Monday 29 January, 2007

How to do a good hospital discharge

Posted in Advice, Emergency Dept., Michael Tam, Rants, Wards at 21:44 by Michael Tam

Original article: Michael Tam :: Printer friendly

Consider a discharge of a patient from hospital (be it a ward or emergency department admission); what is the goal? You are trying to achieve a smooth transfer of care from the hospital team to the general practitioner. Thus, this article has an alternative title:

“How not to annoy the general practitioner with hospital discharges”

As a hospital JMO (the “turfer“), discharging a patient back into the community is often a relief. For the general practitioner who is on the receiving end (the “turfee”), there can often be many things that are frustrating and annoying. Having worked on both sides of the system, this article is about how to discharge patients without annoying the general practitioner (too much), and thereby, improving continuity of care.


(1) Discharge summaries

I hated doing discharge summaries as an intern and resident … especially of a general medical patient who had been for weeks, unwell with no firm diagnosis, has had dozens of investigations and in the end, improved for no particular reason. However, they are nevertheless a vital link for continuity of care and they should be done before the patient has a chance to see their general practitioner. Optimally, the patient should be given the letter on discharge so that they can hand deliver the letter to the GP (the accuracy of the stated local medical officer in hospital records is often poor and patients more often than not may change their minds).

Just as patients are sometimes rather clueless to their medical history in the emergency department, they are equally unclear about what happened to them in hospital after an admission. In general practice, I have had patients present after discharge unsure why they went to hospital, what the diagnosis was, what happened, who they were admitted under or what medications they are on now (except that it has “changed”). Remember that in private practice, a GP is not paid for the time spent chasing results and calling for clarifications.

Even a perfunctory discharge letter is better than none at all, though of course, please aim for excellence!

(2) Discharge medications

The reality of most hospital admissions is that the patient’s regular medications are changed. A discharge letter (or at least, a discharge medication list) is of enormous help as the general practitioner often needs to educate the patient on their new medications, check for side-effects, and write a new prescription.

TIPS:

  • Give a discharge letter or printed discharge medication list to the patient;
  • supply enough medications (or a script) so that the patient can see their regular GP (rather than being forced to a medical centre);
  • please try to give the generic names of medications;
  • try to avoid unnecessary authority drugs as they are annoying for the GP (e.g., choosing metoprolol over carvedilol);
  • avoid discharge medications that do not fulfill PBS indications (see below);
  • avoid discharging patients on regular benzodiazepines and opiates.
PBS indications:

For example, a patient intolerant of a non-selective NSAID (non-steroidal anti-inflammatory) may well benefit from a COX-2 inhibitor like celecoxib. However, the PBS indications for celecoxib is specifically for symptomatic treatment of osteoarthritis or rheumatoid arthritis only. Specifically, the PBS does not fund its use for soft tissue and muscular pain.

Worse is the use of atypical antipsychotics (e.g., olanzapine, risperidone, quetiapine) for delirium or aggitation. Although these are useful agents for these conditions, the specific PBS indications are only for schizophrenia and the maintenance of bipolar affective (I) disorder. Furthermore, these are medications that require an authority, i.e., the general practitioner has to call Medicare Australia. Discharging a patient from hospital on these medications not for a PBS approved indication means that you either expect the patient to pay privately (for which they should be informed of such) or expecting the general practitioner to lie to Medicare Australia (which is unreasonable and unethical).

(3) Discharge investigations and follow up with specialists

If a patient on discharge requires an urgent (but elective) investigation (e.g., gastroscopy and colonscopy), it is usually much easier for this to be arranged while they are an inpatient, compared to the GP from his rooms. Again, remember that the GP does not get paid organising outpatient investigations. This is particularly annoying when a test or intervention is in demand and the GP has to ring around to try to find someone available to perform it, especially if the patient cannot afford it to be done privately.

