Hospital discharges – a piece of paper vs a proper handover

The issue of a proper and meaningful hospital discharge is a challenge for several reasons. I believe that one of the main reasons is the outdated view of the Visiting Medical Officers of the role of the General Practitioner.

When I qualified two decades ago hospital admissions were very different to the present day system.

Patients were admitted under the team of the day and allocated to a Junior doctor and Students who had to get a decent history, actually examine the patient (as opposed to just doing a plethora of tests) and then presented this patient to the Senior Doctor. This person would then either make a decision regarding management or discus it with the “Boss” and a management plan would be implemented. The aim would be to get the patient fixed BEFORE being discharged. If another Speciality needed to be involved they would be consulted to see the patient in the hospital and as far as possibly everything would be done and dusted before the patient would be sent home – usually on a Friday as that meant his/her family could pick them up and look after them and there would be a bed available for the elective admissions planned for the next week. Follow-up with the relevant Specialists would be booked and scheduled prior to discharging them.

In some cases the General Practitioners would be involved and might even have admitting rights – more so in the Regional and Rural Centres.

Very often though the Discharge Letter to the GP was a mere formality so that his records would be up to date and out of this was born the attitude of “just a GP” whose involvement was not a priority. Back then this was not a major concern given that the patient’s problem had actually been fixed so the task was usually delegated to the most junior Doctor in the team.

over the years things changed –  Casemix and other cost cutting measures surfaced and the whole landscape changed – no longer were patients admitted and fixed – instead they were kicked out as soon as they were reasonably stable and increasingly investigations and actual treatment of their conditions where left to the General Practitioner to sort out.

Given the skill set of any reasonably experienced GP this should not have posed a problem but unfortunately some of the outdated attitudes that came along with these new approaches made for a recurring and persistent stream of disastrous clinical stuff-ups.

The current scenario evolved where the hospital team ignores the GP input that the patient came in with (usually stuffed unread into the back of the file) and considers the Discharge Summary as just an administrative nuisance to be delegated to an Intern and to be faxed over a weekend or weeks later to the GP. After all, a mere GP would not be doing anything other than to file the document.

This approach did not create too many problems when the hospitals still bothered fixing their patients before they discharged them but now that they discharge them while still unwell there needed to be a PROPER clinical handover – a fact that the entire hospital team, from the VMO to the Intern, seems to be oblivious to.

The fact that patients are being discharged while still unwell also pose other practical realities.

Interns would advise the patient to make an appointment with the GP within a week yet only give them five days worth of medication. Sounds reasonable unless the punter has been sent home Friday afternoon during a long weekend and the GP has a waiting list of 3 or 4 weeks – the mere thought of an Intern or, perish the thought, a more senior doctor, actually picking up a phone and advising the GP of the urgency for a review, seems just too farfetched. Obviously the fact that Clinicians are actually supposed to be looking after the patient and not just complete their shift seems to be an archaic and quaint concept that only old farts like me still hang on to.

Likewise the discharges often state that the patient needed to see the Specialist under whom they had been admitted in a few weeks. Very often the patient has no idea that this has to happen and only find this out when the GP informs them. Here in Canberra Specialists are hard to get in to – invariably the patient cannot get an appointment within months and are told to get the “GP to send a fax for an urgent referral” – unfortunately many of our local Specialists have taught their reception staff not to accept calls from GPs – even if we are trying to arrange follow-up for a patient who has been under that Specialist’s care so a fax it is and even then the wait is often still several months.

Then we get to the tests and treatment – these patients are still being treated for their acute episode and the Interns are tasked to arrange anything from MRIs to PET scans and send patients out on all sorts of drugs that are not available on the PBS outside of the hospital environment. These very junior colleagues have absolutely no idea of the funding rules in regards to these things so they just document it in the discharge  letter for the GP to arrange – without as much as a phone call to the GP. This invariable result in total chaos on a Monday morning – the fax/e-mail is discovered, the patient’s family is on the phone and the entire GP team is running around, chasing their tails, trying to fix the mess.

I am notorious about the way I aggressively climb into the hospital teams whenever these disasters occur – unfortunately all I manage to achieve is that some junior doctor gets to re-do a discharge letter.

My actions seem to have absolutely no impact on the way in which the Specialists go about teaching their Juniors and treating their patients. My previous comments related to Public Hospital admissions. The Private admissions are usually done without any Junior doctors being involved and in most of these cases we are lucky if we get a one paragraph discharge letter weeks after the actual discharge had occurred – in fact sometimes weeks after the poor patient had passed away from post-discharge complications.

So how does the System deal with complaints from people like myself? They pass it on to Management (made up of non-clinicians) who then devises an elaborate array of Allied Health Discharge Teams, various electronic discharge processes and all kinds of bells and whistles. Sadly though the patient’s actual care often gets lost in the process despite there usually being enough paperwork and people involved to staff an entire hospital. Off course we can add-on all the various bureaucratic processes that our esteemed Medicare Locals and other similar Government Funded Organisations keep developing

What a waste – all of this could have been so easy – a simple proper clinical handover from Senior hospital based Clinician to a Senior General Practioner should need no more than a properly written discharge and a phone call. But that requires something called “commonsense” and that appears to be the exclusive domain of those of us that are “just GPs”

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