Transferring the care of patients who are approaching the end of their lives – a re-audit of hospital discharge summaries

IntroductionDischarge summaries are fundamental in transferring care from hospital to community. However, our GP colleagues tell us these vital letters require improvement.1 Since 2014, junior doctors from Royal Derby Hospital have examined the quality of discharge summaries written about patients who are reaching their last weeks of life. These patients are eligible for immediate access to NHS continuing healthcare funding, the Fast Track pathway, to facilitate discharge.2 This audit has led to a sticker which is added to the notes when Fast Track is invoked, as a reminder of the important aspects of discharge summaries for these patients. It has also led us to deliver education to foundation doctors about discharging patients at the end of their lives. Here, we present a re-audit evaluating the impact of these interventions.MethodThe content of 181 discharge summaries written about patients receiving Fast Track funding produced at Royal Derby Hospital between 31/05/21 and 03/09/21 were reviewed against set criteria. Findings were compared to previous audits to identify trends and areas for improvement.ResultsThis re-audit had positive and negative findings. We found an increase in documented instructions to GP (62% from 46%), and in anticipatory medications prescribed on discharge (94% from 80%). However, we also found ongoing poor documentation of preferred place of care/death (36% from 38%) and fewer discharge summaries detailing a clear follow-up plan (47% from 61%). This may account for the increase in readmissions in this patient group (9% from 16%).ConclusionThe quality of discharge summaries written about patients who are approaching the end of their life remains variable. Disruptions to service provision and education due to COVID have led to a lack of guidance provided for writing discharge summaries. We recommend reinstating early teaching for junior doctors on this important topic. Re-audit following this is advised.ReferencesKripalani S, LeFevre F, Phillips C, Williams M, Basaviah P, Baker D. Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians. JAMA [Internet]. 2007 [cited 14 September 2022];297(8):831. Available from: https://jamanetwork.com/journals/jama/article-/205790Fast-track pathway tool for NHS continuing healthcare guidance [Internet]. GOV.UK. 2022 [cited 14 September 2022]. Available from: https://www.gov.uk/government/publications/nhs-continuing-healthcare-fast-track-pathway-tool/fast-track-pathway-tool-for-nhs-continuing-healthcare-guidance#what-the-fast-track-pathway-tool-is

In-Flight Transmission of a SARS-CoV-2 Lineage B.1.617.2 Harbouring the Rare S:E484Q Immune Escape Mutation.

We describe a flight-associated infection scenario of seven individuals with a B.1.617.2 (Delta) lineage, harbouring an S:E484Q point mutation. In Sweden, at least 10% of all positive SARS-CoV-2 samples were sequenced in each county; the B.1.717.2 + S:E484Q combination was not detected in Sweden before and was imported within the scenario described in this report. The high transmission rate of the delta lineage combined with the S:E484Q mutation, associated with immune escape in other lineages, makes this specific genetic combination a possible threat to the global fight against the COVID-19 pandemic. Even within the Omicron wave, the B.1.617.2 + S:E484Q variant appeared in community samples in Sweden, as it seems that this combination has an evolutionary gain compared to other B.1.617.2 lineages. The here described genomic combination was not detectable with the common fasta file-based Pango-lineage analysis, hence increasing the probability of the true global prevalence to be higher.

Variant SARS-CoV-2 mRNA vaccines confer broad neutralization as primary or booster series in mice.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of a global pandemic. Safe and effective COVID-19 vaccines are now available, including mRNA-1273, which has shown 94% efficacy in prevention of symptomatic COVID-19 disease. However, the emergence of SARS-CoV-2 variants has led to concerns of viral escape from vaccine-induced immunity. Several variants have shown decreased susceptibility to neutralization by vaccine-induced immunity, most notably B.1.351 (Beta), although the overall impact on vaccine efficacy remains to be determined. Here, we present the initial evaluation in mice of 2 updated mRNA vaccines designed to target SARS-CoV-2 variants: (1) monovalent mRNA-1273.351 encodes for the spike protein found in B.1.351 and (2) mRNA-1273.211 comprising a 1:1 mix of mRNA-1273 and mRNA-1273.351. Both vaccines were evaluated as a 2-dose primary series in mice; mRNA-1273.351 was also evaluated as a booster dose in animals previously vaccinated with mRNA-1273. The results demonstrated that a primary vaccination series of mRNA-1273.351 was effective at increasing neutralizing antibody titers against B.1.351, while mRNA-1273.211 was effective at providing broad cross-variant neutralization. A third (booster) dose of mRNA-1273.351 significantly increased both wild-type and B.1.351-specific neutralization titers. Both mRNA-1273.351 and mRNA-1273.211 are being evaluated in pre-clinical challenge and clinical studies.

Safety and immunogenicity of SARS-CoV-2 variant mRNA vaccine boosters in healthy adults: an interim analysis.

The emergence of SARS-CoV-2 variants of concern (VOCs) and variants of interest (VOIs) with decreased susceptibility to neutralization has generated interest in assessments of booster doses and variant-specific vaccines. Clinical trial participants who received a two-dose primary series of the COVID-19 vaccine mRNA-1273 approximately 6 months earlier entered an open-label phase 2a study ( NCT04405076 ) to evaluate the primary objectives of safety and immunogenicity of a single booster dose of mRNA-1273 or variant-modified mRNAs, including multivalent mRNA-1273.211. As the trial is currently ongoing, this exploratory interim analysis includes preliminary descriptive results only of four booster groups (n = 20 per group). Immediately before the booster dose, neutralizing antibodies against wild-type D614G virus had waned (P < 0.0001) relative to peak titers against wild-type D614G measured 1 month after the primary series, and neutralization titers against B.1.351 (Beta), P.1 (Gamma) and B.1.617.2 (Delta) VOCs were either low or undetectable. Both the mRNA-1273 booster and variant-modified boosters were safe and well-tolerated. All boosters, including mRNA-1273, numerically increased neutralization titers against the wild-type D614G virus compared to peak titers against wild-type D614G measured 1 month after the primary series; significant increases were observed for mRNA-1273 and mRNA-1273.211 (P < 0.0001). In addition, all boosters increased neutralization titers against key VOCs and VOIs, including B.1.351, P.1. and B.1.617.2, that were statistically equivalent to peak titers measured after the primary vaccine series against wild-type D614G virus, with superior titers against some VOIs. This trial is ongoing.