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Care Transitions Between Nursing Homes and Emergency Departments: A Failure to Communicate
Care transitions between Emergency Departments (EDs) and nursing homes (NHs) are often poorly coordinated, putting patients at risk for adverse consequences. Studies suggest that in over 90% of all NH-to-ED patient transitions, information essential to adequate emergency care is lacking. Communication by ED staff when patients are discharged back to NHs is often substandard as well. EDs often use electronic or paper discharge templates designed for ambulatory, community-dwelling patients, which are not sufficient for NH residents. This article presents a case to illustrate some of the pitfalls commonly encountered during poorly coordinated NH-to-ED care transitions. Projects to improve poorly coordinated care transitions that include the recently developed quality indicators by the Society for Academic Emergency Medicine’s Geriatric Task Force are discussed. (Annals of Long-Term Care: Clinical Care and Aging 2010;18[4]:17-19)
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Introduction
Emergency Departments (EDs) are frequent providers of care for nursing home (NH) residents.1 Nearly one in four NH residents is transitioned to the ED every year.2 Unfortunately, poor communication is often a hallmark of these care transitions.3,4 Studies suggest that 10% of all NH residents arrive in the ED with no information at all, while in the remaining 90%, information essential to adequate emergency care is missing.5-7 Poor communication during care transitions can lead to higher costs, increased healthcare utilization, and unnecessary duplication of services.8-11 The following case illustrates some of the problems typically encountered during poorly coordinated NH-to-ED care transitions.
Case Presentation
Mr. J is a 79-year-old male who arrives by emergency medical services (EMS) to the ED in respiratory distress from a local long-term care facility. EMS reports that the patient developed respiratory distress about one hour earlier. They placed the patient on high-flow oxygen and obtained intravenous access during transport. They have no further information regarding the medical history but were given some paperwork from the NH to bring to the ED. They are not sure whether Mr. J has any advance directives.
On arrival, Mr. J appears emaciated, diaphoretic, and in severe respiratory distress. He does not respond to verbal stimuli. His oxygen saturation is 85% on a 100% nonrebreather mask. His respiratory rate is 32 breaths per minute, pulse is 134 beats per minute, and blood pressure is 70/40mm Hg. A percutaneous endoscopic gastrostomy (PEG) feeding tube is noted. The only information available is a lengthy photocopy of the NH chart that was brought by EMS. As preparations for endotracheal intubation and hemodynamic support are made, the emergency physician quickly goes through the chart and is unable to locate advance directives. Mr. J suddenly develops ventricular fibrillation. There is no palpable pulse. Advanced cardiac life support (ACLS) measures are initiated, and there is a return of spontaneous circulation. The patient is successfully intubated and placed on a ventilator. Vasopressors are initiated.
The emergency physician begins to review the NH chart. Most of the 24-page chart contains demographic information, progress notes, physical therapy assessments, and scattered laboratory results. In between is found a list of medical problems. Mr. J has advanced Alzheimer’s disease, as well as metastatic prostate cancer. He is bed-bound, nonverbal, and receives feedings and hydration through his PEG tube.
The emergency physician contacts the NH and speaks with the nurse who was caring for Mr. J. She is not his usual nurse and just came on duty an hour before Mr. J decompensated. She is not aware of his advance directives, but she looks in the patient’s chart and finds them. According to these documents, Mr. J is to receive comfort care only in the event of a cardiac or respiratory arrest.
Mr. J’s family arrives in the ED. They see him on a ventilator and are very upset. They are aware of his advance directives and ask what happened. Mr. J is eventually admitted to the Intensive Care Unit (ICU). He is subsequently extubated and placed on a morphine drip. Mr. J dies within an hour of arrival to ICU.
Discussion
This case illustrates some of the problems encountered during NH-to-ED care transitions. NH chart photocopies are often used in lieu of transfer forms.12 These charts may be quite lengthy, containing volumes of information not pertinent to emergency care. It is often difficult to filter information from these charts that is critical to emergency care in a timely fashion. In addition, critical information is often lacking.6,13,14 In one study, the average length of NH transfer information sent to the ED during patient transitions was 24 pages. In these 24 pages, only an average of five of nine elements considered important to ED care were found.12 Going through lengthy photocopies such as these in a busy ED searching for information that is often missing is not feasible on a routine basis. For patients such as Mr. Jones, who arrive unexpectedly in severe distress, finding needed information on a timely basis is absolutely essential to good care.
What is it that emergency physicians need to know when NH patients arrive in the ED? Studies looking at the development and implementation of ED transfer forms identified the following elements crucial to ED care: the reason for the transfer; past medical history; a current medication and allergy list; the patient’s baseline mental and functional status; advance directive wishes; contact information for a healthcare provider at the NH; contact information for a primary care physician; and a recent set of vital signs.12-15 Furthermore, with the rapid pace and high acuity typical of most EDs, it is essential to not only have complete information, but to have information that is easy to find. Few could argue that there is not a better way of communicating than sending 24-page photocopies of NH charts.
