Transitions of care: A patient’s most dangerous journey

Reforms are required to improve safety at transitions of care. Catherine Reilly reports

In recent weeks, a former Medical Council President reiterated the serious patient safety risks occurring at transitions of care.

“Patient recently discharged from hospital – no discharge summary – nothing new there,” stated GP Dr Rita Doyle on Twitter. The patient’s script also contained “four serious errors” including incorrect doses and medications, and omission of insulin. 

“Transitional care is so risky – we need better processes and more pharmacist input,” wrote the Bray GP, who also raised these concerns as Medical Council President from 2018 to 2021.

Online respondents to the post contributed a number of suggestions. These included a requirement for hospital doctors to complete a GP-run module on transitional care safety; a fully integrated e-prescribing solution across healthcare; and ensuring hospital doctors (“primarily interns”) had the time and support to complete “proper discharges”. The difficulty for hospital staff in establishing an accurate medication list at admission was also highlighted.

Recognised risk

The World Health Organisation (WHO) describes transitions of care as “the various points where a patient moves to or returns from a particular physical location or makes contact with a healthcare professional for the purposes of receiving healthcare”. These transitions involve referral, admission, discharge, and internal and external transfers. The HSE Patient Safety Strategy 2019-2024 listed transitions of care, including clinical handover, as a priority area for improvement. In 2022 HIQA’s revised methodology for healthcare inspections included transitions of care as a key category.

Internationally, these transitions are recognised as a patient safety risk. “Care transitions threaten patient safety as they can increase the possibility of losing critical clinical information and require an increased degree of coordination,” according to Transitions of Care: Technical Series on Safer Primary Care (WHO, 2016).

The WHO document stated there was “no easy solution to providing safer care transitions” and a range of strategies were needed. Both large- and small-scale interventions had been tested within healthcare systems, organisations and services.

Potentially beneficial interventions included standardising referral and discharge documents; discharge planning with agreed criteria and protocols; improving the quality and timeliness of discharge documentation; implementing effective medication reconciliation practices; increasing the involvement of primary care physicians; and educating and supporting patients, families and carers, among other measures.

Medisec has supported research into risk at the primary and secondary care interface in Ireland. A key risk identified was medication errors on referral to and discharge from hospital, Ms Aisling Timoney, Medisec GP Lead Counsel, told the Medical Independent (MI).

For example, patients may present to an emergency department (ED) without any medication list, or with a medication list from their GP which is not up-to-date.

“If a hospital doctor transcribes the patient’s medication list based on the GP referral letter without checking it with the patient, an opportunity to correct the information may be lost,” Ms Timoney said.

“Similarly, it can be a challenge for GPs to reconcile patient medication lists without relevant information about medication changes on a discharge letter, or in the absence of any discharge letter.”

She continued: “In Medisec, we strongly believe standardised referral and discharge forms, the latter to include a section dealing with any changes in medication and required follow up, would mitigate the identified risks, improving patient safety and reducing litigation. We would welcome focused collaboration between stakeholders from primary and secondary care on this, as a matter of priority.”

The HRB Centre for Primary Care Research has conducted research into medicines reconciliation at transitions of care. A qualitative study published in 2020 reported on barriers and facilitators in Ireland (Redmond et al, BMC Family Practice). The researchers interviewed a range of healthcare professionals on the topic.

The barriers included resistance from existing professional cultures; staff interest and training; poor communication; and minimal information and communications technology (ICT) support. The suggested solutions included supporting effective multidisciplinary teams; greater involvement of pharmacists in medicines reconciliation; ICT solutions (linked prescribing databases, decision-support systems); and increased funding to provide additional services (eg, admission and discharge reconciliation); and more advanced services (eg, community pharmacist-delivered medicines use review).

Discharge communication

When she was Council President in 2021, Dr Doyle described the transitions between primary and secondary care as “the most dangerous journey the patient ever makes”. During that year, the Council held consultative fora on transitional care. “Following same, Forum members identified key themes for consideration within the upcoming revised edition of the ethical guide, which is expected to be published in October 2023,” according to a Council spokesperson. “Transitional care remains an important area of interest for the Medical Council, and additional key themes will likely be considered for Medical Council position statements in the future.”

Dr Doyle said errors could originate and replicate across multiple settings. She said resourcing for medicines reconciliation in hospitals and general practice was among the measures required.

Several of her tweets have highlighted suboptimal hospital communications to GPs. According to wider feedback for this article, GPs commonly received incomplete or even no communications following outpatient or inpatient discharge.

Dr Doyle told MI a key issue was the level of prioritisation accorded to discharge communication within some settings. She said senior doctors must emphasise the importance of these communications within their teams.

“There are some hospitals where you actually get the discharge letter before the patient is discharged, and that is perfect. But there are other places you never get the discharge letter from,” Dr Doyle said. “It is to do with senior members of the profession prioritising it. I know the young doctors are running around [under pressure]… but unless they learn the prioritisation, once the patient is gone, they think that is the end of it.

“I would always ask the question, who should do the discharge summary? Is it the most junior person? And who checks it. You see letters that have both consultant and junior doctor signature spaces, but you don’t always see two signatures on it.

“If I was to put myself in their shoes, the more senior people need to create an awareness among the junior people that discharge letters and discharge prescriptions are very important documents. Because if they get the prescription wrong, or we don’t know the [details of a] discharge letter, it can be very difficult for the patient. And of course, readmission happens sometimes when the information is not exchanged. So the patient is the one who suffers in all of this.”

