Improving Communication at Transition from NH to ED

1
Improving Communication at Transition from NH
to ED

• Suzanne Gillespie, MD RD
• Division of Geriatrics/Aging
• March 6, 2009
• 2008 AMDA Foundation/Pfizer Quality Improvement
  Award
• One Year Update

2
Background

• University of Rochester Div of Geriatrics
• Primary care for gt 3,000 LTC residents
• 34 NH and ALF facilities
• Monroe Community Hospital (MCH)
• 566-bed county-owned NH with an academic medical
  staff
• Frequently send and receive patients to/from a
  variety of other medical settings in the region.
• Routine
• Emergently

3
Transitions of Care from NH

• Frequently involve multiple people
• Patient, Families, Nurses, SW, EMS, Doctors.
• LTC ( EM providers) expressing frustrations
  about care communication on a daily basis.
• Grant Award
• opportunity to translate frustrations into QI

4
LTC Quality Council

• Focused on improving transitional care between
  organizations
• Bi-Monthly Meetings
• Representatives
• Medical Center, NH/ALF, home care
• Emergency Medicine Geriatric Medicine
• Nursing, social work, physicians
• Quality Management Leaders

5
NH to ED Transitions Perceptions

• ED and LTC teams expressed different perceptions
  of transitions of care
• doing a great job issues on a daily basis
• incomplete inaccurate disorganized
  variable
• Variability in what each of the homes provided
• Variability in how providers define good
  communication
• Neither sending nor receiving caregivers know
  what to expect when a resident is transferred to
  the ED.

6
Survey of ED and LTC Providers

• Respondents, n155
• Physicians (23 n36)
• NPs/PAs (14 n21)
• Nursing (63 n98)
• Comparable LTC and ED respondents
• Experience in their field
• 41 reported gt11 yr
• Response rate 32

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Impressions of Nursing Home Care Transitions
Percent who agree/disagree with the following
statements
Strongly Disagree
Somewhat agree
Strongly agree
Neutral
Somewhat disagree
Important information is lost during transitions
of care between NHs EDs
There is good communication between EDs NHs in
this community
8
how often you believe the following occurs when a
NH resident is transferred TO the ED for
care?(1NEVER, 7ALWAYS)plt.01
ALWAYS
NEVER

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how often you believe the following occurs when a
NH resident is transferred TO the ED for
care?(1NEVER, 7ALWAYS)
always
never
10

• How often you believe the following should
  occur, when a NH resident is transferred FROM the
  NH TO the ED,

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a verbal communication at my position/level
should occur (doctor/NP/PA)
12
a verbal communication at my position/level
should occur (nursing)
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Transfer Form

