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What makes a “successful” or “unsuccessful” discharge letter? Hospital clinician and General Practitioner assessments of the quality of discharge letters
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.
Journal Article
Researching quality in care transitions : international perspectives
\"This book is concerned with the complexities of achieving quality in care transitions. The organization and accomplishment of high quality care transitions relies upon the coordination of multiple professionals, working within and across multiple care processes, settings and organizations, each with their own distinct ways of working, profile of resources, and modes of organizing. In short, care transitions might easily be regarded as complex activities that take place within complex systems, which can make accomplishing high quality care challenging. As a subject of enquiry, care transitions are approached from many research, improvement and policy perspectives: from group psychology and human factors to social and political theory; from applied process re-engineering projects to exploratory ethnographic studies; from large-scale policy innovations to local improvements initiatives. This collection will provide a unique cross-disciplinary and multi-level analysis, where each chapter presents a particular depth of insight and analysis, and together offer a holistic and detail understand of care transitions.\"-- Provided by publisher.
Book
Linking Dynamic Water Storage and Subsurface Geochemical Structure Using High‐Frequency Concentration‐Discharge Records
Shifts in water fluxes and chemical heterogeneity through catchments combine to dictate stream solute export from the Critical Zone. The ways in which these factors emerge in resultant concentration‐discharge (C‐Q) relationships remain obscure, particularly at the timescale of individual precipitation and discharge events. Here we take advantage of a new high‐frequency, multi‐element and multi‐event stream C‐Q data set. The stream solute concentrations of seven major ions were recorded every 40 min over five flood events spanning one hydrologic year in a French agricultural watershed (Orgeval) using a lab‐in‐the‐field deployment we refer to as a “River Lab.” We focus attention on the recession periods of these events to consider how geochemical heterogeneity within the catchment translates into dynamic stream solute concentrations during shifts in water storage. We first show that for C‐Q relationships resulting from data acquisition over multiple flood events, lumping all trends together can lead to biases in characteristic C‐Q parameters. We then reframe C‐Q relationships using a simple recession curve analysis to consider how hydrological processes produce chemical mixing of distinct solute pools immediately following discharge events. We find three distinct classes of behavior among the major solutes, none of which can be interpreted based on water storage changes alone. The shape of C‐Q relationships for each solute can then be related to their vertical zonation in the subsurface of Orgeval, and to the capacity for subcomponents of these distributions to be readily mobilized during a discharge event. Key Points We combine high‐frequency (every 40 min) stream chemistry data and stream discharge recession analysis We propose a conceptual model for the relationship between water storage and solute export at the Orgeval Critical Zone Observatory (CZO), France Three classes of solute behavior are identified at the Orgeval CZO, related to the role of rock dissolution and amendments in their budget
Journal Article
Submarine groundwater discharge as a major source of nutrients to the Mediterranean Sea
The Mediterranean Sea (MS) is a semienclosed basin that is considered one of the most oligotrophic seas in the world. In such an environment, inputs of allochthonous nutrients and micronutrients play an important role in sustaining primary productivity. Atmospheric deposition and riverine runoff have been traditionally considered the main external sources of nutrients to the MS, whereas the role of submarine groundwater discharge (SGD) has been largely ignored. However, given the large Mediterranean shore length relative to its surface area, SGD may be a major conveyor of dissolved compounds to the MS. Here, we used a ²²⁸Ra mass balance to demonstrate that the total SGD contributes up to (0.3–4.8)⋅10 ¹² m ³⋅y ⁻¹ to the MS, which appears to be equal or larger by a factor of 16 to the riverine discharge. SGD is also a major source of dissolved inorganic nutrients to the MS, with median annual fluxes of 190⋅10 ⁹, 0.7⋅10 ⁹, and 110⋅10 ⁹ mol for nitrogen, phosphorous, and silica, respectively, which are comparable to riverine and atmospheric inputs. This corroborates the profound implications that SGD may have for the biogeochemical cycles of the MS. Inputs of other dissolved compounds (e.g., iron, carbon) via SGD could also be significant and should be investigated.
