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The important role nurses play in care transition and reducing readmissions

By Denise Barbera, RN, BSN, MA, chief nursing officer at HealthSouth  /  24 May 2017

In its simplest form, “care transition” is defined as a hospital discharge or movement from one care setting to another. The risk that readmissions pose to patient safety requires that transitional care processes are under constant evaluation.

Nurses are the linchpin in the coordination of patient care, and thus are best equipped to coordinate a successful transition. The bedside nurse, for example, may understand a great deal more about the patient’s needs as they travel through the care continuum than other care team members. And when those needs are communicated effectively, the nurse is given the opportunity to extend to the patient high-value care beyond organizational boundaries.

Nurses create transitional care plans by compiling all the pertinent patient information and creating instructions to be followed. Then they share the plan in detail with all members of the new care team so that the handoff is seamless for both the patient and the new unit or facility.

The most important factor in transition of care is communication during the handoff process.

What to communicate and when

The goal of the handoff is to safely transfer the patient from one care setting to another (or to discharge the patient from the hospital completely) by exchanging the necessary information with, and by effectively transferring the responsibility of care to, either a new care team or the patient’s family.

It’s a lot to put on any nurse’s plate, but by standardizing and implementing an effective and comprehensive transition communication process, nurses can elevate patient safety, avoid adverse events that lead to costly readmissions and decrease patient anxiety during the transfer process.

It’s important to remember that the transfer process doesn’t apply only to moving a patient from an acute setting to the home or a post-acute environment. There are many different handoff scenarios within the same organization, unit and floor that need your close attention.

For example, nurses should be prepared to provide handoff communication:

  • At shift change
  • During a break
  • When patients are transferred within the hospital (e.g., from the ER to ICU, from radiology to the OR, etc.)

It’s extremely important for the purposes of continuity of care that the communication between the nurse and either the new team of clinicians or the family prepares them in such a way that they’re able to anticipate the patient’s needs and make timely decisions.

At a high level, to adequately prepare the new care team, the following should be included in the handoff communication:

  • Patient care instructions
  • Treatment description
  • Medication history
  • Services received
  • Any recent or anticipated changes

More specifically, and especially in the case of transfers to a new care team or facility, an effective care transition communication plan will include:

  • Patient’s name and age
  • Reason for admission
  • Pertinent co-morbidities
  • Code status
  • Current isolation or precautions
  • Elopement risk
  • Lab results—including any pending and/or abnormal findings
  • Relevant diagnostic studies
  • Fall risk assessment
  • Any assessment findings that are appropriate to the patient’s current health

Many times, nurses on the receiving team care for patients for whom they lack pertinent health data. For example, EKG results are often left out of the transition communication between hospitals and subacute rehabilitation facilities. In this case, if a patient has an episode of chest pain, the receiving team could conduct an EKG on their own, but without prior results to compare with, they can’t successfully rule out something dangerous, such as angina. So, they may err on the side of patient safety and send the patient back to the hospital, resulting in a readmission. However, if an EKG result is included in the transition communication, the receiving team can conduct an EKG on their own, compare the results with the EKG performed at the hospital, and determine whether there is an emergent need for a readmission or the issue is something they can safely handle in their own setting.

Pay extra close attention to medication communications

While including all pertinent test results in the handoff communication is extremely important, there’s another area that needs special attention, because it causes more admissions than any other factor: medication.

It’s estimated that 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Communicating medication details is an area that poses the greatest risk for error as well as the greatest opportunity to effect a positive outcome. In fact, over 66% of emergency readmissions for patients over 65 years old are due to adverse medication events.

Breaches in handoff, such as failure to include specific details of the patient’s medication history and future dosage needs, have dire consequences.

However, defective handoffs are also known to cause problems beyond adverse events. Issues such as delays in care, inappropriate treatment, and increased length of stay arise when transition communication is not strategically planned and delivered.

There are many root causes of a defective handoff, but since nurses play the most important role in the transition communication process, you must strategically develop and communicate the transitional care plan—not only by considering what information you believe should be communicated, but by extending a dialogue to the receiving team and understanding what information they feel is necessary to provide the best follow-up care possible.

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KEY RESOURCES: NURSES AND CARE TEAM COLLABORATION
Nurses are vital to effective care team collaboration. Read on for resources you can use to build your own strategy.

Terry Hayes

Optimize rapid response team efforts with automated, real-time communication

By Terry Hayes, MSN, CPNP, CNOR  /  12 Jan 2017

Agnes Cappabianca worked as a stroke nurse manager at NYU Lutheran Medical Center, a Brooklyn-based teaching hospital. She was in the middle of a shift when the unthinkable happened—she suffered a stroke and found herself admitted to the hospital as a patient in her own ward.

The hospital’s rapid response team (RRT)—one that Agnes had helped train and prepare for these critical situations—sprang into action. Within 30 minutes, the team had final results of her CT scan and blood tests and began to administer tPA treatment.

