Quality statement 6 – Transitions of care and clinical communication

A patient with known or suspected sepsis has a documented clinical handover at transitions of care. This includes the provisional sepsis diagnosis, comorbidities, and the management plan for medicines and medical conditions. This information is provided to the patient, their family and carer as appropriate.

Purpose

To ensure an accurate record of care and that the patient’s individualised management plan is accessible to all clinicians, and patients and carers, so that care is coordinated.

For patients

If you or a family member are diagnosed with sepsis, many doctors, nurses and other clinicians might need to provide you with care for a long time. It is important that the clinicians involved in your care share information with each other about your condition and treatment. You should be involved in this process, along with any support people you choose, such as a family member or social worker.

This communication should occur when there is a change of shift of those caring for you, when you are moved within one hospital or moved to another hospital, and when you are discharged from hospital. Important information that you should receive includes:

  • Your diagnosis of sepsis and any underlying conditions
  • Concerns or risks that the clinicians may note about your care
  • Your medical history
  • The plan for antimicrobials and other medicines
  • Your care requirements and recovery goals
  • Who to contact if you have concerns about your condition and ongoing treatment; if there is a central person coordinating your care, this should be documented
  • The healthcare team you are receiving care from; this can range from medical specialists to allied health professionals, such as a physiotherapist or dietitian
  • Who the healthcare service should contact, such as a carer, family member or substitute decision-maker, if you cannot make a decision yourself.

This information should be provided in a way that you understand. It should also be easily accessible and culturally safe.

For clinicians

Patients with suspected or probable sepsis should have a clearly documented handover and care plan at all transitions of care to ensure timely and appropriate treatment.

Where the transition involves transfer to a higher level of care for further assessment and treatment of suspected sepsis (such as from primary care or a smaller hospital to a larger hospital), the initial plan may be limited to relevant history, examinations, initial management and reason for transfer. The documentation should identify the patient’s carer where relevant.

If the patient is managed in an acute hospital, they should have a comprehensive care plan that clearly describes all the required components of their care, including their physical and psychosocial needs, their antimicrobial management plan, and any infection prevention and control precautions that are needed. Ensure that this information is provided at clinical handover between shifts to the patient, their carers and family (as appropriate), and the clinicians and therapists who will be involved in their care.

Ensure that all members of the multidisciplinary team who are required for the patient’s care have access to, and contribute appropriately to, documentation about the patient’s care, and that ongoing access to documentation is available.

When a transition involves transfer to a lower level of care or discharge from hospital, ensure that comprehensive communication and documentation are provided alongside the transfer. If transferring the patient from an acute or referring hospital, ensure that the receiving hospital will have the appropriate resources to manage the patient, including access to appropriate antimicrobials, and are aware of any infection prevention and control requirements.

For healthcare services

Ensure that systems and supports are in place for clinicians to develop a comprehensive care plan with patients and that this is used during transitions of care. This documentation includes:

  • The suspected or probable sepsis diagnosis
  • The management plan, including infection control requirements
  • Any underlying or additional diagnoses and medicines
  • The contact details of the care coordinator.

Documentation needs to be accessible to all relevant clinicians and the patient, and should be captured in clinical information systems. Define the roles and responsibilities of clinicians involved in transitions of care, including a responsibility to complete and communicate discharge summaries. Where local clinical information systems allow, upload information into the patient’s My Health Record.

If the patient is transferred from a larger to a smaller hospital, the referring hospital should ensure that the smaller hospital has appropriate resources to manage the patient, including access to appropriate antimicrobials.

Ensure that clinicians maintain accurate and complete healthcare records (including discharge summaries and death certificates), consistent with the NSQHS Communicating for Safety Standard Actions 6.07, 6.08, and 6.11, and Primary and Community Healthcare Standards Action 1.11. Evaluate the effectiveness of the clinical communication process, in line with the NSQHS Communicating for Safety Standard Action 6.02.

Ensure that clinicians communicate infection control precautions to patients and their carers to ensure consistency with the NSQHS Preventing and Controlling Infections Standard Actions 3.07 and 3.09, or the Primary and Community Healthcare Clinical Safety Standard ‘Communicating for safety’ criterion.

