Transitions of Care Flashcards
1
Q
What may be the first and most significant care transition a patient will experience in their medical care
A
Hospital admission
2
Q
What is the goal of transition of information from the emergency department
A
Transfer information and clarify who is responsible for patient care
3
Q
What is the risk of transition of information from the emergency department?
A
- Delay between information exchange and physical relocation creates opportunity for error and safety issues
4
Q
What should information from ED to hospitalist include?
A
- 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)
5
Q
What are reasons additional information or workup may be requested by the accepting physician in a ED transition?
A
- 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)
6
Q
What are benefits of ambulatory office/direct admit?
A
May save hours of waiting in the ED/help reduce ED overcrowding
But not common :(
7
Q
What are important components to consider when selecting a patient for direct admit?
A
- 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
8
Q
Selection recommendations for direct admission
A
- 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
9
Q
Communication between the PCP and hospitalist during a ambulatory office/direct admit should include
A
- 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
10
Q
Risks and benefits of transfer from outlying facility/hospital to hospital
A
- 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
11
Q
Risks of interhospital transfer prior to transfer
A
- Delay in care initiation due to lack of expertise
- Delay in care finding and accepting facility/delayed transport
- Inappropriate transfer
12
Q
Risks of interhospital transfer during transfer
A
- Decompensation during transfer
- Arrival at night
- Arrival to inappropriate level of care
13
Q
Risks of interhospital transfer after transfer
A
- Discontinuity of care plan
- Unneccessary and/or duplicative testing
- Medication errors
- Back-end discontinuity
- No shared EMR
14
Q
Common components of skilled nursing facility transfer
A
- 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
15
Q
What are patients transferred from a skilled nursing facility at risk for?
A
- Medication errors
- Unnecessary testing
- Inappropriate/unwanted care
16
Q
When is transition of responsibility from emergency department?
A
- 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
17
Q
When is transfer of responsibility from ambulatory office/outlying hospital/SNF?
A
- Admitting/transferring provider responsible for patient while they remain at facility and once patient leaves admitting/transferring facility they become responsibility of accepting provider
18
Q
When admitting a patient what admission status do you choose between?
A
Inpatient and outpatient
19
Q
How do you determine whether a patient should be admitted inpatient or outpatient?
A
- 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
20
Q
If it is unclear whether a patient will need to stay 1 or 2 midnights, what admission type would they be?
A
Outpatient until expectation develops that patient will require second midnight. At that point, inpatient admission order would be written by physician
21
Q
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?
A
Outpatient, but may change to inpatient if complications require 2nd midnight stay
22
Q
What are the 3/4 unit types available at most hospitals?
A
- 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)
23
Q
Do patients always stay in the unit they were admitted to?
A
No! They may start in one unit and transfer to one or more other units throughout admission, based on condition
24
Q
Who goes to telemetry?
A
- 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
25
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
26
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
27
What is the leading root cause of sentinel events?
* Communication
## Footnote
sentinel event = patient safety event
28
What are the types of intrahospital handoffs
* Shift change
* Service change
* Service transfer
29
Which types of intrahospital handoffs require written documentation?
* Service change
* Service transfer
30
What is a shift change intrahospital handoff?
Transfer of content and professional responsibility from one clinican to another at the end of the shift
31
What is a service change intrahospital handoff?
* Permanent transfer of content and professional responsibility at the end of one's on-service time or rotation to a new physician or team or providers who will assume ongoing care of the patients
32
What is a service transfer intrahospital handoff?
* Change of service from care of one group of clinicans to entirely different group of clinicans, usually from a different specialty or ward, to receive a different service that is unique to the receiver's specialty or ward
33
Core components of handoffs
* Verbal communication: allows for questioning and reading back information relayed and received, focus on what receiver really needs to know
* Written communication that supplements verbal handoff with additional information
* Transfer of professional responsibility: acknowledgement of accountability for patient's care
34
Goal of verbal communication in handoffs
Build a shared mental model for a patient, including tasks and priorities
35
Core steps to the handoff process
* Pre-handoff: sender organizes and updates written information
* Arrival: sender completes patient care tasts to conduct handoff and negotiates time and place
* Dialogue: specific verbal exchange between sender and receiver
* Post-handoff: receiver integrates new information and assumes ongoing care of patients
36
Standardized handoff methods
* IPASS
* SBAR
37
Components of IPASS
* I: Introduction = introduce yourself
* Patient: Name, identifiers, age, sex, location
* A: assessment = "the problem", procedure, etc.
* S: Situation - current status/circumstances, uncertainty, changes
* S: Safety concerns - critical lab values/reports; threats, pitfalls, alerts`
38
Components of SBAR
* S: Situation --> What is going on with the patient
* B: Background --> relevant information about history, background, prior diagnosis
* A: Assessment --> what you think is going on and needed
* R: Recommendations --> what you are asking the physician to do
39
Why is the hospital discharge transition a vulnerable time for patients?
* Adverse outcomes common with 50% experiencing a medical error and 20% suffering an adverse event
* Leads to readmission
* If back within 24 hours = discharge failure, hospital admin will assess for medical error
40
What can cause unsuccessful discharge transitions?
* Premature discharge, inappropriate discharge setting
* Unrecognized medical, functional, social needs
* Poor social support, low health literacy
* Specific clinical conditions: CHF, psychiatric comorbidities
* Inadequate handoffs: pending tests, additional work up, incomplete or unreceived discharge summary
* Delayed or unscheduled follow up
* Lack of advanced care planning
* Failure to ensure comprehension of disease education or discharge information
* Medication-related problems
41
What medication related problems can cause unsuccessful discharge transitions?
