Essay Paper

Article

Improving handoff communication from hospital

to home: the development, implementation and

evaluation of a personalized patient discharge letter

BIANCA M. BUURMAN1, KIM J. VERHAEGH1, MARIAN SMEULERS2,

HESTER VERMEULEN2, SUZANNE E. GEERLINGS3,

SUSANNE SMORENBURG4, and SOPHIA E. de ROOIJ1

1Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, Amsterdam, The Netherlands, 2Department of Quality Assurance and Process Innovation, Academic Medical Center, Amsterdam, The Netherlands, 3Department of Internal Medicine, Section of Infectious Disease, Academic Medical Center, Amsterdam, The Netherlands, and 4Department of Quality, Cordaan, Amsterdam, The Netherlands

Address reprint requests to: Bianca Buurman, Department of Internal Medicine, Section of Geriatric Medicine, Academic Medical Center, F4-135, PO Box 22600, 1100 DD Amsterdam, The Netherlands. Tel: +31-20-5665991; Fax: +31-20-5669325; E-mail: [email protected]

Accepted 21 March 2016

Abstract

Objective: To develop, implement and evaluate a personalized patient discharge letter (PPDL) to

improve the quality of handoff communication from hospital to home.

Design: From the end of 2006–09 we conducted a quality improvement project; consisting of a

before–after evaluation design, and a process evaluation.

Setting: Four general internal medicine wards, in a 1024-bed teaching hospital in Amsterdam, the

Netherlands.

Participants: All consecutive patients of 18 years and older, admitted for at least 48 h.

Interventions: A PPDL, a plain language handoff communication tool provided to the patient at

hospital discharge.

Main Outcome Measures: Verbal and written information provision at discharge, feasibility of

integrating the PPDL into daily practice, pass rates of PPDLs provided at discharge.

Results: A total of 141 patients participated in the before–after evaluation study. The results from the

first phase of quality improvement showed that providing patient with a PPDL increased the number

of patients receiving verbal and written information at discharge. Patient satisfaction with the PPDL

was 7.3. The level of implementation was low (30%). In the second phase, the level of implementation

improved because of incorporating the PPDL into the electronic patient record (EPR) and professional

education. An average of 57% of the discharged patients received the PPDL upon discharge. The

number of discharge conversations also increased.

Conclusion: Patients and professionals rated the PPDL positively. Key success factors for implemen-

tation were: education of interns, residents and staff, standardization of the content of the PPDL,

integrating the PPDL into the electronic medical record and hospital-wide policy.

Key words: patient discharge, handover, patient-centered care, patient satisfaction, patient-centered communication

© The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved

International Journal of Quality in Health Care, 2016, 28(3), 384–390 doi: 10.1093/intqhc/mzw046

Advance Access Publication Date: 25 May 2016 Research Article

384

Introduction

Annually around 35 and 1.8 million patients are discharged in the USA and the Netherlands, respectively [1, 2]. The transition from hospital to home is a complex and vulnerable period for patients [3, 4]. Ineffective discharge planning and lack of coordination of care can lead to decreased patient satisfaction, adverse events (AEs) and a higher number of hospital readmissions due to complications [5, 6]. Studies have shown that ∼20% of medical patients experience an AE within 5 weeks of hospital dis- charge [7, 8]. The most common AEs are adverse drug events (66%) and process- and procedure-related injuries, such as an incorrect medica- tion prescription (17%) [7, 9, 10]. Many AEs result from an inadequate communication between the hospital personnel and the patient or his general practitioner (GP) [8, 11]. Incomplete handover from the hospital to the GP is common, particularly for medication management [12].

In addition, treatment or care provided during hospital admission might have (permanent) consequences for a patient’s lifestyle in terms of a new medication regimen, consequences or delayed complications of hospitalization and restrictions in nutrition or activities of daily liv- ing [13]. Approximately 70% of patients face permanent medication changes after hospitalization [14].

Moreover, over the last few decades the length of hospital stay has decreased [15]. Yet more patients with complex care needs and multi- morbidity are admitted to the hospital. The consequence of these changes is that the delivery of in-hospital care has to be provided in a shorter period of time, and might suggest that patients with complex care needs are send home before they are fully recovered.

