Examining Care Transitions of Seniors from Long-Term Care Facilities to the Emergency Department: Im
The purpose of our second assignment in my Facilitating Inquiry Course (MHST 603) is to feed into our initial research proposal. As part of this assignment, we were required to form an introduction and literature review section. The purpose of the introduction and literature review is to introduce and discuss the importance of a problem, discuss current research, previous studies, criticisms, as well as strengths and limitations. Below is my paper examining information gaps during care transitions of seniors from long-term care facilities to the emergency department.
Introduction
Older adults (aged 65 years and over) use a greater proportion of emergency department (ED) services compared to those of younger generations, and seniors who live in long-term care (LTC) facilities are among the highest users (Carson, Gottheil & Lawson, 2017). Over 25% of seniors experience at least one ED visit annually, with several encountering repeat visits (Pearson & Coburn, 2013). Senior transfers from nursing homes to the emergency department usually occur in urgent or emergent circumstances which do not permit adequate time on coordinating care transitions. Studies have shown there is often vital information missing during these patient transfers (Griffiths & Morphet, 2014). Information gaps can cause serious breakdowns in continuity of care, inappropriate treatment, unnecessary re-hospitalizations, and the potential for adverse events (Kessler & Williams, 2013). Several studies recommend the use of standardized transfer forms during these care transitions as a way of improving communication, which in turn improves patient safety and quality of care (Pearson & Coburn, 2013).
Care Transitions from Nursing Homes to the Emergency Department
Care transitions are “a set of actions designed to ensure the safe and effective coordination and continuity of care as clients experience a change in health status, care needs, healthcare providers or location (within, between or across settings)” (Registered Nurses Association of Ontario, 2014). Care transitions between nursing facilities and hospitals have been identified as a known risk factor for patient safety problems (Pearson & Coburn, 2013). Changeovers in care of elderly patients are often long and complicated as they are more likely to suffer from chronic illness, physical and cognitive impairments, polypharmacy, and have pre-
existing social problems (Kessler et al., 2013). Elderly patients are also more likely than other populations to receive care from multiple providers, increasing the frequency of these transitions (Kessler et al., 2013).
The transfer of critical information and the responsibility for care of the patient from one health care provider to another is a fundamental component of communication in health care (Friesen, White & Byers, 2008). “Suboptimal communication between health professionals has been identified as a significant causative factor in incidents compromising patient safety” (Marshall, Harrison, & Flanagan, 2008).
Prevalence of Information Gaps
Information gaps are defined as “previously collected clinical information that is required for patient care but is not available to the treating physician” (Cwinn et al., 2009). Information gaps are important to ED staff who seldom have immediate access to all of the background clinical information of their patients. Missing clinical information is of particular importance for patients transferred from nursing homes, especially for seniors who suffer cognitive impairments and may not be able to provide accurate or complete health information on arrival to the emergency department. In the absence of accompanying family or caregivers, hospital staff rely on accurate personal health information and look for key clinical details in LTC transfer reports in order to provide safe, high-quality care (Carson, Gottheil & Lawson, 2017).
Research has shown consistent and alarming information gaps in LTC transfer reports. Elderly patients are often transferred to the emergency department with little or no documentation of their symptoms, recent treatments, or pertinent medical history (Kessler et al., 2013). Critical information such as the reason for transfer, vital signs, code status, medication lists, or baseline mental status is often missing in the accompanying documentation (Kessler et al., 2013). Studies have also shown that discrepancies in documentation are higher when transfers occur outside of normal office hours (Griffiths et al., 2014).
A study examining transfers of LTC patients via ambulance to The Ottawa Hospital emergency department during a 6-month period showed that out of 457 transfers more than 85.5% of reports were missing at least on essential data element (Cwinn et al., 2009). There were 11 clinical data elements in this study that were identified as essential, and should be present in documentation accompanying patients from LTC facilities. These included: 1) reason for transfer, 2) baseline cognitive function and communication ability, 3) vital signs at time of complaint, 4) advanced directives, 5) medications, 6) activities of daily living, 7) immunization status if wounded, 8) allergies, 9) mobility, 10) bowel continence, and 11) bladder continence (Cwinn et al., 2009). Based on the authors of this study, data elements 1-5 were considered most crucial for the treating emergency physician. Of the 457 transfers examined, reason for transfer was not stated in 12.9%, baseline cognition was not described in 36.5%, vital signs at time of complaint were missing in 37.6%, advanced directives were not indicated in 46.4%, and medications were not provided in 20.4% (Cwinn et al., 2009).
