Safety of Rural Nursing Home-to-Emergency Department Transfers: Improving Communication and Patient Information Sharing Across Settings.

Vol. 37 No. 1 January/February 2015

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Safety of Rural Nursing Home-to-Emergency Department Transfers: Improving Communication and Patient Information Sharing Across Settings Judith B. Tupper, Carolyn E. Gray, Karen B. Pearson, Andrew F. Coburn

Purpose Most healthcare is provided by specialized professionals in settings focused on the type of care providing the care. This “siloed” approach contributes, at a minimum, to challenges in communication when patients move between settings, and, at the worst, to patient harm associated with poor communication and information exchange. This article reports on the results of a 2-year demonstration in 10 rural communities to improve the safety of nursing facility (NF) transfers to hospital emergency departments (EDs) by developing tools and protocols for standardizing critical interfacility communication and information sharing pathways.

Background: The Literature Handoff and transition errors are among the most common and consequential errors in healthcare (Wachter, 2012), with frail elderly patients especially vulnerable to errors due to miscommunication and delays in treatment during care transfers. These NF patients are likely to be compromised by their inability to communicate critical health information due to physical or cognitive impairments (Coleman, 2003; Coleman and Berenson, 2004; LaMantia et al., 2010; Travers et al., 2001). Each year, nearly a quarter of NF residents are transferred at least once to the hospital (Caffrey, 2010; Carter et al., 2006; Gruneir et al., 2010; Gruneir et al., 2011; National Center for Health Statistics, Ambulatory and Hospital Care Statistics Branch, 2010; Nawar et al., 2007). Quality concerns and financial incentives to reduce hospital readmissions

Abstract: The “siloed” approach to healthcare delivery contributes to communication challenges and to potential patient harm when patients transfer between settings. This article reports on the evaluation of a demonstration in 10 rural communities to improve the safety of nursing facility (NF) transfers to hospital emergency departments by forming interprofessional teams of hospital, emergency medical service, and NF staff to develop and implement tools and protocols for standardizing critical interfacility communication pathways and information sharing. We worked with each of the 10 teams to document current communication processes and information sharing tools and to design, implement, and evaluate strategies/tools to increase effective communication and sharing of patient information across settings. A mixed methods approach was used to evaluate changes from baseline in documentation of patient information shared across settings during the transfer process. Study findings showed significant improvement in key areas across the three settings, including infection status and baseline mental functioning. Improvement strategies and performance varied across settings; however, accurate and consistent information sharing of advance directives and medication lists remains a challenge. Study results demonstrate that with neutral facilitation and technical support, collaborative interfacility teams can assess and effectively address communication and information sharing problems that threaten patient safety.

have combined to place greater attention on reducing unnecessary nursing home to hospital transfers (Maslow and Ouslander, 2012; Ouslander et al., 2011; Ouslander et al., 2014; Renom-Guiteras et al., 2014; Tena-Nelson et al., 2012). “Transfer distress” often results in rapid deterioration in condition and a greater risk for iatrogenic illness due to excessive diagnostic and therapeutic interventions (Jensen et al., 2009; Madeira et al., 2007). Meanwhile, efforts to improve the quality and safety of patient transfers are focused on developing mechanisms for ensuring accurate sharing and communication of

Keywords patient safety nursing facility continuum of care emergency rural transitions communication patient transfer nursing facility emergency department visits Journal for Healthcare Quality Vol. 37, No. 1, pp. 55–65 © 2015 National Association for Healthcare Quality

Copyright 2015 National Association for Healthcare Quality. Unauthorized reproduction of this article is prohibited.

