Clinical handover to primary care – what GPs need

AS patients transition between hospital and community, it is essential that a clinical handover precedes or accompanies them as they exit the hospital doors.

This article is the third in a series on the topic of clinical handover to primary care written by representatives of the GPs Down Under (GPDU) Facebook Group. The first article discussed the importance of a clinical handover occurring at the point of transition to the community, and our second article emphasised the need to reframe “discharge summaries” as clinical handovers. In our second article, we discussed “ISBAR” (introduction, situation, background, assessment, recommendation) as a clinical handover tool and drew on the suggestions of Brewster and Waxman to add some “kindness” to the mix, using “K-ISBAR”.

The following draws on the clinical discussions within the GPDU Facebook group and provides a GP wish list for those preparing clinical handovers to primary care.

K-ISBAR

1. Kindness

As GPs, we know our patients well and are grateful for your involvement in our patients’ care. A personalised handover helps GPs to continue ongoing care. Please take a moment to reflect on how important this handover is, and the impact you have had on this patient’s journey.

2. Identify

• Who does the patient identify as their GP? Is the correct GP identified in the patient record?
• Who else in the primary care team needs to be included in the clinical handover?
• Indicate your role and involvement with care.

3. Situation

• How did the patient end up in hospital?
• Why did they seek medical attention?
• What is the impression regarding diagnosis?
• Are there any other significant health concerns?

4. Background

• What were the outcomes for the patient?
• Were there any complications of care?
• Include any specific challenges encountered in getting the patient home.
• Include details of any significant changes to the patient’s level of function.
• Are there any allergies or adverse drug reactions?

5. Assessment

• Summarise significant results.
• Outline what the clinical team did for the patient.
• Provide details of medication changes.

6. Recommendations

• Has a follow-up hospital appointment been made? Include details.
• When is the patient’s appointment to be reviewed by their GP?
• Are other services involved? Provide details of services, when the services are to commence and who the appropriate contact people are.
• Are there any results pending? Outline how these will be communicated to the GP.
• Ensure discharge medications and instructions are clearly recorded and communicated to the patient, GP and pharmacist.
• Have opioids been started? Provide tapering details.
• Is there an advance care plan or directive? Advise the GP if conversations have occurred during admission. Indicate if you would like the GP to continue a discussion or assist with the legal documents.
• Provide details on any specific aspects of care you would like the GP to assist with.
• Are there sutures? How many? When do they need to be removed?
• Are there dressings? When do they need to be changed? If specialised dressings have been recommended ensure the patient has them.
• Are further investigations needed? Include details of what you would like done, why, and a recommendation for management if abnormal. Include details of who the most appropriate clinician is to contact if the GP has any questions. Please provide a contact number.

Further suggestions for effective handover

Here are some tips for those generating the clinical handover to help make the relationship with the patient’s GP better:

• Ensure the clinical handover is succinct and key clinical information is easily seen by the GP. The recommendations need to be prominent, ideally on the first page.
• Please consider picking up the phone and calling. Complex care needs are frequently best communicated with a phone call to complement your written clinical handover.
• If you can’t reach the GP directly, please speak to our practice nurse or administration team.
• If a patient dies, please let us know as soon as possible. A phone call in this situation is appreciated. As specialists in primary care, we care for patients and their families, so we need to know.
• Rather than ask GPs to “chase” or “retrieve” results, if a result is pending, please ensure the GP is copied in to receive the result. If it is a significant result that you feel may change management, please phone the GP to discuss. Remember that the clinician who requests the result is responsible for following up the result. If a significant result comes in after the patient has left the hospital, you will need to ensure that patient has been advised and that they have appropriate management arranged. As GPs we are only remunerated for work undertaken in face-to-face consultations with patients. There are no resources for GPs to chase outstanding investigations. Once again, responsibility for follow-up of investigations remains with the clinician who ordered it, unless handover is agreed with another party. This topic comes up frequently on online forums, and many of us have commented that hospital doctors frequently fail to include GPs in results.
• My Health Record is not a safe or effective communication tool for clinicians: it is a repository of information designed for the patient. While My Health Record can be a useful place to store a copy of a clinical handover, it cannot be used as a substitute for a clinical handover that occurs from one clinician to another. GPs are not notified of information you upload to My Health Record nor is My Health Record use universal across the breadth of primary care. The same goes for other online portals.

The role of hospital administration

At the hospital administration level there is much that can be done to improve clinical handover to GPs. Here are some suggestions:

Change the name; eliminate the term “discharge summary” and rename written documents as “clinical handover to primary care”. Change the language used in conversations. Language shapes culture. GPDU applauds hospitals and universities who are actively incorporating these changes.

Pay doctors appropriately for the time needed to complete these handovers. GPs hear of hospital doctors being denied overtime; many have experienced it. Even in hospitals where policy has changed, the entrenched culture around avoiding overtime payments has remained. This must be addressed.

Redesign electronic discharge systems around the needs of clinicians and patients. Electronic discharge summaries need to be designed in the format that clinical handover is taught. The written ISBAR summary needs to end up on the top of the first page. Recommendations should not be on the bottom of page 20. Electronic discharge summaries should, when completed, not be in excess of 1–2 pages of core clinical information. Data “sucked in” from hospital admissions is seldom helpful and creates a situation whereby patients are at risk because pertinent information is hidden among clutter.

Look beyond the hospital walls with risk assessment. How can adverse outcomes be captured and reported? At present, there is a void of knowledge when it comes to adverse reactions occurring due to absent or inadequate clinical handovers.

Ensure that the senior clinician assumes responsibility for the handover. Senior clinicians must be aware of the content of all written clinical handovers, including to primary care. The clinical handover should not be left to the most junior member of the team to undertake without appropriate support and supervision. It is not acceptable that the clinical handover is completed by a clinician who has never met the patient. Nor is it appropriate that it is completed by a nurse or allied health practitioner. If the patient is under a senior clinician’s care, it is that senior clinician’s responsibility to ensure appropriate clinical handover back to primary care.

Prioritise identification of a GP. If the patient does not have a regular GP, they must be provided with help to find one who is suitable. This is primarily an administrative task. While it is important that the clinician conducting the handover identifies the recipient, if the patient does not have a regular GP, procedures should be in place to ensure this is identified long before the point of discharge.

Ensure that that patient has a copy of the clinical handover and an understanding of the content. Avoid jargon and acronyms. Involve and include the patient in the process.

Ensure that all relevant community team members are included in the handover.

Recognise excellence. Look beyond your own hospital. Where is this being done well? Collaborate and learn from other services who are leading the way in redefining the culture and policy around clinical handover to primary care.

We must all do better at this. Our patients depend on 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 Tim Leeuwenburg is a rural proceduralist on Kangaroo Island, South Australia. He spends his time balancing primary care, emergency medicine and anaesthesia, as well as writing “roadkill recipe” cookbooks and fiddling with chainsaws. When not working, he is an active contributor to FOAMed (free open access medical education) and social media. He’s an administrator for the GPs DownUnder and Rural Anaesthesia DownUnder closed Facebook groups. He blogs at KIdocs.org and tweets as @kangaroobeach.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.