Care in the community
Post date: 14/11/2014 | Time to read article: 5 minsThe information within this article was correct at the time of publishing. Last updated 18/05/2020
One of the biggest risks in treating elderly patients in nursing homes is communication. Dr Rachel Birch, a sessional GP and MPS medicolegal adviser, reviews a case where communication failure led to patient harm. she then answers typical medicolegal queries around community care
Case: A preventable gastrointestinal bleed
Miss Brown was an 89-year- old patient at a local nursing home. She had a history of ischaemic heart disease and had been taking 300mg aspirin daily. She was admitted to hospital with a gastrointestinal bleed and the aspirin was discontinued.
"The practice manager and GP met with the family to discuss these issues and the complaint was resolved to the family’s satisfaction"
When she was discharged from hospital her GP was sent a copy of the discharge letter. The nursing home did not receive a copy of this. The nursing home continued to request aspirin and this continued to be prescribed for her.
Two months later she had a second gastrointestinal bleed and was readmitted to hospital. Miss Brown’s family made a complaint to the practice (with miss Brown’s consent).
What went wrong?
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Neither the nursing home nor Miss Brown were informed of medication changes.
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Miss Brown did not receive a medical review following discharge from hospital.
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The GP did not make the medication changes to miss Brown’s medical record.
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The nursing home did not receive discharge summary instructions for miss Brown from either the GP or the hospital.
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Miss Brown subsequently suffered harm as a result of the discharge failure.
What action did the practice take to prevent a similar future episode?
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The complaint was addressed in line with the practice complaints procedure.
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A significant event analysis (SEA) was held with all members of the practice team present and the failings in the current system were identified.
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The management of discharge summaries within the practice was reviewed.
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A protocol was developed for communication between the practice and nursing home.
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A protocol was also developed to ensure that patients discharged back to nursing care receive a medical review.
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The practice manager and GP met with the family to discuss these issues and the complaint was resolved to the family’s satisfaction.
Your questions answered
Q. Our practice is responsible for the care of elderly patients at the local community hospital. I am the nominated lead GP within the practice. I am concerned that there is very little information provided by other GP practices and hospitals when patients are admitted to this facility. Most of these patients are not registered with our practice and we do not have access to their primary care records. In addition, I feel that some patients are unsuitable for this type of care and have been inappropriately referred.
Dr Rachel Birch: Community hospitals are a valuable resource and are a more appropriate admission option for many elderly patients. They help to reduce pressure on the bed availability in acute hospitals. However, the British Geriatric society advises that older patients should not be disadvantaged as far as specialist medical assessment is concerned and doctors have a responsibility to ensure that the medical care is consistent and of a high quality.1
"Older patients should not be disadvantaged as far as specialist medical assessment is concerned and doctors have a responsibility to ensure that the medical care is consistent and of a high quality"
To ensure continuity of care, patient notes should be available and complete, and contain sufficient detail to enable the consulting GP to safely carry on treatment from a previously attending colleague:
- When patients are admitted to the community hospital, with the consent of the patient, you should request the medical records from referring hospitals and GP practices.
- You should consider developing a handover procedure between practices. If referrals to the community hospital are inappropriate, you must remember that you continue to have a duty of care; however, in order to avoid such problems in the future, you should:
- Consider developing an admissions policy, to be agreed with the PcT, the hospital and the practices involved with the patient.
- Keep a written record of all the steps you have taken to try to resolve your concerns.2
Q. The district nurses often ask the doctors at the practice to prescribe antibiotics, diuretics, dressings and analgesia for patients that they are attending. Can we do this without reviewing the patients ourselves?
Dr Rachel Birch: It is recognised that doctors and nurses work as part of a larger team in primary care and that this can be beneficial for patients. A good relationship and communication between district nurses and GPs not only helps the patients, but helps towards good working relationships and a supportive work environment. However, working in teams does not override your personal accountability for the care that you provide.3 Doctors are responsible for any prescriptions that they sign. The GMC advises that when prescribing, doctors must ensure that prescribing is appropriate, responsible and in the patient’s best interests.4
"A good relationship and communication between district nurses and GPs not only helps the patients, but helps towards good working relationships"
Doctors should be in possession of, or take an adequate history from, the patient. They should ensure that patients agree with the prescription and that they have been given appropriate information, including possible side effects on how to take the medication and if there is any need for monitoring.
The GMC goes on to explain that if a doctor prescribes at the recommendation of a nurse who does not have prescribing rights, then the doctor must be satisfied that the prescription is appropriate for the patient concerned, and that the nurse is competent to have recommended the treatment.
In order to minimise any risks in association with prescribing, you should:
- Consider holding a meeting between the doctors and district nurses to discuss the above issues.
- There may be some situations where you feel it is appropriate to prescribe without reviewing the patients yourselves, and others where you feel the patient should be reviewed by a doctor.
- Develop a protocol for doctors handling requests for prescriptions from district nurses.
- Ensure that the district nurse has given you enough information to be able to make a safe decision.
- Document all discussions that you have in the patients’ medical records. consider encouraging the district nurses to document their assessments in the medical records.
- Arrange for appropriate follow-up and monitoring of the patient.
- If in doubt, visit the patient, as you must be prepared to justify any decision that you make.
Q. The matron at the local nursing home insists that I write in the nursing home notes when I do my weekly visit. Is it acceptable to use these notes as a clinical record?
"Doctors should document all consultations with nursing home patients as soon as they return to the practice"
Dr Rachel Birch: While there is no contractual obligation to write in nursing home records, there may be situations where it is helpful to do so, for example, if the nurse responsible for the patient is not available when you make your assessment and you want to ensure that all relevant information and instructions are handed over.
Remember:
- Writing in the nursing home notes is not a substitute for verbal handover with nursing home staff, which should still take place.
- Doctors should document all consultations with nursing home patients as soon as they return to the practice. This should include which nurse was present and what instructions were given.
- Prescriptions should also be updated on the GP computer system. Not only is this important if another GP subsequently goes to review the patient, but it will serve as a useful “double check” that there are no drug interactions with the patient’s other medication.
These questions were real queries taken on the MPS medicolegal advice line and in the context of a Clinical Risk Self Assessment (CRSA).
References
- British Geriatric Society, Intermediate care: Guidance for commissioners and providers of Health and Social Care, Best Practice Guide (2008)
- GMC, Good Medical Practice, par 6 (2006)
- GMC, Good Medical Practice, par 41 (2006)
- GMC, Good Practice in Prescribing Medicines, par 5-7 (2008)
Please note: Medical Protection does not maintain this article and therefore the advice given may be incorrect or out of date, and may not constitute a definitive or complete statement of the legal, regulatory and/or clinical environment. MPS accepts no responsibility for the accuracy or completeness of the advice given, in particular where the legal, regulatory and/or clinical environment has changed. Articles are not intended to constitute advice in any specific situation, and if you are a member you should contact Medical Protection for tailored advice. All implied warranties and conditions are excluded, to the maximum extent permitted by law.
