Discharge summary versus clinical handover: language matters

PartridgeGP is all about professional, comprehensive, and empowering General Practice care by our GPs. When we refer our valued patients for treatment elsewhere we promote the same high standards, values, and communication  that we provide. A letter, referral, or phone call is just part of the standard PartridgeGP service – it’s good clinical handover. Dr Nick Tellis recently collaborated with some excellent GPs in writing an article for the Medical Journal of Australia’s online Insight Blog on ways to improve communication during these times and stressing the importance of better clinical handover. It’s another one of the ways PartridgeGP provides Better Healthcare for our valued patients. Read on.

 

This article is part of a monthly series from members of the GPs Down Under (GPDU) Facebook group, a not-for-profit GP community-led group with over 6000 members, that is based on GP-led learning, peer support and GP advocacy, and was originally published at the Medical Journal of Australia (MJA) Insight Blog here

 

IN our earlier article we described the concept of “passing the baton” when talking about transfers of patient care. All patients come from their communities and to their communities they shall return. In this transition from tertiary hospital to primary care, they benefit from timely, safe, effective clinical handover as defined in the National Safety and Quality Health Service Standards.

 

In primary care, communication matters, perhaps more so than in tertiary care. Words matter. The language we use matters. It informs thought at conscious and subconscious levels and influences behaviour.

 

The words “discharge summary” evoke feelings of an administrative process at best, and various unsavoury processes at worst. The accidental discharge, the dishonourable discharge, and the smelly discharge all come to mind. The words “clinical handover” instantly sound more professional. They reflect the sort of interaction between clinicians of which we want to be part. Clinical handover is a term familiar to both clinicians and administrators. It is taught in medical schools around the country and practised between junior and senior doctors within our hospitals.

 

Transition of care is well known to be a time of maximum risk: “Adverse events are seen to increase particularly during a transition of care, when a patient is transferred between units, physicians and teams.

 

Clinical handover is a recognised, evidence-based, structured and essential safety mechanism for minimising this risk. Remember, all patients come from their communities and to their communities they shall return. Their community doctor, their primary care physician, is their GP. Patients deserve the best clinical handover we can provide, whether transitioning into or out of our hospitals.

 

Junior doctors in hospitals presently perform the clear majority of clinical handovers to primary care, labelled as “discharge summaries”. According to the Discharge Summary – Literature Review, published by Queensland Health in May 2017 (not available online):

 

 

“Junior doctors perform the clear majority of discharge summaries:

  • Many interns have a flippant attitude to the completion of discharge summaries and have a low perception on the importance of a safe handover of care;

  • Most medical education programs provide minimal education on the completion of discharge summaries;

  • Most interns learn from each other with little input or guidance from registrars and consultants;

  • Interns tend to ‘lump’ discharge summaries together, often completing the summaries on patients they have never met.”

 

 

This frequently happens after the transition has occurred. To borrow from our legal friends, you cannot sell what you do not own. How then can you transfer the care of a patient you have never cared for?

 

 

Junior doctors report that they have limited supervision and lack templates or guides to help them produce a comprehensive and useful handover for community-based care whereas they receive a considerable amount of training for internal clinical handover.

 

 

Medical practitioners frequently use ISBAR (introduction, situation, background, assessment, recommendation) to guide clinical handover. A recent GPDU discussion highlighted that the Gold Coast University Hospital was moving to an ISBAR format for clinical handover to primary care. This was seen by many in GPDU to be a significant step in the right direction. ISBAR for the clinical handover to primary care aligns with hospital handovers and can only improve the transfer of care. Brewster and Waxman recently proposed amending ISBAR slightly to K-ISBAR by adding some kindness into the equation. Taking the opportunity to actively incorporate empathy and understanding into the primary care handover would be a great place to enhance collegiality across community and hospital teams.

 

 

When deciding who is tasked with a clinical handover within the hospital, it is unlikely that this would be handed to the most junior member of the team, and exceedingly unlikely that it would be delegated to someone who had never treated or met the patient. Within hospitals, it is expected that a clinical handover occurs at or before the time a patient’s care transitions to another team or provider. Why should this be any different for the clinical handover back to the GP?

 

 

In our first InSight+ article, we used the analogy of passing the baton. But what happens when the baton is dropped?

 

 

Dr Mandie Villis recently wrote a heartfelt plea for hospital doctors to inform GPs when patients passed away on their watch. Discussions around primary care clinical handover are now occurring around the country and pockets of significant improvement are being made. Momentum is building in regard to formally recognising and changing the language used from “discharge summary” to “clinical handover”. Several hospital and health services have, or are in, the process of implementing “same day” or “24-hour” clinical handover policies, and ultimately the best practice standard will be that this clinical handover occurs at the time of transition of care.

