Introduction
With over 15 million hospital admissions per year in the UK (Health & Social Care Information Centre, 2014), hospital discharge summaries are the principle means of relaying accurate information back to primary care healthcare providers regarding a patient’s hospital attendance, their received treatment and any ongoing care that is required. In the UK, the primary care healthcare providers consist of general practitioners (GP), practice nurses and district nurses, who all work within a ‘GP surgery’, and will be able to access discharge summaries from hospitals (secondary care providers), as well as providing ongoing care for patients in the community following hospital discharge. Criticisms exist of delays between patients’ actual date of discharge and the date that GPs receive appropriate information. In one paper the maximum time between discharge and receipt was 27 days due to dictation and typing delays alone (Farquhar et al., Reference Farquhar, Barclay, Earl, Grande, Emery and Crawford2005). With the advent of electronic discharge summaries this should be less of a problem; however, such systems are still in their relative infancy and the risk of delay, failure to correctly send and reliably receive the relevant information exists. Ideally, the patient is given a physical copy of their discharge summary or care plan to take home with them whilst an electronic copy is emailed to their GP within 24 h (Department of Health, 2003). The Clinical Data Standards Assurance Programme was set up in August 2010 to deliver a national and clinically assured electronic discharge summary that the acute hospital team would send out to the GP within 24 h of discharge (Health & Social Care Information Centre, 2014). Minimum standards of information which should be included are as follows (Katikireddi and Cloud, Reference Katikireddi and Cloud2008): reason for admission, other significant events or illnesses during admission, operations or therapeutic procedures undergone, medication changes, and a clear ongoing primary and secondary care plan stating further investigations, interventions and follow-up appointments as appropriate.
The content of discharge information is often poor (Luker et al., Reference Luker, Beaver, Austin and Leinster2000; Harel et al., Reference Harel, Wald, Perl, Schwartz and Bell2012) as the summaries are often written by the most junior member of the hospital team. They are often reliant on information in the medical records and not always on a direct, personal knowledge of the patient being discharged. The relatively low priority that formal discharge paperwork often has compared with other acute clinical care tasks drawing on a junior hospital doctor’s time and attention makes their completion more often than not retrospective in nature compounding the delay and poor content quality. Delayed discharge summaries have been found to be associated with an increased rate of hospital readmissions, especially in the elderly population (Li et al., Reference Li, Yong, Hakendorf, Ben-Tovim and Thompson2013) and educational strategies (with various effects) have been implemented in various hospitals worldwide to improve the content of discharge summaries, highlighting that this is a global problem (O’Leary et al., Reference O’Leary, Liebovitz, Feinglass, Liss, Evans, Kulkarni, Lander and Baker2009; Key-Solle et al., Reference Key-Solle, Paulk, Bradford, Cockrell Skinner, Lewis and Shomaker2010).
Our trust serves a catchment population of ~500 000. Outside of the city centre the local area is predominantly rural with a number of small towns and villages. Within the trust it was noted by those doctors ‘on call’ for general surgery that they would frequently receive telephone calls from frustrated primary care providers (GPs or practice nurses) that either no discharge summary had been received or that those that had been sent were missing key information, primarily with regards to post-operative care and ongoing wound closure management. Patients would frequently present to their practice post-operatively for routine wound review. Unless formally documented on the discharge summaries, primary care providers would regularly be unaware of when the sutures or clips should be removed, if even required at all.
We set out to identify the knowledge levels on current wound closure techniques and their management amongst local GP practices. Once established, we aimed to instigate an intervention to both improve knowledge on this important and relevant topic as well as facilitate secondary to primary care communication. We defined wound closure as closure of any incision that had been made in the skin for the purpose of a general surgery operation, which had been closed primarily, with either sutures or clips.
Methods
We emailed an anonymous SurveyMonkeyTM survey out to all surrounding 27 GP practices via our hospital’s Education Department, assessing the staff at each practice’s knowledge regarding current methods of wound closure being utilised within our trust. This could be filled in by a GP or a practice nurse as both are key members of the primary care team. Results were then reviewed for perceived confidence and knowledge on wound care, as well as opinions regarding the current system of conveying such information post surgery and patient discharge.
Subsequently, a trust-specific information leaflet on the topic ‘wound closure methods’ (Figure 1), currently being employed by the hospital, along with their required follow-up and management was designed and distributed to all of the above GP practices.
