Orthogeriatrics was created to improve the poor outcomes of patients over 60 years suffering a hip fracture. As many orthogeriatric patients suffer with coexisting medical and social problems, good handover to primary care physicians facilitates good community care. This is part one of a two-part article.
For older people, hip fracture is the commonest serious injury; the commonest reason for them to need emergency anaesthesia and surgery; and the commonest cause of accidental death. As a result, hip fracture is associated with a total cost to health and social services of over £1 billion per year. This one injury carries a total cost equivalent to about 1% of the whole NHS budget.1
These statistics highlight the personal and national impact of sustaining a hip fracture. This is potentiated in the elderly population with pre-existing comorbidities that may lead to serious consequences if managed incorrectly. Orthogeriatrics was created to improve the poor outcomes of patients over the age of 60 years suffering a hip fracture. Orthogeriatricians work with orthopaedic teams and the wider multidisciplinary team (MDT) to address the patient’s medical and social issues.2
The Best Practice Tariff (BPT) was created as a financial incentive to improve the care of these patients. It set out essential pre-operative and postoperative criteria to ensure appropriate patient management. Criteria include time-frames for assessment and operative management alongside other requirements.3
As many orthogeriatric patients suffer with co-existing medical and social problems, good handover to primary care physicians facilitates good community care. This handover is usually provided through an electronic transfer of care document (discharge summary). At the Nottingham University Hospitals (NUH), electronic discharge summaries (e-DS) are generated using the hospitalwide, generic template. Summaries for patients over 60 treated for a hip fracture are written by junior doctors who are in foundation year 1 or year 2 and in a four-month rotation in Trauma and Orthopaedics. However, the quality of these summaries vary from minimalistic to extensive depending on what the junior doctor perceives as important information to include. These discrepancies in content were noted both in the weekly orthogeriatric MDT meetings and through feedback from local GP surgeries. It was evident that guidance from community teams could help professionals in completing these documents.
This study aims to define the relevant information that ensures a good quality transfer of care document, in order to help primary care physicians (GPs) offer a high level of care after the patient is discharged to the community.
An initial literature search was completed using the search terms: discharge summary orthopaedic, discharge summary orthogeriatric, transfer of care documentation orthogeriatric and transfer of care documentation orthopaedic’ This was completed through Pubmed and OvidSP (where only articles with four-star relevancy or more were reviewed). Many studies reviewing the transfer of care documentation, note that there is an inconsistency of information included. For example, in ‘Compliance with the Health Information and Quality Authority of Ireland National Standard for Patient Discharge Summary Information: a retrospective study in secondary care,’4 the authors attribute inadequate information on medication change to a lack of a standardised ‘patient discharge clinical documentation’. They then reference the Health Information and Quality Authority’s National Standard for Patient Discharge Summary Information5 as a standard template for discharge summaries.
A similar document has also been produced by the Academy of Royal Colleges in 2015.6 Whilst these provide a standardised structure, many of the template categories are broad and non-specific such as ‘relevant investigations and results’. This will leave the decision of what is important to include with the professional completing the document. This project aims to identify what specific information is deemed relevant and helpful by community teams.
Other studies reference specific aspects of transfer of care documentation that need to be improved. For example, one study looked specifically at the documentation of continence care.7 Whilst an important factor to consider in an orthogeriatric admission, this does not address other aspects of orthogeriatric patient care.
Another study reviewed discharge summaries in orthopaedic patients and through discussions with patients, families and healthcare professionals they provide a suggested template for orthopaedic discharge documents.8 Whilst more relevant, this study was completed in Canada and its relevance to orthogeriatric patients in the UK is not clear.
A list of contacts was created through established community links to local GP surgeries via the orthogeriatric specialist nurses. These surgeries were chosen by their experience with orthogeriatric patients and their proximity to NUH.
A simple online survey was then created for distribution. The survey questions were centred on the information collated in orthogeriatric assessments. This included general details of the patient’s admission, any osteoporosis management, any functional rehabilitation and more specific information from a standardised falls assessment. Using this method, respondents could view all of the information from a patient’s hospital admission, and identify what they would find helpful. In each category, they were asked if certain information was important, beneficial but not essential, or, not necessary to include.
The survey concluded with two open questions where respondents documented any additional categories they felt should be included in a transfer of care document, as well as other comments. There were two key steps to encourage feedback from contacts.
- Length of survey: The survey predominately comprised multiple choice questions with a space at the end for comments. It was tested on several colleagues and modified, enabling completion within five minutes.
- Direct contact with GP surgeries: Prior to distribution of the survey, we contacted the individual GP surgeries to ask if they would agree to participate in the survey. Once they agreed, we emailed it to the practice managers to distribute to the GPs in the practice.