Handover from EMS to ED
Clinical handover “is the transfer of information (along with authority and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify, and confirm” (Friesen, White & Byers, 2008). Older patients from long-term care facilities often present to the emergency department via ambulance with non-specific, vague symptoms such as falls or confusion (Griffiths et al., 2013). The quality of verbal and/or written handover of care given by the paramedic staff can vary considerably, because it is based on the information provided by the long-term care facility which may be insufficient (Griffiths et al., 2013). There is a tremendous amount of information that needs to be communicated among numerous individuals during these patient transfers. In an effort to compress information and make handover of care among health care providers more manageable, handover may result “in a progressive loss of information known as funneling, as certain information is missed, forgotten, or otherwise not conveyed” (Friesen, White & Byers, 2008). Further, differing styles of communication has been found to affect the quality and accuracy of clinical handover, and can lead to a lack of understanding and frustration among health care professionals. A handover is largely dependent on the interpersonal communication skills, knowledge, and experience level of the caregiver. With reported variability in the quality, and lack of structure in how handovers occur, there is a need for a “common language” when communicating critical information (Friesen, White & Byers, 2008).
Challenges with Care Transitions
Work Environments
Clinical environments are dynamic, complex and present many challenges for effective communication among health care providers, patients and families (Friesen, White, & Byers, 2008). The physical work environment for health care workers may not be conducive for effective handovers as it may be noisy and prone to interruptions (e.g. overhead pages, patient call bells, and phone calls). A study examining communication patterns among physicians and nurses found 31% of communication exchanges involved some form of interruption, which translated to roughly 11 interruptions an hour (Friesen, White, & Byers, 2008). Emergency departments are an example of a multifaceted organization where interruptions are common and disruptive. Paramedics and ED staff care for an overwhelming volume of patients ranging in acuity, and environments where clinical decisions need to be made under time pressures with limited information have been considered conducive to error (Laxmisan et al., 2007).
Organizational Challenges
Inter-facility transitions in care pose a number of challenges including cultural differences and lack of integrated systems, increasing the likelihood of communication difficulties between organizations (Friesen, White & Byers, 2008). Health care professionals in different settings tend to have different perceptions about what information is important to be conveyed. The relationship between LTC facilities and the ED can often be dysfunctional due to different competencies, scopes of practice, and goals of care (Kessler et al., 2013). Lack of collaboration between facilities can impede successful transitional care and ultimately puts the patient at a disadvantage. Further, nursing homes are primarily staffed by personal support workers with a limited number of nurses on each shift. When a resident requires emergency transfer, it is the nurse’s responsibility to complete transfer documentation. Communication gaps during transfers via ambulance to the emergency department are intensified by the combination of staffing shortages, inefficient documentation processes and residents with complex needs (Carson, Gottheil & Lawson, 2017).
Patient Outcomes
A study examining the effects of information gaps on patient outcomes showed that patients with information gaps were associated with a significantly longer stay in the emergency department compared to patients without missing information (Stiell et al., 2003). These
information gaps increased length of stay in the emergency department by 1.2 hours (Stiell et al., 2003). Prolonged length of stay in the emergency department has been linked to an increase in morbidity and mortality (Griffiths et al., 2014). Increased length of stay in the emergency department also contributes to patient dissatisfaction, overcrowding and decreased quality of care (Pearson & Coburn, 2013). Lack of adequate information may also lead to unnecessary investigations and treatments that contribute to patient and family distress as well as increased health care costs (Griffiths et al., 2014).
Standardized Communication Tools
Consistent communication styles have proven to be effective in other high-risk, nonmedical sectors (e.g. aviation and nuclear industries) in reducing error (Kessler et al., 2013). The use of standardized transfer forms as a way of improving inter-facility communication, which in turn improves patient safety and quality of care are strongly recommended (Pearson & Coburn, 2013). Ideally, standardized patient transfer forms should be readily available to the emergency department staff at the time of the patient’s arrival and should be concise, organized and easy to read (Griffiths et al., 2014). A technique to help bridge different communication styles of nurses and physicians is the “situation, background, assessment, recommendation (SBAR)” briefing model that is currently being used successfully in healthcare to enhance handover communication (Friesen, White & Byers, 2008).
