CSP Triple One - Week 3 Lecture Notes

Patient Care Pathways, Hospital Progression, and Discharge

Learning Outcomes

• Describe patient progression in the hospital setting and processes involved in hospital care.

• Understand the importance of continuity of care and seamless transitions from hospital to community, acknowledging the inherent risks during transfer of care.

• Understand interprofessional collaborative practice (ICP), also known as multidisciplinary team.

• Touch on the role of digital health technologies in improving patient safety, care, and journey.

• Identify factors influencing patient outcomes.

Patient Progression

• Definition: Advancement of a hospitalised patient through required care events to achieve a health status suitable for transition to a lower level of care.

• Key is moving the patient to a lower level of care.

• Examples of Transition of Care:

  • Emergency Department (ED) to Intensive Care Unit (ICU) (higher level of care).

  • ED to ward.

  • ICU to ward.

Stages in a Patient's Journey

• Pre-Admission: Initial contact with the healthcare system.

  • Elective Admissions: Planned admissions (e.g., scheduled surgery).

  • Non-Elective Admissions: Unplanned admissions (e.g., physician referral, ED self-referral).

• Reasons for ED Visits (Non-Elective):

  • Infection.

  • Mental health issues.

  • Acopia (inability to cope at home).

  • Lack of access or confidence in primary care.

  • Financial reasons (public hospital ED is often free at the point of access).

  • Minor ailments (inappropriate ED presentations).

• Public Information: Educating patients on when to seek medical help.

  • Guidance on when to consult a doctor for new issues (within one week), ongoing health conditions (within 24 hours), or urgent conditions (immediately).

• Queensland Ambulance Service: Regular source of non-elective admissions.

  • Reasons: Falls, loss of control of chronic conditions (diabetes, asthma), accidents, chest pain, stroke, bleeding, allergic reactions, seizures, abdominal pain, spinal injuries.

• Patient Journey Representation after ED Presentation:

  • Arrival via ambulance or self-presentation.

  • Triage and assessment leading to admission or non-admission.

  • Admitted patients go to an ED cubicle, then possibly a ward or short stay unit.

  • Non-admitted patients may be fast-tracked and discharged with or without medications and follow-up instructions.

• Ramping: Problem of ambulances stuck at the ED due to bed block.

  • Results in paramedics waiting with patients, reducing ambulance availability for other emergencies.

Elective Pre-Admissions

• Planned surgeries or procedures (e.g., knee surgery, colonoscopy, planned caesarean section).

• Admission date is chosen in advance, allowing for pre-operative tests and preparation.

• Pre-admission clinics reduce length of stay by doing pre-work.

• Elective Surgery Categories:

  • Category 1: Urgent; surgery within 30 days.

  • Category 2: Less urgent; surgery within 90 days.

  • Category 3: Surgery within a year.

• Surgical Waiting Lists: Problems arise when patients wait longer than specified times, especially in Category 1.

Patient Flow

• The process of a patient moving through the healthcare system from initial contact to discharge, encompassing medical and administrative processes.

• Importance: Efficient patient flow is crucial to avoid bed block and ED ramping.

• Hospitals often have patient flow teams to manage and improve the process.

• Patient flow is a complex process involving numerous steps, people, and timely actions.

Admission

• Definition: Hospital accepts responsibility for the patient's care and treatment.

• Involves an interview, assessment, and clinical decision to determine the patient's care needs.

• Includes medical and medication history.

• Basic tests like blood pressure and temperature are performed, along with possible blood work.

• Non-Elective Admission: Depends on the patient's acuity or level of illness.

  • Requires a bed in an appropriate clinical area.

  • Involves doctor and nurse assessment; ideally, a pharmacist medication history within 24 hours.

  • Discharge planning begins on admission with an estimated date of discharge (EDD).

• Elective Admission: Often on the morning of surgery after pre-admission clinic workup.

  • More controlled and calmer process involving nurses, anaesthetists, pharmacists, and surgeons.

  • Discharge planning starts on admission.

Processes Experienced by Patients After Admission

• Post-Take Ward Round: Important process with no set format.

