Lack of communication across care settings puts elderly patients at
25 October 2011
Effective coordination across primary and secondary care
settings is crucial in the recovery of elderly people, according to the
findings of a PhD project by University of Stavanger student Kristin
Laugaland. The project focused on transitional care and patient safety
within elderly health and care services in Norway.
The project primarily concerned patient safety and how this is
maintained in transitions across primary and secondary care
services. The PhD project is a collaboration with Førde Hospital and
is part of a larger research project at the University.
The increasing elderly population in Norway — and all developed
countries — makes the interface between primary and secondary
healthcare particularly important when it comes to creating
consistent and safe healthcare delivery.
In response to the expected increase in the elderly population
the Norwegian government has a programme of reform called Proper
treatment — at the right place and time, which will be
implemented in January 2012. A primary goal is that municipalities
will focus on prevention and early intervention, with the result
that patients will receive treatment closer to their homes.
Consequently, primary health and care services will have increased
responsibility of several tasks currently performed in hospitals.
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
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 findings,
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, ie 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
In addition to the risk of misinterpreting dosages,
healthcare 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
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 healthcare system that is able to communicate
appropriately and transfer information and duties properly. Frail
older patients, particularly those with cognitive impairment, are
completely dependent on health professionals who can attend to their
needs, Laugaland emphasizes.
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
Limited research 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 setting.
Relatively little data is available to estimate the extent and
impact of adverse events occurring across organizational boundaries,