Factors influencing discharge decisions in\ud dermatology outpatients:\ud checklist and educational methods to\ud support appropriate discharge

Doctoral thesis English OPEN
Harun, Nur Ainita
  • Subject: RL | RM

The decision whether or not to discharge an outpatient is vital in determining outpatient\ud clinic attendance numbers, directly affecting overall patient care efficiency. A review of\ud the factors influencing discharge decisions revealed that there was limited evidence of\ud these factors and a lack of understanding how clinicians take discharge decisions. This\ud project’s objectives were to describe the influential factors on discharge decisions from\ud the clinicians’ and patients’ perspectives, to demonstrate the development and clinical\ud evaluation of a novel "Traffic-light” design dermatology outpatient discharge information\ud checklist to improve appropriateness and consistency in discharge decision-making.\ud Semi-structured interviews were carried out with 40 consultant dermatologists across\ud England. 148 influences were generated and thematically analysed manually and using\ud NVivo10 software. A wide array of nonclinical factors, clinician-based, patient-based,\ud practice-based and policy-based, influence discharge decision-making.\ud Observations of 64 consultations and 56 semi-structured interviews with dermatology\ud outpatients were carried out to understand their experience concerning the decision for\ud their discharge. Twelve of 31 patients (39%) who were discharged considered their\ud discharge inappropriate.\ud A three-round Delphi exercise with 17 dermatology consultants (100% response) was\ud carried out to reach agreement on what a high quality discharge information checklist\ud should contain. There was strong inter-rater reliability (ICC=0.958) and fair inter-rater\ud agreement (Fleiss Kappa=0.269). Thirteen items were identified that formed the "Trafficlight"\ud design checklist. Twelve (67%) dermatology clinicians who evaluated the checklist\ud found it useful.\ud This study has demonstrated the importance of approaching discharge decision taking\ud in an informed, structured manner. The checklist provide the basis for making discharge\ud decisions more systematic, auditable and transparent, improving patient safety and\ud optimising healthcare costs. These methods are potentially useful in other clinical\ud disciplines.
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