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Journal for Healthcare Quality

critical patient information across the multiple settings and providers often involved in such transfers (American Medical Directors Association, 2010; Hustey, 2010; Terrell and Miller, 2007). Accurate reconciliation of medications, infection status, patient-centered directives and personal information, and other necessary clinical background information are key components of the information transfer process that are all subject to process failures. Missing information is common in transfers between the NF and hospital EDs (Cwinn et al., 2009; Jones et al., 1997; Stiell et al., 2003; Ye et al., 2007). Communication problems during the transfer of patients between NF and the ED result in inefficiencies, potential duplications of care, and potential risk of harm (Cummings et al., 2012; Cwinn et al., 2009; Davis et al., 2005; Gruneir et al., 2011, 2012; Jablonski et al., 2007; Kirsebom et al., 2013; Terrell and Miller, 2007, 2011; Wong, 2010; Zamora et al., 2012). Additionally, insufficient communication between long-term care facilities and hospitals during transfers may adversely affect the patient’s quality of care, lead to adverse events, and contribute to the overall cost of the services provided (Gruneir et al., 2012; Mor et al., 2010; Terrell and Miller, 2007; Ye et al., 2007). Although improving communication handoffs between the NF and hospital ED helps to improve quality and patient safety, effective improvement strategies are less clear. Perry et al., 2008 warn that improving patient handoffs is not a “low-hanging fruit” that can be easily remedied through standardization alone. They describe a complex domain with high consequences for failure that can only be addressed through a combination of tools such as checklists or standardized transfer forms (Dalawari et al., 2011; Terrell et al., 2005), standardized verbal content, shared mental models, communication training (Lee et al., 2012; Toccafondi et al., 2012), and other human factors reengineering processes (Carayon et al., 2014). Many also note the importance of multidisciplinary teams to the effectiveness of any improvement efforts in patient transfers and transitions (Bost et al., 2010;

Cummings et al., 2012; Perry et al., 2008; Terrell and Miller, 2011; Terrell et al., 2009). And finally, there is growing recognition for the importance of the context of quality improvement initiatives on their effectiveness and sustainability and their generalizability to other settings (Kaplan et al., 2010; McDonald, 2013).

Background: Sites and Interventions In 2010, all 16 Critical Access Hospitals (CAHs) in Maine’s statewide Patient Safety Collaborative (the Collaborative) (formed in 2008, the Collaborative’s mission is to identify and work on common patient safety and quality improvement issues, with an interdisciplinary membership of healthcare professionals and quality improvement staff representing the Maine’s 16 CAHs) were invited to participate in the demonstration with the expectation that each CAH would select NF and emergency medical services (EMS) partners in their community, form an interdisciplinary team with those providers to assess current patterns of patient information sharing and communication, develop strategies and tools for addressing identified gaps and problems in the transfer process, and participate in the evaluation of their interventions. Ten of the 16 CAHs participated; all are small rural hospitals (under 25 beds) located in underserved rural communities. The NF partners in each of the 10 communities were predominately small (average bed size of 49) for-profit facilities that are not part of a local or national chain. All 11 EMS units (1 project had 2 EMS partners) were notfor-profit, with 4 community-owned, 4 owned by the hospital, and 3 governmental organizations. The demonstration included both macro- and local-level interventions. At the macro level, the Collaborative, with support from the research team, provided a learning forum in which the participating sites reviewed available models and tools for improving transfers (e.g., universal transfer tools), shared their quality improvement ideas and plans, and reported on their progress and experience throughout the demonstration. At the



local level, the local teams were provided modest financial support to underwrite the expenses of interfacility project meetings, data collection, and other project-related expenses such as travel to statewide Collaborative meetings. The research team worked on-site with each of the community teams to facilitate the mapping of current communication and information sharing processes, identify key problems and gaps (e.g., interprofessional communication problems), and assess and adapt evidencebased best practices and strategies to address identified problems and gaps. Based on the “as-is” assessment, each team developed an intervention strategy and planned to improve communication of key patient information across the settings of care that reflected both local needs and resources. Implementation of the improvement activities was led by each of the local teams with support from the Collaborative and the research team.

Study Design and Methods This study sought to assess the feasibility of using collaborative interprofessional teams to design and implement local quality improvement strategies and tools and to determine whether the interventions improved the completeness and accuracy of patient information sharing across settings (this study was reviewed and approved by the University of Southern Maine’s Institutional Review Board, IRB Protocol #090210 to 02). To accomplish this goal, we used a combination of qualitative and quantitative methods to document the design and implementation of the interventions in each of the 10 communities and to evaluate changes in the consistency and accuracy of shared patient information over a 2-year period from 2011 to 2013.

