General practitioner response to elderly patients discharged from hospital.

OBJECTIVE--To determine the effect of discharge information given to general practitioners on their management of newly discharged elderly patients. DESIGN--A random sample of 133 elderly patients who had unplanned readmission to a district general hospital within 28 days of discharge was compared with a matched control sample of patients who were not readmitted. Information was gathered from the hospital, the patients, the carers, and the general practitioners about the information that the hospital had sent the general practitioner and the general practitioners'' response to this information. SETTING--All specialties in a district general hospital. PATIENTS--266 Patients aged over 65 representative in the main demographic indices of the population of elderly patients admitted to hospital. RESULTS--Ten weeks after discharge the doctors had received notice of discharge about 169 of the patients, but fewer than half the discharge notices were received within the first week. General practitioners were dissatisfied with the information in 60 cases. A general practitioner visited 174 of the patients after their discharge from hospital and three quarters of the visits took place within two weeks of the discharge. These visits were more likely to have been initiated by patients or families than by the doctor, and this was not influenced by the doctor receiving notice of the patient''s discharge. Older patients and those who had carers were the most likely to be visited. Nearly half of the carers were dissatisfied with some aspect of general practitioner care, problems with home visiting being the commonest source of complaint. CONCLUSIONS--Hospital communications to general practitioners about the discharge of elderly patients still cause concern, particularly in the time they take to arrive. Written instruction to vulnerable elderly patients asking them to inform their general practitioner of the discharge might be helpful. Carers complained of lack of support, and it is clearly important for someone (either the general practitioner or another health worker) to visit elderly people shortly after their discharge.     

Patients' and general practitioners' satisfaction with information given on discharge from hospital: audit of a new information card.

OBJECTIVE--To determine the attitudes of patients discharged from hospital and their general practitioners to a new information card giving details about admission, diagnosis, and treatment and to assess the completeness of the information on the card. DESIGN--Consecutive patients discharged from the care of three consultant physicians over 16 weeks. SETTING--One general medical ward in a large teaching hospital. PATIENTS--A total of 275 consecutive discharges of 258 patients were studied. The mean age of patients was 60 years and mean duration of admission five days. INTERVENTION--At discharge from the ward all study patients received an information card and a copy of the card in the form of an interim discharge letter to be delivered to their general practitioner. Patients and general practitioners were asked to complete a questionnaire giving their views on the legibility, helpfulness, quality, and quantity of the information they received. Copies of all the information cards were scrutinised for completeness. MAIN RESULTS--The results were based on 208 (76%) forms returned by patients and 214 (78%) forms returned by general practitioners. Information was considered very helpful or quite helpful according to 170 (83%) forms from patients and 197 (92%) forms from general practitioners; sufficient information was provided according to 160 and 182 forms. Most patients and nearly all general practitioners thought it was a good idea to provide this information for patients at discharge. According to 125 forms from patients and 188 from general practitioners the information card was very easy or quite easy to read; 155 patients had read it at least twice and 149 were likely to refer to it again. OTHER RESULTS--The written information about the patient, the diagnosis, and what the patient had been told was generally well completed, although the date of discharge was omitted from 42 (15%) cards. Details of drugs prescribed at discharge were generally thorough. CONCLUSIONS--Giving an information card to all patients at discharge was feasible and favoured by most patients and their general practitioners. Having made minor changes in design, we think that we have produced an information card that is a convenient size and will improve communication between patients, their general practitioners, and hospital doctors. We now issue this card routinely to all patients discharged from our ward and hope that it might be widely adopted.     

Combining specialist and primary health care teams for HIV positive patients: retrospective and prospective studies.

