Breakthrough on hospital–GP clinical handover

Doug Hendrie

15/02/2019 3:32:27 PM

A major Australian hospital service has moved to reframe discharge summaries as clinical handovers, following years of advocacy by local GPs.

Big improvements for hospital–GP communications expected.
Big improvements for hospital–GP communications expected.

For the first time, interns and junior doctors beginning at the Gold Coast Hospital and Health Service (GCHHS) this year, as well as most senior doctors, were shown a video stressing the need to do a proper clinical handover to GPs at the time of discharge.
The video asks hospital doctors to ensure a handover answers four key questions, namely what the patient’s diagnosis was, whether there were complications, allergies or alerts, what the medications are at discharge, and what plans are there for further care after discharge.
The ground-breaking move addresses a longstanding GP complaint over very slow or lacking communication from hospitals and has been hailed by many local GPs, including Dr Kat McLean, who last year publically called for change.
The Chair of the GCHHS board, Ian Langdon, told newsGP the move was in the best interest of patients.

‘The board and management have made the determination that a clinical handover at the time of discharge is of paramount importance,' he said.

'We believe it’s in the patient’s best interest, because all research clearly indicates that if a patient is not discharged with full documentation, their chances of readmission within a short period is significantly higher than if GPs have access to all the details of their hospital stay from the outset.
‘We have the same patients [as GPs] so it’s in our interests to keep those patients out of hospital for their health, and also for financial outcomes for the health service. There’s a common purpose.’

Mr Langdon said the health service was conscious of the concern GPs have that if they’re out of sight, they’re out of mind.
‘We’re conscious of that, and that’s why we have two full time positions for GP liaison officers in conjunction with the Primary Care Network (PHN), located in the hospital. Having a direct link to GP practices in our district has been invaluable.’
Mr Langdon’s own interest in the issue came after an informal meeting with four Gold Coast GPs, where he asked what the GCHHS could be doing better. 
‘All four immediately talked about discharge summaries and clinical handovers,’ he said.
Early results are not expected before June at the earliest, but Mr Langdon said the goal would be to get as close to 100% compliance as possible over time.
GP and former deputy chair of the Gold Coast PHN, Dr Sue Gardiner, who appears on the video, told newsGP it was the first time there had been real engagement with what GPs have been calling for.
‘For the first time there appears to be a genuine push to try and systematically address the issue of clinical handover in a timely manner. I have been a GP on the Gold Coast now for 26 years. While various messages have been tried at the public hospitals, this is the first time there has been proper engagement with general practice,’ she said.
‘Reframing [discharge summaries] as a handover is much better, because it doesn’t mean that GPs are polar icecaps away from hospitals. It’s more about the fact you look after their patients too.

‘It’s about having timely information so we can see if there’s a new clinical parameter we haven’t addressed before.’
On the video, Dr Gardiner states: ‘It’s not really a discharge summary now. It should really be considered a clinical handover. When in the hospital, you hand over from the medical team to surgical team or vice versa – you perform a clinical handover. In general practice, that’s no different.

‘What you have to remember working in the hospital is that we [GPs] provide the bulk of their care. We give their care 95% of the time.’
On the video, GCHHS Clinical Education Director and Associate Executive Director Dr Jeremy Wellwood, who has been a strong internal advocate for the change, said this had to happen on the same day that patients leave hospital, to minimise errors.
Mr Langdon said Dr Wellwood was focused on the need for cultural change.
‘[He] is very much focused on the fact this is not a procedural issue, it’s a cultural issue. Whenever you introduce something, you’ve got to do it carefully and thoroughly so it doesn’t slip away as soon as you take the focus off. It has to be conscious and well managed to make it so routine it just happens and is sustainable,’ he said. 
GP Dr Kat McLean told newsGP the changes were reflective of GPs being present where decisions were made and strong local GP leadership, as well as a close working relationship between primary and tertiary health.
‘As a grassroots GP who watched a number of my patients experience poor outcomes due to delayed or absent clinical handovers, it's incredibly reassuring. We’ve moved from a conversation around what is the appropriate time for a discharge summary, and what conditions necessitate a discharge summary within 48 hours to a formal recognition that a hospital discharge is a clinical handover to the GP that needs to occur on the day of discharge.’

Kat-Mclean-hero.jpgDr Kat McLean has advocated for change.

RACGP Expert Committee – Quality Care (REC–QC) Chair, Associate Professor Mark Morgan, told newsGP proper clinical handovers during transitions in care – both entering and exiting hospitals – were vitally important.
‘Much of the danger from medication misadventure happens when patients transition through the health system.’
He backed calls for the wider reframing of discharge summaries as ‘clinical handovers’ and called on them to be subjected to the same scrutiny and audit process as critical handovers within acute hospital services.
‘[We need to] ensure that ‘clinical handover’ is the responsibility of the patient consultant or head-of-service, even if the task is delegated to more junior staff, the responsibility must sit with permanent senior staff,’ he said.
Associate Professor Morgan also called for hospitals to ensure a patient’s GP was listed as part of every summary page for hospital in-patients, and given as much weight as date of birth or address.

clinical communication clinical handover discharge summary

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Dr Roslyn Davis   19/02/2019 6:56:27 AM

In January 2018 the SouthernNSW Local Health District appointmented 4 GPLO’s. We have been doing similar work in regard to discharge summaries. I was able to speak at the JMO orientation on Discharge Summaries as a clinical handover to GP’s. This will become a regular part of orientation as well as a one page d/c summary guidelines sheet. We are working with the district on a d/c summary policy. It would be good to connect with other GPLO’s to collaborate and share our work and experiences in this.

Dr Manda Brits   19/02/2019 9:18:49 AM

This is a fantastic idea, provided that no acronyms are used in the hand-over. Acronyms make these reports useless especially for overseas trained doctors. Please avoid them!

Naseem isaacs   19/02/2019 11:05:47 AM

Am a GP living on the Coast for 20yrs. Am a so called IMG came into Australia after having lived in NZ for 10 years. Good progress noted at last. Would like someone to explain to me why it has taken so long to happen! Why is RACGP entering into another quagmire accepting to do training in China (which is good for the country) but what is trade off! Are we going to see more Chinese GP’s instead! What happens to all the IMG’s who are slogging away in Rural placements where let’s face it Australian GP’s don’t want to go? Would like some answers. Thank you

Ian Truscott   21/02/2019 10:02:23 AM

Yes - it's a handover! Phone the GP.
In fact, I look for excuses to phone the GP at, or during admission to hospital; often we discover pertinent info not known before. Then the discharge phone call is briefer.
The biggest problem is GP being not present at time of phone call: practice nurse or another GP might suffice.
I'm sceptical re using a hospital GP liaison officer: such a "middle-man" sets us up for failure. It's the direct doctor-to-doctor chat which truly communicates.