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How faxes improve contact between care settings

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VOL: 98, ISSUE: 10, PAGE NO: 34

Mark Irving, RGN, DipHE, is oesophagogastric clinical nurse specialist;Simon Raimes, MD, FRCS, is consultant surgeon, at the Northern Oesophago-Gastric Cancer Unit, North Cumbria Acute Hospitals NHS Trust, Carlisle

Effective communication between hospital and community is essential when patients receive treatment in both settings. A trial in an oesophagogastric cancer unit evaluated the use of faxes to improve communication with GP practices. These were sent to GPs via a laptop computer and contained information on patients' diagnosis and treatment (Fig 1). An audit of 60 faxes found that 95% were read within 24 hours of being sent, with all GPs indicating that the information was useful.

Effective communication between hospital and community is essential when patients receive treatment in both settings. A trial in an oesophagogastric cancer unit evaluated the use of faxes to improve communication with GP practices. These were sent to GPs via a laptop computer and contained information on patients' diagnosis and treatment (Fig 1). An audit of 60 faxes found that 95% were read within 24 hours of being sent, with all GPs indicating that the information was useful.

This method of communication can ensure that all professionals concerned with a patient's care have up-to-date information, even when they work in different locations.

Upper gastrointestinal cancers are particularly distressing diseases with poor outcomes (Irving, 2002). Most patients move frequently between primary and secondary care settings, and Department of Health (2001) guidance on improving outcomes in this area highlights the importance of effective communication between the two. Closs (1997) also describes the importance of effective communication between hospital and community, particularly as the reduced length of hospital stays means that increasingly dependent patients are being discharged.

Communication is a particularly important issue in the cases of patients with upper gastrointestinal cancers as many have a short life expectancy. There are often sudden changes in their condition and treatment plans frequently need to be changed.

It is now routine practice to fax information from primary to secondary care to speed up referrals. Faxing data from secondary care to primary care, however, is less common, although Booth (1996) demonstrated clear benefits from doing this.

Current practice
Patient discharge

The accepted method of forwarding discharge information to GPs is by handwritten letter, which is posted on the day the patient leaves the ward. This is followed later by a typed discharge summary.

The system has certain limitations: there is a minimum delay of 24 hours before a GP receives the discharge and it is likely to be several days before the surgery receives a more detailed report. One study (Lefever, 1981) showed that it took an average of six weeks for GPs to receive a written summary of their patients' admission and treatment. Another problem is that handwritten discharge letters are often sparse in detail and can be either illegible or unintelligible.

Outpatient information

Following a consultation in an outpatient clinic, a letter to the patient's GP is usually dictated by the consultant immediately, typed by the secretary and posted. However, letters are typed the following day at the earliest, so there is a minimum delay of 48 hours before GPs are notified of the information or treatment their patients are receiving. In practice, the delay can be significantly longer.

Limitations of current practice
Most patients spend far more time at home than in hospital but continuity of care is essential if their time at home is to be maximised. However, continuity cannot be guaranteed without efficient transfer of information.

In the event of a delay, patients may find that the primary care team has insufficient knowledge to deal appropriately with their symptoms. This can lead to a loss of confidence and make patients reluctant to seek help or advice. It can also undo much of the work done by the hospital and, in some cases, may lead to unnecessary readmission (Bowling and Betts, 1984).

The project
The oesophagogastric cancer team, which consists of a consultant and nurse specialist at the special unit at North Cumbria Acute Hospitals NHS Trust, decided to evaluate the effectiveness and acceptability of information faxed from hospital to community practices. The objectives were:

- To devise a method of faxing information that would minimise the risks of breaching patient confidentiality;

- To audit the effectiveness of reducing delays in communicating information to primary care;

- To audit GP satisfaction of this method of communication.

Although a fax machine was available in the unit, we decided to use a laptop and standard software packages. This had three advantages. First, no additional equipment was required so costs were kept to a minimum. Second, fax numbers of all local practices could be programmed into the computer, eliminating the chance of dialling incorrectly and sending information to the wrong place. Finally, faxes could be sent from the ward or outpatient clinic, wherever a telephone socket was available.

A document template was set up to enable data to be entered quickly and easily. It contained space to include information relating to any significant changes in a patient's condition and to record when new information was given to the patient. It was then a simple matter of transferring the document to the fax software and selecting the correct practice address.

The faxes were produced by either the consultant or nurse specialist and sent by the nurse specialist. A record was kept of the date and time each was sent.

To obtain feedback from the GPs and to audit their satisfaction with this method, a number of questions were added at the bottom of the faxed sheet for them to complete. We requested answers to the following:

- When did you read the fax? (with prompts for date and time);

- Was the information useful?

- Are you happy for us to fax you further information about this patient?

The GPs were asked to fax back the sheet to confirm that they had received it. This allowed us to be certain that the fax had reached its destination and had been read by the GP. The feedback section provided information as to its usefulness. Any practice not returning the fax was contacted to ensure that it had received the patient information.

Results
A total of 60 faxes were sent over a six-month period: 32 (53%) were patient discharges from hospital and the remaining 28 (47%) were information sent from the outpatient clinic. The majority of patients had oesophageal or gastric cancer. All discharged patients had their faxes sent within an hour of leaving the ward and, in some cases, these were even sent before discharge. Faxes from the outpatient clinic were all sent within 30 minutes of the patient leaving the department.

Fifty-five faxes (92%) were returned. None went to the wrong destination. A follow-up of the five (8%) that were not returned found they had all reached the correct destination but had not been completed. The five GPs who had not returned the audited faxes had previously returned others.

Feedback from the 55 faxes that were returned showed that all GPs had found the information useful and that they were happy to use this method to receive further information about their patients. The median time between a fax being sent and a GP reading it (Fig 2) was two hours (range 0-122 hours). Fifty-two (95%) of the returned faxes had been read within 24 hours of dispatch. The fax that was read 122 hours after being sent was faxed to a GP who was on holiday. Another fax that was read more than 24 hours later was sent on a Friday evening but was not seen by the GP until Monday.

Conclusion
Close collaboration between primary and secondary care is essential, particularly with poor prognosis cancers. This requires the use of methods of communication that can ensure a smooth flow of information between hospital and community. Based on our audit, faxing information to the primary care team is an acceptable means of relaying such information. It can also prove an effective addition to the discharge planning process. Using a laptop computer offers portability and the preprogrammed numbers provide a safeguard against incorrect dialling, minimising the risk of breaching patient confidentiality.

Faxing significantly reduces the delay between sending and receiving information. Asking the recipient to fax the sheet back enables accurate audit data to be kept and provides confirmation that it has been received and read.

This method can also be easily extended to sending copies of the fax to other members of the multidisciplinary team involved in a patient's care. This would ensure that everyone involved in a patient's care had up-to-date information on the current state of the illness and treatment enabling them to answer any questions when that patient sought advice.

While this initiative was designed to improve communication between the primary and secondary health settings in the case of patients with oesophageal and gastric cancers, it could be used in any specialty.

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