Therefore, it is important to prepare these high-risk patients for hos- pital discharge and provide them with well-defined patient-centered in- structions, which enables them to maintain independent living, perform self-management activities and reduce complications after hospital dis- charge [16, 17]. Research has been moderately effective at improving discharge services such as early discharge planning, medication recon- ciliation, telephone calls after discharge and home visits to prevent avoidable AEs after discharge [18, 19]. The most effective interventions seem to be those that combine pre-discharge and post-discharge inter- ventions with educational components [18]. Initiatives directed toward patients to improve patient empowerment and to improve the informa- tion provided to them at discharge are relatively scarce.

The objective of this quality improvement project was to evaluate the development and implementation of a personalized patient dis- charge letter (PPDL) on information provision at hospital discharge and to study the feasibility, barriers and facilitators of integrating the PPDL into daily practice.

Methods

Design, setting and ethical considerations

From 2006 to 2009, we conducted a quality improvement trajectory at the Academic Medical Center, a 1024-bed university teaching hospital

in Amsterdam, the Netherlands with the aim to improve handoff com- munication directed toward patients. We used two evaluation meth- ods; a before–after study design interviewing patients about the discharge information they received and how they valued the PPDL (post-implementation only) and a process evaluation to study the feasibility, barriers and facilitators of integrating the PPDL into daily practice. Figure 1 shows the timeline of the quality improvement trajectory. The measurements and data collection are described below.

The patients that participated were interviewed on how they per- ceived the information at hospital discharge and not on personal in- formation. The study was checked by the Institutional Review Board (IRB), but did not meet the criteria for formal IRB-approval as formulated by the Medical Research in Humans Act.

Development of the PPDL

The PPDL was developed based on literature research and clinical experi- ences of physicians and nurses of two internal medicine wards. Potential interventions for improving the handoff communication from hospital to home were explored in focus group meeting with physicians and nurses of the department of internal medicine. Research has shown that the most effective approach of providing information to patients is combining written and verbal information [20, 21]. The use of lay language in pa- tient communication is essential to enhance compliance [22]. As a result, the PPDL was designed to provide patient-centered communication. The PPDL is a standardized document addressed to the patient and drafted in a language that is understandable to the patient and his informal giver(s). The goal of the PPDL was to educate patients and/or their informal care- givers about problem-solving skills when discharged to home [23, 24].

The structure and contents of the PPDL were established through an exploratory pilot phase on one (nursing) ward of the department of internal medicine. This first version of the PPDL contained informa- tion on the reason for admission, the treatment during hospitalization, the course of the disease(s), possible sustained consequences or com- plications and information on medication. The PPDL was written and verbally explained to the patient or the informal caregivers of cogni- tively impaired patients by medical interns before hospital discharge. Residents mentored the medical interns during this process. All med- ical interns and residents were trained in drafting and explaining the PPDL and educated about issues related to health literacy [22]. The training was performed on the job. A standard format for creating the PPDL was provided on local computers on the wards (there was no electronic medical record (EMR) during the pilot phase).

First phase of quality improvement

Before–after evaluation study Implementation of the first version of the PPDL was initiated at two medical wards. To evaluate the information provision, satisfaction and content of this first version of the PPDL, the following study questions

Figure 1 Timeline of the development and implementation of the PPDL.

385A better informed discharge • Quality Improvement

were formulated. Does the implementation of the PPDL improve (i) ver- bal and written information provision at hospital discharge and (ii) how do patients value the content of the PPDL (post-implementation only)?

Participants of before–after evaluation study Eligible patients had to meet the following criteria: (i) 18 years or older; (ii) admitted at one of the four internal medicine wards for more than 48 h and (iii) discharged home. Patients were mainly acute- ly hospitalized with a broad range of internal medicine problems, such as infections, gastro-intestinal diseases and kidney problems. The par- ticipating internal medicine wards were staffed with nurses and physi- cians. The wards had an important role in the professional education and training of nurses and physicians. In the post-test phase only those receiving the PPDL were included.

Data collection

Data collection on provision of discharge information was equal in the before and after study group. A research nurse conducted structured telephone interviews 1 week after discharge. The interview contained questions regarding overall satisfaction with the information provided upon discharge as well as whether the patients had been informed about medication, complications and lifestyle. Furthermore, the inter- view contained questions regarding by whom and how they had been informed (verbal, written or both) and whether the information pro- vided was deemed necessary and complete. Patient satisfaction with the PPDL was measured in the after study group only. Patients were asked to appraise the PPDL on a numeric rating scale (between 0 and 10; where 0 = not satisfied and 10 = totally satisfied).

