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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 1  |  Page : 1-5

Evaluation of discharge letters of patients who went against medical advice from the emergency department: A complete audit cycle


Department of Emergency Medicine, Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, Kerala, India

Date of Web Publication16-Jul-2019

Correspondence Address:
Dr. Krishna Prasad
Department of Emergency Medicine, Sree Gokulam Medical College and Research Foundation, Venjaramoodu, Thiruvananthapuram - 695 607, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_13_19

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  Abstract 

Aim: The aim was to evaluate the discharge letters of patients who went “against medical advice” (AMA) from the emergency department (ED) before and after the introduction of a preformatted discharge letter in a tertiary care center in India. Methods: A prospective clinical audit of case sheets of 200 patients who presented to the ED and later went AMA were evaluated in two different time frames. The discharge letters of the first 100 case sheets were evaluated during September–October 2018 time period, and the second 100 case sheets were evaluated during February–March 2019 time period after the introduction of a preformatted discharge letter. Descriptive analysis was used to measure frequency and percentages. Results: The proportions of data recorded in the discharge letters of patients who went AMA before and after the use of a preformatted discharge letter are: cases where discharge letter was given, 74% versus 89%; cases where discharge letter was written by the concerned department, 67.5% versus 93.25%; cases where clinical details were mentioned completely, 86% versus 100%; cases where time of discharge was mentioned, 19% versus 89%; and the cases where name of the doctor who was discharging the patient was mentioned, 20% versus 86.5%. Conclusions: The audit highlighted the shortcomings in the “discharge against medical advice” letters which were rectified using preformatted discharge letters. This was evident from the data analyzed from the second audit cycle. Provision of a standard uniform preformatted discharge letter to every patient leaving the ED would be a step forward in ED current practices and quality improvement.

Keywords: Audit, discharge against medical advice, discharge letter, quality improvement


How to cite this article:
Prasad K, Sekhar L. Evaluation of discharge letters of patients who went against medical advice from the emergency department: A complete audit cycle. Curr Med Issues 2019;17:1-5

How to cite this URL:
Prasad K, Sekhar L. Evaluation of discharge letters of patients who went against medical advice from the emergency department: A complete audit cycle. Curr Med Issues [serial online] 2019 [cited 2019 Aug 19];17:1-5. Available from: http://www.cmijournal.org/text.asp?2019/17/1/1/262822


  Introduction Top


Discharge letters are an integral part of the patient management process.[1] It summarizes all the vital information regarding course in hospital and treatment. They are designed to include all the important data from admission till discharge including postdischarge instructions. They also serve as an efficient tool for future references and treatment.[2] In many cases, patients require postdischarge medical treatment and follow-up either at the same institution or elsewhere, and discharge letters are therefore the most effective tool for guiding this process.[3] Providing discharge letters to inpatients is an accepted routine in most hospitals. However, it is not a standard practice to provide such instructions to patients visiting the emergency department (ED), and there is a wide disparity in its implementation.[4] A discharge against medical advice (DAMA) occurs when a patient chooses to leave the hospital before the health-care provider recommends the patient's discharge at the completion of treatment.[5] AMA disposition for ED patients is not uncommon yet a poorly studied phenomenon.[6] There is ample evidence to support that suboptimal documentation occurs in AMA cases by clinicians from ED.[7]

Aim

The aim of this audit was to evaluate the discharge letters of those patients who went AMA before and after introduction of a prestructured format at a tertiary care center in a rural setting.


  Methodology Top


A prospective clinical audit of case files was carried out and 100 “discharge against medical advice” (DAMA) letters were analyzed between September 27, 2018 and October 18, 2018. Data were collected from these DAMA letters and entered into an MS Excel spreadsheet. This included name, date, file number, working diagnosis, and name of concerned department discharging the patient. Data regarding whether DAMA letter was written or not, whether DAMA letter was written by the concerned department, whether the clinical details written were complete or incomplete, whether the time of discharge was mentioned or not, and whether the name of doctor who was referring/discharging the patient was mentioned or not was also collected. The data were analyzed and presented in a tabular form [Table 1]. Following the analysis, a structured format for DAMA letter [Figure 1] was made on October 26, 2018, which was approved on October 31, 2018 by the Hospital Management Committee and put into daily use from February 10, 2019. The new preformatted discharge letter was put up in the department notice board along with specific instructions on how to utilize it. Awareness regarding this new intervention was also circulated through the duty doctor's social groups. Each DAMA was written by placing a carbon paper beneath it to obtain a copy, which was attached along with the case sheet. Following a month, a audit was carried out on another 100 consecutive DAMA cases and based on the findings; the final data were collected, analyzed, and compared.
Table 1: Data depicting various factors before and after the introduction of preformatted discharge letter

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Figure 1: Preformatted discharge letter implemented at a tertiary care center in a rural setting.

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Audit standards

Referral guidelines for the common conditions for institutions under the Directorate of Medical Education and Directorate of Health Services, Government of Kerala[8] [Figure 2].
Figure 2: Referral card issued by the Directorate of Medical Education and Directorate of Health Services, Government of Kerala.

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Points taken from the above guidelines which were used as the standard for comparison included the following:

  • Patient name, age, gender, and hospital number
  • Date of presentation
  • Presenting complaint
  • Whether discharge letter was given or not?
  • Whether discharge letter was written by concerned department?
  • Whether clinical details written were complete or incomplete?
  • Whether time of discharge was mentioned or not?
  • Whether doctor's name was mentioned or not?



  Results Top


First audit cycle (September 27, 2018–October 18, 2018)

Among the 100 cases that were DAMA, letters were written for 74% of the cases and 26% of the cases did not receive letters before discharge. Of the 26 cases, the major share of the cases disposed without giving DAMA letters were contributed by surgeons (27%) followed by pediatricians (23%). The rest of the cases disposed without DAMA letters were written by emergency physicians, general physicians, orthopedicians, neurosurgeons, and nephrologists. Of the 74 cases where DAMA letters were given before disposal, majority of the letters were written by general physicians (38%), followed by cardiologists (24%) and emergency physicians (16%). The other departments who gave DAMA letters include surgery, neurosurgery, pediatrics, orthopedics, plastic surgery, and ENT. Of the 74 DAMA letters analyzed, clinical details were mentioned appropriately in 86% of the cases, whereas 12% of the letters had incomplete details. Incomplete details include omission of key clinical examination details and vitals. One DAMA letter had the wrong details including the diagnosis. Of the nine cases where clinical details were incomplete in the DAMA letters, 66% were written by general physicians and cardiologists, whereas the rest was written by emergency physicians and surgeons. In the DAMA letters given, time of discharge was mentioned only in 19% of the cases, whereas 81% of the cases did not have such detail. Of the 60 DAMA cases, where the time of discharge was not mentioned, medicine department contributed the highest (43%) followed by cardiology (18%). The rest altogether contributed only 39%. Of the 74 DAMA letter analyzed, the name of the doctor discharging the patient was found in only 20% of the cases, whereas the remaining 80% had no mention of the name of the doctor. Of the 59 cases where doctor's name was not mentioned in the DAMA letters, 42% of the cases were disposed by medicine department followed by cardiology (27%). The others altogether constituted 31%. When it was analyzed whether the concerned department has written the DAMA letter, it was found that it is evident only in 67.5% of the cases. Of the 24 cases where concerned departments have not written the DAMA letters, cardiology topped the list with 62.5%. It was also seen that, 6 out of 9 DAMA letters, i.e., 66.6% which had incomplete details were found in those DAMA letters which was not written by the concerned departments.

Second audit cycle (February 10, 2019–March 3, 2019)

Among the 100 cases that were DAMA, letters were written for 89% of the cases and 11% of the cases did not receive letters before discharge. Of the 89 cases where DAMA letters were given before disposal, majority of the letters were written by general physicians, followed by surgeons and emergency physicians. Of the 89 DAMA letters analyzed, clinical details were complete in all the cases. In the DAMA letters given, time of discharge was mentioned in 89% of the cases, whereas 11% of the cases did not have such detail. Of the 89 DAMA cases, where the time of discharge was not mentioned, surgeons contributed the highest (40%). Of the 89 DAMA letter analyzed, 77 cases had the name of the doctor discharging the patient mentioned. When it was analyzed whether the concerned department has written the DAMA letter, it was found that it is evident in 83 out of the total 89 cases.


  Discussion Top


Many studies have drawn attention to the quality and content of the referral letters to hospital outpatient or EDs and to consultants in various specialties.[9] Significant shortcomings were noticed in the documentation of investigation results and follow-up advice. The first audit cycle revealed gross deficiencies compared to the standard guideline. This was later presented to the hospital management committee and a structured preformatted discharge letter was made and was made to comply with. The second audit showed marked improvement in all the parameters. The proportions of data recorded in the discharge letters of patients who went AMA before and after the use of a preformatted discharge letter are: cases where discharge letter was given, 74% versus 89%; cases where discharge letter was written by the concerned department, 67.5% versus 93.25%; cases where clinical details were mentioned completely, 86% versus 100%; cases where time of discharge was mentioned, 19% versus 89%; and the cases where name of the doctor who was discharging the patient was mentioned, 20% versus 86.5%.

