Monday, August 26, 2013

Transfers from the Hospital to Nursing Home: An F- Grade For Quality



Huge numbers of older persons transition from hospitals to the nursing home.  Often, an older hospitalized patient needs skilled nursing care before they are ready to return home.  In other cases, a nursing home patient who needed hospitalization is returning to the nursing home.  Older patients and their families certainly hope that great communication between the hospital and nursing home would assure a seamless transition in care.

But a rather stunning study in the Journal of the American Geriatrics Society suggests the quality of communication between the hospital and the nursing home is horrendous.  The study was led by researchers from the University of Wisconsin, including nurse researcher, Dr. Barbara King and Geriatrician Dr. Amy Kind.

The authors conducted interviews and focus groups with 27 front line nurses in skilled nursing facilities.  These nurses noted that very difficult transitions were the norm.  Sadly, when asked to give the details of a good transition, none of the nurses were able to think of an example.

Most of the nurses felt that they were left clueless about what happened to the their patient in the hospital.  They lacked essential details about their patient's clinical status.  The problem was not the lack of paper work that accompanied the patient.  In fact, nurses often received reams of paper work, often over 80 pages.  The problem is that the paper work was generally full of meaningless gibberish such as surgical flow sheets that told little about what was actually going on.  Often the transfer information had errors, conflicted with what the facility was told before the transfer, and lacked accurate information about medications.

Essentially, SNF nurses found themselves asked to care for patients with little sense of what actually happened in the hospital, and little insight into the functional and cognitive status of their patients.  These episodes of poor communication led to a number of adverse consequences:

  • Patients were put at risk for medication errors.  In particular, patients were often left in pain while nurses tried to find a physician to write the orders for opiods that were not included with the transfer
  • Efforts to mobilize patients were delayed while nurses tried to figure out what level of mobility was safe, as the transfer information did not indicate what level of ambulation was safe.
  • Time nurses should have been able to spend caring for patients was instead spent on trying to piece together the records and tracking down primary care providers and hospital providers to learn details about the hospitalization and the medicine regimen.
  • The nurses felt their credibiity and the credibility of the nursing home were undermined with patients and families as the chaotic process made them look bad.  Patients and families assumed something was wrong with the nursing home.
King and Kind point to the need for serious efforts to improve the quality of transitions between the hospital and nursing home.  The type of communication problems noted in this article certainly must have a negative impact on patient outcomes.  


by: Ken Covinsky

7 comments:

Sam said...

Thank you for this important article. We need to view all sick patients including older patients as worthy of excellent care.

Kelley Woodfin RN, BS, DFASHRM, CPHRM said...

Thank you for publishing the results of this study. Another very impactful occurrence is the "observation period" that the elderly are being subjected to; it is not uncommon for this period to go well beyone the CMS mandated 72 hours. As a result, discharged Medicare beneficiaries cannot qualify for SNF admission because they didn't have the requisite 3-day acute care admission. I know CMS is working on legislation to change this, but so far what they've produced doesn't address the real issue.

Andrea said...

Unfortunately the hospital nurse is often discharging a patient she barely knows on her first day with the patient and often has trouble reaching someone in the NH to give a report to. The hospital nurse also is struggling with getting a complete picture of the patient and is time pressured to the max. The whole process of transitioning is broken.

Janice Reynolds said...

This is an excellent topic to be addressed. The hospital I retired from had case managers, most of who were nurses, and all patients were assigned a case manager. This was very helpful especially on the paperwork end but the hospital nurse still needed to call a report to the nurse receiving at the NH. This went well sometimes but as a previous comment said it can be difficult to report on someone you don’t know (I might have never even cared for this patient at any time). Then there was trying to make the call in; nurses are under staffed (in relationship to safety) and it would be rare someone could cover my patients while I made this call and this is occurring at the NH as well. One thing which was also frustrating was what I considered important was not necessarily what the NH nurse considered important which could lead to frustration on both sides. I am a certified Oncology nurse (and used to be a Chemotherapy and Biotherapy trainer) and a certified Hospice and Palliative Care nurse (and Pain Management nurse as well) and we were transferring a patient with end stage cancer to an Inpatient Hospice. She had chemotherapy on Tuesday before they decided to make her Hospice (yes, I know, that is a whole different issue). Her transfer was on Wednesday so I reminded the nurse she needed to tell the nurse on the receiving end the patient needed to be on chemotherapy safety precautions for another 48 hours. The nurse came to me and said, the Hospice nurse told her they don’t follow precautions any more when someone was admitted to Hospice. Calling her myself I was treated a little smugly until I explained to the nurse, these precautions were to keep nurses and aides safe not the patient. Chemotherapy can be in body fluids for quite a while. We usually kept people on safety precautions for 48 hours rounding that up to be on the safe side). This was hospital but unfortunately, NH can be just as unknowledgeable about oncology related issues. Difficulties also lie when a patient is transferred from NH to acute care where report is rarely given.

Anonymous said...

As a doctorally prepared nurse and the adult child of a 91 year old father I appreciated the message of this article. Despite our family's best efforts and involvement we have been party to and experienced some terrible hand offs.
Tangential to the article (which I accessed) I was surprised to note that while you highlighted the first (RN/PhD) and last(MD/PhD)authors you failed to note that there were several other authors(PhD/RN, RNs)who were listed. Seemed like an arbitrary and illogical choice. Why the selection and exclusion??

Anonymous said...

Whilst we talk about the transition between the hospital and NH, we tend to forget about the patient who suddenly has to be placed in a NH in which she may have not been involved in choosing. This, coupled with the lack of proper handover is a sad story for our elderly.

Abbie Wellington said...

As the last paragraph points out, there is a need to improve the quality of transitions from hospital and nursing homes. We cannot simply rely on the results of one study.

Whether it is nursing home, PACE, or Medicaid waiver there is one thing we can be sure of: long term care is becoming more significant as the US faces an aging population. More information about long term care is available at www.infolongtermcare.org.