• Focus group
• Feedback
• Survey input
• Pilot
• Revisions

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PRIMARY INFORMATION PRIMARY INFORMATION PRIMARY INFORMATION PRIMARY INFORMATION PRIMARY INFORMATION PRIMARY INFORMATION PRIMARY INFORMATION PRIMARY INFORMATION PRIMARY INFORMATION PRIMARY INFORMATION PRIMARY INFORMATION PRIMARY INFORMATION
Extended Care Facility Monroe Community Hospital Extended Care Facility Monroe Community Hospital Extended Care Facility Monroe Community Hospital Extended Care Facility Monroe Community Hospital Extended Care Facility Monroe Community Hospital Extended Care Facility Monroe Community Hospital Extended Care Facility Monroe Community Hospital Extended Care Facility Monroe Community Hospital Extended Care Facility Monroe Community Hospital Extended Care Facility Monroe Community Hospital Phone(585) 760 - 6500 Phone(585) 760 - 6500
Code Status Code Status FULL DNR DNR MOLST (Include a copy) MOLST (Include a copy) MOLST (Include a copy) MOLST (Include a copy) MOLST (Include a copy) MOLST (Include a copy) MOLST (Include a copy)
Transferred to Transferred to Transferred to
Allergies Allergies Allergies Allergies Allergies Allergies Allergies Allergies Allergies Allergies Allergies Allergies
Precautions Precautions NONE VRE VRE C-difficile C-difficile Respiratory (type) Respiratory (type) Respiratory (type) Respiratory (type) Respiratory (type)
Precautions Precautions ORSA Fall Fall Seizure Seizure Wanders Wanders Wanders Wanders Wanders
Reason for Transfer Reason for Transfer Altered mental status (describe) Altered mental status (describe) Altered mental status (describe) Altered mental status (describe) Altered mental status (describe) Altered mental status (describe) Altered mental status (describe) Altered mental status (describe) Altered mental status (describe) Altered mental status (describe)
Reason for Transfer Reason for Transfer Acute neuro change (describe) Acute neuro change (describe) Acute neuro change (describe) Acute neuro change (describe) Acute neuro change (describe) Acute neuro change (describe) Acute neuro change (describe) Acute neuro change (describe) Acute neuro change (describe) Acute neuro change (describe)
Reason for Transfer Reason for Transfer Fever Fever Fever Fever Fever Shortness of Breath Shortness of Breath Shortness of Breath Shortness of Breath Shortness of Breath
Reason for Transfer Reason for Transfer Chest Pain Chest Pain Chest Pain Chest Pain Chest Pain Abdominal Pain Abdominal Pain Abdominal Pain Abdominal Pain Abdominal Pain
Reason for Transfer Reason for Transfer Fall Fall Fall Fall Fall Injury-Site (describe) Injury-Site (describe) Injury-Site (describe) Injury-Site (describe) Injury-Site (describe)
Reason for Transfer Reason for Transfer Weakness Weakness Weakness Weakness Weakness Blood sugar abnormality Blood sugar abnormality Blood sugar abnormality Blood sugar abnormality Blood sugar abnormality
Reason for Transfer Reason for Transfer Other / further comments Other / further comments Other / further comments Other / further comments Other / further comments Other / further comments Other / further comments Other / further comments Other / further comments Other / further comments
Usual Mental Status Usual Mental Status Alert, Oriented x Alert, Oriented x Alert, Oriented x Alert, Oriented x Alert, Oriented x Confused Confused Verbal Non-verbal Verbal Non-verbal Verbal Non-verbal
Vital Signs Vital Signs Temp Temp HR HR RR BP BP O2 sat On lpm O2 sat On lpm Last Weight
Provider to Contact Provider to Contact Provider to Contact Provider to Contact Provider to Contact Provider to Contact Provider to Contact Name Pager Name Pager Name Pager Name Pager Name Pager
Nurse to Contact Nurse to Contact Nurse to Contact Nurse to Contact Nurse to Contact Nurse to Contact Nurse to Contact Name Number 760 - _ _ _ _ Name Number 760 - _ _ _ _ Name Number 760 - _ _ _ _ Name Number 760 - _ _ _ _ Name Number 760 - _ _ _ _
Medication changes in last 14 days Medication changes in last 14 days Medication changes in last 14 days Medication changes in last 14 days Medication changes in last 14 days Medication changes in last 14 days Medication changes in last 14 days Medication changes in last 14 days Medication changes in last 14 days Medication changes in last 14 days Medication changes in last 14 days Medication changes in last 14 days
Lab studies done in last 72 hours? Lab studies done in last 72 hours? Lab studies done in last 72 hours? Lab studies done in last 72 hours? Lab studies done in last 72 hours? Lab studies done in last 72 hours? Lab studies done in last 72 hours? Lab studies done in last 72 hours? Yes No Unknown Yes No Unknown Yes No Unknown Yes No Unknown
Skin Integrity Intact Woundslocation type Intact Woundslocation type Intact Woundslocation type Intact Woundslocation type Intact Woundslocation type Intact Woundslocation type Intact Woundslocation type Intact Woundslocation type Intact Woundslocation type Intact Woundslocation type Intact Woundslocation type
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SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION SECONDARY INFORMATION
Advanced Care Plans (Send Copies) Advanced Care Plans (Send Copies) MOLST DNR MOLST DNR MOLST DNR MOLST DNR MOLST DNR MOLST DNR MOLST DNR HCP POA HCP POA HCP POA HCP POA HCP POA HCP POA Living Will Guardianship Living Will Guardianship Living Will Guardianship Living Will Guardianship
Language English English Other Other Other Other Other Other Other Other Other Other Other Other Other Other Other Other
Patient Adaptive Equipment Dentures Glasses Hearing aid Dentures Glasses Hearing aid Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Feeding tube-type ____________ Ostomy-type ________________ Tracheostomy-type ___________ Other Other
