When a GP spoke out over discharge summaries, it led to real change

Doug Hendrie

17/12/2018 1:42:22 PM

Dr Katrina McLean called for major improvements to discharge summaries – and her local hospitals responded.

Dr Katrina McLean has found that offering concrete solutions has helped move the issue forward.
Dr Katrina McLean has found that offering concrete solutions has helped move the issue forward.

In March this year, Dr Katrina McLean and two colleagues called for improved clinical handovers between hospitals and GPs.
Nine months later, and as more GPs called for urgent change, Dr McLean – who is also an Assistant Professor at Bond University – told newsGP that speaking out has led to direct improvements in communication with hospitals on the Gold Coast, where she works.
‘There is a long way to go but, locally, I feel we are in a much stronger position than we were 18 months ago,’ she said.
Dr McLean used her March article, published in MJA Insight, to illustrate the impact on GPs of poor-quality or late discharge summaries to the Chair of the Gold Coast Hospital and Health Service, who took the issue to the board.
The result? A commitment that local hospitals would work towards better communication with GPs.
‘At a local level, the Gold Coast HHS [Hospital and Health Service] is edging towards same-day discharge summaries. It is a work in progress, but I remain optimistic,’ Dr McLean said.
Gold Coast GPs have also progressed the issue by forming a clinical handover committee, with representatives from general practice, the Gold Coast Medical Association, primary health networks, and private hospitals.
The move comes after the Sunshine Coast Health and Hospital Service announced it would ensure discharge summaries are sent to GPs on the same day patients leave hospital.
Dr McLean said focusing on positives such as the Sunshine Coast example and offering concrete solutions has helped move the issue forward.
‘Providing solutions has assisted the push for positive change and improved patient care,’ she said.
Other GPs have also used the MJA Insight article to advocate for change, with a NSW GP recently writing to thank Dr McLean and her co-authors, using the article to point out the need for ‘safe, timely clinical handover of care into the community’.
‘[It is] not the first time I’ve asked for it, but the language matters, and having this article to refresh the “talking points” in my mind helps a lot. I think things might actually move forward – there was lots of goodwill,’ the GP wrote in their letter to Dr McLean.
Even with these wins, Dr McLean understands there is still a large task ahead, and change will require ‘considerable clinical leadership to shift the status quo’.
‘Clinical handover back to primary care … [is] unfortunately being perceived as less important than handovers occurring within or between hospitals,’ she said.

‘The hospital culture of a discharge summary being an administrative task undertaken by the most junior team member has not assisted, especially when junior doctors are grappling with high administrative burdens and unpaid overtime.’  
Like other GPs and experts who recently spoke to newsGP on the issue, Dr McLean does not believe uploading discharge summaries to a patient’s My Health Record is a substitute for a proper clinical handover.
‘There is a risk that the increased accessibility of hospital results by GPs may actually decrease the prioritisation of completing a clinical handover within the hospital setting,’ she said.
‘There would be some benefits in regards to accessing hospital discharge summaries via [My Health Record] from GPs who are not the nominated regular GP. One could argue, however, that this is not a handover, it’s throwing the information out there in the hope that a patient will prompt a GP to pick it up.’
Since June 2017, Queensland GPs have also had the ability to see patient data held in public hospitals in real time on the Viewer system. But Dr McLean has similar concerns about this system.
‘Unfortunately I have had the experience of being told “it’s on the Viewer” when phoning for clinical information relating to an acutely unwell patient who had recently been discharged from an acute psychiatric admission,’ she said.

‘This has the unintended consequence of posing safety risks to patients.’

clinical handover communication discharge summaries

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Michael Rice   18/12/2018 8:24:25 AM

Key to this success has been a shift in language.
From something hospitals don't really care about because the patient is "gone" (ie discharge summary) to something that they DO know and care about from internal processes (ie clinical handover).

So, my plea to RACGP is this: banish the term "discharge summary" from our lexicon and speak only of "clinical handover" and instead of admission or discharge, talk about "transition of care". We must emphasize that the patient is a person whose life goes on; it doesn't have an on/off switch when they cross the kerb of the hallowed hospital.

A big nudge will come if ACSQHC specifically includes clinical handover to primary/community care in their hospital Standards. I think we should be promoting more than "day of..." too in favour of "at the point of..." so information is moved WITH THE PATIENT and indeed ahead of the patient. Just as it is for internal hospital transition and hospital-to-hospital transition.

A change in hospital strategy will be required. As GPs we can promote that: just as in our practice records, hospital inpatients will benefit from ONE live record that includes current (active) and past (resolved) problems and management plans and is READY TO GO at any point of transition. No more blinkered handovers from the elbow resident (who was the last one to see the multi-trauma case) that fail to mention the sleep apnoea, diabetes or seizure that caused the injury and were indeed duly attended by the carious inpatient teams and have actual follow-up in place that the GP needs to know about.

Kat McLean   18/12/2018 11:04:17 PM

I echo the comments Michael has made.

Changing the language use has gained the attention needed and elevated the perceived importance of clinical handover back to primary care to being on par to clinical handovers occurring within or between our hospitals.

I have been overwhelmed by messages of support and positive feedback from GPs around the country who have taken on board this approach since the GPDU MJA insight article was published.

It would be fantastic to see our professional organisations rally behind grass roots GPs to support the change in terminology from 'discharge summary' to 'primary care clinical handover' and push for the inclusion of this handover in hospital standards.

Kishore Sieunarine   19/12/2018 7:43:34 AM

I agree with clinical handover and transition of care communication wholeheartedly but my experience in getting personally incontact(not my secretary calling) with a GP is not ideal. The practice receptionist puts you on hold( i really mean on hold) while trying to find The GP, GP is at lunch break, No colleague to discuss case with at the practice , Works only part time, being told that I can speak to the practice nurse, Ring tomorrow when they are at work and other excuses. These issues needs to be addressed as well in this discussion.