Partnerships in Transitions: Acute Care to Skilled Nursing Facility

Improving Communication From Hospital to Skilled Nursing Facility Through Standardized Hand-Off: A Quality Improvement Project

Background: Inadequate hand-off communication from hospital to skilled nursing facility (SNF) hinders SNF nurses’ ability to prepare for specific patient needs, including prescriptions for critical medications, such as controlled medications and intravenous (IV) antibiotics, resulting in delayed medication administration. This project aims to improve hand-off communication from hospital to SNF by utilizing a standardized hand-off tool. This project was conducted in an inpatient, 50-bed, post-hospital skilled nursing care unit of a local SNF. The participants included all 32 staff nurses employed by the SNF. Methods: Lewin’s change management theory (CMT) guided this quality improvement (QI) project. Baseline assessment included a one-month chart review of 76 patient charts that was conducted to assess the disparities related to ineffective hand-off and medication delays in the SNF before intervention. The wait time for the availability of prescriptions for controlled medications and IV antibiotics, and delays in medication administration were assessed. Intervention: Multiple randomly selected hospital-to-SNF hand-offs were observed. Semistructured interviews with all staff nurses were conducted using open-ended questions about hand-off structure and process matters. Data gathered from observation and interviews were used to create the standardized hand-off tool used in this project. In-service training on hand-off tool utilization for SNF nurses was conducted. Champions for each shift were cultivated to assist with project implementation. Results: After six weeks of implementation, a chart review of 101 patient charts was conducted to evaluate the effects of the hand-off tool on the wait time on the availability of prescriptions for controlled medications and IV antibiotics, and medication administration. The wait time of prescriptions availability during the hospital-to-SNF transition was decreased by 79% for controlled medications, with an associated 52.9% reduction in late administration, and decreased by 94% for IV antibiotics, with a 77.8% reduction in late administration. Conclusion: The use of standardized hand-off resulted in improved communication during the hospital-to-SNF hand-off and significantly decreased the wait time for the availability of prescriptions for controlled medications and IV antibiotics. Integrating standardized hand-off into the SNF policies can help sustain improved communication, medication management, and patient transition from hospital to SNF.

Towards the development of a national patient transfer document between residential and acute care-A pilot study

BACKGROUND

A lack of standardisation of documentation accompanying older people when transferring from residential to acute care is common and this may result in gaps in information and in care for older people. In Ireland, this lack of standardisation prompted the development of an evidence based national transfer document.

OBJECTIVES

To pilot a new national transfer document for use when transferring older people from residential to acute care and obtain the perceptions of its use from staff in residential and acute care settings.

METHODS

This was a pre- and post-study design using purposive sampling following the STROBE guidelines. The pilot was conducted in 26 sites providing residential care and three university hospitals providing acute care. Pre-pilot questionnaires focused on current documentation and were distributed to staff in residential care (n = 875). A pilot of the new paper-based transfer document was then conducted over three months and post-pilot questionnaires distributed to staff from both residential and acute care settings (n = 1085). The findings of the pilot study were discussed with multidisciplinary expert advisory and stakeholder groups who recommended some revisions. This consensus informed the development of the final design of the new revised transfer document.

RESULTS

Pre-pilot: 23% response rate; 83% (n = 168) participants agreed/strongly agreed that existing documentation was straightforward to complete but could be more person-centred. Post-pilot: 11% response rate; 75% (n = 93) of participants agreed/strongly agreed that the new transfer document promoted person-centred care but recommended revisions to the new document regarding layout and time to complete.

CONCLUSIONS

This study highlighted some of the challenges of providing safe, effective and relevant transfer information that is feasible and usable in everyday practice.

IMPLICATIONS FOR PRACTICE

Standardisation and being person-centred are important determining factors in the provision of relevant up to date information on the resident being transferred.

Nurse competencies for transitions of care: Implications for education and practice

Although there are a number of transitions of care initiatives that address specific needs as patients move across healthcare settings, adverse events still occur during handoffs. Transitions of care create periods of vulnerability for populations with complex needs that include communication gaps, medication changes, and poorly coordinated treatment plans, often without involving patients and their families. This paper outlines what nurses need to know to provide for safe transitions of care across the healthcare continuum. The theoretical basis for transitions of care at the macro level, examples of nurse-led models for transitions of care, and key activities and implications for nursing education and practice are described. A holistic framework for effective transitions of care across healthcare settings can guide nursing educators in the development of specific nursing competencies for transitions of care.

Lost in Transition: a Qualitative Study of Patients Discharged from Hospital to Skilled Nursing Facility

OBJECTIVE

This research aimed to understand the experiences of patients transitioning from hospitals to skilled nursing facilities (SNFs) by eliciting views from patients and hospital and skilled nursing facility staff.

DESIGN

We conducted semi-structured interviews with hospital and skilled nursing facility staff and skilled nursing facility patients and their family members in an attempt to understand transitions between hospital and SNF. These interviews focused on all aspects of the discharge planning and nursing facility placement processes including who is involved, how decisions are made, patients' experiences, hospital-SNF communication, and the presence of programs to improve the transition process.

PARTICIPANTS

Participants were 138 staff in 16 hospitals and 25 SNFs in 8 markets across the country, and 98 newly admitted, previously community-dwelling SNF patients and/or their family members in five of those markets.

APPROACH

Interviews were qualitatively analyzed to identify overarching themes.

KEY RESULTS

Patients reported they felt rushed in making their SNF decisions, did not feel they were appropriately prepared for the hospital-SNF transition or educated about their post-acute needs, and experienced transitions that felt chaotic, with complications they associated with timing and medications. Hospital and SNF staff expressed similar opinions, stating that transitions were rushed, there were problems with the timing of the discharge, with information transfer and medication reconciliation, and that patients were not appropriately prepared for the transition. Staff at some facilities reported programs designed to address these problems, but the efficacy of these programs is unknown.

CONCLUSIONS

Results indicate problematic transitions stemming from insufficient care coordination and failure to appropriately prepare patients and their family members. Previous research suggests that problematic or hurried transitions from hospital to SNF are associated with medication errors and unnecessary rehospitalizations. Interventions to improve transitions from hospital to SNF that include a focus on patients and families are needed.

Antibiotic prescribing upon discharge from the hospital to long-term care facilities: Implications for antimicrobial stewardship requirements in post-acute settings

OBJECTIVE

To quantify the frequency and outcomes of receiving an antibiotic prescription upon discharge from the hospital to long-term care facilities (LTCFs).

DESIGN

Retrospective cohort study.

SETTING

A 576-bed, academic hospital in Portland, Oregon.PatientsAdult inpatients (≥18 years of age) discharged to an LTCF between January 1, 2012, and June 30, 2016.

METHODS

Our primary outcome was receiving a systemic antibiotic prescription upon discharge to an LTCF. We also quantified the association between receiving an antibiotic prescription and 30-day hospital readmission, 30-day emergency department (ED) visit, and Clostridium difficile infection (CDI) on a readmission or ED visit at the index facility within 60 days of discharge.

RESULTS

Among 6,701 discharges to an LTCF, 22.9% were prescribed antibiotics upon discharge. The most prevalent antibiotic classes prescribed were cephalosporins (20.4%), fluoroquinolones (19.1%), and penicillins (16.7%). The medical records of ~82% of patients included a diagnosis code for a bacterial infection on the index admission. Among patients prescribed an antibiotic upon discharge, the incidence of 30-day hospital readmission to the index facility was 15.9%, the incidence of 30-day ED visit at the index facility was 11.0%, and the incidence of CDI on a readmission or ED visit within 60 days of discharge was 1.6%. Receiving an antibiotic prescription upon discharge was significantly associated with 30-day ED visits (adjusted odds ratio [aOR], 1.2; 95% confidence interval [CI], 1.02-1.5) and with CDI within 60 days (aOR, 1.7; 95% CI, 1.02-2.8) but not with 30-day readmissions (aOR, 1.01; 95% CI, 0.9-1.2).

CONCLUSIONS

Antibiotics were frequently prescribed upon discharge to LTCFs, which may be associated with increased risk of poor outcomes post discharge.