Transitioning Care Flashcards
what is the discharge portion of this lecture
last 1/3 - this is where the assignment is (this is the most important part)
What is the first and most signifant transition of a patient care?
Hospital admission
Goals and risk of emergency department
transfer of info and clarify who will be taking care of patient
risk: delay of info
What is the principal diagnosis vs problem list
main diagnosis and problems that they have
What info is given to ED
Principal diagnosis
diagnosis list
cognitive status
test results
what additional info may be requested for a transfer of care
level of inpatient care
level of admitting service
timing to obtain critical info
ED boarding (can take time)
If a patient comes from an office, what is this called?
Direct admissions
not typically done (as it is complex)
Direct admissions pros/cons
saves hours
saves overcrowding
sometimes stable in office, but may crash so this can be dangerous
What are some recommendations for direct admissions
stable
admitting diagnose is clear
evaluated the DAY of
What is the clear communication between the PCP and the hospitalist
rationale
diagnosis
labs
Prior to transfer
during transfer
after transfer
problems
Prior to transfer: delay in communication d/t going from a small center to large one. Difficult to find a bed. Inappropriate transfer because they went to the wrong center.
during transfer: decompensation as movement from one facility to the next may not have the correct
after transfer: discontinue the care plan causing delay, unnecessary testing increase bill, no shared EMR
What is the complicated patient
skill nursing facility
very hard patients to treat
Post form
tells the code status - full code, DNR, wishes for IV AB
basically what the patient wants
What is the emergency department
Do patients leave the ED immediately after being admitted?
NO
can lead to a lot of issues
should plan for shift changes with a large admitting team to save time
sometimes PAs are there just to transfer care
Can you held liable for patient care during transfer even if they are not at your facility
YES
Outpatient VS Inpatient status is determined by
CMS and insurance
___ midnight rule
2 midnight rule = if they are expected to be there LESS than 2 midnights that will be outpatient. If AT LEAST 2 midnights then inpatient.
Do we prefer inpatient or outpatient
inpatient for money
if they have an acute on chronic, then what is it likely going to be?
Outpatient
stent placement is also outpatient
What units do patients go to if they don’t need cardiac monitoring?
Med/surge
lower critical patients
What is a telemetry unit
more frequent monitoring every 4 hours
have cardio techs
what is an intermediate care unit
treated like intensive care, but NO critical care MEDS
What is intensive care units?
Broken down based on organ system
may transfer from one unit to another
Who needs telemetry
CC of chest pain
Some1 coming in with cardiac history
Stroke patient that cannot maintain airway
Patients with sepsis criteria
telemetry SHOULDNOT replace frequent observation and assessment of a patient
How often should telemetry patients be reevaluated?
DAILY
What is the handoff process?
Fluid dynamic exchange, discharge.
Subject to distraction and interruptions.
What are types of intrahospital handoffs?
Shift change: transfer of care between one shift to another.
Service change: written documentation, permemant transition that will assume care to another team.
Service transfer: care of one group of clinicians to another care of professionals.
What are the core components of handoffs?
Verbal communication: build shared mental model for patient.
Written communication: typically just the note.
Transfer of professional responsibility
What are the core steps of the handoff process
Pre-handoff
arrival
Dialogue
Post-handoff
What are the two standardized handoffs
IPASS and SBAR
IPASS
Introduction
Patient identification
Assessment
Situation
Safety concerns
SBAR
Situation: what’s going on with the patient?
Background: relevant history
Assessment : what do you think is going on
Recommendation: what are you going to do
Nurse and provider does this
What is hospital discharge
Vulnerable times for patient
Adverse outcomes common (50% have medical error and 20% have adverse event)
goal is to make sure that the discharge is adaptive
readmission is troublesome (hospital administration may single you out)
What are some unsucessful discharge transition?
Premature discharge (patient leaves or providers think they are stable)
Inappropriate discharge setting: do not have resources
Poor social support or low literacy
Specific clinical conditions: CHF (fluid problems) or psych comorbidities
Inadequate handoffs: pending tests
Delayed or unscheduled f/o
Lack of advanced care planning
Failure to ensure comprehension
Medication-related problems
What are key elements of discharge care coordination
Appropriate destination
Proactive f/o appointments
Careful med reconciliation
Engagement of patients and caregivers
Be proactive!
Choosing a discharge destination
Make sure that the needs are met to services
MC is home w/ or w/out caregivers
Home with home health services (preferred)
Inpatient rehab facility
Skilled nursing facility (SNF) for PT or OT
How often does a provider need to see a patient at a skilled nursing facility
only once every 30 days!
For scheduling f/o appointments what is important
Appointments need to be made BEFORE the patient leaves the hospital
Often times patients will be too busy and health care providers can also get sick
When should a patient f/o?
Severity of illness
Comorbidites
When should patients f/o with PCP after discharge?
One week, sometimes two
sometimes 48 hours if really concerned, but not realistic
What should be given after discharge?
RED FLAGS
What is a medication reconciliation and who is in charge of this?
Med list is obtained, compared and clarified
evaluate polypharmacy
screens for high alert drugs and drug/drug interactions
should say meds are added, continued, or changed
Starts with you, but requires multidisciplinary approach!
What is some patient engagement and education?
Teach back method with patient (often done by nurses)
Patients only remember about half of info
Perform small sessions of recap so that they are not overwhelmed
What should discharge include
Reason for hospital
Pertinent results
meds
diet and activity
follow-up appointments
What is the handoff discharge summary
needs to be detailed to make sure PCP knows what happens
needs to be done by 30 days, but on you after 15 days
Components of discharge
Primary 2ndary diagnoses
test results
pending results
recommendations
patient condition
complete list of meds
f/o
identification of
56 yo male with CP, 2 hours ago, substernal area. HTN, HLD. Sitting in bed with clenched fist. Pain
Levines sign = clenched fist
EKG which can show ST elevation
COPD case study is for
our discharge assignment