OBJECTIVE: To develop and evaluate a model of health care for HIV positive patients involving specialist, hospital based teams and primary health care teams. DESIGN: One year retrospective and a 2 1/2 year prospective study. SETTING: Two hospitals in West London and 88 general practitioners in 72 general hospitals. SUBJECTS: 209 adults with HIV infection. INTERVENTION: General practitioners enrolled in the project were faxed structured outpatient clinic summaries. When hospital inpatients were discharged, a brief discharge summary was faxed. General practitioners had access to consultant physicians skilled in HIV medicine through a 24 hour mobile telephone service. An HIV/AIDS management and treatment guide containing relevant local information was produced. Quarterly discussion forums for general practitioners were held, and a regular newsletter was produced. MAIN OUTCOME MEASURES: Hospital attendance and general practitioner consultations; perceived benefits and problems of patients and general practitioners. RESULTS: The average length of a hospital inpatient stay was halved for those patients who had participated in the project for two years, and the average number of visits to the outpatient clinic per month fell for patients with AIDS. There was a substantial increase in the number of visits to general practitioners by patients with AIDS and symptomatic HIV infection. Patients and general practitioners both felt that the standard of health care provided had improved. CONCLUSIONS: This model of health care efficiently and effectively utilised existing teams of hospital and primary health care professionals to provide care for HIV positive patients. Simple, prompt, and regular communication systems which provided information relevant to the needs of general practitioners were central to its success.     

Interim discharge summaries: how are they best delivered to general practitioners?

All patients discharged from a medical ward during four months were randomly assigned to one of two groups. In one group the patients were given their interim discharge summary for delivery to their general practitioner by hand; in the other group the summary was posted by the hospital. Of the 289 summaries sent by either method, 279 (97%) arrived at the general practitioner''s surgery. A mean (median) time of two (one) days elapsed before arrival when summaries were delivered by hand and a mean (median) of four and a half (four) days when they were posted; at least 55% of summaries delivered by hand arrived within one day of the day of discharge compared with 8% of those posted. If all interim discharge summaries were given to patients to deliver communication between hospitals and general practitioners would be accelerated and considerable savings might be made.     

Is an information booklet for patients leaving hospital helpful and useful?

OBJECTIVE--To determine whether a booklet given to patients being discharged from hospital giving details of their admission and treatment increased their knowledge and recall when reviewed in outpatient clinics. DESIGN--Patients alternately allocated to receive a booklet or to serve as controls. Assessment by a questionnaire at first attendance at outpatient clinic after discharge. Data were collected over nine months. SETTING--One general medical and cardiological ward in a large teaching hospital and associated outpatient clinics. PATIENTS--One hundred and thirty one patients discharged taking at least one drug and scheduled to return to clinic within 12 weeks. Patients stratified by age and by the number of weeks between discharge and outpatient appointment. INTERVENTION--A booklet was given to 65 patients at discharge from the ward; 66 patients served as controls. MAIN RESULTS--Of the patients who received the booklet, 56 (86%) knew the names of their drugs, 62 (95%) the frequency of the dose, and 55 (85%) the reasons for taking each drug. The numbers in the control group were 31 (47%), 38 (58%), and 28 (42%) respectively. These differences were highly significant (p less than 0.001). Twenty six (40%) who received the booklet brought all their drugs to clinic compared with 12 (18%) control patients. Appreciably more of the first group of patients than control patients knew the reason they had been in hospital, and more of the first group indicated that they would take the correct action when their prescribed drugs ran out. Most general practitioners thought that the booklet was a good idea, that it was helpful, and that it was better than the existing interim discharge letter. CONCLUSIONS--Giving patients an information booklet at discharge from hospital appreciably increased the accuracy and thoroughness of their recall of important medical details concerning their illness and its treatment. The booklet was shown to be feasible, helpful in the outpatient clinic, and preferred by most general practitioners.     

Health of prisoners admitted to and discharged from Bedford Prison.

The age, smoking and drinking habits, active health problems, and occupational fitness of prisoners entering Bedford prison, and the health and willingness of prisoners being discharged from prison to take a letter to their general practitioner were surveyed. This group of men had a high level of illness, neglected their health, and had a high alcohol intake. Fewer problems were found than in a survey in New York City. Many prisoners with active medical problems on discharge from prison were unwilling to take a letter to their own general practitioner.     

