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  1. Harun NA, Finlay AY, Salek M, Piguet V
    Br J Dermatol, 2016 Sep;175(3):572-82.
    PMID: 27060980 DOI: 10.1111/bjd.14650
    BACKGROUND: Although multiple factors influence discharge decisions, there is no structured guidance to assist clinicians in making informed decisions. A discharge information checklist might improve the appropriateness of dermatology clinicians' discharge decisions.

    OBJECTIVES: To generate consensus among dermatologists on the content of an outpatient discharge checklist, to create one and to seek clinicians' opinions on its usefulness.

    METHODS: Seventeen consultant dermatologists from five National Health Service trusts completed a 72-item Delphi questionnaire. A five-point Likert scale was used to rate each item for importance in contributing to a high-quality discharge decision. Eighteen clinicians completed a questionnaire evaluating checklist use.

    RESULTS: Consensus was determined when ≥ 75% of consultants rated an item 'very important' or 'important'. There was strong inter-rater reliability (intraclass correlation coefficient = 0·958) and fair inter-rater agreement (Fleiss kappa = 0·269). There were 26 consensus-agreed items, condensed to 13 that formed the 'traffic-light' checklist. These are disease-related issues (diagnostic certainty, disease severity, treatment appropriateness, patient manageable in primary care, patient's benefit from follow-up), patient empowerment issues (understanding diagnosis and treatment outcome, having a clear plan, treatment side-effects, ability to self-manage) and addressing concerns (patient concerns, easy reaccess to secondary care, whether patient and clinician are happy with the decision). Twelve clinicians (67%) found the checklist useful, 11 (61%) wanted to use it in future, 10 (56%) thought it was useful for training and three (17%) said it helped their thinking. Clinicians suggested its use for auditing and for training clinicians and administrators.

    CONCLUSIONS: Items were identified to create an outpatient discharge information checklist, which demonstrated high acceptability.

  2. Harun NA, Finlay AY, Salek MS, Piguet V
    Br J Dermatol, 2015 Sep;173(3):720-30.
    PMID: 26076194 DOI: 10.1111/bjd.13946
    BACKGROUND: Outpatient discharge decision making in dermatology is poorly understood.
    OBJECTIVE: To identify the influences on clinicians' thought processes when making discharge decisions in dermatology outpatient clinics.
    METHODS: Forty clinicians from 11 National Health Service Trusts in England were interviewed. The interviews were audiorecorded, transcribed, coded and thematically analysed.
    RESULTS: The mean age of the clinicians was 48.8 years (range 33.0-67.0), 17 (43%) were men and 19 (48%) had > 20 years of clinical experience. One hundred and forty-eight influences were reported, with five main themes: (i) disease-based influences included type of diagnosis (100% of clinicians), guidelines (100%) and treatment needed (100%); (ii) clinician-based influences included the clinician's level of experience (100%), seniority (37%), emotional attitude (95%), 'gut feeling' (25%), personal attitude towards discharge (45%) and level of perception (100%); (iii) patient-based influences included patients' ability to cope with their disease (100%), wishes (70%), quality of life (32%), command of English (40%) and cultural background (25%); (iv) practice-based influences included good primary care (100%), secondary support structure (100%) and clinic capacity pressure (67%); (v) policy-based influences included pressure from hospital managers (57%) and an active discharge policy (7%). Fourteen (9%) influences were potentially inappropriate.
    CONCLUSION: This study has identified multiple factors influencing outpatient discharge decision making. This provides the basis for developing evidence-based training to improve discharge decision appropriateness.
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