Data analysis

Descriptive statistics were obtained on the patient characteristics and information provision. We did not perform a formal sample size calculation. As in the post-implementation phase only those receiving the PPDL were included, and this was only 30% of the study sample, we did not calculate statistical differences between the before and after groups and present the data as descriptive.

Feasibility of the PPDL in daily practice

A process evaluation of the implementation of the intervention was con- ducted. A focus group session with seven professionals (nurses, medical interns and residents) was held to evaluate the acceptability and feasibil- ity of the PPDL in daily practice, including barriers and facilitators.

Second phase of quality improvement

In the second phase of the QI we used the evaluations of the first phase of quality improvement to improve the PPDL. In addition, we imple- mented the PPDL in the EMR, which was evaluated by measuring the number of PPDLs provided to patients at discharge. Pass rates were calculated from this information after implementation of the interven- tion. Furthermore, we developed hospital-wide policy and profession- al education on discharge communication to alter patient-centered communication during the handover process.

Results

First phase of quality improvement

Evaluation of pre-/post-test of PPDL implementation A total of 141 patients participated in this study of which 111 patients participated in the pre-implementation phase and 30 patients in the

post-implementation phase. The median age in both groups was 59 years and 48 versus 41% were male in the pre- and post- implementation group (P = 0.67). Table 1 demonstrates about what topics and how patients were informed at discharge. Most patients of the pre-implementation group received verbal information about their disease (90%) and treatment (90%), but rates of information provision were much lower for medication (69%), complications (47%) and lifestyle (36%).

After the implementation of the PPDL, the amount of patients re- ceiving information on medication, complications and lifestyle was improved on almost all domains, in particular in terms of medication. More patients received a combination of written and verbal informa- tion for the topics of medication and complications, respectively.

Overall, patients of the post-implementation group were satisfied with the PPDL as indicated by a score of 7.3 (SD 1.0). Positive remarks were made about the clear language of the PPDL, and patients viewed it as a useful discharge service. Suggested improvements for the PPDL included elaboration on complications and lifestyle, include a contact person for questions and professionalize the layout.

Level of implementation Four months after the implementation of the first version of the PPDL on the two medical wards, the average level of implementation was 32%. On the first ward 76 of 173 discharged patients received the PPDL upon discharge (44%). On the second internal medicine ward the pass rate was 23%, 58 out of 249 patients received a PPDL.

Feasibility of the PPDL into daily practice

Overall, the nurses and physicians that participated in the focus group session were positive about the PPDL and rated the initiative as import- ant to improve the quality of care. The participants concluded that the process of preparing and supervising the PPDL could be improved. Fur- thermore, medical interns felt that explaining medical terms in under- standable plain language was a difficult task. They also felt great responsibility to ensure the correctness of the content and felt insecure about this even though a resident supervised the PPDL. All professionals involved noted that the electronic preparation and availability of the PPDL within the EMR was a key component for successful implemen- tation and secure the use of the PPDL into daily practice. On average, interns spend 30 min preparing the PPDL, because an EMR was lacking.

Second phase of quality improvement

Establishing hospital-wide policy An essential step for further implementation of the PPDL was develop- ing a hospital-wide policy on handover summaries, to both the GP and patients. Furthermore, the PPDL had to be integrated into the hospital-wide policy on discharge procedures, which contained more interventions related to the discharge procedure (e.g. discharge con- versation, telephone follow-up) [25]. The development of a hospital- wide policy was enhanced by the release of a patient manifest in our hospital that contained 24 patient rights, including one on a personal patient discharge letter [26]. The hospital-wide policy on handover summaries was launched in April 2009. This document enabled us to integrate the PPDL in the electronic patient record and contained three versions of the PPDL: one for adults, one for teenagers and one for parents of under-age children.

Integrating the PPDL in the electronic medical record

Next, to improve the feasibility of the PPDL, a project was started to facilitate the preparation and availability of the PPDL within the

386 Buurman et al.

EMR. Standardization and quality of the content of the PPDL was en- sured by using templates on common health conditions and predefined texts on diagnosis, treatments, medication and lifestyle. Standard in- formation on who to contact in case of frequently asked questions was added, as well as the recommendation to bring the PPDL to each visit with a medical professional. This electronic version of the PPDL was made visible for all professionals in the hospital and could be sent directly to the general practitioner at hospital discharge (Appendix).

