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Rapid Responses: Rapid Responses published:
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The benefits of a strong multidisciplinary team
- Nicola G Lovett (22 February 2009)
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Pity the junior doctor!
- Jan Karmali (24 February 2009)
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The best way to timely deliver the interim discharge letter to the GP
- Elzbieta Wegorowska, Eric Bouvard, Gilles Grateau, Olivier Steichen (26 February 2009)
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Alcohol and Readmission after Hospital Discharge
- Mathis Heydtmann (2 April 2009)
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Nicola G Lovett, ST2 CMT John Radcliffe, Oxford OX3 9DU
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I was very interested to read the article by Katikireddi and Cloud in this week’s issue of the BMJ. I agree that early discharge planning and involvement of a multidisciplinary team, is a key step in decreasing the length of hospital stay for patients. I was fortunate to work for the POPS department (Pro-active care for Older People undergoing Surgery) at Guys and St Thomas’ Hospital, as an SHO in 2007, where elderly patients who were undergoing elective, mainly orthopaedic surgery, were assessed prior to admission by a multidisciplinary team, led by a consultant geriatrician. The aim of this program was to optimise patient’s health, prior to surgery and to anticipate any problems, which may occur around discharge, such as a need for an increased care package for a short while after discharge. This program led to a decrease in length of hospital stay in these patients and a reduction in post operative complications. I would suggest that the early involvement of the multidisciplinary team in this way would benefit patients in other hospital trusts if such a scheme were to be implemented on a wider basis. References 1. Age and Ageing 2007 36(2):190-196 Proactive care of older people undergoing surgery (‘POPS’): Designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients Danielle Harari, Adrian Hopper, Jugdeep Dhesi, Gordana Babic-Illman, Linda Lockwood and Finbarr Martin Competing interests: None declared |
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Jan Karmali, General Practitiioner Waddesdon Surgery HP18 0LY
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Katikireddi & Cloud's article, "Planning a patient's discharge from hospital", is a council of perfection which, in my experience and that of many fellow GPs, rarely translates into real life. Moreover, it underestimates the significant systemic obstacles to achieving this ideal in practice. Inadequate, tardy hospital discharge summaries have long been a bone of contention between GPs and hospitals. Some years ago, on behalf of our PCT, I sat on a working group at our local DGH aimed at improving the quality and promptness of discharge summaries. Most members of the group (all hospital based), but not I, thought the solution would be a computerised discharge summary form which could be collectively completed by members of the multidisciplinary team in advance of the discharge date and be signed off on the day by the junior doctor to be given to the patient on their departure. In the event, this form never materialised, for technical reasons. However, even if it had, I felt it would fail to solve the problem because of the unrealistic expectation that the junior doctor, who needed to fill in the bulk of the clinical information, would be able to complete their part of the process in time. This was difficult enough 20 years ago when I was a junior hospital doctor. In today's chaotic, overstretched acute hospitals, with doctors working shifts, the demise of 'the firm' and its clinical leadership and continuity, and patients scattered throughout the hospital being looked after by rotating doctors, none of whom have personal responsibility for the individual patient, it is rarely possible, as experience has repeatedly shown. It is not the fault of the junior doctor but that of a system which increasingly militates against him or her being able to carry out this vital function. Competing interests: None declared |
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Elzbieta Wegorowska, fellow AP-HP, Tenon Hospital, Internal Medicine Department, 75020 Paris, France, Eric Bouvard, Gilles Grateau, Olivier Steichen