Formative Implementation Assessment At the beginning of the demonstration, we conducted in-person site visits in each of the 10 participating communities meeting separately with each of the participating providers to map and discuss current information sharing practices

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and procedures. With the baseline information, we created a site-specific flow diagram describing the interfacility transfer process and developed a matrix demonstrating the conflicting understandings of what and how patient information is shared across settings. This matrix was shared in a subsequent meeting with the local teams to identify the critical information sharing gaps and problems. This process of generating the “as-is” information was used both to support the local assessment of problems and gaps and the design of the planned strategies and tools. Over the course of the demonstration, thematic analyses of qualitative interviews and aggregate chart review data informed educational and best practice activities to advance individual and organizational learning through the Collaborative. Each of the local projects received feedback from the site visits and site-level chart review summary reports on a quarterly basis. Local sites used these summary reports to target areas for improvement, establish improvement activities, and track changes over time. This information also was used to describe the baseline communication processes, assess the environment in which the intervention occurred, and document changes in the communication processes after project interventions. We conducted follow-up semi-structured phone interviews with project participants and partners in the participating sites in both years of the demonstration along with a project closeout survey. The interviews and survey information provided critical data and insights about the unique characteristics and environment of each site, relationships developed through the intervention, factors that made partnerships successful, barriers encountered, and how these barriers were overcome. Some of the contextual factors assessed included ownership of the NF and/or EMS (independent or owned by the hospital), a description of the health system to which the NF and EMS belong, and the extent to which the hospital or partners attempted to work on transfer-related policies before this demonstration. Additionally, the project close-out survey covered completed project activities, factors that affected


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implementation, local impact of the project, and plans for the future.

Quantitative Evaluation Study Population. The study population is all transfer events (n = 829) from the NF to the ED in the 10 projects during the baseline quarter (Q2, 2010) and the intervention quarters (Q2–4, 2011, and Q2, 2012). The 829 transfers include individuals with multiple transfers; because the data were deidentified, the number of unique individuals transferred is unknown. Data. As a requirement for participation, CAHs agreed to conduct quarterly ED chart reviews of all NF residents transferred to the local hospital ED to document what patient information was shared across settings. A total of 829 chart reviews were conducted in specified quarters and analyzed to assess changes in total scores for the 5 patient information items; 312 chart reviews were analyzed to compare the baseline (Q2, 2010; 128

charts) to the last quarter in the intervention (Q2, 2012; 184 charts). Based on the initial local assessments, the research team identified five patient information items that presented a common challenge in the transfer process between the settings of care: (1) advance directives, (2) infection status, (3) current medication list, (4) baseline mental status, and (5) baseline physical status. Chart reviews assessed presence and consistency of information on each of these items from each of three sources of information: the NF transfer record, the EMS electronic run report, and the patient’s ED record. The hospital’s patient chart, which included these three sources of information, was reviewed for presence of all these data in addition to consistency of the information provided by each setting. The research team developed a chart review tracking form to record data and provided training to the hospital staff responsible for conducting the chart reviews (Figure 1). The training provided operational definitions for each patient

Figure 1. Chart Review Tracking Form.



information item in the chart review. Chart reviews were deidentified and reflected all transfers to the ED during the specified time periods. Hospital team leaders conducted chart reviews during the baseline quarter and the four subsequent intervention quarters. Chart review scoring sheets were submitted to the research team, checked for completeness, entered, and analyzed. Analysis. Each chart review was given a score for the number of settings with the particular piece of information documented (e.g., infection status) and if the information was consistent across the three settings. If the chart review indicated information was provided by all three settings with consistent information, then the chart review score for that patient information item totaled 4. The Wilcoxon rank sum test was used to assess statistical significance of changes from baseline to the postintervention period (Q2, 2010 and Q2, 2012). To account for clustering of data by site/project, the means of each variable for a project were applied to the Wilcoxon rank sum test (Galbrieth et al., 2010). Analyses comparing the percentage of charts documented with a specific information item (e.g., infection status) by each setting were conducted using the chi-square test, with an adjustment for clustering by site. For both analyses, the level of significance was set at P , .05, with the Bonferroni procedure used to account for the multiple tests conducted (e.g., advance directives, medications, infections, baseline mental status, and baseline physical status; Napierala, 2012).

