TICTOC: Implementing co-designed outpatient discharge guidelines

Aim

The overall aim of the TICTOC project was to reduce cardiology outpatient review (follow-up)  appointments, where clinically appropriate, by implementing co-designed, evidence-based, outpatient discharge guidelines.

Outcomes

A set of cardiology outpatient discharge guidelines for a range of cardiology conditions  was developed by a multidisciplinary cardiology team, including input from local GPs and consumers.

• After implementation of the guidelines, the cardiology outpatient discharge rate increased up to 40% compared to baseline.
• Compared to the pre-intervention  group, the discharge rate increased in absolute terms from 28.6% to 40.2% with nurse-prompting, a difference of 11.6% (p<0.001). In the group without nurse-prompting the difference was 8.6% (p<0.001).
• There was no significant increase in re-referrals, emergency  department presentations or admissions in the nine months following implementation of the discharge guidelines.
• Satisfaction rating of consumers, hospital doctors and GPs were high.

Background

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 clinics setting. At the outset of this project, to our knowledge, there were no established local, statewide, or national discharge criteria, procedures, or guidelines to inform the transfer of care process from outpatient clinics to general practice.

The evidence to support effective and sustainable discharge processes is limited, and implementation research in this area remains underdeveloped. Continuity  of care hinges on effective two-way 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 study. (1) Hospital specialists participating in this study estimated that a substantial  portion (20-60%) of outpatient appointments could be managed in primary care. Furthermore, participating general practitioners 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 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 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. The project received funding from Queensland Health’s Healthcare Improvement Unit (HIU).

The TICTOC project represents an important step  towards system-wide reform of outpatient care, demonstrating that the use of specialist services can be optimised by supporting safe and timely discharge of stable patients from hospital-based cardiology outpatient clinics to primary care, in combination with  structured clinical handover, to safely continue the care as required. TICTOC launched at the Sunshine Coast University Hospital in February 2024 and finished in June 2025. A scientific rigor in combination with a wider systems approach has been applied throughout  the project. Co-design with consumers and clinicians was a central theme. Recommendations for scaling have been included in the project report. A paper has been submitted for publication. (2)

Discussion

The TICTOC project demonstrated that the introduction of co-designed, condition-specific  outpatient discharge guidelines leads to a statistically significant improvement in discharge rates of up to 40% compared to baseline. The process is safe and acceptable to stakeholders and creates outpatient appointment capacity by reducing review appointments.

Patient flow is only as good as the main bottleneck; The ‘backdoor’, or timely transition from outpatient clinics to general practice, is a key process not to be overlooked in outpatient reform as it effectively creates additional appointment availability  as demonstrated by TICTOC. Co-design in the broadest sense of the word helps to embed a systems-approach to outpatient discharge and clinical handover and ensures multidisciplinary clinical expertise and lived experience are considered in process design and  evaluation. 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. TICTOC confirmed that GPs are prepared to continue the care after outpatient discharge.

Most patients who responded to our survey (74%) attended a GP one or more times within 9 months of discharge, which supports the assumption that follow-up care in general practice is utilised by the TICTOC patient cohort. A scientific rigor has been applied
throughout the TICTOC project to be able to provide health services with the best available evidence when making decisions about implementation and scaling of outpatient discharge guidelines & clinical handover recommendations. Based on the TICTOC findings
we recommend wider implementation of discharge guidelines to support optimisation of hospital outpatient efficiency and patient flow back to general practice. 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.

References

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