Background: The demand for community palliative care is increasing, with greater preference to stay at home. Effective communication between inpatient consult palliative care and community palliative care teams is vital to ensure effective transitions of care. Diversity, inconsistency and accessibility of information documented by the inpatient consult team at each consultation can negatively impact the quality of care provided in the community on discharge. The aim of this quality improvement (QI) project was to improve documentation for the consult team to improve care transitions to the community.

Method: This QI was conducted within a metropolitan hospital in NSW Australia as part of the Sydney Partnership for Health, Education, Research & Enterprise Palliative Care Clinical Academic Group collaborative with Stanford Medicine (USA). QI methodology was adapted from the Realizing Improvement through Team Empowerment (RITE) and Clinical Excellence Leadership Training (CELT).  The A3 problem solving process guided the multidisciplinary interventions to increase documentation using the ISBAR principles in the initial and final consult of the inpatient palliative care team.  Patient electronic medical records (eMR) were retrospectively reviewed for content and identification of the ISBAR principles from April – November 2022, to identify gaps in the content, develop a specific audit tool and deliver education material.

Results: The percentage of patients who had documentation following the ISBAR principles across the initial and final consultation entry in eMR increased from 50% prior to the QI project to 80% at project completion.  

Conclusion: The project demonstrated the potential to instigate impactful and meaningful change within healthcare in a short period of time, with limited resources through simple and low-cost interventions. It achieved Palliative Care specific content within documentation and standardisation of location for timely access to written communication when there is transfer of care from inpatient to community to ensure ongoing person centred and safe care.