1. Coordination of care
Tony Kofkin Director of Investigations Health Care Complaints Commission

2. What is coordination of care?
Good patient care requires coordination between all treating practitioners. Good practice involves:
Communicating all the relevant information in a timely way
Ensuring that it is clear to the patient or client, the family and colleagues who has the ultimate responsibility for coordinating the care of the patients or client.
Source: Dental Board of Australia: Code of Conduct for registered health practitioners, p. 9

3. Systemic literature review findings
Numerous different definitions exist. Common key elements that comprise care coordination:
Numerous participants are typically involved
Coordination is necessary when participants are dependent on each other to carry disparate activities in the patient’s care
Adequate knowledge about available resources and participants’ roles are imperative
Information exchange is possibly the most pivotal exchange of critical patient related information to facilitate effective coordination and medical decision-making.
Source: McDonald KM, Sundaram V, Bravata DM, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun. (Technical Reviews, No. 9.7.) Available from:

4. Incident Causes The Swiss cheese model
Usually, systems are imperfect, like a swiss cheese, there are holes
If there are errors, usually the get caught by one of the defence layers
However, if the layers are too similar and line up, the error can pass through all of them and leads to a serious adverse event.
Adapted from Reason, J. (1990). Model:

5. Who has the ultimate responsibility?
Admitting consultant: responsible until patient is handed over, or until patient is discharged?
How much can a consultant rely on other clinicians with or without checking?

6. Key themes from Commission's experience
Problems arise for many reasons; however, key themes are:
lack of or poor communication (instructions misunderstood, not documented)
patient care plan is not actioned or not followed up
key clinical information not available (written or oral at time of patient visit)
poor handovers (information missing, incomplete, inadequate, or inaccurate)

7. Key themes Coordination primary and hospital care
Lack of or inadequate discharge plans and medications to patient’s general practitioner (GP)
Poor, untimely or no feedback from specialist to GP, and vice versa
GP unaware that patient has been hospitalised
subset of patients who do not have regular GP – no follow up after discharge
-> Coordination of care issues can lead to unnecessary hospitalisation, can have adverse effects on patient outcomes and increase the cost of health care.

8. Case study Unclear responsibilities
Elderly patient, with significant co-morbidities, was admitted for elective knee replacement performed by Orthopaedic VMO
Day1:
Surgery uneventful, no intraoperative problems, patient moved to surgical ward
Day 2:
Oxygen Saturation (Ox Sat) 76% -> improves to 95% on 6 litres of oxygen
oxygen reduced to 2 litres Ox Sat 94% - no request for clinical review
Ox Sat levels drop to 88% -> no review, no MET (Medical Emergency Team) call
patient reviewed by RMO, further investigations ordered
RMO recorded calf tenderness right side, but did not consider this an indicator for Pulmonary Embolism
These further investigations included a chest x ray

9. Case study .... continued
RMO discussed with Medical Registrar – Registrar took no further action, confident with RMO’s decision
Chest x-ray available before midnight, shows abnormal results and radiologist recommends further investigation
Day 3:
patient very agitated, removing oxygen mask, not maintaining normal oxygen levels -> RACE call (Registrar Activating Clinical Emergency)
Internal Medicine registrar responded – required blood sample -> sends request to pathology
Registrar also, on recommendation of respiratory physician, arranges chest CT
Pathology results available within 1 hour, showed abnormal results
Abnormal results: nodular opacity in the right superior mediastinum and prominence and increased density in the hilar were noted.
RACE: registrar activating clinical emergency -> concern but does not warrant med call
-> pathology request included blood culture, C reactive proteins, creatinine, electrolyte high sensitive Tropinin T Calcium, Magnesium, Phosphate and a full blood count
Pathology results: high sensitive Tropinin level. C reactive protein high.