Significance The Mediterranean Sea (MS) is one of the most oligotrophic seas in the world, and external inputs of nutrients are especially relevant to sustaining primary productivity in this basin. Here we evaluate the role of submarine groundwater discharge (SGD) as a source of nutrients to the entire MS, a pathway that has been largely overlooked. This study demonstrates that SGD is a volumetrically important process in the MS, is of a larger magnitude than riverine discharge, and also represents a major source of dissolved inorganic nitrogen, phosphorous, and silica to the MS.
Journal Article
Patient Activation and 30-Day Post-Discharge Hospital Utilization
ABSTRACT
BACKGROUND
Patient activation is linked to better health outcomes and lower rates of health service utilization. The role of patient activation in the rate of hospital readmission within 30 days of hospital discharge has not been examined.
METHODS
A secondary analysis using data from the Project RED-LIT randomized controlled trial conducted at an urban safety net hospital. Data from 695 English-speaking general medical inpatient subjects were analyzed. We used an adapted, eight-item version of the validated Patient Activation Measure (PAM). Total scores were categorized, according to standardized methods, as one of four PAM levels of activation: Level 1 (lowest activation) through Level 4 (highest activation). The primary outcome measure was total 30-day post-discharge hospital utilization, defined as total emergency department (ED) visits plus hospital readmissions including observation stays. Poisson regression was used to control for confounding.
RESULTS
Of the 695 subjects, 67 (9.6 %) were PAM Level 1, 123 (17.7 %) were Level 2, 193 (27.8 %) were Level 3, and 312 (44.9 %) were Level 4. Compared with highly activated patients (PAM Level 4), a higher rate of 30-day post-discharge hospital utilization was observed for patients at lower levels of activation (PAM Level 1, incident rate ratio [IRR] 1.75, 95 % CI,1.18 to 2.60) and (PAM Level 2, IRR 1.50, 95 % CI 1.06 to 2.13). The rate of returning to the hospital among patients at PAM Level 3 was not statistically different than patients with PAM Level 4 (IRR 1.30, 95 % CI, 0.94 to 1.80). The rate ratio for PAM Level 1 was also higher compared with Level 4 for ED use alone (1.68(1.07 to 2.63)) and for hospital readmissions alone (1.93 [1.22 to 3.06]).
CONCLUSION
Hospitalized adult medical patients in an urban academic safety net hospital with lower levels of Patient Activation had a higher rate of post-discharge 30-day hospital utilization.
Journal Article
Potential role of permafrost thaw on increasing Siberian river discharge
Despite the increasing Siberian river discharge, the sensitivity of streamflow to climate forcing/permafrost thawing is poorly quantified. Based on the Budyko framework and superposition principles, we detected and attributed the changes in streamflow regimes for the three great Siberian rivers (Ob, Yenisei, and Lena) during 1936–2019. Over the past 84 years, streamflow of Ob, Yenisei and Lena has increased by ∼7.7%, 7.4% and 22.0%, respectively. Intensified precipitation induced by a warming climate is a major contributor to increased annual streamflow. However, winter streamflow appears to be particularly sensitive to temperature. Whilst rising temperature can reduce streamflow via evapotranspiration, it can enhance groundwater discharge to rivers due to permafrost thawing. Currently, every 1 °C rise in temperature likely leads to 6.1%–10.5% increase in groundwater discharge, depending on the permafrost condition. For permafrost-developed basins, the contribution to increased streamflow from thawing permafrost will continue to increase in the context of global warming.
