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.

  1. 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.
  1. 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.

 

6 thoughts on “Clinical handover to primary care – what GPs need

  1. Deirdre Criddle says:

    “If the patient does not have a regular GP, they must be provided with help to find one who is suitable.” Helping patients understand the importance of good medical and medicines care is crucial here. A hospital admission is one of the greatest risks for readmission. The sheer pace of acute care system works against this task being undertaken within the hospital. But it is such an important preventative intervention. Interdisciplinary teams working across transitions of care need to be utilized more as they can address the multifactorial issues which bring people into the acute care system. These teams are the bridge between acute and primary care and know the value of a warm handover from hospital to the patients home .. including their medical home. They understand the imperative of finding good longitudinal primary care for those at greatest risk.

  2. Kate McAuliffe says:

    I have 2 comments as a current hospital junior doctor and future rural GP.

    I am broadly supportive of a change in culture regarding discharge summaries to clinical handover with an appropriate emphasis on only patient/GP relevant data included. However, as the junior whose job it is to formulate the discharge summaries, it is very clear that we are at cross-purposes. From the hospital perspective, the goal is to provide the appropriate list of bill-able items (ideally with how they were managed so more billable items can be identified), to generate funding for the departments. I am not commenting on whether this is “right”, mearly that this is the current funding models in which junior doctors generate discharge summaries. If GPs want more readable summaries, then we need to discuss the mechanisms by which hospitals can generate funding in briefer documents or junior doctors will continue to bare the brunt of increased documentation requirements (providing a “kinder, readable version” and a “hospital coder” version), which will inevitably be completed during unpaid overtime.

    Also, given the personal nature of choosing a GP I am rather incredulous that the hospital teams assigning a generic GP for a patient will result in better patient care. I agree with the above commenter regarding encouraging the patient to seek involvement in their own healthcare and find a GP they are willing to form a therapeutic relationship with. I have, in extreme cases, located GPs for isolated, complex and impaired patients whilst they were in-patients, however, if this was standard of care for all otherwise healthy, reasonably sensible patients, it would become a very onerous situation for hospital teams.

    In general, the more GPs and hospital systems are working together the more likely it is that the documentation will meet the needs of everyone.

  3. Ratnakar Bhattacharyya says:

    I am afraid Australia or any other country can have both ways when treading health as an item of commodity for a fee.
    In real term it means simply that your living is dependent of how many patients and how may billable services you are able to generate. There are conflict of interests all around. Entire medical profession has a stake . As far as patients are concerned they are intelligent enough to choose which doctor to choose and their carers have to be intelligent enough to remain viable in healthcare business as it is at the time.

  4. Michael Rice says:

    There’s no (technology-based) reason why the processes of coding for billable items and clinically-relevant handover can’t be done at the same time as Kate McAuliffe describes; there’s also no (technical) reason why only one output is possible. The community team can receive a patient-centred view and the coding/billing team can receive another view.

    That’s the wonder of computers and databases: from one entered dataset we can extract whatever views are relevant to the end user.

    It’s not inevitable that clinical handover (and billing/coding) take place in unpaid overtime, either. When handover to community is embedded an ACSQHC standards and accreditation (that IS inevitable IMHO) we will see it funded. We’re already seeing it funded in leading centres (eg https://vimeo.com/307594856)

  5. Matthew Rogers says:

    I am a hospital registrar and agree with many aspects of this article.
    I don’t agree with Kate that discharge summaries drive funding, as the coders review the entire medical record to ensure patient episodes are coded correctly.
    I strongly support hospitals and GPs working more closely together and I think we need to share more examples of where that occurs. I will often call a patient’s GP and find the information and advice they provide extremely beneficial in the treatment I provide. I would also strongly support changing the name of the discharge summary.
    I do disagree, however, with the article’s assertion that allied health and nursing staff can’t complete the discharge summary. While most of the summary should be complemented by a doctor, nurses and allied health practitioners should also contribute where it is relevant. Often as a medical team we refer to allied health for an assessment and treatment, and they will often follow-up patients post discharge. Also, many patients require ongoing nursing care in the community or had wound care or bowel care management strategies established in hospital. In these should be documented by the relevant clinicians in the discharge summary as they are the experts in their field, rather than the JMO or senior clinician.

  6. Ali Krollig says:

    It would appear that taking down the barriers to true integrated care continues unabated.

    Agreement and implementation of a sound clinical handover process is imperative to patient clinical safety on and post discharge. While ensuring understanding between clinicians is a must, inclusion of the patient in the process improves the health literacy of the patient and enable adherence to prescribed actions including taking of medication. Discharge discussions with patients is often a process of verbal bombardment of information and instructions at a time when the patient and even their carer are suffering a level of shock from whatever event has occurred, even if planned. Where discharge summaries are used as coding for funding alone, raises issues of high risk behaviour with medico-legal implementations.

    This is not a game, nor a competition between acute and primary care or health professionals. Change in thinking and process as described above can only lead to better outcomes for the patient due to better care being able to be provided and in a timely fashion.

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