Her role in advocating advances in stroke care within the hospital seems to have saved her life.

The primary goal of rapid response

The American Heart Association and the American Stoke Association® have warned since 2010 that “the benefits of tPA in patients with acute ischemic stroke are time-dependent.” The associations’ guidelines recommend a door-to-needle time of 60 minutes or less for the treatment to be effective.

In most hospital settings, the process for communicating the needs of a newly admitted stroke patient to care team members is manually intensive. These workflows usually have many steps, numerous decision points and multiple handoffs—creating many opportunities for communication breakdowns and delays in a situation in which every second counts.

One of the primary goals all RRTs strive for should be to reduce the number of steps in the communication process—including the number of decision points, communication handoffs and number of people involved in transmitting the information.

Some hospitals have achieved this goal by implementing a unified communication and collaboration solution that automates many of the steps in the RRT process, such as sending notifications to all team members—including team leadership—at the same time. With just one call, schedules are analyzed and the appropriate care team members are identified and contacted simultaneously—based on their preferred contact method.

This eliminates numerous steps and players from the communication processes and makes significant strides toward improving patient outcomes by speeding time to treatment.

Building an effective rapid response protocol

Pre-planning is required for a communication platform to optimize the capabilities of RRTs. Evidence based guidelines and individual hospital protocols determine the number and composition of responding teams. Some hospitals assign different care team members to different teams depending on urgency levels.

For example, Henry Ford Macomb Hospital in Clinton Township, Michigan, has two RRTs. One is dedicated to Level II traumas and does not include an anesthesiologist in the alert system because Level II trauma patients rarely require advanced airway management. However, the Level I trauma RRT—the team assigned to the most critical cases—does include an anesthesiologist.

Deciding whom to alert depending on the urgency of the situation is a key factor in RRT success.

Another important factor is identifying timelines for each care team member’s arrival at the patient’s bedside. For St. Rita’s Medical Center, a 419-bed hospital in Lima, Ohio, the pre-set arrival time for the rapid response nurse is three minutes; it’s five minutes for their 4A nurse. St. Rita’s also set guidelines for both the physician arrival and ordering of the CT scan at 10 minutes.

An effective communication platform feature that aids RRT outcomes is an automated callback and escalation process. This eliminates critical minutes being wasted on resending notifications and manually escalating the issue to another provider when team members do not arrive on time.

The proof is in the results

St. John Hospital and Medical Center (SJHMC) in Detroit aimed to comply with the guidelines set by The Joint Commission and the American Heart Association/American Stroke Association, all of which call for having CT scans interpreted within 45 minutes of the patient’s arrival and having treatment administered within 60 minutes.

SJHMC implemented PerfectServe Synchrony™ and used the flexibility of the platform to develop its stroke team protocol. The protocol called for alerts to a multidisciplinary team of nurses, physicians and staff from neurology, the ED and neurosurgery, as well. Each team member’s preferred method of contact was configured in PerfectServe Synchrony so that when a stroke alert is sent from the ED, each member (or their on-call counterpart) is contacted via their preferred method.

The ability to contact team members directly on their personal mobile devices, as opposed to using overhead paging systems, eliminates the potential for missed pages.

After the system and process were implemented, SJHMC saw significant improvements in time to treatment for its stroke patients. The on-call neurologists’ response times dropped 90%, from 22 minutes to just 2 minutes.

Graph 1

Their door-to-CT scan completion time decreased 41%, from 78 minutes to 46 minutes.

Reduce communication times

 

 

 

 

 

 

Additionally, SJHMC was able to administer life-saving tPA to three times more stroke patients than they were before.

Making lasting, life-saving process improvements

Most hospitals in the Unites States have some version of an RRT in place for major medical events. Some hospitals have even included local EMS organizations in their rapid alert processes in order to improve speed-to-treatment times.

There’s no question that streamlined and automated communication aids RRTs in their work to lower mortality rates for stroke patients and other traumatic injuries.

Rapid response alerts have proven benefits for clinicians, too. Having a rapid response alert program in place eliminates stress and frustration for the ED staff, which usually has the primary responsibility of initiating treatment to stroke and trauma patients.

In addition to simultaneous instant alerts to appropriate response team members, PerfectServe Synchrony’s rapid response alert system also sends activation notices to hospital leadership. These notices include the time the alert was activated and the time each care team member arrived (as input by the nurses involved). This additional insight into rapid response operations gives healthcare leaders the opportunity to identify problem areas and make lasting process improvements that ultimately save more lives.

 

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When communications work, patients win
In every hospital, communication is at the heart of what care teams do. Physicians need to communicate with one another for consultations; nurses need to reach physicians to update them and receive treatment order. Case managers need to communicate with nurses and physicians to ensure on-time discharges and proper care transitions.

Embracing change: Four steps to an “A-Ha!” moment

By Chris McEachin  /  09 Sep 2015

At Henry Ford Macomb Hospital, we saw an opportunity to improve upon our care delivery by implementing a secure and efficient clinical communications solution to ensure that a message was delivered to the right person at the right time no matter what method was used.