Hospital discharge reports: content and design.

The information required by family doctors on initial and final discharge reports from hospitals was specified and 546 such reports from hospitals in Aylesbury, Amersham, Banbury, Oxford, and High Wycombe were reviewed for the availability and accessibility of important information. Several items could have been recorded better, including the name of the hospital, the specialty (or department) concerned, and the name of the consultant in charge of the case. Drug reactions seemed to be under-reported in the initial discharge reports and information about treatment on discharge was inadequate. The recording of the prognosis and information given to the patient was deficient and communication on follow-up needs to be improved. The use of obscure abbreviations was widespread. There is room for improvement in the ease of access to important information, especially the diagnostic assessment, and the time taken for final reports to reach the general practitioner.     

Reduction in hospital readmission stay of elderly patients by a community based hospital discharge scheme: a randomised controlled trial.

STUDY OBJECTIVE--To compare a community support scheme using care attendants with standard aftercare for their effects on independence and morale of elderly patients discharged from hospital and on their use of health and social services. DESIGN--Randomised controlled study of cohort of patients over 75 discharged to their own homes. SETTING--District general hospital and community. PATIENTS--Total of 903 patients (mean age 82, 25% over 85). INTERVENTIONS--Total of 464 patients received support from care attendants on first day at home and for up to 12 hours a week for two weeks. Support comprised practical care, help with rehabilitation, and organising social help. The remaining 439 patients received standard aftercare. END POINT--Difference between two groups of 7% in hospital readmission rates or one point on activities of daily living scale (power 80%, significance level 5%). MEASUREMENTS AND MAIN RESULTS--Three months after the initial discharge 763 patients were interviewed (84%). There were no significant differences between the two groups in physical independence (activities of daily living scale), in measures of morale (Philadelphia scale), or in death rates. Hospital readmission rates within 18 months of discharge, however, were significantly higher in the control group and they spent more days in hospital (mean; control group 30.6 days, support group 17.1 days; p = 0.014). Of the patients living alone who were followed up for 18 months 21 (15%) receiving standard aftercare were readmitted more than twice compared with 6 (5%) supported by care attendants (p less than 0.01). CONCLUSIONS--If the findings are confirmed, and the policy extended to all patients over the age of 75 living alone, an average health district might expect either to save about 23 hospital beds at a net annual saving of about pounds 220,000 in the short term or to increase available beds by this number.     

Complaints and Diagnoses of Emergency Department Patients in the Netherlands: A Comparative Study of Integrated Primary and Emergency Care

ObjectiveIn the Netherlands, an increasing number of emergency departments (EDs) and general practitioner cooperatives collaborate by creating one Emergency-Care-Access-Point (ECAP). This has resulted in fewer patients at ECAP EDs. The objective of this study was to explore differences in patient characteristics, presented complaints and ED discharge diagnoses between EDs with an ECAP and EDs without an ECAP.MethodsA retrospective observational study was performed with 1800 consecutive patient records sampled from six EDs spread over the Netherlands in 2013. We extracted data on time and date of presentation, sex, age, presenting complaint, discharge diagnosis, origin and follow up.ResultsAt ECAP EDs, the mean age was 47.8 years (95%CI 46.1-49.4) compared to 41.3 (95%CI 39.7-42.9). Compared to non-ECAP EDs, more patients were referred by medical professionals (74.7% versus 46.8%), more patients received hospital admission (45.2% versus 29.0%) and fewer patients received GP follow-up (4.1% versus 16.9%). There was no significant difference in presenting complaints between ECAP and non-ECAP EDs. Most prevalent complaints were trauma (25.7% versus 29.7%), abdominal pain (12.1% versus 10.9%) and general symptoms (7.8% versus 4.8%). The most prevalent ED diagnoses significantly differed with fractures and dislocations (10.8%), sprains and strains (10.4%) and respiratory infections (6.8%) at ECAP EDs versus fractures and dislocations (10.7%), wounds (9.3%) and sprains and strains (8.9%) at non-ECAP EDs.ConclusionCompared to non-ECAP EDs, patients at ECAP EDs were older, medical professionals referred more patients and more patients received a hospital admission. We found some small differences in discharge diagnoses between ECAP EDs compared to non-ECAP EDs, but no difference in presented complaints.     

