PRIMARY CARE QUALITY AND INFORMATION TEAM
Transfer of Care Communication (TOCC)
Referral & Discharge Communication
CONTENTS PageIntroduction and Background / 4
Aims of the Quality Improvement Toolkit
A & E Admissions / 5
6
Methodology / 7
· Organisational Checklist / 9
· Patient Audit Data Proforma / 10
· Practice Review / 11
Transfer of Care Communication / 12
Methodology / 14
· Organisational Checklist / 17
· Patient Audit Data Proforma
· Practice Review / 18
19
Electronic Transfer of Care Communication in Wales
Appendices
A Audit of GP Referral Letters, Emergency Admissions
/ 20
24
B Scottish Intercollegiate Guidelines Network, Referral
Document
/ 25
C.1 Referral Letter Template for IPS Vision / 26
C.2 Request for Open Access Endoscopy Examination / 28
C.3 Shared Care Template / 29
C.4 Death in the Community Notification - Primary Care
/ 31
D Model 1 Correspondence to GPs advice on
completing template
/ 32
E Implementation Template Guidance notes for IPS
Vision users – How to add the referral template
F SIGN – Immediate Discharge Document
G Discharge Letter Template
H Death Advice Notification Letter from Trust
I Conclusions from Bro Morgannwg, Bridgend
J Conclusion & Recommendations –Referral
References / 3334
35
36
39
41
47
National Public Health Service for Wales / Transfer of Care Communication
PREFACE
Quality Improvement Toolkits
The Primary Care Quality and Information Team (PCQIT) have developed Quality Improvement toolkits to assist practices in collating and auditing information on nGMS Enhanced Services.
You can access other quality improvement toolkits that support Enhanced Services and National Service Frameworks from the National Public Health Service (NPHS) website:
Intranet http://nww2.nphs.wales.nhs.uk/page.cfm?pid=1267
Internet http://www.wales.nhs.uk/sites3/page.cfm?orgid=719&pid=23548
Introduction
Referral letters of high quality are an essential part of good clinical care. Following a decision to refer there is usually a written communication. The Referral Letter acts as the interface between primary and secondary care, as such they have a number of functions1
Ø Provides administrative information for those not directly involved in the patients care
Ø Provides clinical information (including demographics)
These letters have been the subject of comments over many years and are often haphazard and lacking in consistency and content. This may have improved over the last 10 years, there is still evidence to suggest that this could be further improved2 - 15
The health community in Scotland undertook research to underpin this with evidence relating to appropriate information required when a transfer of care occurred. They found that there was an absence of such material so they held a conference to determine what was appropriate1, 2
A working party produced a recommended minimum data set for elective and emergency communication primarily for GP to Consultant Transfer of Care Communications (TOCC), however it was envisaged that these could be adapted for other allied professions1,2
The Immediate Discharge Document (IDD)2 is also an important instrument for communication between secondary and primary care.
The IDD is a minimum dataset, however, subsequent information maybe necessary and this should be delivered as quickly as possible. The IDD and the dataset are not exclusive and additional documentation is often required to supplement this minimum.
There is continuing evidence that the quality of immediate discharge documents used in NHS Scotland fall far short of the ideal. These deficiencies occur in the:
Ø content
Ø structure and
Ø production of the document.
Several publications have indicated continuing problems with the production of discharge documentation10, 12. The problems relate to content, the process of production and transmission.
A prospective audit of discharge summaries using a computerised system of discharge letter generation reported a 10% overall error rate, 22% of which were errors relating to the diagnosis12.
Another prospective audit scored 100 ‘interim’ discharge letters on their level of completeness and found an average score of 13 out of a potential 16.
Only 83% were legible and 30% did not name the doctor preparing the summary. Only 43% were dispatched within five days from discharge11.
One audit has revealed differences between the ward prescription and the discharge prescription in 13% of cases. Differences between the ward prescription and the final letter were identified in 29% of cases13. Medication-related problems two weeks after discharge were found in 57% of patients and some summaries did not reach the GP13.
The majority of family doctors prefer a structured discharge document rather that one with a narrative format9, 15, 20, 21. The reasons for this preference include:
Ø completeness
Ø readability
Ø conciseness and
Ø the ease of locating key information.
Structured format discharge documents can easily be produced by computer systems. A randomised controlled trial comparing dictated discharge summaries to computer generated summaries found that computer generated summaries were shorter than dictated and were produced more quickly9. The computer generated summaries contained data relating to active past medical history and medications more often than the dictated summaries but contained admission diagnosis and discharge functional status less often. A global assessment of quality found no difference between the two types of summary9.
Aims
Local health communities or health economies may wish to validate these sentiments associated with the quality of Transfer of Care Communications (TOCC) in their locality. This document proposes;
Ø A method to validate the content of TOCC and some tools to
assist the process of validation
Ø Some standards to apply in terms of appropriate content
Ø Model TOCC templates
Ø Provide some NHS Wales evidence to validate the need to
structure TOCCs
Background in Wales
We are aware of two Health communities in South Wales who have undertaken significant quality audits associated with TOCC18, 19.
Work has also been undertaken by Iechyd Morgannwg MAAG and Bro Morgannwg NHS Trust Clinical Effectiveness and Audit Group in the Bridgend LHB area (200118). This evaluated 200 Discharge forms. Latterly they have also examined TOCC for A&E admissions from Primary Care and the Out Of Hours provider for Bridgend (Primecare) Oct 200519
In Carmarthenshire an audit of referral and discharge TOCC content was undertaken on a larger scale, 500 elective referrals and discharges were examined in 2004. In addition a re-audit took place two years later using similar volumes.
Validating the quality of TOCCs
The methodologies and templates supplied are based on the models used in Carmarthenshire TOCC work and Bridgend A&E Dept.
A & E Admissions
A&E Admission
The Bridgend Health Community looked at the quality of emergency referral TOCCs in October 2005. The following provides a methodology, standards and evidence from this audit to validate the need for a standardised emergency referral TOCC document.
Methodology
Obtain a list of all emergency medical admissions to the Trust over an agreed period. Bro Morgannwg selected a period of one week a total of 468 admissions were identified by the Trust information department. The notes of these patients were available and examined. In some instances the notes were not available.
Before commencing the audit undertake an inter-rater reliability test to assess consistency amongst the data collection staff. This test is used to ensure consistency of data extraction is maintained throughout an audit when there are two or more data collectors. In Bro Mogannwg the test was carried out by four members of the audit team on 12 sets of notes. A few inconsistencies were identified primarily in relation to legibility. Areas of disagreement were discussed, and clear definitions developed for each criterion. The inter-rater reliability score was 88.2%.
Audit staff should then review the admission documentation using the data collection form (Appendix A). This applied a modified standard indicated in SIGN 31: Section 4 - Recommended referral document1 . This shows the information requirement for emergency admissions highlighted in red type.
The data collected is then analysed.
By Referrer
Ø Primary care
Ø Out of hours provider
Ø Self referral
Then by site if a multi-site trust and by time of admission by three groupings, for example:
Site 1 Site 2
Week daytime Week daytime
Weekday Night (6.30pm- 8am) Weekday Night (6.30pm - 8am)
Weekend Weekend
Where referral documentation was found and the type of referral document was annotated.
Ø Proforma
Ø letterhead
Ø Tidy plain paper/other.
They went on to examine legibility and content against the modified criteria of SIGN 311
Ø To score an excellent in legibility the document had to be
100% legible.
Ø The percentages for good and fair were approximate
figures and were not precisely calculated.
Ø Where the auditor could not read more than 75% of the
document, legibility was deemed to be of poor quality.
The content is then examined by Trust Location, referrer and Referral documentation type (proforma/letter/plain paper etc).
Examine results and draw conclusions that are appropriate to your health community. Examples from Bro Morgannwg can be found at Appendix I
Action / Not Achieved / Partly Achieved / Achieved in full / Action Plan
Template / To include the data collection criteria shown at Appendix A – Item 1 - 16
Completion of Template / Preferably link the template to the clinical system to allow automated population in specific fields such as demographics – medication – clinical warnings etc
Ensure that confirmation of negatives is covered eg, the patient does not have any clinical warnings
Recording / Ensure that referrals / admissions are recorded on your clinical system.
