A better discharge summary

Discharge summaries, often considered the bane of every junior doctor and ED physician’s existence. But what if we took a step back and considered these as a clinical handover to primary care – similar in nature to the clinical handover that occurs in the transfer of care documents that you would send with a patient you are transferring to another hospital? They suddenly take on a whole other level of importance. Studies from the ‘adult medicine world‘ have shown that roughly 20% of patients experience an adverse event during the hospital-to-home transition, many of which could be mitigated by good handover between the hospital and the primary care provider.

We often talk about communication, ‘closing the loop’, being kind to one another, referring to each other by name, but rarely does written communication with our primary care counterparts get mentioned. But these documents are more than just a task to tick off the to-do list, or an extra piece of paperwork. They are how we handover care to our GPs, the people providing the ongoing care (and a lot of the grunt work) for our patients.  (Ed. note: and as a secondary use – it is how our institutions get funded). Clear, concise and timely discharges promote high quality patient care and safety and prevent unintentional harms.

We take much effort and preparation when handing a patient over from the ED to the ward, or when making a consult to another team, but are often surprisingly flippant regarding the clinical handover to primary care once a patient leaves our institution. I know I am personally guilty of hammering out discharges for patients I have never met after wading through what may be weeks of documentation from the team. My institution (and I am sure many others), roster junior doctors on a ‘discharge’ shift every weekend where their sole job is pump out discharges. Whilst this may be effective for patient flow, what impact is this having on patient safety? And how can we improve?

This lack of enthusiasm and apathy towards discharge summaries may be secondary to the fact we are never formally taught how to do them and that most guidance on how to compose  a discharge letter comes in the form of Chinese whispers from those who have gone before us, or we resort to copy-pasting with small edits. Mclean, et al.  have recently published a series of articles suggesting a method of clinical handover they call KISBAR, adapting the tradition face-to-face handover we use every day into appropriate, effective communication with our primary care colleagues. This does away with the pejorative “GP to chase” and mandated “refer patient to Paediatric gastroenterology”.

So how do we write a good discharge summary? What do GP’s actually want? Here are some Top 10 do’s and don’ts of communication with GPs:

1. Do make the pertinent points clear – such as results pending, important follow up or major changes – Busy GPs may get hundreds of discharge summaries a week
2. Don’t forget the patient – Include them in the process, aim to discuss the document with them and ensure they understand it before they leave the hospital
3. Do start from the beginning of the admission/presentation – Explain how and why the patient ended up in hospital and what your team did for them. 
4. Don’t hide the needle in the haystack by copy-pasting bulk investigations – Summarise significant results 
5. Do identify who the GP is, and who else is involved in the patients’ care.
6. Don’t ask the GP to ‘chase’ results, they really don’t like it.  Think about how you are going to communicate a pending result to the GP and let them know what you would like them to do with It if it is abnormal.
7. Do include all medication changes and why they occurred
8. Don’t just copy-paste your ED assessment into a discharge summary – take the time to summarise the case – it may also present a useful learning opportunity to synthesize the information. 
9. Do include details of follow up appointments, and ensure the patient is aware they need to follow up with their GP. 
10. Don’t do discharge summaries in your own time – Claim overtime!  Clinical handover to primary care is a key clinical task and the system needs to change to recognise this.  The current culture around “discharge summaries” is reflective of an unhealthy system – we can collectively demand better

Selected References:

Leyenaar, J.K.; Bergert, L.; Mallory, L.A.; Engel, R.; Rassbach, C.; Shen, M.; Woehrlen, T.; Cooperberg, D. & Coghlin, D. Pediatric primary care providers’ perspectives regarding hospital discharge communication: a mixed methods analysis. Academic Paediatrics, 15(1), 2015. pp 61-68

Mclean, K.; Rice, M.; Leeuwenburg, T. Clinical handover to primary care – what GPs need. MJA InSight+ 2019.