Integrating the PPDL and discharge conversation

into professional training

The results from the first implementation phase indicated that health- care professionals perceived difficulties in using lay language and other aspects related to health literacy in communicating with the patient and their informal caregivers about discharge instructions. Further- more, the PPDL was considered as an important educational tool for addressing these issues for medical interns of the department of in- ternal medicine. A 3-h communication-training program was devel- oped by focusing on hands-on practice of discharge communication skills and awareness of health literacy in cooperation with the depart- ment of clinical psychology, who already provided communication training before and during the internships. This training program was provided before the internship. During the internship, training op- portunities in which medical interns had to videotape an admission interview were already in place. We added to this training the possibil- ity of videotaping a discharge conversation instead. Furthermore, all medical interns were obligated to write ten PPDLs during their 8-week internship, and these PPDLS were discussed with the professor at the end of the internship. Throughout the entire process, the resi- dent had the ultimate responsibility for the content of the PPDL and authorized the PPDL before it was provided to the patient.

Evaluation of second phase of quality improvement

The interventions that were adjusted and implemented to improve the feasibility of incorporating the PPDL into daily healthcare delivery processes were measured again by focusing on the percentage of PPDLs provided to patients at discharge. The evaluation was con- ducted on four internal medicine wards during a 3-month period. On these wards, the electronic version of the PPDL was implemented. The implementation rate in this cycle varied between 14 and 71% (Fig. 2a), with an average implementation rate of 51%, signifying an important improvement when compared with the first cycle. There were 2 weeks with low percentages of PPDLs provided; this was due to a change in both residents and medical interns. They had to be in- structed in writing and authorizing the PPDL in the electronic patient record. If not considering these 2 weeks, the average implementation rate was 57%. Moreover, we observed an improvement in the number of discharge conversations that were held (Fig. 2b).

Discussion

The objective of this study was to improve the information provided to patients at discharge. At the start of the quality improvement trajectory, patients felt poorly informed at discharge from the hospital. As a result, a PPDL was developed, implemented and evaluated. This PPDL consists of a structured plain language discharge summary accompanied with a ver- bal explanation of diagnosis, treatment, medication and recent changes in medication, potential complications and lifestyle. Providing patients with a PPDL increased the numberof patients who recalled that they received a combination of verbal and written information. Integrating the PPDL in the EMR, offering training to medical interns and integrating the PPDL in hospital-wide discharge policies facilitated the implementation. With these actions, we were able to achieve an implementation rate of 57%. Moreover, the number of discharge conversations improved.

Table 1 Information needs of patients discharged from the hospital before and after implementation of the PPDL

Variables Before implementation (n = 111)

After implementation (n = 30)

Age (median, IQR) 59 (42–70) 59 (46–67) Gender (% male) 47.7 41.4 Previous admission in the past 4 weeks (% yes) 26.1 27.6 Information on diagnosis and treatment Do you understand the reason for your admittance to the hospital? (% yes) 90.2 93.1 Do you understand the treatment that was given? (% yes) 90.2 89.7

Information on medication Did you use medication before admission? (% yes) 87.6 86.2 Where there changes in the medication regimen at discharge? (% yes) 64.0 75.9 Did you receive information on the medication that you should use after discharge? 69.0 84.6 How did you receive this information

Only verbally 54.2 13.0 Verbally and in writing 45.8 87.0

Information on complications Did you receive information on possible complications that might occur after discharge? 46.8 67.9 How did you receive this information? Only verbally 82.0 26.3 Verbally and in writing 18.0 73.7

Information on lifestyle advice Did you receive information on changes in your life style, such as nutrition, movement and wound care?

36.0 55.2

How did you receive this information Only verbally 89.0 58.8 Verbally and in writing 11.0 41.2

IQR, interquartile range.

387A better informed discharge • Quality Improvement

Our study is not the first one that is performed on improving the discharge from hospital to home. Several studies have demonstrated the need for better discharge procedures [16, 17]. These studies mainly focus on better information exchange between professionals and iden- tified many deficits in the communication between the hospital and general practitioner. With the PPDL we improved the information pro- vision to patients at discharge. More patients actually indicated that they received a combination of verbal and written information at dis- charge. This is important, because the length of hospital stay has de- creased dramatically in the past 10 years, yet more patients are admitted with complex diseases and multiple morbidities [27, 28]. For this group of patients a combination of verbal and written infor- mation on changes in treatment, new medication, what complications can occur and when to contact the hospital is essential to self-manage after hospital discharge and to recognize severe complications needing medical care. Only providing information orally in for example a dis- charge conversation is not sufficient; it limits the recall of information [20–22]. The PPDL should be part of a bigger strategy to improve the discharge from hospital to home. In our hospital, the PPDL is part of a larger project on improving the discharge procedure [25].

