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4Ds: Documenting delirium diagnosis in discharge summary

Published online by Cambridge University Press:  13 August 2021

Z. Azvee ,
I. Khair ,
N. Barry  and
J. Sheehan
Z. Azvee*
Affiliation:
Liaison Psychiatry, Mater Hospital, Dublin, Ireland
I. Khair
Affiliation:
Liaison Psychiatry, Mater Hospital, Dublin, Ireland
N. Barry
Affiliation:
Liaison Psychiatry, Mater Hospital, Dublin, Ireland
J. Sheehan
Affiliation:
Liaison Psychiatry, Mater Hospital, Dublin, Ireland
*
*Corresponding author.

Abstract

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Introduction

Hospital discharge is a significant transitional phase with varying levels of needs and risks to be managed as lapses in communication commonly happen between secondary/tertiary and primary care.

Objectives

Our aim was to look at inclusion of delirium diagnosis in discharge summaries based on standards set by: 1. Health Information and Quality Authority (HIQA) National Standard for Patient Discharge Summary Information 2. NICE Guidelines on Delirium: prevention, diagnosis and management (CG 103)

Methods

All inpatients referred to Liaison Psychiatry from 9thJuly 2019 till 5th January 2020 were included, n = 729. Compared discharge summaries diagnoses to the internal Liaison Psychiatry ICD 10 consensus diagnosis and also HIPE coded diagnosis specifically for delirium.

Results

Delirium diagnoses and inclusion of delirium-specific information on discharge summary

nProportion (n=112*) (%)
Q1 Any F05 diagnosis coded by Liaison Psychiatry117100
Q2 F10.4 diagnosis coded by Liaison Psychiatry00
Q3 F1x.4 diagnosis coded by Liaison Psychiatry00
Q4 Any F05, F10.4 and F1x.4 diagnosis coded in discharge summary on patient centre2320.5
Q5 Was the word delirium or its synonym such as acute confusional state mentioned in the body of the discharge summary?6255.4
HIPE Code Diagnosis6658.9

Conclusions

Hospital discharge summaries are essentially the main communication link between hospitalists and general practitioners to ensure continuity and future care of patients. Delirium diagnosis is not always recorded in discharge summaries. This is a risk to be managed. Education is vital to ensure awareness, prevention, early recognition and to ensure recording of diagnosis of delirium.

Keywords

Patient safetyService improvementcommunicationdelirium
Type
Abstract
Information
European Psychiatry , Volume 64 , Special Issue S1: Abstracts of the 29th European Congress of Psychiatry , April 2021 , pp. S499 - S500
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of the European Psychiatric Association
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