Making these changes required us to get clinicians to embrace the new procedures that would guarantee all messages were delivered and received in the proper manner. The process required more than IT changes, it meant creating a cultural shift among clinicians and employees who were already facing busy schedules and had little time for additional training.

We followed a four step approach to get clinicians on board and embrace the change:

  • Raise awareness – The first step was to work with clinicians to help them understand there was room for communication improvement in our hospital or health system in general. If clinicians could see how previous methods of communication were bogging them down and affecting the overall flow and efficiency, we felt they would be more likely to help implement a change.
  • Calm fears – It can be difficult to mobilize an entire staff that may be used to the “old way” of doing things and are fearful of potentially new issues such as “alert fatigue” or learning a new technology. It was important to get everyone on board and familiar with the new process so the transition would be smooth. We found the best way to accomplish this was to be transparent, keeping everyone informed and educated.
  • Remind them of the benefits – During any implementation, it can be easy to get discouraged. The best way to stay the course is to remind clinicians why they are doing this. The answer is simple: to ensure that people can connect in a timely manner, ultimately improving workflow which improves patient care and healthcare provider satisfaction.
  • Set the standard – As with any new endeavor, the path from implementation to seasoned veteran is comprised of a series of trial and error. Along the way, we realized that we needed to identify which physicians were necessary to be copied on all alerts and who should be the point person for coordinating these messages, among other things. What once was a foreign concept is now the standardized process that is well-ingrained in our community.

Change does require time, but education and transparency during transition times will help the process go smoothly. Hospitals and health systems today need to embrace the new frontier of healthcare through organized and secure communication methods, where patient care and physician satisfaction will always remain the heart of these organizations.

In the comments below, tell us how you’re embracing change.

The What and Why of Physician Engagement

By Kenneth H. Cohn, MD, MBA, FACS  /  02 Feb 2015

As Mark Dixon pointed out in The Changing Role of the Physician, the healthcare industry continues to undergo transformation that will improve outcomes of not just one patient, but that of the entire population. This transformation will require physicians to step up and lead their peers through these critical changes. Physicians influence every step of the care process. However, physicians’ background, outlook, and training are different from hospital leaders, creating challenges in how to respond rapidly to marketplace and regulatory change.

A seat at the table
Why is physician engagement so critical for a successful patient care experience in hospitals today? A physician from upstate New York said, “When we are not invited to sit at the table, we feel like we are on the menu.”

When physicians feel a lack of engagement, it manifests itself in ways ranging from burnout to leaving their jobs. Physician employment alone does not yield engagement. The same skills of communication and collaboration are needed regardless of the percentage of employed physicians (Perry MR. A Local Solution for Hospital-Physician Relationships. Frontiers of Health Services Management 24(1):31, 2007).

What is engagement?
There are two definitions of engagement. One meaning involves a promise, as in engaged to marry. The other involves conflict, as in engaging the enemy. Perhaps it’s this dual definition that makes healthcare organizations struggle to understand how to get physicians engaged. According to Tom Atchison in Leading Healthcare Cultures: How Human Capital Drives Financial Performance, physician engagement is an intangible process that depends on the degree to which doctors are proud, loyal, and committed to a hospital’s mission, vision, and values. It differs from alignment, which is a tangible, time-delimited state reflecting compensation and contractual mandates.

Easier to pronounce than to achieve
Physician engagement is challenging because physicians and hospital administrators have different backgrounds and outlooks on how to deliver care. Physicians are trained to think in hours or days, whereas administrators’ time horizon may extend for years. Physicians and administrators also may differ in their perception of teamwork. As Joe Bujak wrote in Inside the Physician Mind: Finding Common Ground with Doctors, physicians view themselves as members of an expert culture who conceive of teams in terms of individual performance, like members of a golf team who compete in their own matches. However, administrators tend to see themselves as part of an interdependent affiliated culture, like members of a volleyball team, who dig, set, and spike to win points.

Dr. Cohn is CEO of Healthcare Collaboration that works with disgruntled doctors and hospital leaders to improve clinical and financial performance. He has mentored physicians since 1998, finding that physicians enjoy learning from fellow physicians. His recent novel, Dead at His Desk, explores the conflicts between physicians and hospital administrators using the framework of a mystery thriller. His webinar, Physician Engagement: A Case-Based Approach, will take place Tuesday, February 10, 2015 at 1:00 PMEST.

Welcoming 2015 with a Look Back at 2014

By The Connected Clinician  /  05 Jan 2015

Over the past year, our expert authors from varying corners of the healthcare industry have discussed the issues that are top-of-mind for today’s healthcare organizations. They’ve also provided a forward look at where the industry is headed, and what we can do now to improve the way we care for patients. Take a look at some of our top posts from 2014 and consider where your own priorities align for the year ahead: