Unco-ordinated care: we need named responsible clinicians in hospital too!

Ron Murphy is a software designer, he blogs at ronmurp.net card

I read the “Named clinicians …” post today, and the linked post by Prof David Oliver. It addresses continuity of care after discharge. This is a concern, as he quotes, “we need to know that there is a clinician accountable for vulnerable older people in the community, just as there is in hospital”.

My concern is with the actual lack of continuity of care while in hospital, or across hospital admissions.

My mother has had a UTI since sometime in January. But, just since January she has seen 16 hospital doctors that I’ve counted. These have been in various A&E, in-patient, out-patient visits, across two hospitals in the North West. There may be more. I’ve not counted the junior doctors on the wards and other care teams. And the number of nurses, on at least 7 wards? Who knows?

The problem on the ward is that many details have been missed because the patient’s file is so thick the busy nurses don’t get to take it all in. Messages don’t get handed over at shift changes, so even if a nurse is present when a doctor visits, that nurse isn’t always around. Nurses are sometimes new to the ward and don’t know the patient at all.

The variation in care is surprising, but I still think the problem is the system, not always the individuals. I’ve seen nurses I have found to be good, but then they have really rough days when they are so overloaded they haven’t a clue what I’m talking about when I ask questions.

It is frankly ridiculous how often I’ve had to give details of the back-story that have had a direct effect on patient care by the current team. Here we have lay person telling nurses and doctors what needs to be done for the patient.

I managed to persuade one consultant that continuity was essential. He continued the care and involved other disciplines, more than had happened already and more than I suspect would have happened had I not laboured the point. The result was good, in that the cause of the UTI was discovered at last.

Out-patient clinics complicate matters. If the patient manages to avoid going into hospital, then the outpatient clinics are at best an organisational mess. Different clinics are never co-ordinated. Appointments are often postponed by the clinic, so that the next available appointment is a month or more away; and if the patient is too ill to attend one, you get put back again.

Across two in-patient periods, of about one month each, I asked several times that the ward doctors liaise with these outpatient clinics, but mostly with no result.  The result was that the outpatient attendance didn’t happen.

When an older patient has been laid up in hospital for a month, why drag her back to the same hospital’s out-patient clinic the day after discharge, when she could have been seen on the ward? These clinics aren’t helping the patient recover from the long in-patient period. If the appointments are so urgent, see the patient in hospital. If they’re not, postpone them.

Don’t always rely on the patient to know what’s going on. They may have cognitive problems.

The memory clinic nurse visited in January; but three out-patient clinics for this have been cancelled because the patient has been in hospital. I tried to have the consultant see the patient on the ward, but with no luck. I emailed the Patient Advice and Liaison Service (PALS) with the most recent request, but they couldn’t locate him, because he was on the mental health side. Don’t physical and mental health go hand-in-hand for older patients?

What this system needs is something like an internal GP (the ‘named accountable clinician’ – NAC). When older patients are first admitted they should be assigned a single consultant, who becomes their in-patient consultant for future in-patient visits, and for concurrent out-patient clinics – come on, you know there will be future visits and coincidental out-patient clinics; we’re talking geriatrics.

Whenever his patient comes into hospital the NAC should pick this up (they have computers, right?), and he should liaise with the specialist teams. It should be the patient’s NAC that makes sure the patient’s file contains the latest most pertinent summary of the patient’s needs, at the front; and all current doctors and nurses on the ward should read this. I can’t tell you the number of blank faces I’ve seen on nurses as they’ve thumbed the patient’s file, flicking through countless pages, when I’ve told them of some condition they need to take into account (e.g. the catheter is long-term, so don’t leave it out because you think “she seems to be managing”). See previous post…

The internal NAC needs to co-ordinate out-patient care too, with the positive intention of making the clinic consultants aware of the patient’s current visit, and to arrange consultation if possible, or rescheduling if not.

Prof David Oliver posed some questions, regarding the NAC:

Who will we define as sufficiently ‘vulnerable’ to merit the ‘named clinician’? How long after discharge will the arrangement continue? What are the consequences of ‘accountability’ for the ‘named’ doctor or nurse? …we already have patients registered with named GPs. …  Are they not the de facto accountable clinician?

These seem easy to answer.

Who? Any patient with co-morbid conditions that are on-going (i.e. attending out-patient clinics), especially if cognitive impairment is part of the condition – e.g. delirium, or longer term dementia, or the patient is under investigation for it.

How long? From the first such in-patient visit, until some agreed term of no re-admission has passed. My mother was re-admitted just ten days after her first one-month stay. I think that counts as continued NAC responsibility.

Consequences? Same as a GP.

Is the GP not the de facto accountable clinician? Yes. But the GP cannot manage in-patient care. The GP may instigate but has no control of out-patient clinics

At least then the patient and family have good access to two known clinicians, the GP and the NAC, who should be able to co-ordinate long term in-patient and home care between them. Once an in-patient, the internal NAC should take over. That still leaves room for improvement in out-patient clinics – another topic.

2 thoughts on “Unco-ordinated care: we need named responsible clinicians in hospital too!

  1. Ron you might be interested in the paper on the kings fund website “continuity of care for hospital inpatients” which addresses these precise issues. And for primary care, two things Martin Roland BMJ 2013 on multimorbidity – all about continuity and a very interesting project from Birmingham (Ellins and Glasby) called the Care Transitions Project – very much asking older people and their carers what its like bouncing around betweeen multiple services and struggling to navigate the system. You will be pleased to know that despite the poor experiences you have had there are many hospitals (my own included) where care is under the care of a ward based consultant and team and after the initial trip through A&E or the medical admissions unit one consultant is responsible for care from start to finish. It isnt that unusual. But in places where patients suffer multiple ward moves for instance, continuity is lost

  2. Outliers are the issue, though. Recent efforts by the Royal Colleges of Physicians in Edinburgh and London highlight that patients being made to move multiple times over one admission is not unusual and is a widespread source of concern.

    This winter, we are piloting a new way or working across our local healthcare community (primary and secondary care) in an effort to improve patient flow and do away with the need to outlie patients. I don’t know, yet, if it will work (although it clearly has elsewhere, witness South Warwickshire).

    We know that it is very difficult to conduct multi-domain comprehensive assessment in frail older patients (the type of care that is evidence-based and has been shown to improve outcomes) peripathetically. So outlying is the enemy of gold-standard clinical practice.

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