Background CQC recommendations for the trust following a visit, included a trust wide consistent and robust approach to assessment and planning of transitional care and a consistent approach to completion and storage of transition medical records. A ‘live’ transition plan was created in 2018 in the electronic eDMS patient notes. This enabled health professionals to document a summary of transitional discussions addressing key areas and creating a clear timeline, which could then be shared by the transferring team with the receiving adult team. It also ensured that when a young person was under multiple specialities, all involved professionals could rapidly access transitional discussions and plans made.
Objectives To audit the use of the live transition plan against standards based on completion of key information in the live plan and whether the plans were transferred to adult specialities during transition of care.
Methods Retrospective case note review of the eDMS live transition plan updated in the month of July 2021, for young people with chronic long term conditions that required transition of care to adult services.
Results 210 live transition plans were updated between 1st and 31st July 2021. 55% (n=94) of the plans had an identified key worker1 documented. In 21%(n=45) a user error was noted because teams were creating duplicate plans instead of updating the existing transition plan, which meant a clear timeline of discussion would not be available at transfer. All plans had completed an answer to the mental capacity act question but professionals had documented uncertainty over this. Documentation indicated that 10 young people had a life-limiting condition and two included documentation of an advance care plan. There was limited use of the snapshot function to share the transition plan with adult services at transition. 17 of the young people had safeguarding alerts in their electronic notes but only 3 had a safeguarding concern documented in the transition plan. 23 different specialities completed the transition plan and 18 of these were within medicine care group. 80% (n=168) of the entries were completed by specialist nurses, 10% (n=20) by consultants and the rest by other healthcare professionals. 75% (n=158) of the entries had the intended adult team/hospital destination identified.
Conclusions This first review highlighted variability in the completion of the ‘live’ transition plan in patient notes and the need for further education and training promoting use with all members of the multi-disciplinary team. Training to address this is now included in the mandatory trust transition training. This audit also enabled a review of the question on mental capacity act to make it clear and signpost professionals to trust resources. A ‘top tips’ document was created to share key themes and messages with all health professionals in the trust.
National Institute for Health and Care Excellence. (2016). Transition from children’s to adults’ services for young people using health or social care services.
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