Medicines in the Discharge Summary: Addressing Gaps and Improving Communication

1. It’s time to talk:“Medicines information in the Discharge Summary”Presenter Insert your hospital logo here

2. Aims • To provide an understanding of the typical gaps seen in the provision of discharge medicines information to GPs. • To describe practical and efficient methodologies to address gaps and communicate comprehensive medicines information on the discharge summary • To gain feedback on current challenges when attempting to complete comprehensive discharge summary medicines information

3. -Case report 1 • Patient presents to hospital after generalised tonic-clonic seizure- first one. • Patient commenced on Phenytoin • Required to remain in hospital for an extended period due to sub-therapeutic Phenytoin level • Discharge medicines list stated the patient was on 450mg Phenytoin at night. Patient’s carer reports to GP that the dose is 300mg at night. (unpublished) What safety issues does this raise for the GP? How could these have been avoided?

4. -Case report 2 • Patient presents to hospital for admission due to ischaemic foot:occluded left popliteal artery • PMHx includes: PVD, HTN, Hypercholesterolaemia, IHD, GORD, THR(Right) • Patient remained in hospital 3wks… • Discharge medication list: “Aspirin” (unpublished)

5. The discharge summary: why is it needed and what is required? Needs: • Frequently, the discharge summary is the only communication provided to the General Practitioner (GP) about their patients’ and the events that occurred whilst their patients’ were in hospital. Requirements: • Complete • Accurate • Legible • Concise

6. What is the evidence- gaps in practice? Evidence in Australia and internationally shows there are deficiencies in the quality of the information documented in the discharge summary for GPs, Patients and Carers

7. Completing high quality discharge summaries NEHTA Continuity of Care program March 2010* Barriers include: • lack of support • time • uncertainty over what information a GP desires *Continuity of Care Program- National E-Health Transition Authority, March 2010: Issues and barriers faced by Junior Hospital Doctors for the Implementation of the Discharge Summary

8. What do we want to achieve? Improvement happens slowly over time…we need a starting point: Discharge medication list in the discharge summary Specifically, improve documentation to include: • All medications a patient is to continue taking after discharge • All explanations for changes to medication therapy • Ceased medications

9. Defining “changes” to and “explanations” for medication therapy? Refers to changes to the patient’s pre-admission regimen which are intended to continue after discharge2 New medication Change in the dose, form, route or frequency of a medicine taken prior to admission Cessation of a medicine taken prior to admission Explanations for changes: Should include sufficient detail to inform future management decisions in the discharge summary or discharge letter.

10. Throughout the patient journey…

11. Top Tips • Know where the Best Possible Medication History (BPMH) is located (In our hospital, the BPMH is located…) Why? • Consistency • Collation (reconciliation)

12. Top Tips continued… 2. ALWAYS document as you go; the changes made to medications and ceased medications, WITH reasons - if you don’t know why, please ASK! Why? • Safety and continuity of care • Clarification

13. At patient discharge…

14. Top Tips 1. Include all medications the patient is to take after hospital discharge on the discharge summary Why? • To ensure continuity of care • To save your time Remember! Any change made on the prescription must have the equivalent change made on the discharge summary

15. Top tips continued… 2. Document explanations for changes to medicine therapy as described in patient notes. Why? • Clarifies the intention of the medication change • Is the final medication record prior to discharge • Time saving Ensure explanations are placed in the appropriate area

16. Top tips continued…. 3. Legibility! Why? Communication…. -This document is only effective when the information can be clearly understood. -It will be used by GPs, patients and/or carers -It may even be referred to again by you or clinicians in your hospital at next admission/appointment

17. The good, the great and the ugly… What a GP needs versus what is provided

18. Good D/C Summary • Please insert your discharge summary here

19. Questions? • Discussion

20. Where to from here? NSW Therapeutic Advisory Group Discharge Summary Improvement Program Tools to assist: • Lanyard cards • Term Supervisor walk-through for use at assessment time Practice and reflection

21. Support • Hospital coordinator contact: XXXX • Clinical Champion: XXXX • Other

22. Workshop discharge summary examples

23. Continuing improvements • 3 common problems with the discharge medicines list: unjustified and omitted medicines, changes to dose, route, frequency. • What can you do in your every day practice to assist continuity of patient care and patient safety in order to write the best possible discharge summary for your patient’s? • TOP-TIPS lanyard cards