The data was collected over two months. Once the results were analysed, a proforma was developed for use as a template in completing the e-DSs. After implementation of the proforma, a survey was completed to assess the impact on the quality of e-DS. This will be repeated after a further 12 months to ensure that quality is monitored and maintained.
Twenty seven GP surgeries were contacted and sent the survey. The survey period was extended from one month to two months as the method of data collection took longer than initially estimated. Community teams were contacted by the two foundation doctors working with the orthogeriatric team. They then distributed the survey to those practices that agreed to participate. The results are presented in Figures 1-2.
All of the respondents recognised that any information relating to medication should be included in the e-DS. This included any medications that have been altered, stopped or started and the reasons for this change, as well as medications that are being recommended for treatment of osteoporosis. Information on further osteoporosis management was also considered important to include by nearly all (96%).
Other areas most respondents felt should be included were details of preoperative and post-operative complications and postural blood pressure. These were considered important by >90% of the GPs who responded. Regarding discharge planning nearly all respondents felt that the support arranged for patients, and any community service involvement at discharge should be included.
There were several categories where >50% of respondents felt the information was not important to include. However, in these categories the majority stated that it may still be beneficial but not essential. These categories included: findings of routine ECGs, routine post-operative blood results and social history. In addition, the category entitled ‘preadmission mobility’ had the largest proportion of responses stating it was not necessary to include at 32%, followed by ‘findings of routine chest x-rays’ at 20%.
When asked if they would find the inclusion of a falls assessment useful, 91.6% of respondents replied yes. The majority requested that all but one category in the falls assessment should be included. Here 52.38% of respondents felt that ‘visual acuity and any recommendations from the optometrist’ was beneficial but not essential. In contrast all GPs believed it was necessary to include details of any medications stopped/reduced and the reasons for this.
Of the ‘free-text’ questions, nine respondents offered suggestions for additional information that they felt should be included. For the ‘general comments’ section there were six respondents.
Through this project, we were able to define what information in a transfer of care document is helpful for community care providers. The resulting proforma ensures efficiency is maximised for hospital and community physicians. It has the potential to be used by orthogeriatric teams in other hospitals and across other specialties. The positive impact of this proforma is demonstrated in a follow up survey and this quality will continue to be monitored in future surveys.
We would like to acknowledge Catherine Neighbour (Nurse Practitioner) for her invaluable support during the project.
Part two of this article will include a discussion of the results and also how to monitor the quality of transfer of care documentations
Dr Sarah Fitch, Paediatric ST1, Derby Children’s Hospital, Derby
Dr Michael Cheah, Paediatric ST2, St Peters Hospital Guilford, UK
Dr Kateryna Arlachova, Core Medical Trainee 1, Nottingham University Hospitals, Nottingham
Dr Namal Weerasuriya, Consultant Orthogeriatric Medicine, Nottingham University Hospitals, Nottingham
Conflict of interest: none declared
1. Royal College of Physicians Falls and Fragility Fracture Programme Audit. National Hip Fracture Database Annual Report 2016 [internet]. London: Royal College of Physicians; 2016. Available from: http://web1.crownaudit.org/Report2016/NHFD2016Report.pdf (Accessed December 2017)
3. NHS England. 2016/17 National Tariff Payment System [internet]. London: Monitor; 2016. Available from: https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/509697/2016-17_National_Tariff_ Payment_System.pdf (Accessed December 2017)
4. Aziz C, Grimes T, Deasy E, Roche C. Compliance with the Health Information and Quality Authority of Ireland National Standard for Patient Discharge Summary Information: a retrospective study in secondary care. European Journal of Hospital Pharmacy. 2016; 23(5): 272–77
5. Health Information and Quality Authority. National Standard for Patient Discharge Summary Information [Internet]. Dublin: Health Information and Quality Authority; 2013. Available from: https://www.hiqa.ie/system/files/National-Standard-Patient-Discharge-Summary.pdf (Accessed December 2017)
6. Health Informatics Unit, Clinical Standards Department, Royal College of Physicians. Standards for the clinical structure and content of patient records [internet]. London: The Health and Social Care Information Centre; 2013
7. Williams C, Voytas J, Lewis-Hengy K, Evoe S. A quality audit on the effectiveness of continence care documentation during care transitions. 2010 Annual Scientific Meeting of the American Geriatrics Society. Orlando, FL United States. Embase Journal of the American Geriatrics Society; 2010
9. National Institute for Health and Care Excellence. Osteoporosis: secondary prevention of fragility fracture [Internet]. London: NICE Quality and Outcomes Framework indicator; 2011 [cited 2017 February 17]. Available from: https://www.nice.org.uk/Standards-and-Indicators/QOFIndicators?categories=3905&page=1 (Accessed December 2017)