* Adverse drug events
* Failure to obtain necessary medications
* Therapeutic duplication
* Poor adherence
42
Key elements of discharge care coordination
* Appropriate discharge destination
* Proactive scheduling of follow-up appointments
* Careful medication reconciliation
* Engagement of patients and caregivers
43
When does discharge planning begin
* At admission
* Continues throughout hospitalization in parallel to medical evaluation and treatment plan
44
What are the msot common discharge locations?
* Home with or without caregivers
* Home with home health services
* Inpatient rehabilitation facilities
* Skilled nursing facilities
* Long-term acute care hospitals
* Extended care facilities
45
What are specific certification or medicare requirements for skilled nursing facilities
* Qualifying event of 3-night inpatient stay
* skilled needs >1 hour per day, 5 d per week
* Initial physician visit required within 30 d of admission to facility
46
What nursing/physician/rehab/diagnostic services are available at skilled nursing facilities?
* Nursing services: 2-4 h per patient per day
* Physician services: physician visit every 30 d; often utilize nonphysician providers for medically necessary visits
* Rehab: physical, occupational, speech therapy approx 1 hr per day
* Diagnostic: off-site lab and radiology, limited ability to manage unstable patients
47
What are specific certification or medicare requirements for inpatient rehabilitation facilities?
* 75% fall into 13 diagnosis categories
* Require multidisciplinary therapy
* >3 h of therapy per day, 5 d per week
48
Nursing/physician/rehab/ diagnostic services available at inpatient rehabilitation facilities
* Nursing: 5-6 h per day
* Physician: face to face visits by rehab physician at least 3 times per week
* Rehab: multimodal services at least 3 h per day
* Diagnostic: lab and radiology available, some ability to handle unstable patients
49
Specific certification or medicare requirements for long term acute care hospitals
* Average length of stay >25 days
* Highly complex medical patients (ventilator management, complex wound care)
50
Nursing/physician/rehab/diagnostic services available at long term acute care hospitals
* Nursing: 5-6 h per patient per day
* Physician: daily or near-daily physician visits; consultant specialists widely available
* Rehab: multimodal services
* Diagnostic: lab and radiology available, some ability to handle unstable patients
51
Certification or medicare requirements for extended care facilities
* Long term custodial care; reimbursement through medicaid
52
Nursing/physician/rehab/diagnostic services for extended care facilities
* Nursing: <2 h per patient per day
* Physician: every 30 d
* Rehab: physical, occupational, speech, recreational therapy
* Diagnostic: off-site lab and radiology, limited ability to manage unstable patients
53
Specific certification or medicare requirements for home health
* Medicare requires face to face encounter form and physician certification of homebound status
54
Nursing/physician/rehab/diagnostic services for home health
* Nursing: examples wound care, IV, medication, disease education
* Physician: requires physician to oversee plan of care
* Rehab: physical, occupational, speech therapy
* Diagnostic: N/A
55
How should follow-up appointments be made?
* Before patient leaves to ensure access to follow-up care
* 50% rehospitalized within 30 days after discharge to community had no outpatient visit within 30 days
56
Why are follow up appointments important?
* Ongoing medical issues
* Medication adjustments
* Reassessment of treatment plan
57
What are considerations for time frame of follow up?
* Severity of acute illness
* Pre-existing comorbidities
* Ability to manage medications and self-care needs
* Social issues such as transportation and caregiver support
* Physician availability
58
What is reasonable time frame for follow up for most patients?
7-14 days with instructions at discharge on red flag symptoms and who to contact with questions and concerns
59
How soon is appropriate follow up for patients at high risk for readmission and adverse drug events?
* 48-72 hours following discharge
60
What is medication reconciliation?
* Medication list obtained, compared, and clarified across different sites of care, in order to decrease medication errors during transitions
* Opportunity to evaluation polypharmacy
* Screen high alert drugs and inappropriate meds
* Identify drug-drug and drug-disease interactions
* Assess medication adherence
* Barriers to adherence
* Communicate updated list to patient
* Includes explicit notation of medications added, discontinued, or changed during hospitalization
61
Whose responsibility is medication reconciliation?
Shared responsibility with multidisciplinary team
* Long term care
* Patients
* Nursing
* Hospital pharmacy
* Provider
* Community pharmacy
62
Fundamental component of the discharge planning process and may help bridge the discontinuity inherent between inpatient and outpatient settings
Patient engagement and education
63
What are key components of patient education and engagement?
* Ability to ask questions of health care providers
* Enable patient access to medical information
* Support communication with care providers
* Facilitate self-management of illnesses
Patients recall and comprehend about 1/2 of information provided in medical encounter
64
How should patient education and engagement be completed?
* Small sessions throughout hospitalization
* Reiterate main points
* Provide written handouts
65
Patient education and discharge instructions reviewed and comprehension ensured via what method
Teach back method
66
Steps should be taken to create patient-centered instructions that are what?
* Clear
* Tailored to patient language and literacy
* Focused on critical details of self-management
67
What should be included in discharge instructions?
* Reason for hospitalization
* Treatment received
* Names of clinicans involved in care if questions arise postdischarge
* Pertinent test results as well as pending test results
* Diet and activity
* Medications, including any changes in regimen and potential side effects
* Follow-up appointments
* Identification of the person to contact with questions or concerns
* List of concerning symptoms and how to respond
68
What is important in the discharge summary?
* Timeliness
* Accuracy
* Completeness
* Quality
* Allows communication with PCP
## Footnote
--> decreases risk of medical error
69
Recommended components of the discharge summary
* Primary and secondary diagnoses
* Important test results
* Pending results and responsible party
* Recommendations regarding additional work-up or treatment plan
* Patient's condition at discharge (including cognitive and functional status and abnormal exam findings)
* Complete list of reconciled medications
* Follow up arrangements
* Identification and contact information for sending and receiving providers
* Resuscitation status
* Documentation of patient education
