ABSTRACT
Introduction A recognised problem in the Royal Devon & Exeter Hospital and across the NHS is that discharge summaries are often sent to general practitioners (GP) long after the patient is discharged, or not at all. This is a safety issue when for example the summary includes time-sensitive requests for the GP or information relevant to ongoing care. Methods A quality improvement project was devised to tackle this important problem. First, the Royal Devon & Exeter Hospital's electronic patient record system was used to construct a report allowing measurement of the scale of this problem and stratification by factors such as discharging department or ward. This report identified that 22.6% (12,965/57,367) of discharge summaries are sent outside the Trust's target (two working days from discharge). A three-pronged approach was devised targeting discharges of deceased patients using educational material, discharges from a medical ward using an automated list, and finally optimising the technical steps required to send a discharge summary to attempt to reduce the delay. Results Plan, do, study and act (PDSA) cycles were implemented, one targeting discharges for deceased patients and another targeting discharges from a medical ward. Though not sustained, the former resulted in a six-week increase in the percentage of discharge summaries sent within the target from 50% to 80%. The latter did not lead to improvement due to a number of factors including workload in the midst of a global pandemic and other factors explored in a root cause analysis. The most ambitious intervention aimed to automate an administrative step, which proved challenging due to software and human factors. As such this intervention was not completed during the study period. Conclusion The sending of discharge summaries is often delayed and this has potential consequences for patient care. This study has used the hospital's electronic patient record system to create a report which provides detailed information on areas with the most potential for improvement. Though the targeted interventions were respectively nonsustained, unsuccessful and not implemented, this data can suggest reasons behind poor performance and therefore targets for future interventions, illustrating great sustainability.
ABSTRACT
INTRODUCTION: Pulmonary tuberculosis (TB) is an important risk factor for chronic respiratory disease due to residual lung damage. Yet, the WHO End TB strategy does not mention post-TB chronic lung disorders (PTBLDs) and programmatic interventions to address PTBLD are lacking. This study assessed the scope of current guidelines and evidence on PTBLD to inform policy and research action. METHODS: A systematic literature search was conducted following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Eight databases (TRIP, International Guideline Library, MEDLINE/PubMed, EMBASE, Web of Science, Global Health, Cochrane Library) were searched for records on PTBLD published between 1 January 1990 and 1 December 2017. Non-English records, case series, conference abstracts and letters to editors were excluded. Data were extracted and charted on publication year, location, PTBLD condition(s) and main study outcome. RESULTS: A total of 212 guidelines and 3661 articles were retrieved. After screening, only three international TB guidelines mentioned TB sequelae, but none described how to identify or manage the condition. A total of 156 articles addressed PTBLD: 54 (35%) mentioned unspecified TB sequelae; 47 (30%) specific post-TB conditions including aspergillosis, bronchial stenosis or bronchiectasis; 52 (33%) post-TB obstructive disorders or lung function impairment; and 20 (13%) post-TB respiratory symptoms or chest X-ray abnormalities. The first two groups mostly assessed surgery or ventilation techniques for patient management, while the last two groups typically assessed prevalence or predictors of disease. CONCLUSION: This is the first review to provide a comprehensive overview of the current literature on PTBLD. The scope of evidence around the burden of PTBLD warrants inclusion and recognition of the problem in international TB guidelines. Research is now needed on early detection of PTBLD and patient management options that are suitable for high-burden TB countries.
