A change in ceiling of care at hospital discharge towards the end of life: the perfect storm for communication at the primary-secondary care interface

Problem

Despite decades of research, avoidable communication-related harm at hospital discharge persists. Discharge summaries written to GPs by time-pressured and inexperienced junior doctors remain the near-exclusive format of this communication system. The limited success of previous interventions to improve quality, such as adherence of summaries to standardised templates, has led to recognition of the need for greater understanding of this complex problem space in order to identify high risk patient groups and targets for future improvement.

Approach

A qualitative exploration was undertaken using a ‘systems approach’, recently redefined for the healthcare domain by the Royal Academy of Engineering, Royal College of Physicians and Academy of Medical Sciences in their 2017 publication Engineering Better Care. A systems approach is of particular value when addressing complex, system-wide issues, and its set of 13 'driving questions' provided a framework to address the research question of "How can communication to GPs at hospital discharge be improved?" One focus group and twenty semi-structured interviews were conducted with key clinical and administrative stakeholders across the primary-secondary care interface of a large tertiary hospital in England, and thematically analysed.

Findings

Participants reported that decisions to reduce the ceiling of patient care made during hospital admission as the end of life approached, acted as the greatest stressors on the system of discharge communication. Conveying plans made to initiate a palliative care approach, and to avoid future treatments, investigations or hospital admissions, were felt to require a level of nuance and detail often missing from discharge letters. Such cases are often complicated by multimorbidity, polypharmacy, cognitive deficits, and involvement with social care and multidisciplinary teams. and this exponential complexity was felt to pose a communication challenge to both discharge summary authors and recipient GPs. Participants noted that the risk of subsequent suboptimal care and avoidable patient harm dramatically increased: discharge communication for patients in this period of care, before the community resources for the end of life phase are needed, was described as one of the largest opportunities to improve system performance and the quality and continuity of post-discharge care.

Consequences

We propose that bespoke discharge documentation is refined for this patient group, alongside GP-led teaching sessions for junior doctors, in order to increase system-wide awareness of this vulnerability in the discharge process. Quality feedback loops, more open lines of communication and shared medical records would also have significant benefits for this patient group, as well as for other groups identified at risk of communication-related harm at hospital discharge.