Given the increasing number of frail hospitalised patients, a better adapted discharge summary to improve communication between primary and secondary care is necessary to protect the most vulnerable when returning to the community. The discharge summary is a communication tool vital to continuity of care, provided the information in the summary is reliable, relevant, and received within a reasonable time frame.
Percentage increase of each item within the discharge letter pre- and post-implementation of the frailty-specific discharge summary.
We created a frailty-specific discharge summary to transmit relevant information to the GP. It included the following key information: Edmonton frailty score, do not attempt cardiopulmonary resuscitation (DNACPR) status, living status and home support services, cognitive status, mobility status, and escalation plan including palliation and Gold Standard Framework. We also created posters containing a glossary of social and therapy terminology to educate junior doctors after discovering via surveys that 83% of the doctors felt unfamiliar with these terms on starting their older care placements. This could lead to the transfer of wrong information to GPs. Improving junior doctor knowledge on social care and therapy terminology is essential to avoid inaccuracies on discharge summaries, poor care continuity, duplication of consultations or community assessments, and multiple hospital admissions. These posters will be discussed in the departmental inductions for new staff members every 4-month rotation.
Having educated the doctors on the frailty ward what key information should be contained on the discharge letters and implementing the frailty-specific discharge letter to the GP, patient care and continuity have been optimised, helping the interface between primary and secondary care.
- © British Journal of General Practice 2019