Results Implementation of Improvement Projects All 10 local sites implemented 1 or more activities to improve communication and the transfer of patient information between settings of care. All local teams developed a transfer form based on collaborative team input, with one using the INTERACT (Interventions to Reduce

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Acute Care Transfers), 2014 template (http://interact2.net), and most included a checklist to standardize the information shared during the patient transfer process. Team activities also included transfer packets that traveled with patients across settings of care, revisions in electronic records to include transfer information, increased efforts to communicate infection status, equipment purchases to improve patient transfers, and professional staff development and training. This training included relevant topics such as advance directives, infection control, handoff communication, and medication documentation. The local teams reported the following positive outcomes: • Use of transfer forms resulted in more complete and consistent transfer of key patient information from the NF and improved the consistency and standardization of communication • Critical information was easier to locate during the patient transfer • Staff were more knowledgeable about the importance of documenting information • Relationships between the between settings of care (NF, EMS, ED) improved and • Patient transfer communication improved along with communication about other issues that affect patients and staff. Most teams reported improved documentation of mental and physical functioning, infection status, reason for transfer, advance directives, EMS report, nursing report, documentation of treatment provided to a patient, and vital signs. Some teams reported improvement in the transfer of information about vaccinations, contact information about providers, medical history, the medication list, and the face sheet. Most reported no change in communication of recent laboratory work, information from the primary care provider, and information from the patient/ family—information items not targeted in the chart reviews.


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Interviews, site visits, and the project close-out survey indicated several factors influencing implementation success, including strong leadership at each of the partner sites (NF, EMS, and hospital ED) and the availability of grant funds. Although several project teams indicated that the process to implement changes across settings of care took longer than anticipated, strong leadership in the form of a project champion contributed to intervention success. Additionally, the availability of grant funds to cover local expenses was critical as these costs may have otherwise impeded engagement or full participation. These funds were especially critical for the NF and EMS partners who have greater difficulty freeing staff to participate in quality improvement initiatives. Several sites reported that physical proximity of the NF and EMS partners to the CAH (or lack of proximity) affected implementation. Similarly, some hospitals reported greater engagement in process improvement because the NF or EMS partners are owned or are business affiliates of the hospital. It is worth noting as well that the small size of the communities in which this demonstration was undertaken may have been a factor contributing to success. For example, in several communities, healthcare staff worked at more than one partner organization, which could have promoted and reinforced communication and process improvements across settings of care.

Impact on Communication of Patient Information Across Settings Analyses of the chart review data showed significant improvement in key areas across the three settings, including infection status (P , .0001) and baseline mental (P , .0001) and physical functioning (P = .0015) (Table 1). Improvements in each of the five targeted areas (advance directive, medication list, infection status, baseline mental status, and baseline physical status) varied across setting however. All three settings (NF, ED, EMS) showed improvements in the documentation and sharing of infection status (P value range ,.0001 to .003) and baseline mental status (P value range ,.0001 to .0014; Table 2). Additionally, the NF showed significant improvements in documentation and sharing of patient information on baseline physical status (P = .0032) (Table 2). Improvements in documentation of advance directives and medication lists were not significant and suggest that accurate and consistent information sharing of this information remains a challenge in all settings.

Limitations The results of this study are limited by the methodological challenges inherent in conducting evaluations of community interventions with nonequivalent interventions and in conditions that do not allow for controlled research designs. Chart reviews were conducted by project

Table 1. Average Number of Settings and Consistency With Documentation

Advance directive Medication list Infection status Baseline mental status Baseline physical status

Baseline quarter average (n = 10 projects)

Final quarter average (n = 10 projects)

P*

1.2 2.6 0.5 1.8 1.4

2.4 3.3 2.0 3.4 3.1

.0600 .1373 ,.0001 ,.0001 .0015

Maximum score = 3 with additional point if consistent across settings. Difference between baseline and final quarter averages tested using the Wilcoxon rank sum test with P , .01 used for statistical significance based on the Bonferroni procedure to account for multiple tests.