  • Involves a consultant, registrars, junior doctors/interns (JHOs), ward nurses, and sometimes a pharmacist.

  • Main job of junior doctors to document the consultation.

  • Opportunity for learning.

  • Ward round reviews medical, medication and social history; reason for admission, signs and symptoms.

  • Orders diagnostics.

• Multidisciplinary Team (MDT) Meetings: Opportunity for healthcare professionals (social workers, occupational therapists) to discuss patient care and treatment plans collaboratively.

• Diagnostic Phase: Testing to determine the patient's condition, plan treatment, assess treatment effectiveness, and establish a prognosis (likely outcome).

  • Involves blood tests, imaging (ultrasound, CT, MRI, PET, X-rays), biopsies, colonoscopies, endoscopies, ECGs, EEGs.

• Vital Signs: Monitored regularly by nursing staff.

  • Includes body temperature, heart rate, respiratory rate, blood pressure, oxygen saturation.

  • Monitoring frequency depends on patient's condition.

    • e.g. insulin infusion requires hourly blood sugar checks.

• Clinical and Diagnostic Reasoning: Two categories:

  • Non-Analytic: Rapid pattern recognition based on clinical experience.

    • If it looks, waddles, and quacks like a duck… it's probably a duck.

  • Clinical/Diagnostic Reasoning: More elaborate process for complicated presentations.

    • Involves an in-depth, step-by-step process in an attempt to reach a diagnosis as to what's wrong with the patient.

  • It can also be a mystery to the diagnostic team.

Treatment Phase

• Development of a treatment plan based on the diagnosis.

  • Medication Administration: Including dose adjustments based on regular monitoring.

  • Therapeutic Interventions: Surgery, physical therapy, wound care, rehab referral, specialist referral.

  • Referrals to Other Healthcare Professionals: Dietetics, social work, speech therapy, pharmacy.

• Monitoring and Evaluation: Assessing the effectiveness of the treatment plan.

  • Vital signs and clinical observations.

  • Documentation in progress notes.

  • Multidisciplinary team rounds to discuss progress and discharge planning.

The Healthcare Team

• Team composition depends on the patient's diagnosis and situation.

• Patient should be at the centre of care.

• Care is wrapped around the patient with relevant healthcare professionals.

Attributes of Interprofessional Collaborative Practice

• Clear role and purpose with well-defined goals.

• Well-led and organised.

• Sufficient diversity of professions to meet patient needs.

• Supported by enabling infrastructure.

• Trust and mutual respect among team members.

• Good access to partner organisations and shared resources.

• Shared access to patient records.

• Involvement of patients and carers in decision-making.

• Opportunities for professional development and joint training.

Role of Interprofessional Practice

• Identify current physical and mobility status.

• Ascertain patient goals (patient-centred care).

• Collect social history, home setup.

• Create ongoing treatment plans and management advice.

• Family meetings and training for families/carers if needed.

• Community referrals for treatment after discharge.

Benefits of Interprofessional Practice

• Each discipline provides specialised knowledge.

• Collaboration on decision-making.

• Effective coordination of care.

• Effective communication between team members and with the patient.

• Holistic and patient-centred care.

• Improved continuity of care.

• Continuing education and improved job satisfaction.

• Improved satisfaction of patients and carers.

Roles of Healthcare Professionals

• Scope of Practice: What you are competent to do, authorised to do, and accountable for.

• Scopes of practice can overlap between healthcare professionals; do not act outside your scope.

• Communication and understanding of each other and their respective scopes is very important.

• Patient-Centred Care: Establishing patient wants, needs, beliefs, values, preferences, and financial factors.

Roles of Specific Healthcare Practitioners

• Medical Practitioners: Diagnosis, clinical decision-making, medical procedures, monitoring progress, prescribing.

• Radiographers: Produce medical images to assist with description, diagnostics, treatment and monitoring; operate advanced technical equipment.

• Nurses and Midwives: Direct patient care (assessing health status, developing care plans, medication administration, monitoring vital signs), ensuring patient safety and comfort.

  • Checklist driven from fall risk assessment to pressure ulcer risk assessment.

