2014-03-19 12.00 Coordination of care

Coordination of care
Tony Kofkin
Director of Investigations
Health Care Complaints Commission
What is coordination of
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
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
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:
Incident Causes
The Swiss cheese model
Adapted from Reason, J. (1990). Model: http://blogs.esa.int/astronauts/files/2013/01/swisscheese.png
Who has the ultimate
 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
 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
 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
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
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
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
 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
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
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
 orthopaedic team paid little attention to non-orthopaedic
 expert and internal medical advisor stated that while not
ideal it is common practice
 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
 Coordination of care is pivotal for prevention of incidents
and good patient outcomes
 Safety and quality programs minimising coordination of care
o ISBAR protocol
o 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
Thank you!

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