10. Case study .... continued Day 4:
Ox Sat levels 88% on 2 litres -> no MET call
Observations showed that patient was stable through the day
Review by VMO: observes patient to be comfortable, VMO not made aware of low oxygen levels or RACE call previous day
Observations remain stable though afternoon – 95% on 3 litres of oxygen
Day 5:
observation note that Ox Sat were 89-91%, neither observations were recorded in medical records or patient’s Standards Adult General Observation Chart until hours later
Patient reviewed by Internal Medicine Registrar – patient stable at the time
VMO does not read the patient notes. Relying purely on the his observations at that time, rather then looking at the complete picture. Sated to the Commission that he was not aware of previous low oxygen levels. Had awareness and knowledge of only a small window of his care and treatment on the surgical ward.

11. Case study .... continued Day 5 continued:
patient Ox Sat levels drop to 89% - no MET call
2 hours later, RACE call: Medical Registrar attended, patient found to be alert and speaking – thorough review of records, noted that patient had de-saturated for days with several spikes in temperature
suspected pulmonary embolism -> urgent CT ordered
less than two hours later, patient had a cardiac arrest and died
Cause of death- combined effects of Pulmonary Embolism and Acute Myocardial Infarction.

12. Case study - post incident
Hospital Root Cause Analysis made a number of recommendations:
Pathology policy to notify when critical results
Acute pain services to refer to SAGO chart and patient medical records as part of clinical review
All nursing staff to attend DETECT training
DETECT- Detect deterioration; Evaluation, Treatment. Escalation and Communication in teams.
Lack of coordination and communication which played a contributory factor to the adverse outcome.

13. Case study - post incident
HCCC investigation finds:
poor coordination and management of overall care
over 5-day period, several missed opportunities to appropriately review and escalate patient’s care
VMO did not adequately review patient progress notes or observation charts, both of which noted Ox Sat deterioration
orthopaedic registrars reviewed patients twice in the period, but reviews not documented in medical records
lack of overall management was compounded by lack of follow up on critical test results
Time line identifies where these missed opportunities are. Pathology reports, ox sat levels, chest x ray, ct Scan . Just required a Doctor or a Nurse to escalate appropriately- take control- recognize the clear signs of a deteriorating patient.
The patients family attended every day. They were never informed about his low ox sat levels, about the met calls. They had no idea how critical his condition as, which isn't surprising since nether did those charged with his care.

14. Case study - post incident
Expert opinion:
ultimately, orthopaedic team responsible for patient, but no one took ownership for overall management of care
over reliance on medical registrars working fragmented shifts in troubleshooting role with no primary patient responsibility
orthopaedic team paid little attention to non-orthopaedic issues
expert and internal medical advisor stated that while not ideal it is common practice
Under such a system the danger is that no one has ownership of the patient for ultimately responsibility for co ordination of their care.
There is a reasonable likelihood that someone taking this role might have noticed the elevated tropinin level and recurring desaturation.

15. Outcome
Internal Medical Registrar referred to Medical Council to address the lack of following up pathology results
Recommendation to the hospital to develop policy to assess orthopaedic patients with co- morbidities whether they should be admitted jointly under the care of both an orthopaedic surgeon and physician
-> recommendation was implemented
-> Clinical Excellence Commission advised
-> Agency for Clinical Innovation implements program addressing similar issues
Evidence of implementation of recommendation- shared care- developed a policy where patients with several co morbities an assessment is completed whether the patient should be admitted jointly under the care of the consultant and the physician consultant.
CEC had identified similar issues and work is ongoing .
Ministry of Health noted several opportunities to streamline care in this case and implemented a number of initiatives- including a tool kit for safe clinical handover for LHD’S AND specialty health networks.

16. Summary
Coordination of care is pivotal for prevention of incidents and good patient outcomes
Safety and quality programs minimising coordination of care issues:
ISBAR protocol (Introduction-Situation-Background-Assessment-Recommendation)
Between the flags
In addition
overall cultural aspects in the provision of clinical care
feeling confident and having the mechanisms in place to escalate, appropriately
proactive supervision
Proactive supervision- Ask- outstanding pathology results/ radiology-
Record reviews, articulate expectations of those you supervise clearly.
Assume nothing, believe no one and consider everything when appropriate.
Ask for updates on sick patients, call me if things start to change does not always work. On going updates are at times required.

17. Thank you!