• Pharmacists: Medication history and reconciliation, ensuring safe and effective medicine use, reviewing medication orders, dispensing medications, providing drug information, recommending therapeutic drug monitoring, adverse drug management, assist with diagnosis.

• Physiotherapists: Assess, diagnose, and treat movement impairments, improve physical mobility, prescribe exercises, manual therapy, functional training, equipment prescription.

• Social Workers: Psychosocial assessments, addressing social and emotional impacts of illness, arranging counselling, providing crisis intervention, advanced care planning, grief counselling.

• Dietitians: Assess nutritional needs, tailor meal plans based on medical conditions, manage chronic diseases, tube feeding.

• Occupational Therapists: Focus on activities of daily living (ADLs), help patients regain the ability to perform ADLs, assess functional limitations, suggest personalised interventions to improve independence/safety.

• Speech Therapists: Diagnose communication disorders, swallow assessments (important for medication administration), work with pharmacists to optimise the patient's treatment.

• Indigenous Health Liaison Officers (IHLOs): Provide cultural support and advocacy to First Nations patients, facilitate communication, ensure culturally appropriate care, assist with referrals and coordination, family/language support, discharge planning.

• Psychologists: Assess, diagnose, and treat mental health conditions, provide therapy, collaborate with other healthcare professionals to improve patient well-being.

Roles Common to All Healthcare Professionals

• Communication with and education of patient, family, and carers.

• Discharge planning (starting on admission).

• Advocating for the patient's needs.

• Supervision of junior staff and students.

Transfer of Care (Transition of Care)

• Occurs when a patient moves between locations or contacts a different health professional.

• Examples: Primary care to secondary care (home to hospital), ED to ICU, ICU to ward, ward to transit lounge.

• The Australian Commission on Safety and Quality in Healthcare focuses on transitions of care as a high-risk time in the patient journey.

Importance of Transfer of Care

• Patients are at higher risk of harm during transitions of care.

• Vulnerable populations (older people, those with disabilities, etc.) are at greater risk.

• Studies show adverse events and medication-related issues post-discharge.

• Poorly defined communication, lack of accountability, and inadequate patient engagement contribute to safety issues.

• Deakin University review: Poor documentation/communication at transition leads to higher readmission rates, failure to follow-up, increased costs, and medication errors.

Medication-Related Harm and Transitions of Care

• Two to three percent of hospital admissions are attributed to medications.

• Fifteen percent of medications can be admitted from the discharge prescription.

• Up to seventy-nine percent of discharge summaries contain a medication error.

• Medication-related harm affects seventeen to fifty-one percent of older adults within thirty days of discharge.

Opportunities for Improvement in Transfer of Care

• Recommendations include compatibility of electronic information systems and seamless, accurate transfer of patient information.

Digital Health

• Systems, tools, and services based on information and communications technology to treat patients, collect, and share health information.

• Examples: Mobile health apps, electronic referrals, wearable devices, telehealth, telemedicine; Australia has a national digital health strategy.

Benefits of Digital Systems

• Real-time patient information when and where it is needed.

• Safer, more reliable, less paperwork, and more time with patients.

• Powerful clinical and management data capabilities.

• Improved efficiency.

• My Health Record (MyHR) and Integrated Electronic Medical Record (IEMR) in Queensland Health are important digital tools.

• The Viewer helps with transfer of healthcare data but still has room to be optimized for information transfer.

• ELMS or Enterprise Wide Liaison Medication System is a valuable tool for documenting medication on discharge; the system is used really well within Queensland Health for medication changes and information but lacks transfer methods into primary care.

• In 2025 these healthcare facilities are often still faxing to GPs and pharmacies.

• Electronic discharge summary (completed by a junior doctor) is crucial for a critical clinical handover.

Challenges of Digital Technology

• Equity of access (not everyone has the technology and education to use it).

• Interoperability and data standards (seamless and accurate transfer of information)

• Digital literacy.

• Security and privacy.

Conclusion

• Apologies again for the lack of a live lecture.

• Questions can be addressed in subsequent workshops or by email.

• Clarification of missed online/recorded content will be provided as needed.