improve the timeliness of transfer of care communications to the benefit of patient care. The Board is asked to note for information the progress made. Financial Assessment and link to Financial Recovery Plan Risk Assessment Annual Quality Framework Standards for Health Services Wales Equality Impact Assessment There are no financial considerations Risks associated with electronic clinical communication are maintained with the Informatics Programme portfolio Timely transfer of care communication at discharge has an important contribution to the reduction of readmission rates and therefore is part of the Integration within health and with partners AQF agenda This work contributes to Standards 6, 7 & 8 Equality Impact Assessment is not required as this transfer of care communication applies to all patients and is a normal part of the care process 1
2 Background Patient safety & readmissions There is a well established literature on the importance of timely and properly completed discharge summaries in post discharge care to maintain both patient safety and reduce the risk of patient readmission to hospital. The Institute for Health Improvement s literature review and compendium of promising interventions to reduce readmissions highlights the importance of discharge communication between hospital and primary care clinicians. IHIs own readmission prevention programme recommends 4 action areas, the third of which is to provide real-time handover communications including medicines reconciliation at discharge and providing customised, real-time critical information to next clinical care providers. ABHBs e-discharge project provides this function. E-Clinical Communications Programme The e-discharge Project sits within the e-clinical Communications Programme that oversees the development and implementation of local and national systems that support clinicians in everyday tasks of clinical communication. The ability to maximise opportunities presented to improve essential clinical operational processes that underpin safe and effective patient care by moving from paper based to paperless electronic systems is a cornerstone of the Health Board s Informatics Programme The e-clinical Communications Programme remit includes: Welsh Clinical Communications Gateway (WCCG) a national product now replacing the local Gwent e-referral product that allows GPs to make referrals and receive discharge notifications and in the near future other clinical correspondence electronically. Hospital workflow - moves referrals to clinicians after registration for paperless triage, prioritisation and effective routing to diagnostics and appointment booking Medical secretaries paperless letter writing and on-line approval of letters by clinicians Digital Dictation the ability to dictate letters on-line for preparation by medical secretaries without recourse to Dictaphones linked to medical secretaries system e-discharge electronic discharge summary production including clinical information and reconciled medications 2
Internal referrals plans to use WCCG to support e-referral for internal referrals where required The programme links with NWIS user groups and service boards for WCCG and Hospital Electronic Referral Systems. 3 e-discharge project Phase 1 Design & implementation of e-discharge notification The first phase of this project was to replace paper no carbon required discharge notification forms and dictated discharge summaries with a single standard design and content discharge notification using Clinical Workstation. The electronic version would include clinical and medication templates to form a summary of the patient s admission and provide GPs with the information required to manage care after discharge. These templates can be completed incrementally and independently but with the expectation that this will begin on admission ready for final details to be entered on discharge. Details are completed by doctors and some advanced nurse practitioners and the medications are checked by pharmacy staff. These staff can easily access their DNs from lists and notifications on CWS which show the status and progress of completion. A project team consisting of clinicians, pharmacists from both primary and secondary care and informatics staff undertook this work. The product was introduced in November 2007. At this time the discharge notification was produced and held on CWS but was still printed and posted to GPs. Between 2007 and 2012 the product was rolled out to 64 wards across the Health Board. About 4,000 DNs are produced per month. Current project scope includes all patients discharged from wards in ABHB hospitals, who were admitted onto CWS. Exclusions are Mental Health, A&E departments and most daycase patients whose activity is recorded on epex, Symphony and the ORMIS theatre system. Phase 2 Introduction of electronic transmission of the electronic discharge notification In 2011 the Health Board worked with NWIS to develop and implement the transmission of discharge notifications via WCCG directly to GP surgeries. This allows the immediate transmission of the discharge notification to the practice on 3
completion of the two elements reconciled medications and clinical information. Roll-out to practices has been undertaken since November 2011. 84 practices now receive electronic discharges including 2 in Powys. Over 40,000 discharge notifications have been sent via this route. At preparation of report, 7 practices remain outside of this project but several of these now have plans to adopt e-discharge notifications. Over 80% of discharge notifications are now sent electronically Graph 1: DNs & electronic DNs as a percentage of total DNs 7000 Discharge Notifications (DNs) sent March 2011 to Jan 2013 & e-dns sent as a percentage of total DNs 90%. No DNs (Green & Blue lines) 6000 5000 4000 3000 2000 1000 0 Mar-11 Apr-11 e-discharge Notifications using WCCG start Nov 2011 Total Discharge Notifications completed on CWS % Discharge Notifications sent electronically May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Phase 3 consolidation of roll-out and performance management of discharge summary production In March 2012 a monthly Discharge Summary Action Group was established by the Medical Director. The group had two purposes, to support the ongoing roll-out process and to work with consultants to ensure the system is being utilised to its maximum potential in the interest of patients. Action Group membership includes clinical representation from GPs, LMC, surgical and medical consultants, informatics staff and from planning & service improvement. In this time there has been significant roll out progress including to high volume areas of medical assessment units at RGH, NHH and YYF. 80% 70% 60% 50% 40% 30% 20% 10% 0% % DNs sent electronically (red) Just under 6,000 discharges are now completed through the discharge notifications module on CWS each month. Since March 2012 there has been a statistically significant 4
improvement in the discharge notification completion rate for patients discharged in month which can be attributed to interventions planned and implemented from this group. A Discharge Notification Policy is in draft form to underpin this work including a requirement for on the day discharge notification completion in most instances and will be shortly shared with partners and clinicians before final approval. Graph 2: Discharge Notification completion rate 100% ABHB Discharge Notification Completion Rates March 2011 to January 2013 Median 90% % Completion 80% DSAG starts 0.79 70% 2 shifts one beneath & one above median line No. runs = 4 (3+1) No. data points = 22 significant as runs < 10 60% Mar 11 Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Jul 12 Aug 12 Sep 12 Oct 12 Nov 12 Dec 12 Jan 13 Month 4 Recommendations The Board is asked to note the progress to improve clinical performance in timely completion of discharge notifications and the key role that informatics systems have in service improvement for the benefit of patients Sponsored by: Dr Grant Robinson Medical Director Prepared by: John Frankish Senior Service Planning & Improvement Manager Date: February 2013 Brenda Chetcuti Systems & Implementation Manager 5