Optimising outpatient flow: Implementing discharge guidelines and GP clinical handover criteria

Dr Edwin Kruys, GPLO, Sunshine Coast Health and Co-chair QGPL Network

Introduction

The TICTOC project (The Introduction of Criteria for Transfer of Care), led by the Sunshine Coast GP Liaison Unit in partnership with the Cardiology Department and the Sunshine Coast Health Institute, evaluated the impact of co-designed, evidence-based cardiology outpatient discharge guidelines on discharge rates, re-referrals, emergency department presentations and hospital admissions.

The project also assessed consumer, Senior Medical Officer (SMO), and General Practitioner (GP) satisfaction with the discharge guidelines. Using an implementation research methodology, the project identified key enablers and barriers to implementation and developed recommendations to support the scale-up and adaptation of the model across other hospitals and clinical specialties.

The challenge

Timely outpatient discharge, when appropriate and safe, plays an important role in optimising hospital outpatient service utilisation, streamlining patient flow, creating appointment availability for new and review patients, and facilitating continuity of care in the community.

Although there is acknowledgement of the significance of establishing robust guidelines and protocols for the discharge process, this has not been implemented widely in the outpatient clinic setting.

Continuity of care hinges on effective communication between GPs and hospital clinicians, ensuring seamless transitions for patients from referral to discharge. This requires comprehensive clinical handover of patient information, including management recommendations, to enable high-quality care across healthcare settings.

The outpatient discharge process is intricate and influenced by various factors, as demonstrated in our previous study¹. Hospital specialists participating in this study estimated that a substantial portion (20-60%) of outpatient appointments could be managed in primary care. Furthermore, participating GPs expressed readiness to continue patient care in the community if provided with clear management plans. These findings are consistent with international literature.

Previous initiatives—such as the Sunshine Coast Cardiology Collaborative Care Criteria and the pilot for the statewide Continuity of Care Criteria (COCC) for ear, nose and throat (ENT) and orthopaedics in Queensland—offered important lessons and highlighted both the potential benefits and the challenges associated with introducing structured discharge criteria within outpatient services.

Building on these experiences, the TICTOC project was developed to address this gap. With the support of a dedicated implementation and research team, the project aimed to develop and embed co-designed, condition-specific discharge criteria and structured clinical handover recommendations to general practice within the cardiology outpatient clinic at the Sunshine Coast University Hospital (SCUH).

Central to TICTOC’s approach was the active involvement of key stakeholders—including cardiologists, cardiology trainees, nurses, general practitioners, other health professionals and consumers—to ensure the process was co-designed from the outset, clinically relevant, and acceptable to all stakeholders. All parties were also involved in the evaluation.

TICTOC launched at SCUH in February 2024 and finished in June 2025. A scientific rigour in combination with a wider systems approach has been applied throughout the project. Co-design with consumers and clinicians was a central theme. The project received funding from Queensland Health’s Healthcare Improvement Unit (HIU).

The project findings have been summarised in the project report (published in October 2025), including recommendations for scaling, and a paper has been submitted for publication².

The approach

The TICTOC evaluation utilised a mixed-methods approach, with data analysis of clinical records and hospital outpatient administrative (discharge) data as well as SMO, GP and patient experience surveys and interviews. Discharged patients were invited to provide feedback 1 and 6 months after discharge.

A pre-post interventional study design was used to measure the impact of the guidelines on the average discharge rate over a period of 6 months, with and without ‘readiness-for-discharge’ nurse-prompting of doctors.

Condition-specific discharge guidelines and clinical handover recommendations were developed via a co-design process and implemented in a cardiology outpatient clinic. For the first 3 months, a cardiology nurse assisted with prompting doctors with regards to readiness for discharge in line with the agreed guidelines.

A consumer and GP focus group provided valuable input in the project design. A secure, bidirectional electronic messaging system (GP Smart Referrals Request for Advice) was established to enable GPs to seek clinical guidance following patient discharge, as needed.

Next steps

Based on TICTOC project findings we recommend wider implementation (including in other specialties) of discharge guidelines and clinical handover recommendations to support optimisation of hospital outpatient efficiency and patient flow back to general practice.

We argue that a shift in thinking is required about the outpatient clinic model, away from long-term care and towards more episodic care provision, supported by effective clinical handover (noting that there are of course patient cohorts requiring ongoing hospital specialist input). Condition-specific discharge guidelines add value to new-to-review ratios and are more patient-centred than generic discharge checklists.

We hope the outcomes, learnings and recommendations provide inspiration and assist with improving the patient’s journey through the different parts of our health system.

Sources  

1. Kruys E, Wu C-JJ. Hospital doctors’ and general practitioners’ perspectives of outpatient discharge processes in Australia: an interpretive approach. BMC Health Serv Res. 2023;23(1):1225. https://doi.org/10.1186/s12913-023-10221-3
2. Kruys E, Halpin N, Jones R, Tung M, Cox S, Bowles J, Roydon Smoll N, Carberry A, Greaves K. Implementation of co-designed hospital outpatient discharge guidelines: a pilot study in cardiology. Research Square 2026 (pre-publication/under review). https://doi.org/10.21203/rs.3.rs-8101070/v1