Alternatives to hospital care: what are they and who should decide?

OBJECTIVE--To examine potential for alternatives to care in hospitals for acute admissions, and to compare the decisions about these alternatives made by clinicians with different backgrounds. DESIGN--Standardised tool was used to identify patients who could potentially be treated in an alternative form of care. Information about such patients was assessed by three panels of clinicians: general practitioners without experience of general practitioner beds, general practitioners with experience of general practitioner beds, and consultants. SETTING--One hospital for acute admissions in a rural area of the South and West region of England. SUBJECTS--Of 620 patients admitted to specialties of general medicine and care of the elderly, details of 112 were assessed by panels. MAIN OUTCOME MEASURES--Proportion of hospitalised patients who could have received alternative care and identification of most appropriate alternative form of care. RESULTS--Both general practitioner panels estimated that between 51 and 89 of the hospitalised patients could have received alternative care (equivalent to 8-14% of all admissions). Consultants estimated that between 25 and 55 patients could have had alternative care (5.5-9% of all admissions). General practitioner bed and urgent outpatient appointment were the main alternatives chosen by all three panels. CONCLUSION--About 10% of admissions to general hospital might be suitable for alternative forms of care. Doctors with different backgrounds made similar overall assessments of most appropriate forms of care.     

Prevalence of symptoms of dyspepsia in the community.

To study the prevalence of dyspepsia in the community a postal questionnaire was sent to 2697 patients who were selected at random from the lists of patients registered in two health centres in Hampshire. A total of 2066 returned questionnaires were suitable for analysis (response rate 77%). It was found that the six month prevalence of dyspepsia was 38%. There was considerable overlap between symptoms of heartburn and upper abdominal pain, with over half of patients with dyspepsia experiencing both. One in four of these patients had consulted their general practitioner during that time. The proportion of patients with dyspepsia who consulted their general practitioner varied widely among the eight doctors who participated in the study, from 17% to 45%. Frequency of symptoms tended to fall with age, particularly in men, while the proportion of patients with dyspepsia who sought medical advice increased with age. Almost one in five of the 2066 patients had been investigated with radiology or endoscopy at some time, and 143 (7%) of them claimed to have had a diagnosis of peptic ulcer.     

AIDS and the general practitioner: views of patients with HIV infection and AIDS.

An unselected series of outpatients infected with the human immunodeficiency virus (HIV) who attended two London hospitals were interviewed to assess their relationship with their general practitioner. Although most of the 192 patients were registered with a general practitioner, the doctors of only one half knew of the diagnosis. Patients feared a negative reaction from their general practitioner or were concerned about confidentiality. Although those who had told their doctor had received favourable reactions, few general practitioners attempted to counsel or educate their patients. The patients who previously had been open about their homosexuality were not more likely to have told their general practitioner of their HIV infection. Although most did not think that general practitioners were well informed about AIDS, half of the patients wished that general practitioners could take a bigger part in their care.     

Contribution of a general practitioner hospital: a further study.

OBJECTIVE--To audit the workload of a general practitioner hospital and to compare the results with an earlier study. DESIGN--Prospective recording of discharges from the general practitioner hospital plus outpatient and casualty attendances and of all outpatient referrals and discharges from other hospitals of patients from Brecon Medical Group Practice during one year (1 June 1986-31 May 1987). SETTING--A large rural general group practice which staffs a general practitioner hospital in Brecon, mid-Wales. PATIENTS--20,000 Patients living in the Brecon area. RESULTS--1540 Patients were discharged from the general practitioner hospital during the study period. The hospital accounted for 78% (1242 out of 1594) of all hospital admissions of patients of the practice. There were 5835 new attendances at the casualty department and 1896 new outpatient attendances at consultant clinics at the hospital. Of all new outpatient attendances by patients of the practice, 71% (1358 out of 1896) were at clinics held at the general practitioner hospital. Since the previous study in 1971 discharges from the hospital have increased 37% (from 1125 to 1540) and new attendances at consultant clinics 30% (from 1450 to 1896). The average cost per inpatient day is lower at this hospital than at the local district general hospital (pounds 71.07 v pounds 88.06 respectively). CONCLUSIONS--The general practitioner hospital deals with a considerably larger proportion of admissions and outpatient attendances of patients in the practice than in 1971 and eases the burden on the local district general hospital at a reasonable cost. IMPLICATIONS--General practitioner hospitals should have a future role in the NHS.     

Use of hospital beds: a cohort study of admissions to a provincial teaching hospital.

An instrument was developed to study the use of hospital beds and discharge arrangements of a cohort of 847 admissions to the John Radcliffe Hospital, Oxford, for a three week period during February-March 1986. For only 38% of bed days were patients considered to have medical, nursing, or life support reasons for requiring a provincial teaching hospital bed. The requirements for a bed in the hospital decreased with the patient''s age and length of stay in hospital. For only a tenth of patients was the general practitioner concerned in discussions with hospital staff about the patient''s discharge and less than one third of patients had been given more than 24 hours'' notice of discharge. Several features might increase the proportion of bed days that are occupied by patients with positive reasons for being in hospital. Among these are an increased frequency of ward rounds by consultants, or delegating discharge decisions by consultants to other staff; providing diagnostic related protocols for planning the length of stay in hospital; planned discharges; and providing liaison nurses to help with communication with primary care staff.     

Self referral to an accident and emergency department for another opinion.

OBJECTIVE--To determine whether patients referring themselves to an accident and emergency department for another opinion after consulting their general practitioner present with serious illness, show any risk factors for being admitted, or are more likely to be patients of particular practitioners. DESIGN--Six month prospective survey. SETTING--District general hospital''s accident and emergency department, receiving 42,000 new patients a year. PATIENTS--180 Patients identified as attending for another opinion having already consulted a general practitioner. INTERVENTIONS--Classified as admission, referral to specialist clinic, follow up in accident and emergency department, or referral back to general practitioner. END POINT--Admission, with an analysis of admitted patients. MEASUREMENTS AND MAIN RESULTS--General outcome, diagnostic category, age, time of attendance, time since seen by general practitioner, and name of general practitioner were recorded. Forty seven patients were admitted, 99 were discharged back to the general practitioner (62 without a letter), and two died. Patients were most likely to be admitted if they attended within 24 hours after seeing a general practitioner, were aged under 5, or presented with respiratory or gastrointestinal complaints. Some general practitioners were overrepresented. CONCLUSIONS--Important disorders present in this way, and therefore these patients should be seen by a doctor. Information about these attendances could be useful to general practitioners in reviewing their performance.     

Nursing role to improve care to infarct patients and patients undergoing heart surgery: 10?years’ experience

Background

The nurse practitioner may be the ideal healthcare worker to create a new environment and may facilitate in the process of expediting discharge and improving patient safety. They can play an intermediary role between the consultants, nurses and patients, thereby combining the aspects of care (nursing) and cure (physicians).

Method

We describe the contribution and role of the nurse practitioner in a teaching hospital and provide an overview of the changes in care and cure that were facilitated by two nurse practitioners in the treatment of cardiac surgery patients or non-complicated acute coronary syndrome patients.

Results

The nurse-led clinic for postoperative patients has registered 1967 patients in the past 10 years. These patients were transferred at a mean of 5.5 days after their bypass operation. All patients had an uneventful clinical course in our hospital and were discharged alive. The period between discharge and outpatient clinic visit could be set at 4 weeks.The post-acute coronary syndrome (ACS) group included 1236 patients. Mortality in this patient cohort was 4% while 0.4% of these patients experienced a re-myocardial infarction. Additional surgery was needed in only 2% of these stable post-infarction patients. The mean length of stay was 5.9 ± 14.5 days.

Conclusion

This observational study confirms that a nurse-led postoperative care unit and post-ACS care unit is feasible and effective for the treatment of patients returning from cardiac surgery or transferred after uncomplicated ACS to a general cardiology ward.     

Physician communication skills and malpractice claims. A complex relationship.

We assessed the relationship between patients'' opinions about their physicians'' communication skills and the physician''s history of medical malpractice claims. The sample consisted of 107 physicians and 2,030 of their patients who had had an operation or a delivery. Although patients tended to give their physicians favorable ratings, they were least satisfied with the amount of explanations they received. Patients gave higher ratings to general surgeons and obstetrician-gynecologists and poorer ratings to orthopedists and anesthesiologists. Women and better-educated patients gave higher ratings on explanations and communication to physicians with fewer claims. Men and patients with less education, however, gave higher ratings on these dimensions to physicians with more claims. These findings suggest the need for physicians to tailor their communications to a patient''s individual needs. Improved communication between physicians and patients may result in fewer nonmeritorious malpractice claims while leading to less costly resolution of meritorious claims.     

Newly registered elderly patients: who are they and why such delay in the transfer of their medical records?

The time taken to transfer the records of elderly patients registering with a new general practice was investigated. Thirty five (5%) of a total of 671 patients aged 75 and over were entered as new patients on to the age-sex register of an urban group practice during one year. Twenty nine had moved into the area and six had changed their general practitioner for personal and other reasons. An average of 141 (range 71-296) days elapsed before dispatch of their medical records to the new practice. During this period an average of 3·5 (range 0-15) consultations with a general practitioner were recorded, indicating the need of such patients for medical care. The long delays were caused by the processing of medical records at the central register and the transfer of records between family practitioner committees and general practitioners. Delays were most apparent in the time taken for general practitioners to dispatch the necessary documents to the family practitioner committees, and these should be minimised.The use of a summary card written and updated by the general practitioner and retained by the patient would facilitate continuing care should patients change to a new practice. Meanwhile, assessment of elderly patients after registration with a new practice by a member of the primary health care team may identify problems before the records have been transferred and may help the resettlement of these high risk elderly patients.     

Electronic communication between providers of primary and secondary care.

OBJECTIVE--To study the effects of the introduction of electronic data interchange between primary and secondary care providers on speed of communication, efficiency of data handling, and satisfaction of general practitioners with communication. DESIGN--Comparison of traditional paper based communication for laboratory reports and admission-discharge reports between hospital and general practitioners and electronic data interchange. SETTING--Twenty-seven general practitioners whose offices were equipped with a practice information system and two general hospitals. OUTCOME MEASURES--Paper based communication was evaluated by questionnaire responses from and interviews with care providers; electronic communication was evaluated by measuring time intervals between generation and delivery of messages and by assessing doctors'' satisfaction with electronic data interchange by questionnaire. RESULTS--Via paper mail admission-discharge reports took a median of 2-4 days, and laboratory reports 2 days, to reach general practitioners. With electronic data interchange almost all admission-discharge reports were available to general practitioners within one hour of generation. When samples were analysed on the day of collection (as was the case for 174/542 samples in one hospital and 443/854 in the other) the laboratory reports were also available to the general practitioner the same day via electronic data interchange. Fifteen general practitioners (of the 24 who returned the questionnaire) reported that the use of electronic admission-discharge reports provided more accurate and complete information about the care delivered to their patients. Ten general practitioners reported that electronic laboratory reports lessened the work of processing the data. CONCLUSION--Electronic communication between primary and secondary care providers is a feasible option for improving communication.