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Deterioration in community patients routinely overlooked

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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.”

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Readers' comments (1)

  • The infrastructure in primary care has not really developed at the pace that the early discharge following an acute admission of patients with chronic diseases has. The drive for shorter hospital stays is good but only if PCT are robust and efficient enough to do effective intermeadiate care and monitoring to avoid a relapse. My mother with severe COPD for example, had the signs of deteriation increase SOB and sputum production however the earliest urgent appoinment she could get was 4 days later, she has now been unwell for 6 weeks and on her 3rd course of antibiotics. I wanted to take her to NHS drop in centre or A/E which is what the receptioist also said but she said that her GP knows her best and insisted on waiting because he is paid to look after her and may lose his job if she dosent use him!!!

    GP may be better developing as a well person only service as they are often not available if you are really ill

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