What makes a “successful” or “unsuccessful” discharge letter? Hospital clinician and General Practitioner assessments of the quality of discharge letters

Abstract

Background Sharing information about hospital care with primary care in the form of a discharge summary is essential to patient safety. In the United Kingdom, although discharge summary targets on timeliness have been achieved, the quality of discharge summaries’ content remains variable. Methods Mixed methods study in West Midlands, England with three parts: 1. General Practitioners (GPs) sampling discharge summaries they assessed to be “successful” or “unsuccessful” exemplars, 2. GPs commenting on the reasons for their letter assessment, and 3. surveying the hospital clinicians who wrote the sampled letters for their views. Letters were examined using content analysis; we coded 15 features (e.g. “diagnosis”, “GP plan”) based on relevant guidelines and standards. Free text comments were analysed using corpus linguistics, and survey data were analysed using descriptive statistics. Results Fifty-three GPs participated in selecting discharge letters; 46 clinicians responded to the hospital survey. There were statistically significant differences between “successful” and “unsuccessful” inpatient letters (n = 375) in relation to inclusion of the following elements: reason for admission (99.1% vs 86.5%); diagnosis (97.4% vs 74.5%), medication changes (61.5% vs 48.9%); reasons for medication changes (32.1% vs 18.4%); hospital plan/actions (70.5% vs 50.4%); GP plan (69.7% vs 53.2%); information to patient (38.5% vs 24.8%); tests/procedures performed (97.0% vs 74.5%), and test/examination results (96.2% vs 77.3%). Unexplained acronyms and jargon were identified in the majority of the sample (≥70% of letters). Analysis of GP comments highlighted that the overall clarity of discharge letters is important for effective and safe care transitions and that they should be relevant, concise, and comprehensible. Hospital clinicians identified several barriers to producing “successful” letters, including: juniors writing letters, time limitations, writing letters retrospectively from patient notes, and template restrictions. Conclusions The failure to uniformly implement national discharge letter guidance into practice is continuing to contribute to unsuccessful communication between hospital and general practice. While the study highlighted barriers to producing high quality discharge summaries which may be addressed through training and organisational initiatives, it also indicates a need for ongoing audit to ensure the quality of letters and so reduce patient risk at the point of hospital discharge.

Discharge communication study: a realist evaluation of discharge communication experiences of patients, general practitioners and hospital practitioners, alongside a corresponding discharge letter sample

“…► 53 GPs were recruited from 18 practices within the West Midlands (UK) through the local Clinical Research Network and Warwick Medical School links with practices. ► They were asked to purposively sample 24 14-24 recent (<3 weeks) discharge letters in accordance with the inclusion and exclusion criteria (see table 1). ► Each GP completed a discharge letter selection template (see online supplemental file 1) with their discharge letter grading (successful or unsuccessful) and their comments.…”

“…In brief, GPs were asked to screen (see table 1 for screening criteria) and select a sample of recently received discharge letters according to what they considered to be ‘successful’ or ‘unsuccessful’ letter exemplars; for each letter, GPs were asked to complete the selection proforma ( online supplemental file 1 ) and rate the letters ‘successful’ or ‘unsuccessful’. 24 There were no set criteria for letter ratings as the selection was based on each participating GP’s interpretation of what makes a successful or unsuccessful discharge letter. 24 This purposive 25 letter sampling approach was intended to increase sample diversity and address the research questions within dichotomous contexts.…”

“…Recruitment and data collection took place, as detailed in previous publications [21][22][23][24] between August 2017 and September 2018. In brief, GPs were asked to screen (see table 1 for screening criteria) and select a sample of recently received discharge letters according to what they considered to be 'successful' or 'unsuccessful' letter exemplars; for each letter, GPs were asked to complete the selection proforma (online supplemental file 1) and rate the letters 'successful' or 'unsuccessful'.…”

“…Finally, the hospital professionals who wrote or signed the sampled discharge letters were sent an invitation pack by the research team; this invited them to take part in a survey on their evaluation of the discharge letter they wrote, their current practices and their views about how discharge communication processes may be improved. 24 Packs were sent by post and email as well as being internally distributed by hospital sites. For this study, we reinterpreted data collected across all of the other studies.…”

“…They were asked to purposively sample 24 14–24 recent (<3 weeks) discharge letters in accordance with the inclusion and exclusion criteria (see table 1 ).…”