Figure 1 Trust-specific suture information sheet distributed to all surrounding primary care practices
In an attempt to eliminate the potential time delay in transference of this relevant wound care information and in doing so both meet the UK Department of Health clinical guidelines (2003) on best practice and maximise patient healthcare ownership empowerment, a wallet-sized personalised information card was designed for the patient to take home. This detailed the name and date of the operation that the patient had undergone, the type of wound closure employed and if requiring removal, the date. This was then completed and given to all general surgical patients on discharge to keep on their person and piloted over a two-month period.
The GP practices were re-surveyed two months later, asking whether any changes had been noted and perceived knowledge levels following wound closure information sheet distribution.
Results
In total, 22 (81%) of 27 GP practices surveyed replied, with a mixture of responses coming from GPs and practice nurses (Figure 2). Of these, only a third of respondents (86% of whom were practice nurses) stated that they were satisfied with the information regarding surgical wound closure currently supplied on the discharge summaries they received. Another third of respondents were dissatisfied, 66% of these were GPs, with the final third feeling indifferent (Figure 3).
Figure 2 Proportion of responses from GPs and practice nurses
Figure 3 Satisfaction with general surgery discharge summaries
When the relevant information was present on written/electronic discharge paperwork, over half of those surveyed (70% GPs) found the information difficult or very difficult to find and understand (Figure 4).
Figure 4 Ease at which to find skin closure information within discharge summary
The majority of primary care providers had patients present to them with post-operative wound queries or problems at least fortnightly.
In total, 70% of practices felt that an up-to-date trust-specific wound closure information would be extremely useful, and that a readily distributed personalised patient-held card could be both practical and efficient.
Following distribution of the trust wound closure leaflet and a two-month trial of the patient-held information cards, a quarter of practices had encountered and utilised the patient-specific card, whilst the majority (16 of 19 replies) felt that wound care information availability and their own personal knowledge on the topic had improved.
Discussion
We found that within our surrounding primary care providers, there was general dissatisfaction with discharge summaries as a whole and within that, information concerning post-operative wound care in particular. This is similar to what has been found in the literature, a recent systematic review showed that poorly written communication between hospital specialists and primary care trusts can have many negative effects (Vermeir et al., Reference Vermeir, Vandijk, Degroote, Peleman, Verhaeghe, Mortier, Hallaert, Ven Daele, Buylaert and Vogelaers2015). Through the means of a targeted information sheet and patient-specific discharge cards, there was an improved sense of knowledge on the topic and a decreased need for the primary care team to ring the on-call surgical team for advice (noted both in the survey and anecdotally amongst surgeons). Such interventions also eliminate the time delay that may occur with routine discharge summaries. We found a positive response on re-surveying the practices, in that 60% of those responding felt that the information available to them on discharge specifically regarding wound closure had improved considerably.
In addition, the production and distribution of trust-specific information on the topic of surgical closure both reinforced the message that was trying to be delivered, as well as providing a simple reference document to both interpret the information provided on the discharge cards as well as offer further information in the event of a problem or ongoing uncertainty concerning a patient’s post-operative wound care in the community.
Giving the patient the responsibility of keeping the card had the additional unanticipated benefit of allowing the patient to show any healthcare provider, whether an out of hours GP in the area or another hospital team if required, both their operation and which team had provided the care. Aside from the communication benefits, the patients themselves occasionally reported an improved sense of empowerment on discharge in knowing what their operation was and how it would continue to be managed in the short term post discharge, when questioned informally in the outpatient clinic.
No formal cost analysis of this intervention has been performed due to the currently limited size of the trial performed and the associated costs being low. The suture information sheets were compiled by the study investigators from information available in the public domain, and following approval from the trust’s communications team were distributed electronically. The initial trial of patient-held information cards was funded from the local departmental research fund. Such cards cost less than £0.01 (GB Pounds) per unit to produce. It is anticipated that these costs could be factored into the total cost of operative care per patient.
Following its success, the wound care card has now been adapted and incorporated into a trust-wide leaflet entitled ‘Looking after your surgical wound’, which is given to all surgical patients on discharge. This provides both specific and general information with regards to post-operative wound care, that is, minimising infection, as wellas what the wound closure method utilised was.
Conclusion
Good communication between secondary and primary care is key in order to ensure patient’s health needs are met. This simple intervention facilitated better communication by the distribution of prompt and specific information via the patient directly. This should help save time and money through decreasing unnecessary telephone consultations and emergency admissions, and subsequently reducing the workload for both those in primary and in secondary care in the future.
Acknowledgements
We would like to acknowledge the support of Mr Mike Williamson as project supervisor and Louise Corrigan for assistance with design and construction of the patient information leaflet.
Financial Support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflicts of Interest
None.
