Razones de la no cumplimentación del Informe de Continuidad de Cuidados en el Área de Hospitalización Quirúrgica de un Hospital de Agudos

Abstract

The Continuing Care Report (CCR, which in some countries is part of the Discharge Letter) is a crucial tool for the nurse, as it details the care patients will need once they have been discharged. The CCR is an essential tool for communication between primary and secondary assistance, as well as for the patient, their carer and their GP. It is also an important legal record of the care received and needed. During the latest annual review at the Vigo University Hospital, it was observed that 21% of post-surgical discharges were carried out without filling out a CCR. The level of compliance varied sharply between different departments. In my study I have aimed to determine the exact number of patients discharged with no CCR and establish the reasons for this failure to comply with standard procedure. Objectives: To establish the number of patients by department who were discharged with no CCR and understand the reasons that contribute to this failure. Data and method: Retrospective study focusing on February 2012. Subjects: All post-surgical patients discharged from the Vigo University Hospital during that period. The list of discharges is provided daily by the Admissions Office. Then, using applications Gacela and IANUS, we verify whether the CCR was filled out. In the cases of no compliance, we find out who the nurse responsible for the patient was and examine the reasons behind their failing to comply. The data was stored and analysed using Excel. Results: There were 629 discharges. 67 patients (11%) did not receive a CCR. Reasons for failing to comply were: Their operation was suspended: 28%, Lack of time: 12%, Peripheral patient (i.e. a patient hospitalized in a different department or ward as a result of a bed shortage): 3%, Unexpected motives: 57% (CCRs written on paper, 16.5%; non-standard CCR, 15%; confusion over nurses' shifts, 7.5%; other, 18%). Conclusions: Having discussed the lack of compliance with the staff affected the result of the study, as correcting measures were implemented. The lack of time to comply with regulation happens less frequently than expected in certain units and amongst certain specific members of the staff it is necessary to write a CCR for those patients whose operations have been suspended. A significant reason for the lack of compliance is the result of inadequate work dynamics - correcting measures must be implemented.