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If coordination fails

The Norwegian healthcare services are organized in primary and secondary service levels. According to PhD student Kristin Laugaland at UiS effective and safe care depends on coordination across the two service levels in which transitions across them represent a crucial stage in the recovery of elderly people.

Laugaland`s PhD project focuses on transitional care and patient safety within elderly health and care services in Norway. Primarily she is concerned with patient safety and how this is maintained in transitions across primary and secondary health and care services. Her PhD project is a collaboration with Frde Hospital and is part of a larger research project at UiS. The research project Quality and safety within elderly health and care services the role of transitions and interactions is led by professor Karina Aase and is funded by the Norwegian Research Council and the Western Norway Regional Health Authority.

The increasing elderly population in Norway makes the interface between primary and secondary healthcare particularly important when it comes to creating a consistent and safe health care delivery. As health and care conditions for elderly represents a growing challenge in society Laugaland awaits how Norwegian authorities will meet, solve and overcome tomorrow's biggest health challenge.

In response to the expected increase in the elderly population the coordination reform Proper treatment at the right place and time will be implemented as of January 2012. A primary goal of the reform is that municipalities to a greater extent shall fulfill the objectives of prevention and early intervention with the result that patients will receive treatment closer to their homes. Consequently, giving primary health and care services increased responsibility of several tasks currently performed in hospitals.

Critical transitions

Poorly executed transitions may lead to poor clinical outcomes, inappropriate use of hospitals, re-hospitalization, dissatisfaction among patients and inadequate follow-up and thus inadequate care states Kristin Laugaland.

- A growing body of evidence suggests that the elderly population is particularly vulnerable to experiencing discontinuity in care with the potential of adverse outcomes due to poorly executed transition. International research indicates that the risk of adverse events and medical errors is significant in the interface between GPs, care givers and hospitals. The severity of the adverse events can vary from laboratory abnormalities to permanent disability and in worst case death says Laugaland.

The major contributing risk factors are inadequate communication and documentation. When communication breaks down patients are at risk due to the fact that vital information such as diagnostic finding, test-results pending and follow-up care is not always shared adequately between physicians and nurses across primary and secondary health and care services.

- According to a Norwegian research study both referral and discharge summaries, i.e. the overall presentation of a patient's medical history, can be deficient to the degree that it might represent a health hazard for older patients, Laugaland says.

Older patients often hold a compound treatment picture characterized by complexity followed by complex medical regimen. Failures in transferring adequate medical information may lead to adverse drug events and medical discrepancies with the potential to cause harm. In addition to the risk of misinterpreting dosages, health care personnel do not always receive information about the time period patients should stay on particular medical treatments.

- Patients who have taken tests like X-ray, digital scans and blood samples, can be discharged with test results pending. Potentially actionable test results may be overlooked if information transfer is insufficient from the inpatient physician to the outpatient physician. Laugaland emphasizes that several of the adverse events occurring within transitional care have been identified and reported in the literature as preventable, which she thinks is alarming.

- People aged 65 and older are especially at high risk for adverse events and medical errors during transitions between service providers. This population has typically complex health problems frequently requiring care in multiple settings. Older patients, many with reduced mental capacity are also most dependent on a health care system that is able to communicate appropriately and transfer information and duties properly. Frail older patient, particularly those with cognitive impairment are completely dependent on health professionals who can attend to their needs, Laugaland emphasizes.

Unclear responsibility

Laugaland believes that poor coordination between primary and secondary health and care services are caused by a lack of holistic thinking and unclear responsibility. Each service provider tends to focus on its own tasks and not on the system as a whole, which is paradoxical given that it is the system the patient actually experiences.

- Limited research displays and highlights the importance of transitions and interactions for safety in Norwegian healthcare. Existing research has primarily been concerned with adverse events and medical error occurring within the hospital. Relatively little data are available to estimate the extent and impact of adverse events occurring across organizational boundaries, Laugaland says.

The PhD student and the rest of the research group at UiS look forward to contribute to important answers concerning transitions of elderly between care settings.


Contact: Kristin Laugaland
University of Stavanger

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