Verbal reports among healthcare providers play an important role in the development of well-coordinated care transitions. Nursing-to-nursing report is probably the most common form of verbal communication, and at least the option of a verbal report is mandated by law in some environments. A verbal report ideally gives the opportunity to ask questions that may otherwise remain unanswered in paper correspondence. However, even when a verbal report is implemented, the necessary information may not reach the definitive ED care provider. In many EDs, reports on incoming patients are fielded by a charge nurse, who is then expected to pass the information on to ED care providers. In fewer cases, verbal reports are actually relayed by NH physicians to their ED counterparts. The ED nurse or physician receiving a report must document this information and ensure that it will be available to the ED care providers when the patient arrives.
However, delays may occur in the transmission of information that can compromise its integrity. Charts often are not generated nor nurses typically assigned to patient care until the patient arrives in the ED. In addition, many EDs operate with more than one staff physician on duty at a time providing patient care. While advanced electronic medical records and patient tracking systems have made it easier to enter pre-hospital patient information that can eventually become a part of the ED chart, many EDs still operate without this technology. Such factors may increase the risk that critical information may be lost along the way in the chaos of the ED.
Calling the NH for more information does not often resolve the problem. As EDs continue to grow more congested, it is not uncommon for noncritically–ill patients to wait hours before being seen by a physician. By the time the patient is evaluated in the ED and an attempt is made to contact the NH, there has often been a change of nursing shift in the facility. In such cases clinicians can be faced with speaking to a NH provider who knows little about the patient and often nothing about the reason for transfer. With many opportunities for gaps in verbally-communicated information, “hard” copies of transfer information, such as those on paper or in shared electronic medical records, still play an essential role in well-coordinated care transitions.
ED communication with NHs when patients are discharged back to care facilities is often substandard as well.16 Many EDs use electronic or paper discharge templates based on a variety of common conditions seen in the ED. Most of these templates were designed for ambulatory, community-dwelling patients and are not sufficient for NH residents. EDs often fail to communicate which (if any) tests were performed, as well as the results of those tests done in the ED. Discharge information may be such that NH care providers are unable to determine whether the complaint leading to the ED visit was adequately addressed, and therefore must rely on the patient to try to explain what occurred in the ED. Having to rely on patients (many of whom may have dementia) to explain their ED care is less than ideal. Poor communication in both directions of the care transition can be particularly problematic. For example, if a patient with dementia is sent to the ED for a fall, with concern for head or spine injury, it would be important to know whether the patient had radiographic imaging in the ED and, if so, what the results were. If the reason for transfer was not clear, these tests may not have been performed. It is not safe to assume that the ED would not have sent the patient back if imaging wasn’t performed and unremarkable for acute injury.
Given these well-documented communication deficiencies and the potential for the impact on quality of care, poor communication between NHs and EDs was recently identified as a priority topic for quality improvement projects by the Society for Academic Emergency Medicine’s Geriatric Task Force.5 Communication during ED transitions of care was one of only three initial areas selected by the Task Force for development of quality indicators in geriatric emergency care. The methodology for the development of these indicators was modeled after the Assessing Care Of Vulnerable Elders (ACOVE) project.17 Content experts were identified for each topic, and a preliminary set of indicators was developed based on a comprehensive search of the literature, using expert opinion when necessary. The indicators were then vetted through a series of experts in emergency medicine and geriatric medicine in several settings and national forums over a two-year period, and feedback from these sessions was used to refine the indicators to their final format. These indicators address deficiencies in both directions of care transitions, and call for a Minimum Data Set to be relayed from NHs to EDs, and vice versa. They are considered to represent floor measures of communication during care transitions—that is, they are absolute minimum standards below which care would be considered substandard.5
Quality indicators are but one small step in what is likely to be a much longer process towards improving poorly-coordinated NH and ED care transitions. Standardized transfer forms have been implemented for NH-to-ED transitions with some degree of success.7,12,14,15,18 Terrell et al14 designed a one-page standard NH-to-ED transfer form for use during patient transitions in nine extended-care facilities. When the form was used, the amount of essential information communicated to the ED increased. However, the form was used in less than one-third of all patient transitions.14 Incorporating standardized transfer templates into electronic health networks has also been tried in an attempt to improve communication between NHs and EDs. In one such study, the amount of critical information communicated to the ED during care transitions more than doubled after the intervention was initiated. However, the electronic health network was used in only 40% of all care transitions towards the end of the study.12 As the use of health information technology continues to increase, implementing such electronic networks may prove to be one method by which communication can be improved.
The limited success of transfer template implementation as a sole solution to the communication problem demonstrates that other factors need to be considered along the road to process improvement. Antagonistic relationships and negative attitudes between ED and NH personnel have been identified as one potential barrier,12,19 likely fostered by communication failures and frustrations over long periods of time. Developing collegiality and team building approaches can play an essential role in improving care transitions across these healthcare settings.
Summary
Care transitions between EDs and NHs are often poorly coordinated, putting patients at risk for adverse consequences. Both ED and NH personnel share a responsibility to work towards improving these communication deficiencies. While transfer templates and electronic health networks may play an important role in process improvement efforts, fostering collegiality and team-building approaches between NHs and EDs is likely to be critical to successfully addressing this important issue in the future.
The author reports no relevant financial relationships.
Dr. Hustey is Assistant Professor, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH. Dr. Hustey is an American Geriatrics Society Dennis W. Jahnigen Scholar whose project involved a study aimed at improving communication during skilled nursing facility transitions to the Emergency Department.
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