Consultants

Chair of the IMO consultant committee, Prof Matthew Sadlier, said doctors were operating with a “surreal” information system, which was contributing to problems in the transitions of care.

There was a preponderance of paper-based processes and lack of ICT interoperability across the health system. Hospital staff were transcribing and extracting patient information onto and from paper records for the purposes of admission, care, and discharge.

“It is 2023 and we are still, in hospitals, largely working off paper-based notes – cardboard folders and paper-based notes. Of course there is a difficulty in the transition of care and with discharge summaries,” stated Prof Sadlier, a Consultant Psychiatrist. “We should have an electronic patient record system that integrates between primary care and secondary care.”

In Prof Sadlier’s experience, GP referral letters were generally “very good” and typically generated via GP practice software. However, when received, information then had to be transferred onto paper records. In addition, many patients presented through the emergency department and may not have brought their medications. In these cases, the psychiatry team would need to contact the GP and pharmacy to seek a medication list. These issues added further layers of risk at transitions of care.

“Our integration of medical records is so ridiculously poor that, 100 per cent, there are going to be problems at the interface,” commented Prof Sadlier.

Mr Martin Varley, IHCA Secretary General, stated that “enhanced ICT systems, including fully electronic discharge summaries and a national electronic medication prescribing system, would significantly improve efficiency and save time on admission to and discharge from hospital”.

In his written response, Mr Varley emphasised the broader problem of delayed transfers of clinically discharged patients from hospital to community care. He said this was largely due to lack of step-down facilities, home care, rehabilitation or nursing home care.

In regard to improving patient safety at discharge, Prof Sadlier said that a senior clinician should have oversight of the discharge summary.

“Patients are seen by consultants on ward rounds and some hospitals have a system where discharge summaries are co-signed off by a junior doctor and a consultant, and some they are just written by the junior doctor….” He acknowledged the term ‘junior doctor’ encompassed a wide spectrum of seniority.

“If not done by a consultant, it should have oversight of what we would call a ‘senior junior’, like a senior registrar and a registrar, who would have a good understanding of the transition of care, and what GPs are facilitated in doing; what we are facilitated in doing.”

Work transfer

A core aim of national healthcare policy is to shift care to the community. However, the road to equitable and supported integrated care is a bumpy one.

A longstanding but increasing frustration for GPs is the “inappropriate” transfer of workload to them from secondary/tertiary care. GPs say the situation is creating additional patient safety risks.

Monaghan GP Dr Illona Duffy said work considered part of the patient’s assessment and management in hospital is increasingly directed back to the GP.

She explained that “if we felt we could do [the required] tests and if we felt we could manage the problem, we wouldn’t have been sending them to hospital”.

One element of the risk is that discharge letters may take weeks if not months to arrive.

“[These letters] can have really acute things that need to be done, like ‘repeat a U&E’, so a kidney function test. In elderly patients, renal function can drop quite rapidly during acute illnesses; medications can be started that can drop the renal function and it has to be monitored, but it has to be monitored in a timely fashion. We have repeatedly seen letters coming saying ‘repeat U&E within one week’, but we get the letter a month later….” There is also a risk in the context of identifying time-sensitive requests amid a huge volume of letters and reports crossing many GPs’ desks daily.

“It is just creating another layer of risk for the patient, and something not being followed up. And the duty of care should lie with the doctor who started that medication and who is responsible for ensuring the medication is doing no harm,” said Dr Duffy.

While she strongly advocated the need for timely discharge communications, Dr Duffy said this should not be used by the HSE to facilitate inappropriate transfer of work. “[Hospitals have] got to stop this trend where we are treated like junior hospital doctors in the community, left with a list of things to arrange. I think there is a misunderstanding of what we do in the community and people seem to feel in the hospital setting that perhaps we are not as busy as they are.”

Also speaking on transfer of care, Dr Doyle said this required agreement on both sides. “There are sometimes agreed protocols and that is fine. But if they are not agreed, [the hospital] cannot expect the ‘follow-up x-ray’ will be ordered by the GP.” 

On discharge communications in general, Dr Duffy echoed the view that this should be overseen by a senior doctor.

“The ideal scenario… is before a patient is discharged that there is a review by the team, who would include senior members of the team, either the consultant or the registrar, along with the hospital pharmacist.”

In regard to information provided from general practice to hospitals, Dr Duffy said provision of up-to-date medication lists could be difficult.

“Somebody may be attending a heart failure clinic and the medication you have down, let us say a dose of a diuretic, may have been changed, and may be changing on a weekly basis for all we know,” she said.

“So, we may not always have the most accurate and up-to-date list, but we should be aiming to have that. But generally, I would always say to the patient ‘take in your medications as well’ in case there are any changes.”

‘Disconnect’

According to Prof Sadlier, there is a “disconnect” between the policies of the Department of Health, which advocate more care in the community, and the implementation capacity of the HSE.

He provided an example from his own specialty. Some GPs “would be unhappy about the fact we send people to them and say ‘please can you do bloods on this patient because we have started them on lithium’” or another medication that requires blood monitoring. However, Prof Sadlier said the fact was that some community psychiatry teams had no access to bloods.

“So there is a bit of a disconnect with some of the policy documents, specifically the community policy documents, and the resources and facilities that are given to services in the community to follow patients up, which then often results in GPs having to pick up the slack.”

He added: “Hospitals are being told that certain things should be done in primary care and that ‘this is not a hospital-specific activity’. And then at the same time, primary care is not being resourced or being given the facilities [to do this work].”