"Mind the gap"
Patients, treatment regimes, referrals, prescriptions and health care personnel cross borders – between primary health services and specialized health services, between different levels in the hierarchy, between work shifts, and between departments. Breeches in continuity can result in health care personnel loosing track of the situation. This can have unfortunate consequences for patients, since information can be lost and placement of responsibility can be unclear.
- A newborn baby had a lot of mucus in her airways after birth. The midwife contacted the paediatrician, who gave advice over the telephone that the child’s stomach should be sucked out. An anaesthetist was contacted to carry this out, but he did not manage to get the suction tube properly in place. He reported back to the midwife, but there was no communication between the paediatrician and the anaesthetist about the child’s symptoms. The child’s condition deteriorated, and after 12 hours the child was examined more closely. A constriction in the oesophagus (gullet) with a fistula (a connection) to the trachea (windpipe) was detected, and the child was operated on for the condition.
- A middle-aged patient had his gallbladder removed using keyhole surgery. The operation was uncomplicated, but his recovery progressed slowly. First, it was suspected that he had a haemorrhage (bleeding) in the abdominal wall with subsequent infection. The clinician, who was a locum, did not rcord his suspicions, and he did not report the problems when he finished his locum. The doctor who took over observed the patient’s condition for some days, while the patient’s condition became gradually worse. Later, under a new operation, an infection in the abdominal wall and leakage of bile were detected.
- A 70-year-old patient had been treated for 30 years with lithium for a manic-depressive disorder. She was admitted to a surgical department for a minor operation, but for reasons that were not clear her recovery progressed slowly. She was discharged to a nursing home, but her general condition was weak. She was rather unsteady and forgetful. She was readmitted to hospital four weeks after the operation to check the incision, and was treated with antibiotics, including Flagyl, which potentiates the effect of lithium. All the time, she was taking the normal dose of lithium, even though she had periods when she ate very little. There are no notes in her patient record about her gradually deteriorating general condition. She was readmitted to hospital seven weeks after the operation, with kidney failure due to lithium intoxication, and she died three weeks later.
- A 50-year-old patient was admitted with acute abdominal pain to a medical department in a hospital before a weekend. Gastroscopy indicated a suspected hiatus hernia. An x-ray was ordered, but was not taken until after the weekend. This showed a large hiatus hernia, with half the stomach in the thorax. The patient had pain and nausea the whole time. The radiographs were read by the radiologist the following day, and seen by a student locum, but the doctor responsible for the patient was not aware of the result until five days after admission. The surgical department was contacted, and the surgeon, who was a holiday locum, examined the patient, and referred her for an operation. Because of fluid and salt imbalance, the anaesthetist wished to postpone the operation. The following day, blood tests showed improved values, but the operation was still postponed in order to continue to improve the values. The health care personnel from the four specialities that were involved never had a joint discussion. The next day, the patient’s condition deteriorated and she suffered from respiratory and circulatory failure.
These case histories demonstrate the challenges of teamwork between different departments and staff in an acute situation, and of communication between actors when treatment is provided over a long period of time. They also demonstrate the importance of collecting and coordinating information from different sources, and of reconsidering the first diagnosis.
Gaps in continuity of care present a central challenge in health services. Gaps occur because of the way in which health services are organized, with different levels of responsibility, increasing specialization, and provision of health care at different times and in different places. Gaps can occur when patients are moved from one treatment institution to another, when there are changes in the health care personnel with responsibility for the patient’s treatment, when oral or written information is transferred, when duty shifts change, and when processes are interrupted because of pressure of time.
Health services are often organized as teamwork, but without members from different areas of responsibility. Formal and informal teamwork presents challenges associated with a common understanding of procedures and allocation of responsibility. Health care personnel must be familiar with and agree with procedures and allocation of responsibility. The autonomy of professions or individuals must take second place to meeting common objectives.
Gaps often occur when patients are referred from primary to specialized health services. Therefore it is particularly important that information follows patients when they are referred – referral notes, patient records and case summaries. The discussion about electronic patient records and teamwork clearly demonstrates the importance of effective information systems.
A less stable labour market with increased use of temporary staff and a high turnover of health care personnel demands robust systems that ensure continuity, and that provide an overview of the course of patients’ illness.
Increased specialization and greater mobility of health care personnel make greater demands on management to guard against risky situations. This will involve, for example, initiating measures for identifying areas where there is a risk of deficiencies occurring, for preventing deficiencies, and for detecting deficiencies when they occur in order to limit injury to patients. Health service managers and planners must acknowledge the fact that gaps in continuity of care occur all the time, and they must establish systems to deal with them.
“Gaps in continuity of care present a central challenge in health services.”
“Increased specialization and greater mobility of health care personnel make greater demands on management to guard against risky situations.”