Could more hospital outpatients be discharged to GPs earlier?

With wait times blowing out to years for patients waiting to see specialists in public hospitals, there is an urgent need to identify ways to improve access to outpatient departments.
 
Queensland-based researcher and GP Dr Edwin Kruys, along with his colleague Associate Professor Jo Wu, set out to understand the experiences of both GPs and hospital-based specialists at a large regional hospital.
 
Their research, Hospital doctors’ and general practitioners’ perspectives of outpatient discharge processes in Australia: an interpretive approach was published this month in BMC Health Services Research
 
Fifteen doctors shared their experiences during in-depth interviews that examined the barriers and facilitators to discharging patients from hospital outpatient clinics to primary care and helping to open up much needed appointment slots.
 
‘Unnecessary delays in patient discharge have direct consequences for timely access of new patients and the length of outpatient waiting times,’ Dr Kruys told newsGP.
 
‘Hospital specialists and GPs participating in our study agreed that not all follow-up appointments that take place in hospital outpatient clinics are necessary.’
 
The research offers insights into the experiences of these doctors and the complexities involved in streamlining primary care discharge pathways.
 
It was estimated that a significant proportion of patients who attend these clinics for follow up could be safely managed by their GP. A bi-directional digital communications platform and rapid re-entry pathway were both identified as central to safe discharge protocols.
 
However, Dr Kruys said he was surprised by the extensive list of the difficulties faced when it comes to discharging patients from the hospital system, alongside a raft of potential solutions that could be implemented.
 
‘What was unexpected was the large number of barriers and facilitators, which demonstrated the complexity of the discharge and clinical handover process,’ he said.
 
‘Hospital specialists believe many patients seen in their outpatient clinics – estimates varied between 20–60% – can be managed in primary care.’
 
GPs and specialists agreed on the need for more discharges to take place. However, the research indicates a lack of standardised policies and protocols to facilitate discharge and support both hospital doctors and GPs to provide comprehensive clinical handover that optimises patient care and reduces the strain on outpatient departments.
 
‘Study participants mentioned various system problems hampering discharge from hospital outpatient clinics to general practice, such as the absence of agreed discharge principles, workforce and workload challenges, limitations of electronic communication tools, concern about lack of follow up in the community and an inability to escalate timely hospital care following discharge,’ Dr Kruys said.
 
Hospital specialists expressed concern over poor communication systems in place, as well as the possibility that discharged patients may face lengthy wait periods if their condition changes and they need to be seen again.
 
‘Basically we have complete failure of real-time, asynchronous digital communication with primary care,’ said one hospital-based specialist, with another saying that working in a system with extended wait times means discharge comes with added risks.
 
‘It’s really hard to get the patient back into our clinic so if we discharge them, and then the GP wants to send them back to us because they’ve got a new problem, or they’ve got a flare up of their problem, then they become a new referral and might be on the waitlist – and that could be anywhere from three to 12 months,’ they said.
 
A promising solution lies in the co-development of discharge pathways, which Dr Kruys says are needed to address how hospital doctors can identify patients who can be safely managed in the community, what kind of support they need, what information GPs need to continue care and how care can be escalated quickly if needed post-discharge.
 
‘To our knowledge there are at present no uniform local, statewide or national hospital discharge principles or discipline-specific guidelines to support the outpatient discharge or continuation-of-care process, and our study participants noted that there is a need for more consistency,’ he said.
 
‘They suggested that there is a role for GPs to be involved in the co-production of these discharge and shared care principles.’
 
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