Secondary care interface: optimising communication between teams within secondary care to improve the rehabilitation journey for older people

Effective communication between members of the multidisciplinary team is imperative for patient safety. Within the Medicine for the Elderly wards at Royal Victoria Hospital (RVH) in Dundee, we identified an inefficient process of information-sharing between the orthopaedics outpatient department (OPD) at the main teaching hospital and our hospital's rehabilitation teams, and sought to improve this by introducing several changes to the work system. Our aim was for all patients who attended the OPD clinic to have a plan communicated to the RVH team within 24 hours.Before our intervention, clinic letters containing important instructions for ongoing rehabilitation were dictated by the OPD team, transcribed and uploaded to an electronic system before the RVH team could access them. We analysed clinic attendances over a 4-week period and found that it took 15 days on average for letters to be shared with the RVH teams. We worked with both teams to develop a clinical communication tool and new processes, aiming to expedite the sharing of key information. Patients attended the OPD with this form, the clinician completed it at the time of their appointment and the form returned with the patient to RVH on the same day.We completed multiple Plan-Do-Study-Act cycles; before our project was curtailed by the COVID-19 pandemic. During our study period, seven patients attended the OPD with a form, with all seven returning to RVH with a completed treatment plan documented by the OPD clinician. This allowed rehabilitation teams to have access to clinic instructions generated by orthopaedic surgeons almost immediately after a patient attended the clinic, essentially eliminating the delay in information-sharing.The introduction of a simple communication tool and processes to ensure reliable transfer of information can expedite information-sharing between secondary care teams and can potentially reduce delays in rehabilitation.