Journal Article
Evaluation of a Width‐Based Satellite Discharge Algorithm for Detecting Longitudinal Flow Changes in a Human‐Regulated Continental River Basin
This study investigated the capabilities and limitations of estimating spatially continuous river discharge using satellite‐observed river width and the AMHG‐based algorithm (BAM). We applied this method to 668 reaches along the Yellow River mainstem, examining whether width‐derived discharge estimates can capture both natural and anthropogenic streamflow variations. Results show that discharge increases at tributary confluences and decreases in irrigated sections were successfully reproduced, indicating the potential to represent realistic spatial patterns from satellite observations. We further evaluated the impact of prior discharge, which serves as an initial guess in BAM; incorporating irrigation‐corrected priors improved estimation accuracy, particularly in downstream reaches affected by human activities. However, large errors remained in levee‐confined reaches, where poor co‐variability between width and discharge limited performance. Our findings highlight that satellite‐based width measurements, when supported by appropriate priors, offer a promising means to monitor discharge in ungauged basins, while also revealing key challenges in regulated rivers.
Journal Article
Recent changes to Arctic river discharge
Arctic rivers drain ~15% of the global land surface and significantly influence local communities and economies, freshwater and marine ecosystems, and global climate. However, trusted and public knowledge of pan-Arctic rivers is inadequate, especially for small rivers and across Eurasia, inhibiting understanding of the Arctic response to climate change. Here, we calculate daily streamflow in 486,493 pan-Arctic river reaches from 1984-2018 by assimilating 9.18 million river discharge estimates made from 155,710 satellite images into hydrologic model simulations. We reveal larger and more heterogenous total water export (3-17% greater) and water export acceleration (factor of 1.2-3.3 larger) than previously reported, with substantial differences across basins, ecoregions, stream orders, human regulation, and permafrost regimes. We also find significant changes in the spring freshet and summer stream intermittency. Ultimately, our results represent an updated, publicly available, and more accurate daily understanding of Arctic rivers uniquely enabled by recent advances in hydrologic modeling and remote sensing.
The authors combine satellite data with hydrologic models to investigate recent changes in pan-Arctic river discharge magnitude, trends, and seasonality for nearly half a million rivers. They reveal that these rivers likely exported 3-17% more water to the global ocean than previously thought from 1984-2018.
Journal Article
Patient-centered discharge summaries to support safety and individual health literacy: a double-blind randomized controlled trial in Austria
Background
To ensure a safe patient discharge from hospital it is necessary to transfer all relevant information in a discharge summary (DS). The aim of this study was to evaluate a bundle of measures to improve the DS for physicians, nurses and patients.
Methods
In a double-blind, randomized, controlled trial, four different versions of DS (2 original, 2 revised) were tested with physicians, nurses and patients. We used an evaluation sheet (Case report form, CRF) with a 6-point Likert scale (1 = completely agree; 6 = strongly disagree).
Results
In total, 441 participants (physicians
n
= 146, nurses
n
= 140, patients
n
= 155) were included in the study. Overall, the two revised DS received significant better ratings than the original DS (original 2.8 ± 0.8 vs. revised 2.1 ± 0.9,
p
< 0.001). Detailed results for the main domains are structured DS (original 1.9 ± 0.9 vs. revised 2.2 ± 1.3,
p
= 0.015), content (original 2.7 ± 0.9 vs revised 2.0 ± 0.9,
p
< 0.001) and comprehensibility (original 3.8 ± 1.2vs. revised 2.3 ± 1.2,
p
< 0.001).
Conclusion
With simple measures like avoiding abbreviations and describing indications or therapies with fixed contents, the DS can be significantly improved for physicians, nurses and patients at the same time.
Trial registration
First registration 13/11/2020 NCT04628728 at
www.clinicaltrials.gov
, Update 15/03/2023.
Key messages
1. To ensure a safe patient discharge from hospital it is necessary to transfer all relevant information in a discharge summary (DS).
2. Several issues related to the medical DS have already been identified delayed transmission of the DS to the subsequently treating physician and others, low quality or lack of information, lack of consistent formats, lack of patient understanding, and inadequate training for medical students in writing medical DS.
3. It would also be necessary that the patients understand the DS; - or at least receive therapeutically relevant care information in form of a patient-directed DS.
4. With simple measures like avoiding abbreviations and describing fixed content, the DS can be significantly improved for patients, physicians, and nurses at the same time.
5. The DS should become a patient‐centred tool ensuring that improved communication and understanding between healthcare professionals, patients and relatives succeeds.
Journal Article