Deteriorating patients in the community routinely go unnoticed as information is not shared with community matrons, a study has suggested.
The research project in Ealing, west London, examined communications in primary care and found information on vulnerable patients was not shared between all health professionals - which could lead to delays in deteriorating patients accessing care.
GPs use “special patient notes”, which are posted on the out-of-hours database to alert colleagues to patients whose condition could deteriorate. They are typically made for palliative care patients or those with a long term condition.
In most areas, community matrons do not have access to the database. But six practices in Ealing piloted giving the matrons access.
Researchers found that the pilot practices posted two special patient notes for every 1,000 patients, nearly twice the average across the borough.
Yvonne Leese, associate director of operational services for Ealing and Harrow Community Services, said: “A couple of years ago we noticed that many patients with complex needs were ending up in hospital and that the communication lines between community matrons and GPs were not good enough.
“Now we have a simple formula for all to follow and a shared approach to communication problems which supports joined up working.”
The research, which compared the pilot practices with other practices across the borough, was published by the London Journal of Primary Care last month.
It said: “Many GPs did not even know that community matrons were attached to their practice. Other GPs had lost touch with the patients, becoming less able to fulfil their role when needed.
“Too few patients were known to the out-of-hours services, inhibiting good decisions. Out-of-hours services send information to GPs and not to community matrons, delaying recognition that their client was deteriorating.”
Deterioration in community patients routinely overlooked