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Katikireddi and Cloud conclude their review on preparing patients’ discharge from the hospital with an important topic: the discharge letter. It is obviously important for GPs to know as soon as possible that their patient was hospitalised and what was undertaken during the stay. Unfortunately, the full discharge summary is often unavailable to the GP at the first post-discharge visit. The reasons are numerous: discharge summaries are not dictated, they are dictated but not typed, typed but sent too late, or sent on time but not received [1,2]. As underscored by Katikireddi and Cloud, the interim discharge letter is an appealing solution to timely provide GPs with the information they need to follow-up their patient. The authors do not discuss the best way to deliver the letter to the GP. The case study suggests that sending the letter by post is an adequate solution. However, hand delivery to the physician by the patient is much more efficient: the median time of delivery was 2.5 days by hand vs. 7.5 days by post in one study [3] and 1 day vs. 4 days in another [4]. The better results in the second study may be due to a written note on the envelope stating that the letter should be delivered to the GP as soon as possible. Indeed, a third study compared delivery by hand with and without such a written note: median times of delivery were 2 and 4 days respectively [5]. Best evidence therefore favours giving the interim discharge letter to the patient, with a reminder note on the envelope urging him to deliver it to the GP as soon as possible. Using both mail and hand delivery would of course increase the probability of the GP getting the discharge letter in time, but would also increase costs. Competing options to get the information timely across could be a phone call [6], a faxed letter [7] or an email [8]. References [1] Penney TM. Delayed communication between hospitals and general practitioners: where does the problem lie? BMJ 1988;297:28-9. [2] van Walraven C, Seth R, Laupacis A. Dissemination of discharge summaries. Not reaching follow-up physicians. Can Fam Physician 2002;48:737-42. [3] Dover SB, Low-Beer TS. Study of "discharge communications" from hospital. BMJ 1986;293:1505. [4] Sandler DA, Mitchell JR. Interim discharge summaries: how are they best delivered to general practitioners? BMJ 1987;295:1523-5 [5] Curran P, Gilmore DH, Beringer TR. Communication of discharge information for elderly patients in hospital. Ulster Med J 1992;61:56-8. [6] Marks MK, Hynson JL, Karabatsos G. Asthma: communication between hospital and general practitioners. J Paediatr Child Health 1999;35:251-4. [7] Paterson JM, Allega RL. Improving communication between hospital and community physicians. Feasibility study of a handwritten, faxed hospital discharge summary. Discharge Summary Study Group. Can Fam Physician 1999;45:2893-9. [8] Branger PJ, van der Wouden JC, Schudel BR, Verboog E, Duisterhout JS, van der Lei J, van Bemmel JH. Electronic communication between providers of primary and secondary care. BMJ 1992;305:1068-70. Competing interests: None declared |
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Mathis Heydtmann, Locum Consultant Gastroenterologist Southern General Hospital, Glasgow, G51 4TF
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Dear Editor, I read the article by Katikireddi and Cloud[1] with great interest. I agree with the importance of early discharge planning. However, I am surprised that alcohol related problems are not mentioned in the article. I recently audited patients admitted to hospital with a diagnosis of alcoholic liver disease in a Glasgow hospital during 1 year (9/2006- 8/2007). Of 124 patients admitted with the diagnosis, 22 died during the initial admission and 102 were discharged and followed up for 1 year. 76 (75%) were re-admitted at least once after discharge. Many re-admissions were early and the average number of re-admissions was 3.2 per patient (mostly emergency admissions). The average duration of the admissions and re-admissions was 12 days accounting for 3887 days in hospital by these patients in the study period. 26 of the patients discharged with alcoholic liver disease died within 1 year, most (22) during a re-admission. Thus 40 % of the population studied died within the period analyzed and the burden for the hospital was enormous. Even though the epidemiology of alcohol related problems is worse in Glasgow and Scotland than the rest of the UK and Western Europe [2], I do not think that this problem is specific to Glasgow.
References: 1) Katikireddi SV, Cloud GC: Planning a patient's discharge from hospital. BMJ. 2008,337:a2694 doi:10.1136/bmj.a2694 2) Leon DA, McCambridge J. Liver cirrhosis mortality rates in Britain from 1950 to 2002: an analysis of routine data. Lancet. 2006 Jan 7;367(9504):52 -6. Figure 1: Re-admission free survival of patients with alcoholic liver disease after being discharged from hospital. (figure will be sent by e- mail) Competing interests: None declared |
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I therefore believe that certainly alcoholic liver disease and in my
experience also other alcohol related problems are an important predictor
for re-admission and worth mentioning as a red flag warning (table 1 of
the authors article). Obviously, these patients do tick many of the other
boxes mentioned in the article such as psychosocial factors and high use
of medical resources.