Couper and Henbest reported an improvement in the quality of referral letters after the introduction of a form letter, i.e., a structured or standardized referral letter which includes headings for relevant information. Form letters have therefore been found to be shorter and contain more details than nonform letters.[10],[11] Juan et al. on the other hand, looked into the documentation proficiency of ED patients who are discharged AMA and was able to demonstrate improvement in quality and compliance rates after implementation of a checklist. They also postulated that the improvement was seen in the post intervention group (i.e., introduction of a checklist) is likely that the discharge AMA checklist provided standardization of practice and a visual reminder to the doctors of the critical steps in their communication with the patient, and then documenting the process.[12] The ED environment poses several challenges whenever a new patient comes in. Many factors such as time constraints, unpredicted interruptions, diagnostic uncertainty, shift changeover, and overcrowding frequently undermine good intentions.[13] It is important that this informed communication immediately preceding discharge AMA is clearly documented despite these challenging ED situations. Properly executed DAMA letters does not completely insulate doctors from liability in a medical malpractice action. It is however important from a medicolegal point of view because it can provide important legal protection. The AMA records evidence of refusal of care and its documentation can provide vital evidence for any ensuing litigation.[14] Implementing a preformatted discharge summary definitely provided more information than a mere prescription form in terms of the amount of information written by virtue of its structured nature.[15]


  Conclusion Top


The audit highlighted several shortcomings in the DAMA letters. This can be improved by changing and enhancing the current practices such as the introduction of a preformatted structured discharge letter as in the above example. In this regard, the authors recommend various steps to improve the standards.

Recommendations

  1. To formulate and fill-up the preformatted structured discharge letter always while discharging patients from the ED
  2. To make sure that vitals on arrival and on discharge are taken and entered in the discharge letter correctly
  3. Training house officers and trainee medical officers in writing discharge letters for maintaining better standard and quality of care.


Acknowledgment

The authors would like to thank the entire nursing staff of the ED, Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, for their help and support in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Lehman LW, Long W, Saeed M, Mark R. Latent topic discovery of clinical concepts from hospital discharge summaries of a heterogeneous patient cohort. Conf Proc IEEE Eng Med Biol Soc 2014;2014:1773-6.  Back to cited text no. 1
    
2.
Stein R, Neufeld D, Shwartz I, Erez I, Haas I, Magen A, et al. Assessment of surgical discharge summaries and evaluation of a new quality improvement model. Isr Med Assoc J 2014;16:714-7.  Back to cited text no. 2
    
3.
Mc Larnon E, Walsh JB, Ni Shuilleabhain A. Assessment of hospital inpatient discharge summaries, written for general practitioners, from a department of medicine for the elderly service in a large teaching hospital. Ir J Med Sci 2016;185:127-31.  Back to cited text no. 3
    
4.
Taylor DM, Cameron PA. Emergency department discharge instructions: A wide variation in practice across Australasia. J Accid Emerg Med 2000;17:192-5.  Back to cited text no. 4
    
5.
Bitterman RA. Medicolegal issues and risk management. In: Marx JA, Hockberger RS, Walls RM, Adams J, Rosen P, editors. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia: Mosby/Elsevier; 2010. p. 2582-99.  Back to cited text no. 5
    
6.
Jerrard DA, Chasm RM. Patients leaving against medical advice (AMA) from the emergency department – disease prevalence and willingness to return. J Emerg Med 2011;41:412-7.  Back to cited text no. 6
    
7.
Schaefer MR, Monico EP. Documentation proficiency of patients who leave the emergency department against medical advice. Conn Med 2013;77:461-6.  Back to cited text no. 7
    
8.
Referral Guidelines for the Common Conditions for Institutions under DME and DHS in Kerala. Available from: http://www.dhs.kerala.gov.in/docs/pdf/reference.pdf. [Last accessed on 2019 Mar 12].  Back to cited text no. 8
    
9.
Westerman RF, Hull FM, Bezemer PD, Gort G. A study of communication between general practitioners and specialists. Br J Gen Pract 1990;40:445-9.  Back to cited text no. 9
    
10.
Couper ID, Henbest RJ. The quality and relationship of referral and reply letters. The effect of introducing a pro forma letter. S Afr Med J 1996;86:1540-2.  Back to cited text no. 10
    
11.
Jenkins S, Arroll B, Hawken S, Nicholson R. Referral letters: Are form letters better? Br J Gen Pract 1997;47:107-8.  Back to cited text no. 11
    
12.
Juan JS, Lim GH, Lim BL. Audit of documentation proficiency of emergency department patients who are discharged against medical advice before and after implementation of a checklist. J Hosp Admin 2016;5:28-33.  Back to cited text no. 12
    
13.
Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the emergency department. Ann Emerg Med 2012;60:152-9.  Back to cited text no. 13
    
14.
Levy F, Mareiniss DP, Iacovelli C. The importance of a proper against-medical-advice (AMA) discharge: How signing out AMA may create significant liability protection for providers. J Emerg Med 2012;43:516-20.  Back to cited text no. 14
    
15.
Dudi-Venkata N, Rajavelu P, Rajagopalan A. Pre-formatted written discharge summary-a step towards quality assurance in the emergency department. Int J Emerg Med 2008;1:321-5.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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