*



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Table 2. Percent of Charts With Documentation by Setting

Advance directive Baseline Quarter Final quarter P† Medication list Baseline quarter Final quarter P† Infection status Baseline quarter Final quarter P† Baseline mental status Baseline Quarter Final quarter P† Baseline physical status Baseline quarter Final quarter P†

Consistent information documented in all settings*

Nursing facility

Emergency department

Emergency medical services (ambulance)

64% (n = 119) 82% (n = 184) .1330

31% (n = 128) 53% (n = 184) .0617

15% (n = 128) 37% (n = 184) .1494

12% (n = 85) 36% (n = 166) .0592

73% (n = 119) 78% (n = 184) .6195

82% (n = 128) 96% (n = 184) .1247

57% (n = 128) 70% (n = 184) .5546

41% (n = 121) 56% (n = 180) .4075

13% (n = 119) 49% (n = 184) .0030

29% (n = 128) 86% (n = 184) ,.0001

2% (n = 128) 32% (n = 184) .0020

4% (n = 48) 29% (n = 164) .0129

25% (n = 119) 68% (n = 184) .0004

62% (n = 128) 97% (n = 184) ,.0001

56% (n = 128) 93% (n = 184) .0014

31% (n = 94) 62% (n = 183) .0044

27% (n = 119) 72% (n = 184) .0032

59% (n = 128) 88% (n = 184) .0357

46% (n = 128) 73% (n = 184) .1097

39% (n = 82) 55% (n = 176) .3845

n = number of transfer charts reviewed. One project had missing data for the NF setting at baseline, so this project’s consistency measures are based on ED and EMS data. † The chi-square test, accounting for clustering by project, was used to determine differences with P , .01 used to establish statistical significance based on the Bonferroni procedure to account for multiple tests. *

leaders, with technical assistance and guidance provided by the research team. The chart review scoring sheets were checked for completeness, but chart reviews could not be audited by the research team. Chart reviews were deidentified and reflected all transfers to the ED during the specified time periods; specific patient outcomes were not within the scope of this investigation. Additionally, outside the scope of this article was the sustainability of NF quality improvement efforts, such as the Quality Assurance and Performance Improvement (QAPI) process (Centers for Medicare and Medicaid Services, 2014).

Discussion The results of this demonstration indicate that focused community-level patient safety interventions can improve the sharing of critical patient information across healthcare settings. Notwithstanding variations in communication and information sharing strategies and tools, each of the 10 communities and improvement teams showed improvement in some of the targeted areas. Key factors that facilitated improvement included (1) the conduct of an initial “as-is” assessment and process mapping that revealed to staff in each setting the inconsistencies in process, practice,


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and communications, 2) the availability of outside technical assistance, training, and support to facilitate the process of identifying problems and gaps and potential improvement strategies, 3) information and data feedback from the research team that allowed the local teams to track their performance, 4) the availability of strong local champions and partnerships, and 5) the safe and supportive learning environment provided by the Maine CAH Patient Safety Collaborative that informed and reinforced local activity. Although each setting of care (NF, EMS, and ED) participated in internal quality improvement, none of the providers in this demonstration had focused on transitions between the settings or on other areas of mutual quality improvement interest. The “as-is” assessments conducted at the beginning of the demonstration revealed significant misinformation and misunderstanding among the participants regarding regulations/practices in the other settings, particularly regarding communication protocols, advance directives, staff roles, infection control and prevention, and documentation. The documentation of inconsistent or missing patient information in all sites of care during patient transfers was a significant surprise for all providers that served to equalize the playing field and led to the development of team building relationships that influenced the success of the project. The local sites all reported some difficulties and inconsistencies transferring patient information including advance directives, infection status, baseline physical and mental functioning, and current medications. Each site developed or adapted tools including checklists, transfer forms, and staff communication training to address these deficiencies. In addition to improving communication and information sharing between settings of care, participation in the demonstration prompted several sites to reach out to other NFs and other EMS services in their catchment area, to begin to address documentation on the return trip from the ED/hospital to the NF, and to offer in-service training with ED and NF staff on infection control issues. Four

of the sites committed to continuing periodic chart reviews to provide quality improvement information about patient transfers.

