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

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

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: http://www.ncbi.nlm.nih.gov/books/NBK44015/

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: http://blogs.esa.int/astronauts/files/2013/01/swisscheese.png

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?

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)

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

Thank you! www.hccc.nsw.gov.au