Usual Respiratory Care None Oxygen ___ lpm ATC HS None Oxygen ___ lpm ATC HS None Oxygen ___ lpm ATC HS None Oxygen ___ lpm ATC HS None Oxygen ___ lpm ATC HS BiPap Setting CPAP Setting Vent Setting BiPap Setting CPAP Setting Vent Setting BiPap Setting CPAP Setting Vent Setting BiPap Setting CPAP Setting Vent Setting BiPap Setting CPAP Setting Vent Setting BiPap Setting CPAP Setting Vent Setting BiPap Setting CPAP Setting Vent Setting BiPap Setting CPAP Setting Vent Setting BiPap Setting CPAP Setting Vent Setting BiPap Setting CPAP Setting Vent Setting BiPap Setting CPAP Setting Vent Setting BiPap Setting CPAP Setting Vent Setting BiPap Setting CPAP Setting Vent Setting
Transfers Independent Independent Independent 1 assist 1 assist 1 assist 1 assist 1 assist 1 assist 2 assist 2 assist 2 assist 2 assist Lift Lift Lift Lift Lift
Mobility Independent Independent Independent 1 assist 1 assist 1 assist 1 assist 1 assist 1 assist 2 assist 2 assist 2 assist 2 assist Non-ambulatory Non-ambulatory Non-ambulatory Non-ambulatory Bedfast
Mobility Equipment Cane Wheel Chair Cane Wheel Chair Cane Wheel Chair Walkertype Walkertype Walkertype Walkertype Walkertype Walkertype Walkertype Walkertype Walkertype Walkertype Walkertype Walkertype Walkertype Walkertype Walkertype
Sent with Patient Dentures Upper Lower Dentures Upper Lower Dentures Upper Lower Dentures Upper Lower Dentures Upper Lower Dentures Upper Lower Dentures Upper Lower Glasses Hearing Aide Glasses Hearing Aide Glasses Hearing Aide Glasses Hearing Aide Other Other Other Other Other Other Other
Patient Diet Patient Diet Patient Diet Patient Diet Patient Diet Patient Diet Patient Diet Patient Diet Patient Diet Patient Diet Patient Diet Patient Diet Patient Diet Patient Diet Patient Diet Patient Diet Patient Diet Patient Diet Patient Diet
Resident Eats Independently Independently Independently Independently with set-up with set-up with set-up with set-up with set-up with set-up with set-up with set-up total assist/fed total assist/fed total assist/fed total assist/fed total assist/fed total assist/fed
Resident Drinks Regular Thin Liquids Regular Thin Liquids Regular Thin Liquids Regular Thin Liquids Modified Liquids Consistency Nectar, Honey, Pudding Modified Liquids Consistency Nectar, Honey, Pudding Modified Liquids Consistency Nectar, Honey, Pudding Modified Liquids Consistency Nectar, Honey, Pudding Modified Liquids Consistency Nectar, Honey, Pudding Modified Liquids Consistency Nectar, Honey, Pudding Modified Liquids Consistency Nectar, Honey, Pudding Modified Liquids Consistency Nectar, Honey, Pudding Modified Liquids Consistency Nectar, Honey, Pudding Modified Liquids Consistency Nectar, Honey, Pudding Modified Liquids Consistency Nectar, Honey, Pudding Modified Liquids Consistency Nectar, Honey, Pudding Modified Liquids Consistency Nectar, Honey, Pudding Modified Liquids Consistency Nectar, Honey, Pudding
Smoking Status Current Former Unknown Current Former Unknown Current Former Unknown Current Former Unknown Current Former Unknown Current Former Unknown Current Former Unknown Current Former Unknown Current Former Unknown Current Former Unknown Current Former Unknown Current Former Unknown Current Former Unknown Current Former Unknown Current Former Unknown Current Former Unknown Current Former Unknown Current Former Unknown
Type of Residence SNF Rehabilitation SNF Long-term care SNF Rehabilitation SNF Long-term care SNF Rehabilitation SNF Long-term care SNF Rehabilitation SNF Long-term care SNF Rehabilitation SNF Long-term care SNF Rehabilitation SNF Long-term care Assisted Living Home with Home Care Hospice House Assisted Living Home with Home Care Hospice House Assisted Living Home with Home Care Hospice House Assisted Living Home with Home Care Hospice House Assisted Living Home with Home Care Hospice House Assisted Living Home with Home Care Hospice House Assisted Living Home with Home Care Hospice House Assisted Living Home with Home Care Hospice House Assisted Living Home with Home Care Hospice House Other (describe) Other (describe) Other (describe)
Dialysis (if applicable) Schedule (days/time) Schedule (days/time) Schedule (days/time) Schedule (days/time) Schedule (days/time) Schedule (days/time) Schedule (days/time) Schedule (days/time) Schedule (days/time) Schedule (days/time) Schedule (days/time) Schedule (days/time) Schedule (days/time) Schedule (days/time) Schedule (days/time) Schedule (days/time) Schedule (days/time) Schedule (days/time)
Dialysis (if applicable) Center Center Center Center Center Center Center Center Center Center Access Access Access Access Access Access Access Access
Immunizations Influenza Yes No Date Influenza Yes No Date Influenza Yes No Date Influenza Yes No Date Influenza Yes No Date Influenza Yes No Date Influenza Yes No Date Influenza Yes No Date Influenza Yes No Date Influenza Yes No Date Pneumovax Yes No Date Pneumovax Yes No Date Pneumovax Yes No Date Pneumovax Yes No Date Pneumovax Yes No Date Pneumovax Yes No Date Pneumovax Yes No Date Pneumovax Yes No Date

COPIES TO SEND WITH RESIDENT

Facility Face Sheet If available MOLST
Last History Physical Health Care Proxy
Acute visits prompting transfer Living Will
Last routine provider 30/60-d note POA
Last 3 days of progress notes Guardianship
Medical administration record Last EKG
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Pilot

• 45 residents transitions audited
• 17 (38) nothing- no information
• 16 (36) used an old form
• 12 (27) new form
• 100 code status
• 100 reason sent often with extra detail
• 100 usual mental state
• 50 contact information

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Pilot

• Challenges
• Change
• Xeroxing
• Option to use something else
• Revisions
• Hospitalists call.
• Acute Quality Measures
• (Smoking, Vaccination, Wound status)
• Streamline data included
• Process
• Re-engage staff
• Units pre-customize data
• Re-assessment

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Reflections

• The improvement
• is not just the form.it is the process
• Most valuable aspect of this QI initiative
• Introduction of joint accountability for
  transitions
• Establishing a feedback mechanism

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Next Steps

• Reassess after revisions
• Implement at other local facilities
• Regional standard
• Define the role of verbal communication
• Improvements in Ed to NH transitions

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