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This is the third article in a monthly series from members of the GPs Down Under (GPDU) Facebook group, a not-for-profit GP community-led group that is based on GP-led learning, peer support and GP advocacy.
“PASSING the baton” describes what health care professionals try to achieve as care of patients is transferred between providers in our complex health care systems. The topic of safe and effective clinical handover comes up repeatedly in discussions on GPDU.
It is apparent that the impacts from delayed or poor clinical handover on patient care across the country are significant, under-reported, and have a profoundly negative effect on the care patients receive.
Dropping the baton
First-hand accounts of treatment delays, duplication of testing, medication errors, and unplanned readmissions are frequently discussed by GPs. Recent clinical case discussions have included a patient in palliative care being transferred to a hospice on a Friday afternoon with no clinical handover, and a 3-month delay in the completion of a discharge summary for a truck driver who was admitted with a myocardial function.
The safety concerns related to poor clinical handover are not new: it’s a problem the health care industry and doctors as a profession have been grappling with for decades. Poor clinical handovers are wasteful of limited resources. How can we improve patient outcomes and “drop the baton” less often?
Rules of the game
The National Safety and Quality Health Service Standards (NSQHS) and the Australian Commission on Safety and Quality in Health Care (ACSQHC) define clinical handover as; “the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group”. Appropriate clinical handover is a requirement of the NSQHS. The ACSQHC notes the importance of “transition of care” that “ends only when the patient is received into the next clinical setting”. The Australian Council on Healthcare Standards EQuIP National Standard 12, in particular, specifies the planned provision of transfer information, including results of investigations.
Breakdown in the transfer of clinical information has been identified as one of the most important contributing factors in serious adverse events, and is a major preventable cause of patient harm.
Why is clinical handover from hospitals to GPs done so inconsistently for patients transitioning from our major private and public institutions? The benefits of passing the baton smoothly are clear. It’s time to coach the team to get it right.
Timing is everything
Health services continue to debate the appropriate timeframe for communicating with the GP who is continuing the patient’s care. Timeliness of clinical handover is a topic that comes up frequently. Hospital targets for transfer of care communications vary widely. A recent discussion on GPDU identified several targets within one small geographical area, ranging from “at the point of discharge”, “48 hours after discharge” and “5 days after discharge”.
The reality is that few patients leave hospital with an effective clinical handover. Some will be received within the hospital’s current targets; however, many clinical handovers are not received for weeks, months or, as one post highlighted, years after the patient care is transferred. Some never occur.
Many GPs are asking whether these targets are consistent, appropriate, acceptable or safe. A robust discussion took place after GPs were approached to complete a survey that included a question asking what conditions should warrant a discharge summary on discharge, and what the acceptable timeframe for receiving a discharge summary should be.
The overwhelming consensus was that the gold standard should be clinical handover on discharge for all patients. Many were frustrated that this question even needed to be asked. Some GPDU members wondered whether this was a trick question aimed at moving the goalposts further away from quality patient care.
Services promoting clinical handover to GPs on discharge were highlighted. The Sunshine Coast Hospital and Health Service was identified as a provider that was actively trying to effect positive change. They received plaudits from the wider GP community simply by having a discharge summary management policy specifying complete discharge summaries available at the time of patient discharge.
It is well known in GP circles that starting late ensures that you will run late all day. Timely discharge summaries aren’t late. Timing is everything when you want to be a frontrunner.
Don’t fumble the handover
The consensus among GPs is that well timed, efficient, effective and safe clinical handover, at or before the point of transition of care is essential. Alternative strategies risk adverse outcomes. Clinical handover must be a standardised process between clinicians.
Returning to the athletics track, we can see a clear difference between a handover, a throw, and a drop. Highly trained athletes accept nothing less than a smooth handover – nor should highly trained clinicians. Delegating the handover to non-clinicians, including nurses and medical students, is not good enough. Supervision and ongoing coaching of clinicians is vital.
