October blog 2017 – Hospital Discharge: Next Steps

Hospital Discharge: Next steps?

Patient discharge from hospital should be a positive, stress free experience – the opportunity for a patient to return to normality with proper professional support.

With more than 13 million hospital admissions in England every year, a slick NHS wide best-practice process should really be in place. However, the sheer scale of the NHS, the number of admissions and indeed readmissions makes this real a challenge. In 2012-13 there were 1 million readmissions within 30 days of discharge at a cost of £2.4 billion!

In the same year between October 2012 and September 2013 there were around 10,000 reports to the National Reporting and Learning System (NRLS) of patient safety incidents related to discharge. Around a third were cited as being due to poor communication. It is sadly the case that information, even when provided, is not always acted on in a timely manner which can result in avoidable deaths, failure of continuity of care and avoidable readmission to secondary care.

So something needs to change. Developing an integrated approach to patient care and proper support following hospital discharge has been shown to reduce frequency of hospital readmission and generate significant savings for the local health economy1:

As pharmacists, it is no surprise that “Patients receiving a follow up review at their community pharmacy were three times less likely to be readmitted to hospital after discharge.”

Therefore, involving community pharmacy makes economic sense and pharmacy should be an integral part of patient discharge pathways.

We know that if a patient has been in hospital only around 1 in 10 will come out on the same medicines they went in on so pharmacists need to assure themselves that the correct medication has been prescribed when they receive the first post-discharge prescription.

Currently, most queries will result in a call to the surgery, but, with the patient’s informed consent, the Summary Care Record (SCR) could be accessed. N.B. GPs have ownership of the SCR and any updates to medication will need to be done by them and updates are processed overnight, so there could be a delay.

With unintended discrepancies in patient’s medicines after discharge from hospital affecting up to 87% of patients there is great potential for adverse health consequences and many of these could be preventable.

GPs are usually sent a discharge summary, including a current medication list, within 24 hours of discharge. A patient’s pharmacist doesn’t routinely get this information at the moment. This causes problems, as medication changes may not be acted upon (e.g. dose changes, continuity of newly prescribed medicines, discontinuation of previous medication, etc.).

How much better would it be if the pharmacy received the discharge information directly and at the same time as the GP?

GOOD NEWS: This is now possible with PharmOutcomes and Chesterfield Royal Hospital (CRH). With support from NHS England North Midlands they have implemented a fully integrated solution, which should help to make a real difference. It will reduce hospital workload and all discharge information can be transferred automatically to the community pharmacy when the discharge letter is published. The community pharmacy will be notified of all referrals requiring action at the top of their PharmOutcomes service screen. In addition, a non-patient identifiable e-mail is sent to the pharmacy to notify them.

Referral criteria will be agreed between NHS England and CRH, so not every newly discharged patient will be notified to the pharmacy. This will mean that those ‘at risk’ patients most in need of support will be prioritised. Consequently, there will be opportunities for New Medicine Service (NMS) interventions and post-discharge MURs. It should also help with workload as post-discharge information will be received in a much timelier manner.

The LPC fully supports the smarter referrals facility and encourages all pharmacists to make the most of the opportunities that are on offer. In particular, post-discharge MURs can provide invaluable support and should be conducted if at all possible. This would ensure that the patient was fully aware of any changes, side effects and interactions, and knew why they were taking any new medication (or not taking their old medication). What better way to discharge your responsibilities…

In December 2014 the Royal Pharmaceutical Society published a referral toolkit: “Hospital referral to community pharmacy: An innovator’s toolkit to support the NHS in England”. This document laid out the case for change:

  • 30-50% of patients don’t take their medicines as intended
  • Non-elective admissions are estimated to cost £1,739
  • Between 30% and 70% of patients have either an error or an unintentional change to their medicines when their care is transferred
  • 1.3 unintended discrepancies for every medicines reconciliation completed by a non-pharmacist member of staff
  • Two-thirds of discharge summary letters are inaccurate or incomplete prior to pharmacy screening

Well that change has come and I hope you will join me in welcoming it!

John Sargeant,

Chairman, Derbyshire LPC,

October 2017