Implementing the PPDL in daily practice proved to be challen- ging. The level of implementation in the first cycle was on average 30%. Several reasons have been indicated; first, the lack of integration of the PPDL into the EMR was a considerable barrier, since many items that could have been predefined through the EMR had to be en- tered manually. Moreover, the decision for discharge was often made on the day of discharge. This time pressure was an important imple- mentation barrier for creating and supervising the PPDL. In the second quality improvement cycle we implemented many solutions for these barriers. The medical interns received training to prepare the PPDL

and to held discharge conversations, the letters were supervised better, the PPDL was integrated in the EMR and a hospital-wide discharge procedure was implemented. Although there was an increase in the number of PPDL provided at discharge, the implementation rate was still 57%. We hypothesize that this is due to the extra handover that has to be made for patients, instead of putting the patient and informal caregiver at the center of the information handover. It would be well possible to use the PPDL as a formal handover for the patient and sent it to the GP as well. In the end, the patient is the only continuous factor in the transition from hospital to home. This would make the PPDL wider applicable and reduces the number of handovers that have to be written. Moreover, for specific patient groups (e.g. some surgical procedures) standardized letters could be prepared, where only limited amount of tailoring needs to be performed.

Our study has several limitations. We used a non-controlled be- fore–after design, which is not the most strong evaluation design and did not collect information on health literacy, education and socio-economic status. Therefore, the results should be interpreted with caution. We did not perform a formal sample size calculation, as the project started as a quality improvement trajectory. The study was a small-scale initiative limited to only four medical wards in one university teaching hospital in the Netherlands, and therefore the generalizability and applicability of the PPDL in other patient po- pulations and general hospitals needs further study. More knowledge is needed on the specific advantages and feasibility of the PPDL for cer- tain age-groups and patients with multiple morbidities. Additional re- search, in a broader patient population and in a multi-center context, is needed to establish external validity and study long-term effects on patient empowerment and AEs in the post-discharge phase. Currently, the PPDL is adopted by the Senior Friendly hospital concept and hos- pitals in the Netherlands have to demonstrate whether they provide a PPDL to patients.

In conclusion, the PPDL improved the provision of verbal and written information at discharge. Education of interns, residents and staff, standardization of content of the PPDL, integrating the PPDL into the EMR and hospital-wide policy to promote the PPDL were key success factors for feasible implementation. Further research should focus on the impact of the PPDL on adverse health outcomes.

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Figure 2 (a) Percentage of patients that received a PPDL at discharge from the

hospital. (b) Percentage of patient that had a discharge conversation prior to

discharge.

388 Buurman et al.

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Appendix

An example of a personalized patient discharge letter (with a hypothetical patient)

AMC Meibergdreef 9 Postbus 22660 1100 DD Amsterdam www.amc.nl

Amsterdam, November 15th 2011

Patiëntnr : 1234567 Date of birth : 13-11-1934 General Practitioner: Dr. Hansen

Concerns: personalised information upon discharge Dear Mrs. Jansen,

Hospitalization can be a stressful event in which a lot of information is provided to you. In this personalised discharge letter, we provide you with the necessary information you need at home. We advise you to bring this personalised discharge letter when visiting your general practitioner or specialist. Your general practitioner will receive a copy of this letter.

Admission: You were admitted in the AMC from 19-10-2011 to 12-11-2011 and resided at F7zuid, general internal medicine & gastro-intestinal diseases Telephone number: 020-5666666

Reason of admission: Insufficient intake because your bowel is very short. You were unable to take enough food and take the necessary ingredients. It was follow- up treatment after discharge from the OLVG hospital.

The medical term for this disease is: Insufficient intake/resorption due to short bowel syndrome (as a result of therapy-resistent Crohn’s disease).

Your important medical background You were diagnosed with Crohn’s disease in 1992. Since then you have had multiple resections of the bowel (subtotal colectomie and multiple resections of small intestine), complicated with fistulae. Your last oper- ation was in August this year in the OLVG, where 50 cm of intestine was removed. Now there is approximately 120 cm of small intestine left.