Conclusion
With our aging population, emergency department staff are caring for increasing numbers of seniors with complex, multisystem problems including dementia. There are many challenges associated with the transfer of elderly patients to and from the emergency department. “Transitions between health care settings are increasingly recognized as a time when older adults, especially those with complex needs, are particularly vulnerable to complication or error” (Pearson & Coburn, 2013). There is currently no consistency in how communication is managed between long-term care facilities and emergency departments. The purpose of this study is to examine if implementing a universal standardized communication tool for transfers from long-term care facilities via EMS to the hospital emergency department will improve communication gaps of pertinent health information between nursing facilities and ED's, reduce risk of medical error, improve patient safety and quality of care.
References
Carson, J., Gottheil, S. & Lawson, S. (2017). London Transfer Project: improving handover documentation from long-term care homes to hospital emergency departments. BMJ Open Quality,6(2), e000024.Retrieved fromhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5699131/
Cwinn, M.A., Forster, A.J., Cwinn, A.A., Hebert, G., Calder, L. & Stiell, I.G. (2009). Prevalence of information gaps for seniors transferred from nursing homes to the emergency department. Canadian Journal of Emergency Medicine (CJEM), 11(5), 462-471. Retrieved from https://www.researchgate.net/publication/26855633_Prevalence_of_information_gaps_for_seniors_transferred_from_nursing_homes_to_the_emergency_department
Emergency Nurses Association (ENA). (2014). Collaborative Care for the Older Adult. Institute for Quality, Safety and Injury Prevention. Retrieved from https://www.ena.org/docs/default-source/resource-library/practice-resources/topic-briefs/collaborative-care-for-the-older-adult.pdf?sfvrsn=c4edff5b_8
Friesen, M.A., White, S.V. & Byers, J.F. (2008). Handoffs: Implications for Nurses. Patient Safety and Quality: An Evidence-Based Handbook for Nurses, Chapter 34. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK2649/
Griffiths, D., Morphet, J., Innes, K., Crawford, K. & Williams, A. (2014). Communication between residential aged care facilities and the emergency department: A review of the literature. International Journal of Nursing Studies, (51), 1517-1523. Retrieved from https://www.journalofnursingstudies.com/article/S0020-7489(14)00159-X/pdf
Kessler, C., Williams, M.C., Moustoukas, J.N. & Pappas, C. (2013). Transitions of Care for the Geriatric Patient in the Emergency Department. Clinic Geriatric Medicine, (29)49-69. Retrieved from https://geri-em.com/wp-content/uploads/2013/05/ClinGeriatrMed_Transitions-3.pdf
Laxmisan, A., Hakimzada, F., Sayan, O.R., Green, R.A., Zhang, J. & Patel, V.L. (2007). The multitasking clinician: Decision-making and cognitive demand during and after team handoffs in emergency care. International Journal of Medical Informatics, (76)11-12, 801-811. Retrieved from https://www.sciencedirect.com/science/article/pii/S1386505606002413
Manias, E., Geddes, F., Watson, B., Jones, D. & Della, P. (2015). Perspectives of clinical handover processes: a multi-site survey across different health professionals. Journal of Clinical Nursing (JCN), 25, 80-91. Retrieved from https://onlinelibrary.wiley.com/doi/epdf/10.1111/jocn.12986
Naylor, M. & Keating, S.A. (2008). Transitional Care: Moving patients from one care setting to another. The American Journal of Nursing,108(9 Suppl), 58-63. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2768550/
Pearson, K.B. & Coburn, A.F. (2013). Emergency transfers of the elderly from nursing facilities to critical access hospitals: Opportunities for improving patient safety and quality. (Policy Brief #32). Maine Rural Health Research Center (MRHRC). Flex Monitoring Team. Retrieved from http://digitalcommons.usm.maine.edu/cgi/viewcontent.cgi?article=1001&context=longterm_care
Stiell, A., Forster, A.J., Stiell, I.G. & Walraven, C. (2003). Prevalence of information gaps in the emergency department and the effect on patient outcomes. Canadian Medical Association Journal (CMAJ), 169(10),1023-1028. Retrieved from http://www.cmaj.ca/content/169/10/1023.long
World Health Organization (WHO). (2007). Communication During Patient Hand-Overs. Patient Safety Solutions. Retrieved from http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf