4.1 Local implementation

Implementation of national clinical guidelines is the responsibility of each NHS Trust and is an essential part of clinical governance.³² It is acknowledged that every Trust cannot implement every guideline immediately on publication, but mechanisms should be in place to ensure that the care provided is reviewed against the guideline recommendations and the reasons for any differences assessed and, where appropriate, addressed. These discussions should involve both clinical staff and management. Local arrangements may then be made to implement the national guideline in individual hospitals, units and practices, and to monitor compliance. This may be done by a variety of means including continuing education, training, and clinical audit. Approaches to reduce prescribing errors such as electronic prescribing and medicine administration and systems for the use of compliance aids should also be examined locally.

The following suggested implementation and audit measures are based on consensus within the guideline development group. It is recognised that this is a minimum dataset and therefore certain specialties, for example obstetrics, will have additional data field requirements.

4.1.1 NON-ELECTRONIC IMPLEMENTATION

Problems exist regarding the accuracy of coding and the content of immediate discharge summaries. In most NHS Trusts there is a delay before the final discharge documentation is processed. Current paper systems result in duplication of effort and may waste a considerable amount of time. These problems are compounded by separating the immediate discharge document from the final discharge document and by running separate systems within different departments. This may increase the level of risk to patients.

• NHS Boards should aim to reduce duplication to a minimum
• all the fields in this document should be included in the discharge documentation; the precise content and presentation should be subject to local agreement
• the final discharge document should be either the IDD or follow with minimal delay
• access to required information should be improved to reduce errors and delays, for example, radiology, laboratory and pharmacy reports.

4.1.2 ELECTRONIC IMPLEMENTATION

Good quality standardised paper systems can provide a template for electronic versions. Electronic systems should be designed so that data are entered only once. Any electronic system should be available to all areas of the health service with access restricted to a “need to know basis”.

• the immediate discharge document should be the final discharge document wherever possible.

This will require instant access to the results of all investigations

• coding should be carried out electronically and checked on discharge
• the electronic patient record should include the current medication details with a record of previous prescriptions and reasons for changes
• drug interactions should be highlighted and modified according to associated clinical conditions.

Standardised electronic implementation should improve the quality of patient information recorded, which may reduce the number of complaints. Properly designed systems will improve the quality of patient care and should improve communication across the service.

4.2 Key points for audit

• baseline audit of current practice
• completeness of the immediate discharge document
• time of delivery of the IDD to primary care
• accuracy (including coding errors) of the IDD
• time required to complete the IDD.

4.3 Recommendations for research

• whether electronic prescribing reduces the error rate of medication histories in discharge letters
• the best way of managing patient medicines to ensure accurate medication records can be maintained across primary and secondary care
• a comparison of quality of IDD use across NHS Boards in Scotland
• the difference between clinical terms and codes
• clinicians’ coding preferences
• how electronic coding should be carried out
• how the accuracy and completeness of electronic coding should be checked on discharge
• the information needs of patient’s carers on discharge
• the cost and benefits of one national system of IDD production versus multiple smaller systems.

4.4 Sources of further information for health professionals

Information and Statistics Division (ISD)
NHS National Services Scotland
Gyle Square, 1 South Gyle Crescent, Edinburgh EH12 9EB
Tel: 0131 275 7777
www.isdscotland.org

Electronic Clinical Communication Implementation (ECCI)
Contact: Mike Lister on 0131 244 1726
Mike.Lister@scotland.gsi.gov.uk
www.show.scot.nhs.uk/ecci

Scottish Health on the Web (SHOW)
www.show.scot.nhs.uk