For patients

If you or a family member are diagnosed with sepsis, many doctors, nurses and other clinicians might need to provide you with care for a long time. It is important that the clinicians involved in your care share information with each other about your condition and treatment. You should be involved in this process, along with any support people you choose, such as a family member or social worker.

This communication should occur when there is a change of shift of those caring for you, when you are moved within one hospital or moved to another hospital, and when you are discharged from hospital. Important information that you should receive includes:

  • Your diagnosis of sepsis and any underlying conditions
  • Concerns or risks that the clinicians may note about your care
  • Your medical history
  • The plan for antimicrobials and other medicines
  • Your care requirements and recovery goals
  • Who to contact if you have concerns about your condition and ongoing treatment; if there is a central person coordinating your care, this should be documented
  • The healthcare team you are receiving care from; this can range from medical specialists to allied health professionals, such as a physiotherapist or dietitian
  • Who the healthcare service should contact, such as a carer, family member or substitute decision-maker, if you cannot make a decision yourself.

This information should be provided in a way that you understand. It should also be easily accessible and culturally safe.

For clinicians

Patients with suspected or probable sepsis should have a clearly documented handover and care plan at all transitions of care to ensure timely and appropriate treatment.

Where the transition involves transfer to a higher level of care for further assessment and treatment of suspected sepsis (such as from primary care or a smaller hospital to a larger hospital), the initial plan may be limited to relevant history, examinations, initial management and reason for transfer. The documentation should identify the patient’s carer where relevant.

If the patient is managed in an acute hospital, they should have a comprehensive care plan that clearly describes all the required components of their care, including their physical and psychosocial needs, their antimicrobial management plan, and any infection prevention and control precautions that are needed. Ensure that this information is provided at clinical handover between shifts to the patient, their carers and family (as appropriate), and the clinicians and therapists who will be involved in their care.

Ensure that all members of the multidisciplinary team who are required for the patient’s care have access to, and contribute appropriately to, documentation about the patient’s care, and that ongoing access to documentation is available.

When a transition involves transfer to a lower level of care or discharge from hospital, ensure that comprehensive communication and documentation are provided alongside the transfer. If transferring the patient from an acute or referring hospital, ensure that the receiving hospital will have the appropriate resources to manage the patient, including access to appropriate antimicrobials, and are aware of any infection prevention and control requirements.

For healthcare services

Ensure that systems and supports are in place for clinicians to develop a comprehensive care plan with patients and that this is used during transitions of care. This documentation includes:

  • The suspected or probable sepsis diagnosis
  • The management plan, including infection control requirements
  • Any underlying or additional diagnoses and medicines
  • The contact details of the care coordinator.

Documentation needs to be accessible to all relevant clinicians and the patient, and should be captured in clinical information systems. Define the roles and responsibilities of clinicians involved in transitions of care, including a responsibility to complete and communicate discharge summaries. Where local clinical information systems allow, upload information into the patient’s My Health Record.

If the patient is transferred from a larger to a smaller hospital, the referring hospital should ensure that the smaller hospital has appropriate resources to manage the patient, including access to appropriate antimicrobials.

Ensure that clinicians maintain accurate and complete healthcare records (including discharge summaries and death certificates), consistent with the NSQHS Communicating for Safety Standard Actions 6.07, 6.08, and 6.11, and Primary and Community Healthcare Standards Action 1.11. Evaluate the effectiveness of the clinical communication process, in line with the NSQHS Communicating for Safety Standard Action 6.02.

Ensure that clinicians communicate infection control precautions to patients and their carers to ensure consistency with the NSQHS Preventing and Controlling Infections Standard Actions 3.07 and 3.09, or the Primary and Community Healthcare Clinical Safety Standard ‘Communicating for safety’ criterion.

Equity and cultural safety

Resources

Related resources have been identified which are relevant to the quality statements, including:

  • Decision support tools and sepsis pathways and other guidance about sepsis - including state and territory resources
  • Guidelines and tools for recognising and responding to acute deterioration, including patient escalation pathways for each state and territory
  • Resources to support management of antimicrobial therapy
  • Education and information for patients and carers during hospitalisation for sepsis, on discharge and through survivorship.

A range of implementation resources have also been developed by the Commission including guidance, factsheets and tools for healthcare services and clinicians, and resources for consumers.