Training / Ensure all staff who are able to make referrals are competent in the completion of the template.
Patient Audit Data Proforma
The Trust reviews patient admissions in this instance using the proforma at Appendix A, The practice does not need to review patient data in this audit.
Review
This review should be completed following dissemination of the results from the Trust.
A What lessons did the Practice discover from carrying out this audit?
B What changes, if any have the Practice agreed to implement as a result of
this audit?
C What support would enable the Practice to enhance the service it provides to
patients?
This audit was compiled by;
Name(s) ______
Signature(s) ______
Practice Name & Address
Date: ______
Version: / Date: 17 April 2008 / Status: FinalAuthor: Dr Chris John/Martin Holloway / Page: 11 of 48 / Classification:
National Public Health Service for Wales / Transfer of Care Communication
Transfer of Care Communication
Version: / Date: 17 April 2008 / Status: FinalAuthor: Dr Chris John/Martin Holloway / Page: 11 of 48 / Classification:
National Public Health Service for Wales / Transfer of Care Communication
Generic TOCC
In Carmarthenshire the local health community wanted to look at referral and discharge (TOCC). We have used the methodology and sample volumes applied in Carmarthenshire to give indicative amounts, however, this may vary depending on local circumstances. This would take the form of an audit of content against the modified SIGN standard in 2004 and then a re-audit in 2006 to see if the TOCC documents and procedures had embedded.
The following gives a methodology, standards and audit tools that we used to do this.
This joint collaborative project was undertaken in the early part of 2004.
Criteria
A modified Minimum Dataset for Referral and Discharge TOCC (based on the documents SIGN 31 and 65 see Appendix B and F) was used to check the received TOCCs for completeness.
Standard
Following comprehensive research it is suggested that you should use a modified version of the Scottish Intercollegiate Guidelines Network Referral1 and Discharge2 Information.
Devised modified templates that meet local requirements but still retaining the integrity of the SIGN templates see below:
Referral Template Document – Appendix C
Discharge Template Document – Appendix G
A 100% compliance was agreed given that this was the Minimum Data Set
Sample
For Referral - In order to get a good picture of the standard of your TOCCs, larger samples are preferable. It is suggested that you take a three month period and look at all of the referrals received in this period (in the Carmarthen project this accounted for 500 referrals). If there are multiple sites taking referrals then this sample should be spread across all sites. These are provided as a guide; obviously it should be up to local determination.
For Discharge - A minimum of three practices should be involved and again they should examine all the discharge notes received in this period (in the Carmarthen project three practices participated and examined 650 discharge notes), the proportion varied according to Practice size. This again is provided as a guide and is for local determination.
Methodology
A model steering group for the audit is listed below made up of representation from primary and secondary care.
Trust Consultant Physician
Trust Principal Pharmacist
Trust Medical Records Manager,
Trust Medical Records Supervisor
Trust Clinical Audit Manager
Trust Clinical Audit Administrator
Trust Clinical Audit Assistant
Junior Doctor
General Practitioner
Practice Medical Secretary
LHB GP Board Member
LHB Clinical Governance Representation
Computer Operator GP staff (involved with administration of Referral & Discharge letters
Practice Manager
LHB Information Lead
LHB Admin Support
This group should develop and review all aspects of the implementation of TOCCs between Primary and Secondary care including the process by which the audit is conducted.
Referral Methodology
The following steps were taken:
Ø A review was undertaken of information required when patients are referred between Primary and Secondary Care.
Ø Standardised Referral templates should be devised for General Medical Practices which should be adapted from the SIGN1 standard. It is recommended that these are piloted by at least two GP Practices to reduce administrative burden and inaccuracy in the transcription of information. The information required by the template should if possible, automatically be transferred from the GPs clinical systems.
Ø A process of consultation and promotion should be undertaken by the Local Health Board with its General Medical Practitioners to gain endorsement for the use of referral templates. If there are any GP clinical system user groups running in the area, it may be useful to consult with these as well.