 

 

My Health Record (MHR) has been touted as a partial solution to the problems that have traditionally plagued clinical handover. It is important, however, to remember what MHR is and what it was created for. It is a repository of information for patients – a “shoebox” of documents akin to the jumble of receipts we burden accountants with at tax time. It is not, nor was it designed to be, a communication tool for clinicians. The baton transfer cannot occur within the MHR shoebox. It was not designed to replace current clinical record systems or current communication channels between clinicians. These limitations and precautions are outlined in the RACGP My Health Record guide for GPs:

 

 

“My Health Record is not designed as a substitute for direct communication between healthcare providers about a patient’s care, and should not be used in this manner. Healthcare providers must continue to communicate directly with other healthcare providers involved in the care of a patient through the usual channels, preferably through secure electronic communication.”

 

 

The  Australian Digital Health Agency states:

 

 

“The My Health Record system supports the collection of Discharge Summary documents. When a healthcare provider creates a Discharge Summary document, it will be sent directly to the nominated primary healthcare provider, as per current practices. A copy may also be sent to the individual’s digital health record.”

 

 

Mission creep of MHR is real, with multiple reports on GPDU of GPs stumbling across clinically relevant information in MHR rather than receiving a timely clinical handover. Important clinical information is “pushed” into MHR and the receiving clinician is not “pulled” to it by any sort of notification. There is no handover without closing the communication loop. Health professionals and organisations must ensure that clinical handover occurs with the intended recipient at the time of care transition. A copy uploaded to MHR for the patient to access, as an archive, may serve as a safety net if all else fails, but should not be relied on as the only source of communication.

 

 

Hospital systems must support and value the safety delivered by effective clinical handover to primary care. This will reduce the readmission rates to hospital care and improve the care patients receive. Patient care and practitioner wellbeing should not continue to be compromised due to the hospital culture of a discharge summary being an administrative task undertaken by the most junior team member. The challenges of high administrative burdens, inadequate staffing and unpaid overtime all need addressing. Junior doctors should not be left alone grappling with piles of outstanding discharge summaries to complete on patients they have never met.

 

 

The patient journey can be tracked, important milestones bookmarked, and plans documented as they are formed so that when it’s time for a transition, the “baton” is ready. The need for handover cannot come as a surprise when the patient’s trajectory was plotted from the day they were admitted. Adequate clinical staffing levels with protected time for clinicians to prepare clinical handovers should be a key performance indicator in hospital care. Proactive strategies must be put in place to identify and document who will be receiving the clinical handover. The culture that prevails within many of our hospitals needs to change.

 

 

Safety and quality bodies, such as the Australian Commission on Safety and Quality in Health Care through its National Safety and Quality Health Service Standards, and the Australian Council on Healthcare Standards through its accreditation regime, can provide effective oversight. All clinicians must lead in continuous improvement in “best practice” for quality and safety in transition of care both into and out of our hospitals.

 

 

Let us recognise and applaud our hospitals and health services leading the way in acknowledging discharge summaries as the clinical handovers that they are. May 2019 bring us all closer to high quality, timely, safe and patient-centred clinical handovers.

 

 

GPDU dragon head-3

 

clinical handover

 

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 a happy new father. He blogs at www.partridgegp.com when not administrating on GPDU.

 

Contact Dr Nick Tellis at drnt@partridgegp.com.au or 0882953200 if You are a Great GP and want a Better Place to practice great medicine!

 

 

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GPs want clinical handovers, not discharge summaries

PartridgeGP is all about professional, comprehensive, and empowering General Practice care by our GPs. When we refer our valued patients for treatment elsewhere we promote the same high standards, values, and communication  that we provide. A letter, referral, or phone call is just part of the standard PartridgeGP service – it’s good clinical handover. Dr Nick Tellis recently collaborated with some excellent GPs in writing an article for the Medical Journal of Australia’s online Insight Blog on ways to improve communication during these times and stressing the importance of better clinical handover. It’s another one of the ways PartridgeGP provides Better Healthcare for our valued patients. Read on.

 

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 and was originally published at the Medical Journal of Australia (MJA) Insight Blog here

 

“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”.

 

GPDU dragon head-3

 

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.

 

clinical handover

 

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 a happy new father. He blogs at www.partridgegp.com when not administrating on GPDU.

 

Contact Dr Nick Tellis at drnt@partridgegp.com.au or 0882953200 if You are a Great GP and want a Better Place to practice great medicine!

 

 

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