Interprofessional Communication

Stroke patient care tends to be complex and require ongoing monitoring and management. Clear communication in a timely manner is essential to ensure continuity of care, patient safety, and reduce risk of complications and adverse events resulting from the confusion and ambiguity that can arise during transition points.

• Processes to ensure timely discharge summaries sent to primary care and other relevant healthcare professionals to facilitate continuity of care at transition points.
• Processes for coordination of ongoing medical management through primary care, community services, follow-up, and access to required healthcare services (e.g., ongoing rehabilitation or acute care).
• Resources available to enable appropriate and timely access to services at the next stage of care with the required specialties, intensity, and frequency.
• Following stroke, providing the right care and services in the right settings at the right times.
• Staff who are aware of patient/client’s right to privacy and who comply with privacy legislation and patient preferences when releasing patient/client information.

1. Percentage of patients for whom a discharge summary is completed within 48 hours of transition and received by the patient/family and the care provider at the next stage of care.
2. Percentage of patients with documentation that a plan of care has been established on discharge from acute care and/or inpatient rehabilitation, and with the patient’s primary care provider after discharge to the community.

Measurement Notes

• Performance measure 1: A copy the discharge summary should be included in acute care or inpatient rehabilitation chart, and in the chart of the primary care provider. It can be electronic or hard copy.
• Performance measure 2: Applies at all transition points across the continuum.

• Canadian Interprofessional Health Collaborative: http://www.cihc.ca
• Centre for Advancement of Interprofessional Education: http:///www.carpe.org.uk
• University of Toronto- Centre for Interprofessional Education: http://www.ipe.utoronto.ca

Research into transitions across care settings, particularly for stroke has just recently begun to emerge. Common to most investigations into transitions of care are the premises that there are significant safety and quality issues during transitions, and an interprofessional approach with clear communication and transfer of information are essential to ensuring patient safety through transitions. ^{216, 509} Many patients have more than one physician caring for them and this adds to both the burden of communicating information to all relevant providers, and to the risk of an adverse event due to lack of communication.

In 2008, the National Transitions of Care Coalition was formed and engages healthcare professionals from across disciplines to address key issues in transitions of care. ⁴⁹⁰They propose a framework for transitions of care and communication among providers at all transition points which includes the following elements: an accountable provider; a tool for plan of care; use of health information technology; care team processes of care; information transfer; patient and family education; and monitoring of outcomes. ⁴⁹⁰

A systematic review of discharge from hospital cited lack of communication between physicians as a significant factor is adverse events.^510,511 The study found direct communication between hospital physicians and primary care physicians occurs infrequently (in 3-20 percent of cases studied), and the availability of a discharge summary at the first post discharge visit was low (12%- 34%) and did not improve greatly even after four weeks (51%- 77%); this affected the quality of care in approximately 25 percent of follow-up visits.⁵¹⁰ They also reported that discharge summaries often lack key information required by the responsible physician at the next stage of care.  A study by Van Walraven and colleagues highlighted that discharge summaries should be disseminated to all physicians who see patients after discharge from hospital.⁵¹² Due to the poor dissemination of discharge summaries, physicians have “to rely on patients’ recall or on other sources of information, such as interim discharge reports or telephone calls to hospital physicians.”  This lack of complete information creates additional pressures on already busy physicians and often leads to incomplete follow-up and understanding of the intended plan of care following transition.

In a prospective study of 400 patients, Forster reported the incidence of adverse events during transitions of care was one in five.⁵¹³These occurred during discharge from hospital to home within three weeks of leaving hospital, and two-thirds (66%) were related to adverse drug events. Another prospective cross-sectional study involving 2644 patient discharges reported approximately 40 percent of the patients had pending test results at the time of discharge and that 10 percent of these required some action, yet the outpatient physicians and patients were unaware of these results.⁵¹⁴

Tregunno (2009) reported “The fundamental aim of any handover is to achieve the efficient transfer of high quality clinical information at times of transition of responsibility for clients.”⁵¹⁵Arora and Farnan (2007) identified factors that contribute to the risks for patients during care transitions.⁵¹⁶They cited inefficient and unstructured systems for communication of important clinical data, such as medication changes or tests that are pending; lack of a longitudinal patient relationship; and [lack of] standardized follow-up procedures. The infrequency of hospitalist-primary care physician communication and omission of details of patients’ hospital course have further adverse impacts on patient care.