Transitions of Care Flashcards
What may be the first and most significant care transition a patient will experience in their medical care
Hospital admission
What is the goal of transition of information from the emergency department
Transfer information and clarify who is responsible for patient care
What is the risk of transition of information from the emergency department?
- Delay between information exchange and physical relocation creates opportunity for error and safety issues
What should information from ED to hospitalist include?
- Principal diagnosis and problem list (acute and persistent chronic)
- Medication list (home and current)
- Patient cognitive status
- Test results/pending results (and who is responsible for those pending)
What are reasons additional information or workup may be requested by the accepting physician in a ED transition?
- Determine level of inpatient care
- Determine appropriate admitting service (does it need to be a specialist?)
- Based on timing to obtain critical information
- ED boarding can be a problem (stay in ED when beds aren’t available)
What are benefits of ambulatory office/direct admit?
May save hours of waiting in the ED/help reduce ED overcrowding
But not common :(
What are important components to consider when selecting a patient for direct admit?
- Ensure admission to correct care location and ensure they are not at risk for deterioration prior to admit
- Prolonged wait at admission could lead to decompensation
Selection recommendations for direct admission
- Admitting diagnosis is fairly certain/no additional triage is needed
- Patient is clinically stable- does not require supplemental O2, immediate IV fluids, antibiotics, or urgent imaging
- Has been evaluated on the day of admission by PCP
- Arrives at hospital early in the day (before 4 pm) to facilitate communication between the admitting physician and the hospital team before shift change
Communication between the PCP and hospitalist during a ambulatory office/direct admit should include
- Rationale for admission
- Working diagnosis
- Problem list
- Key history components and recent changes
- Relevant laboratory and radiologic results
- Medication list and allergies
- Patient/family preferences and support system
Risks and benefits of transfer from outlying facility/hospital to hospital
- 3-5% of admissions
- Higher severity of illness/medically complex
- Improved disease-specific transfers ie MI and trauma
- Overall, higher morbidity and mortality that cannot always be accounted for by severity of illness alone
- Benefit should outweigh risk
Risks of interhospital transfer prior to transfer
- Delay in care initiation due to lack of expertise
- Delay in care finding and accepting facility/delayed transport
- Inappropriate transfer
Risks of interhospital transfer during transfer
- Decompensation during transfer
- Arrival at night
- Arrival to inappropriate level of care
Risks of interhospital transfer after transfer
- Discontinuity of care plan
- Unneccessary and/or duplicative testing
- Medication errors
- Back-end discontinuity
- No shared EMR
Common components of skilled nursing facility transfer
- Medically complex
- Frequently unable to provide coherent medical history or describe their medication regimen
- Frequently present with non-specific complaints such as falls, dehydration, or confusion, and without accurate info, will result in more investigations, particularly head CTs
- Less likely to be accompanied by relative or caregiver
- Many (10%) transferred without documentation and additional 40% missing information such as baseline cognitive function, current medications, and advanced directive status
What are patients transferred from a skilled nursing facility at risk for?
- Medication errors
- Unnecessary testing
- Inappropriate/unwanted care
When is transition of responsibility from emergency department?
- May be ambiguous
- Do patients leave the ED immediately after being accepted for admission? (often no may stay in ED)
- Institutions should have a clear plan for transfer of responsibility including shift changes and standardized order sets to be initiated in ED prior to transfer to inpatient unit
When is transfer of responsibility from ambulatory office/outlying hospital/SNF?
- Admitting/transferring provider responsible for patient while they remain at facility and once patient leaves admitting/transferring facility they become responsibility of accepting provider
When admitting a patient what admission status do you choose between?
Inpatient and outpatient
How do you determine whether a patient should be admitted inpatient or outpatient?
- Outpatient if admitting physician expects to stay in hospital less than 2 midnights
- Inpatient if admitting physician expects patient to stay in hospital more than 2 midnights
If it is unclear whether a patient will need to stay 1 or 2 midnights, what admission type would they be?
Outpatient until expectation develops that patient will require second midnight. At that point, inpatient admission order would be written by physician
If a 46 year old male presents for cardiac catheterization due to abnormal stress test and requires stents to the LAD and must stay overnight for observation, is he inpatient or outpatient?
Outpatient, but may change to inpatient if complications require 2nd midnight stay
What are the 3/4 unit types available at most hospitals?
- Intensive care units: may be broken down by organ system or specialty in large centers
- Intermediate care/step down units: may not be present at smaller hospitals
- Telemetry units (provides continuous ECG monitoring)
- Medical/surgical wards (non-monitored units)
Do patients always stay in the unit they were admitted to?
No! They may start in one unit and transfer to one or more other units throughout admission, based on condition
Who goes to telemetry?
- Chest pain/CAD
- Syncope of suspected cardiac origin
- After electrophysiologic procedures/ablations
- After pacemaker or ICD implantation procedures
- Other cardiac conditions such as infective endocarditis and HF
- Postconscious sedation
- Noncardiac surgery
- Stroke
- Moderate to severe K or Mg imbalance
- Drug overdose
- Hemodialysis
- Sepsis
Need for telemetry reassessed on patient daily
still need to observe and assess patient frequently
What has resulted in the need for care coordination and focus on transitions, particularly for the hospitalized elderly population?
Complex hospital care delivery models leading to increased fragmentation of care
What is the handoff?
- Fluid, dynamic exchange
- Regarding patient admission, change of service, discharge, or any other time of communication
- Subject to distraction and interruptions
- Dependent on on-coming clinican’s confidence in the quality and completeness of information
What is the leading root cause of sentinel events?
- Communication
sentinel event = patient safety event
