Case Study: West Suffolk Hospital Trust

A brief description of the project

West Suffolk is a district general hospital that saw the need in 2007 to improve the quality of patient handover to primary care. The solution was to replace handwritten discharge summaries with electronic capture and this was achieved on all 19 main wards within one year. Latterly the sending of paper has been removed by switching to direct transmission to GP systems.

The solution chosen was the Epro product from Bristol-based Bluewire Technologies because it additionally provided wider EPR functionality for similar or lower cost. The Trust has since worked closely with the supplier to tailor functionality to the needs of the hospital and the outcome has been a broad range of benefits that are difficult to pigeon-hole in a brief article. For example, instant access to patient information for a clinician delivers an efficiency benefit that can lead to better patient care but also reduces patient safety risk and leads to patients going home sooner. The benefits of clinicians maintaining a shared daily status of their patients’ diagnosis, treatment, jobs to be done and social factors are also multi-faceted.

While this was a small-budget initiative, the system has been well accepted on the wards, it receives over 4000 logins per week and is the largest system in the Trust for the capture of clinical information.

Why the project was started and what its key objectives were

The project began with the key objective of the timely delivery of quality, legible, standardised discharge summaries to GPs. Secondary objectives were improvements to the content of the summaries, better context for the pharmacists in checking prescriptions and the ability to track the prescribing error rate.

A second phase of the project had the objective of electronic transmission direct to GPs and of trialling the creation of letters and patient lists.

A third phase is under way in which functionality such as the letters, lists and consultant review of discharge summaries is being rolled across all wards. Further objectives are to implement electronic nursing handover and internal referrals.

How it breaks new ground

Electronic doctor’s worklists that pre-populate discharge summaries, allow the addition of unregistered TCI (‘To Come In’) patients and can be nested to populate from other lists are, we believe, unique. For the future system offers the ability to further incorporate nursing handover information within the same lists also achieves the rare sharing of knowledge about patients between doctors and nurses. This sharing, and access to the same information by other authorised staff such as the discharge planning team, is certainly unprecedented at this hospital.

The mechanism for consultants to see all recent discharge summaries for their patients, quickly review them and re-send them to the GPs is new. This avoids the need for follow-up letters, improves the quality of information to GPs and reduces risk. Additionally, it provides a powerful training tool to for consultants to give feedback to junior doctors on the discharge summaries that they write.

The information captured by the system in relation to prescription amendments has enabled refinement of the Drug Dictionary, which has in turn reduced the number of commonly occurring prescribing issues and informed the pharmacy-led education agenda for prescribers.

The system tracks the progress of TTOs through the whole prescription writing, dispensing and delivery steps. Each key step is automatically time stamped, allowing progress of any delays in the process to be viewed and analysed by all parties. The Discharge Tracker function also shows the number of minutes that a TTO has been in pharmacy. This information is available to all staff involved in the discharge process, so reduces the need to phone around to check on the status of urgent items.

The system allows discharge summaries and TTO drugs to be created early in a patient’s episode and thereby discharged sooner on their day of discharge.

18WW pathway information is fed to and from the Trust 18WW reporting database when transfer letters are created to other hospitals.

Discharge planning information such as estimated length of stay, planned discharge date and reason for stay is passed between Epro and the Trust’s Length of Stay Tracking system so that medical and nursing staff can enter and view information in either system.

What the outcomes were and how they were measured

Electronic discharge summaries are created for 90% of discharges, there being various explanations for the remaining 10%, from locum doctors to tertiary referrals. These figures are monitored monthly by ward.

100% of electronic discharge summaries are transmitted electronically within 24 hours of the patient being discharged on the Patient Administration System, the majority on the day of discharge.

Feedback from Chief Pharmacist Simon Whitworth: ‘The EPRO discharge letter system allows the Trust to provide high quality, legible discharge letters to GP's using standard template formats. The system, with password protected access, is used by Pharmacy staff, either in the dispensary or on the wards, to clinically screen TTO prescriptions and if necessary produce a specific printed pharmacy dispensing list. The use of a printed discharge letter and dispensing list has reduced the number of dispensing errors due to handwriting legibility. Any changes or comments made by the pharmacy staff on TTO's are captured for further analysis.’

Embedding system use on wards has involved new ways of working for doctors, pharmacists and ward staff from the beginning. With the usual teething problems of moving from paper to electronic processes, where disadvantages tend to be perceived before the benefits, these new ways of working are now accepted as standard. Over time the broader advantages of a comprehensive system have been appreciated, such as being able to find the contact details of other staff members or viewing the previous entries of a clinical diagnosis.

Advantages for support staff include the ability to track the current and past activity of every user. This has proved valuable both for tracing the history of changes to clinical documents and for smooth management of upgrades.

Summary of Functions

• Work which reflects the national IT priorities
• Demonstrable benefits to the patient
• Mainstreaming IT within the organisation
• Partnership working between trusts and the private sector
• Engaging with clinicians
• Supporting new ways of working

Discharge summaries

• PAS feeds, ADT & demographics
• Drugs for episode pulled into summary, also Adverse Drug Reactions and Alerts
• Diagnoses and procedures can be ICD10 & OPCS4 coded and pulled automatically into summaries
• BNF link for junior doctors unsure of a drug they are prescribing
• Access by clinical coders
• Full clinical document history available to authorised clinicians eg in A&E for an emergency

Transmission of summaries to GP surgery systems (TPP, EMIS, INPS Vision) via 3rd party transmission system

• Responses via NHSmail
• Also letters, deceased notifications & other docs
• Both manual sending and automatic catch-all
• Transmission by auto-NHSmail/fax to GP out-of-hours services
• Other hospitals, care homes etc receive printed summaries

Consultant review allows re-transmission of revised summaries and avoids the need to dictate new follow-up letters. The review section is highlighted to the GPs.

Patient lists

• Handover between day & night teams
• Handover from one on-call consultant to the next
• Access by discharge planning team
• Exporting to Excel
• Nursing handover sections to be rolled out soon and enable nurse & doctor sharing of electronic clinical information for the first time

Letters

• Accurate patient and GP details from PAS system
• NHS number and all other key fields auto-populated
• Ability to find any clinician across the country using Google-style search
• Current NACS codes for GPs
• Interfaces with Word for document previewing & printing
• 18WW pathway information is captured on hospital transfer letters and exchanged with the Trust’s 18WW database for SUS reporting

Integration with Length of stay tracking system – exchange of discharge planning information. This allows nurses and doctors to enter the information in whichever system they use most frequently and share it.

Comprehensive reporting allows managers to track progress against targets – eg 48 hour delivery of discharge summaries, earlier time of day of discharge, rate of drug correction by pharmacists, TTO turnaround time, excess of bed days beyond estimated stay lengths.

Future potential

• Referrals between departments
• Path & Rad results
• GP portal (drug or other info at referral time)