Transitions of care is a phrase that propels chills through the spines of all primary care practitioners. While inpatient care is typically exemplary, there is something deeply dysfunctional at the core of our ability to interact with the hospital system. I am not excluding any primary care practitioner from this. I recently spoke to a GP of long–standing who told me, since he gave up ringing the local hospital, his stress levels have come down enormously. If we take the problem at its simplest, it falls around the discharge prescription. Sometimes this is merely a discharge note or, in the worst case scenario, no paperwork at all. I have stated previously, in this column, that my rule of thumb is simple: If there are more than two items on a hospital discharge prescription there are probably more than two queries, some that are potentially outright mistakes. Now, in the spirit of evidence-based revisionism, I can see that the obvious errors have dropped in volume, but the complex situations seem to be escalating.  

Let me give a simple example. I recently had a patient discharged with a ten-item prescription. Most were routine, in that they had been on them on admission, but a few were new. One, apixaban, was only commenced on discharge — not that I could tell this from the discharge paperwork, only upon questioning the prescriber, an intern. The patient had been diagnosed with atrial fibrillation on admission and had been commenced on parenteral anticoagulants. Now, this patient happens to be on a relatively uncommon drug, ibrutinib. Look at the SPC for this drug and you will see that there is a high incidence of afib associated with this medicine. According to Stockley’s drug interaction bible, we are told that there is a potential for a severe interaction between ibrutinib and apixaban, with two case reports of haemorrhagic cardiac effusion. 

We all know that drug interactions, while having a large body of both theoretical and practical evidence surrounding them, are still in the realm of statistics. You can be unlucky and experience a severe interaction, or you can sail off into the sunset, taking potentially fatal combinations, without an apparent glitch. The one major obligation we, as pharmacists face, is to act in the best interest of the patient. So, if we see a potentially fatal interaction, we need to be assured that the prescriber is aware. The decision to co-prescribe could have been made in a fully informed manner, where the benefits were deemed to exceed the risks. Mitigation strategies might have been adopted. If this is the case, we need to know. We cannot second guess. 

The glaring hole in discharge process from secondary, or even tertiary care, to primary care is the almost structural inability of primary carers to contact hospital-based prescribers in a timely manner. It is my view that any discharge prescription should have, at a minimum, the contact details of a person that will respond appropriately to any queries that arise on the document. Currently, if I ring my local hospital there is a fair chance that the phone will not be answered on my first or even second attempt. Once I am lucky enough to speak to a receptionist, I then roll the ball on the roulette wheel that is accessing the ward where the patient had resided. Once again, if I am lucky, someone will actually pick up the phone. Then I get into the serious business of communication, where we try to find someone who was actually dealing with the patient. Aside from the sheer frustrating inefficiency of this process, there is frequently the risk of verbal misunderstandings. We are now, relatively shortly, heading into an era of proper electronic prescriptions. The long-awaited electronic health record is taking shape. The summary care record will soon be out in the wild. In an era of digital plenty, we have a communications famine at its core. The inability to resolve legitimate safety questions upon discharge. This is an addressable issue. It could be solved.  

Speaking of IT improvements, it is now the best part of a month since parts of the HSE website took a nosedive, losing whole swathes of professional information. This was particularly relevant for pharmacists, as the current CCS protocols on their site are required to operate the service. Without them, it is a showstopper. While an interim location has been found for these protocols, we are still missing key areas like circulars and antibiotic prescribing guidelines. While there are a few workarounds, it is clear that some major malfunction occurred. It is somewhat of a headscratcher, as there has been little noise about the genesis of this issue. Indeed, in the interests of open disclosure, it would be great if we knew what exactly is, and has been, going on with the HSE website.