Allergies reported: none During your hospital stay the following diagnostic procedures were carried out We did several bloodtests, to see whether there were signs of infection in the blood and to see whether there were any nutritional deficiencies. The first days there were some signs of infection seen, but these values de- creased after a few days. A few slight electrolyte deficiencies were seen, but were corrected soon after start of the total parenteral nutrition (TPN).

We made some cultures of the pus from the rectum and from the wounds on the belly. Some bacteria were found, but it was not neces- sary to use antibiotics.

We also performed an endoscopy, on which the small intestine seemed healthy, not inflamed and no fistulae were seen. We did a rectal examination with a scope, but we could not see where the pus was com- ing from, since the rectum was very narrow after just a few centimetres.

We tried to do a MR-enterogram to make sure there were no fistu- lae under the wounds on the belly, but it was not possible for you to drink all the contrast fluid as it made you very nauseous.

During your hospital stay the following treatment was started We have placed a TPN-line, first in your left upper arm, later in the jugular vein, so you could be fed intraveneously. This could be tem- porarily, the small intestine might adapt to the fact that there isn’t much bowel left. But for now it is important to improve your nutritional status and your general condition.

You received a training from the nurses so you’ll know how to take care of the TPN-line and how to feed yourself with it. We also started medication (Sintrom) to prevent blood clots in your veins, which can

389A better informed discharge • Quality Improvement

occur in people with an intravenous line, especially in combination with active IBD. We nursed the wounds on the belly, to let them heal properly. The in- flammation had decreased by the time you went home.

Summary of the hospital stay: You were admitted to our ward because of insufficient intake/resorption of food, due to a short bowel in combination with your therapy-resistent Crohn’s disease.

We monitored the signs of infection in your blood, which had de- creased after a few days in the hospital. We gave you an TPN-line so you can be fed intraveneously and we trained you to take care of the line and feed yourself with it at home. Since the small intestine seemed healthy on the endoscopy, we lowered the dosage of Humira to 40 mg every other week, instead of 40 mg every week. The Lanvis was stopped altogether, since you felt you did not benefit from taking it. We started Sintrom in order to prevent the forming of blood clots in your veins, due to the TPN-line. In the beginning you will have to go to the Thrombosis Service (Trombose Dienst) regularly, to achieve the right dosage for you.

For now it is important to improve your nutritional status and your general condition. Dr. One will be the doctor in the outpatient clinic who will check up on how the TPN is going and if alterations will have to be made in your nutrition. Dr. Two will be your IBD doctor in the outpatient clinic, together you will think of what will be the next step once you’ll have strengthened.

Important information for you to take care of at home Once you experience fever, increased abdominal pain or blood/pus in the stoma bag along with your stools, please contact the outpatient clinic and ask for Dr Two, telephone number 020-5666666

Advice for food and fluids You will receive TPN for now, but if possible it is good to eat as well.

Advice for daily activities You can resume your daily activities as much as is possible for you.

The following appointments are made with you You have got an appointment with Dr. Two from the IBD outpatient clinic on the December 20th at 14.45u.

You have got an appointment with Dr. One, the TPN-doctor, on De- cember 20th at 15.30u.

If you have any questions

Contact with the hospital Within 48 hours after discharge a nurse of the ward you were admitted on will contact you, to see if you have any questions. The nurse will contact the medical resident if necessary

Contact with the outpatient department If you have an appointment scheduled with the outpatient department, please contact the outpatient department if your question cannot wait until the appointment. Telephone number 020-5666666

Contact with your general practitioner If you do not have a scheduled appointment at the outpatient depart- ment, than contact your general practitioner in case you have ques- tions. If any problems occur out of office hours, please contact the central emergency post related to your general practice.

Questions related to medication use If you have any questions on the use, effects or side effects of medica- tion, contact your general practitioner. The general practitioner will contact the hospital if necessary.

Do you have medication that is not prescribed anymore? Deliver these medications at your pharmacy.

Is your medication finished? Than call your general practitioner for a new receipt.

Frequently asked questions related to discharge and care On the website of the AMC, you will find information on the frequent- ly asked questions. www.amc.nl/discharge

With kind regards,

Marije de Jager, medical intern

Harro Klein, medical resident

390 Buurman et al.

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