(4) Social supports

Hopefully, with good discharge planning, the patient is well supported by community teams or family when they arrive home. When this does not occur, it is usually the general practitioner who has to pick up the slack as a matter of neccesity. Again, the nature of private practice usually means that there are barriers to arranging services like home nursing.

Please try to ensure patients are not being discharged into a void.

(5) Call the general practitioner

For patients who are complex and in danger of being a disaster once unleashed to the community, give the local medical officer a buzz! I would very much like to know ahead of time and the two minutes of the history of the recent illness over the phone is probably worth more than a thin discharge summary.

You may learn a few things as well (e.g., perhaps the GP has never heard of the patient before, or that they are on holidays), thus giving you time to modify your discharge plan.

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5 Comments »

  1. Alan said,

    Think you’ll find that risperidone is available for the following indication:

    Behavioural disturbances characterised by psychotic symptoms and aggression in patients with dementia where non-pharmacological methods have been unsuccessful.

  2. Michael Tam said,

    Cheers. Thanks for pointing it out… I was deliberately lumping them all together though. ;-)

    Yes, there is good evidence that both olanzapine and risperidone improve psychotic symptoms and behaviour disturbance in patients with Alzheimer’s disease (when compared to placebo). They may be better tolerated than typical antipsychotics (i.e., haloperidol) and may have a lower rate of extrapyramidal side-effects (from the studies I’ve seen, they trend that way but are not statistically signficant).

    Nevertheless, both olanzapine and risperidone have signficant serious adverse effects including an increased risk of cerebrovascular accidents (1). It has been argued, that much of the apparent improvement in behavioural symptoms in Alzheimer’s disease over the longer term with these agents were in fact due to the natural history of the dementing process rather than any great effect of the drug. As such, these agents should only be used in the short term, with a clear discontinuation strategy and only in severe behavioural disturbances not controllable by other means.

    Quetiapine, which is newer and more sedating was for a while seen as the great hope (for control of behaviour symptoms in dementia) when the RCT data revealed the increased risk of CVA for risperidone and olanzapine. However, this was dashed when a doubled blinded RCT revealed that quetiapine was not an effective therapy for agitation in institutionised people with dementia; and furthermore, that it significantly accelerated the rate of cognitive decline (2).

    Worryingly, neither risperidone or olanzapine has been studied for cognitive decline in this fashion and worsening cognitive function in advancing dementia does lead to improvement in the behavioural symptoms as well.

    References

    (1) Ballard C, Waite J, Birks J. Atypical antipsychotics for aggression and psychosis in Alzheimer’s disease. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD003476. DOI: 10.1002/14651858.CD003476.pub2. [Link]

    (2) Ballard C., Margallo-Lana M., Juszczak E., et al. Quetiapine and rivastigmine and cognitive decline in Alzheimer’s disease: randomised double blind placebo controlled trial. BMJ. 2005 Apr 16;330(7496):874. Epub 2005 Feb 18. [Link]

  3. tina said,

    I would like to know if you are tranfer a patient from community to hospital, what do you have to do? before and after.

    thank you

  4. Michael Tam said,

    It depends on the clinical context but ultimately, the community practitioner will need to find a medical practitioner at hospital to accept care for the patient.

    In the case of an emergency, the obvious pathway is to send the patient to the Emergency Department. Good communication by a referral letter and a telephone call to the admitting officer or senior medical officer in the ED should be performed.

    In a subacute setting, one generally has to liaise with the admitting doctor. More often than not, they will want to see the patient in their outpatient rooms before deciding on whether an admission under them is the most appropriate course of action.

    The third setting is when you yourself have admitting rights to a hospital. In this setting, you will have to contact the bed manager (or equivalent) to ensure that a bed is available. Obviously, unless you have deputised staff, you will also need to do the necessary admission paperwork and regular rounds on the patient as well.

    Regards.

  5. Emily said,

    Thanks for the tips, Michael, especially regarding PBS indications for meds and meds requiring authority. I’ll check the meds with my bosses / hospital pharmacists next time.

    I’ll try my best to book the outpatient investigations and clinics.


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