The baton is passed between people not machines
Imagine the difference electronic systems could make to this smooth handover. Sadly, this smooth electronic handover exists only in the imagination.
In the real world, GPs are grappling with being thrown links to hospital electronic records through systems such as “The Viewer”. Investigations are likely to be uploaded (after a delay) to MyHealthRecord. These are raw data, unfiltered and disorganised, and more of a throw than a handover. Being thrown raw data and being expected to catch them in this way is akin to a hospital doctor being given the login to the GP clinic’s patient management system and being expected to extrapolate a referral.
Personal bests are set; medals are won
The late Sir Roger Bannister ran the 4-minute mile and reset the expectations for all that followed him. GPs and their discussions can highlight outstanding clinical handovers and applaud initiatives and hospitals that are doing it right. Feedback and constructive criticism can be passed back to hospitals that are raising the bar. Medal-winning performances show the possible and provide a model for future improvement. GPs are uniquely placed to spot the talent and report the score widely and rapidly.
Eyes on the prize: what’s the next goal?
If we can normalise the clinical handover to young GPs who are the future of general practice, it will encourage them to demand it of their hospitals.
Hospitals are incredible places, but the aim is for patients to return home to their communities and trusted GPs. They come home. Their GPs are waiting, willing and able. We can do better, and we will. We extend an open hand to our amazing hospitals. Pass us the baton – we won’t drop it.
Dr Katrina McLean is a Gold Coast-based GP, Assistant Professor in the School of Medicine and Health Sciences at Bond University, and a GPDU administrator.
Dr Michael Rice is past-president of the Rural Doctors Association of Queensland, an educator of students and registrars, a long term resident and rural GP in Beaudesert. He’s a keen user of social media.
Dr Nick Tellis is passionate about great general practice. He’s a proud GP, beachside Adelaide practice owner, and soon to be a father. He blogs at www.partridgegp.com when not on GPs Down Under.
To find a doctor, or a job, to use GP Desktop and Doctors Health, book and track your CPD, and buy textbooks and guidelines, visit doctorportal.
In this article and the more recent one entitled “Discharge summary versus clinical handover: language matters” there is a key word missing which is the solution to all of your legitimate concerns – it is …..pharmacist.
The body of recent supporting the merits of a discharge hospital pharmacist liaising with the GP and community pharmacist appears not to be well know by the authors, not do they appear to appreciated the merits of a post-DC HMR (home medicines review), for which there are dozens of papers attesting to the merits of this clinical service by an accredited consultant pharmacist.
Once you bring us into the continuum of care loop, many of your “baton” issues will vanish.
I am a GP and thus understand the GPs perspective on lack of/poor discharge summaries and communication issues that occur between the hospital and the patient’s GP/practice, and the implications it can have. However I do remember back to my intern/resident days and have to agree with every comment made by ‘anonymous intern’ above. I had no training on how to complete ‘useful’ discharge summaries nor did I often have the relevant information to write one. Interns have always been stretched past their capacity and at times feel very unsupported.
I may not know the solution but do know that this is a multifaceted issue ie education, communication, discharge summary template , the registrar/specialist/hospital and GP/practice.
Summarising so far, this is an un-resourced and unplanned – and therefore obviously low-priority – aspect of the healthcare system. Want answers? Follow the money. Want better performance? Plan, invest, measure, report.
I’m currently an intern, so I’m the poor bastard staying till 11pm to do those discharge summaries for you. Sorry. I know they’re late – there’s still quite a stack of pt files waiting for tomorrow too. I know the content is rubbish, I’ve had very little guidance on what to put in or leave out. I often have no clue what exactly happened on the ward round or why certain decisions were made or even what actions to recommend to the GP to do. The consultant continues on their merry way without verbalising their thought process or pausing long enough for me to write it down. I may have never even met the poor pt, and am completing the summary from notes alone as a favour to a poor co-intern who is near tears with other urgent ward jobs.
If a written summary is wanted, it seems from my lowly vantage point to be a medical workforce / funding problem – if they could possibly fund a few more interns, maybe we would be able to complete the jobs to the require standard? I feel like I’m working to capacity, and I’ve given up all I can to the job (friends, family, exercise, sleep…), not sure what more I can do.
A 1 minute phone call handover from the consultant or registrar to the GP seems far more efficient to me.
Why they leave the job of handover to the least qualified in the team I have no idea
The ability to “cut and paste” from one part of an electronic medical record to another has certainly affected the relevance of written documentation – whether it is a referral into hospital from a GP or a referral back to the GP from the hospital. It’s easy to generate lots of volume of little relevance.
Since both hospital staff and community providers are time-poor, it’s worth remembering that hospital doctors generally don’t have a secretary or receptionist to make calls for them, and patients may be discharged (from ED) at any time of day – not necessarily during the GP’s working hours.
Limitations exist at all steps, but it’s worth assuming that everyone is trying their best within their own circumstances, and working together rather than judging each other.
45 seconds phone discussion is worth 4.5 pages of Discharge Summary.
Such fulsome praise for hospitals. I do not agree or endorse the opinions or sentiments expressed. In case there is some doubt about my authority to speak, this is the fifty first year I have been a practising doctor and that has included tertiary teaching public hospital, rural public hospitals in NSW and Queensland and international specialist hospitals both first and third world.
I am currently a private GP in town with my wife, who has the misfortune to be VMO at the local NSW Health public institution ridiculously mis-labelled as a multi-purpose centre.
We never, ever send people to hospital ED/OPD without phone call and written and signed referral.
It is extremely rare that we are notified about whether they have been admitted and even rarer to be notified of planned or enacted discharge. The most annoying and dangerous behaviour is the chuck-out on Friday afternoon to clear beds for the weekend. Lives have been put in danger and avoidable complications induced.
If we ever get an electronic “discharge summary” it is pages of absolute useless rubbish and whether or not a tiny bit of pertinent information is contained in it, the time taken to scan it is long and wasted. Often it is days later than the discharge, as well.
No psychiatric referrals have ever, EVER, been reported or even acknowledged and I have it on second hand authority that concern for PRIVACY trumps all other considerations.
If young doctors were routinely given proper hand-overs, there is a possibility that they will begin to recognise that the family GP is a fellow doctor with complicated needs for the same respectful treatment.
I cannot blame the hospital doctors for the format of the electronic discharge summary – formatted data in pro-forma array is the best that the second-rate public service IT personnel can manage.
Agreed Coralie, but at least the effort needs to be made, and in both directions! When a radiologist responds to a request about a mis-shaped skull with the 2 word report”No fracture”, then when queried the reply is “I never read the request – it usually says nothing”, you get the level of frustration clearly! Every time a patient is referred to ED, the WRITTEN REFERRAL should, IMHO, include a phone call indicating urgency (which also garners the name of the potential receiving ED physician) and if admission does occur, the good GP will try to make at least one contact with the inpatient team, thus establishing a sound basis for ongoing clinical interaction and discharge handover. This process works with tertiary public, private and regional hospitals BUT is time-consuming and receives no direct recompense so the resort to e-communications is understandable. Unfortunately this is more likely to lead to information overload and thus a poorer level of clinical interaction- but still better than none!
Hi There,
I am a rural generalist (also a GP) who works in the hospital system
I applaud your efforts for safe clinical handover.
I admit to being rather frustrated though.
Good handover has to be two way.
About half of the patients we get through the emergency department referred from GP clinics come without a letter.
I understand that GP’s live in a time pressured environment, but what I really can’t understand is that when I ring back to ask what they want from me in the ED department or when I ring personally on discharge of a patient because I think it is particularly important to “close the loop” in a patient, I am screened and then not rung back.
It is very easy to request an action in clinical care but there has to be reciprocity. To take your sporting analogy further there has to be a person to hand the baton to.