Implications for Practice The literature shows that poor communication and information sharing during handoffs between the NF and the hospital EDs are negatively correlated with patient outcomes (Grunier et al., 2012; Stiell et al., 2003; Ye et al., 2007). Incorrect, missing, or inconsistent patient information becomes part of the patient narrative as the patient receives care in the acute care setting, and once documented inaccurately in the patient record can have cascading effects through the patient’s stay. The results of this study demonstrate that with appropriate neutral facilitation and technical support, collaborative interfacility teams can assess and effectively address these communication and information exchange problems to help prevent patient safety errors and improve patient outcomes. Chart reviews of transferred NF patients indicate some gains in both communication and documentation of key clinical information categories; however, deficiencies in the documentation of the advance directive and an accurate medication list proved more recalcitrant to improvement in this demonstration project. Although inaccuracies in the patient medication list have significant implications for safe and appropriate clinical care in the ED, the failure of accurate and timely communication of patient treatment goals through advance directives is contrary to patient-centered care. Nursing facility patients are especially vulnerable during transitions of care between settings, and the advance directive plays a critical role in the expression of patient wishes when physical or cognitive decline may prevent patient–provider communication. Further research to design and evaluate both staff education and transfer process improvement is warranted to ensure that healthcare providers are aware of the personal end-of-life directives of NF residents.



The lessons of this demonstration suggest that local healthcare organizations and staff can devise practical strategies that can improve the communication of patient information across settings provided the usual cross-setting trust and other issues documented here can be overcome. As McDonald, 2013 and others have stressed, recognizing the important local contextual facilitators and barriers is critical to crafting effective quality improvement interventions. In the case of this demonstration, the involvement of neutral facilitators and the use of a positive nonblaming approach were essential for overcoming distrust organizational boundaries and other challenges that tend to be deeply rooted in community settings. Having objective information that quantifies the problem both within and across setting is also critical. Although the longer term sustainability of the gains demonstrated in this evaluation is unknown, it was clear over the 2 years of this demonstration that routine frequent monitoring of key information data points in patient records served to reinforce the local teams’ quality improvement efforts. Monitoring progress serves not only to help target areas to improve communication, coordination, and the accuracy and timeliness of patient information but also provides critical positive reinforcement for improvement efforts and gains.

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Authors’ Biographies Judith B. Tupper, DHEd, CPPS, CHES, Graduate Program in Public Health Faculty, Managing Director, Population Health and Heath Policy, Muskie School of Public Service, University of Southern Maine, Portland, ME. Dr. Tupper’s current research portfolio includes patient safety, rural healthcare, medication management, patient education, healthcare provider education, health literacy, quality improvement, and chronic illness and disability. Her roles in these applied research and demonstration projects include the roles of principal investigator, project director, and consultant. She also provided leadership and technical assistance to the Maine Critical Access Hospital Patient Safety Collaborative. A Certified Health Education Specialist (CHES), Dr. Tupper has field experience in a variety of clinical and administrative healthcare settings. She earned the designation, Certified Professional in Patient Safety (CPPS), in 2012. Carolyn E. Gray, MPH, Research Associate, Muskie School of Public Service, University of Southern Maine, Portland, ME. Ms. Gray has provided quantitative and qualitative analysis in program evaluation and research projects related to the patient-centered medical home, improving health outcomes for children (IHOC), and patient safety in hospital and community settings. In addition, she has worked on projects related to primary care,

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patient safety, transitions of care, medication management, and emergency department use. Karen B. Pearson, MLIS, MA, Policy Analyst, Muskie School of Public Service, University of Southern Maine, Portland, ME. Ms. Pearson has conducted research and published in the areas of rural patient safety, community paramedicine, and rural hospitals in her role as policy analyst and project director in the Maine Rural Health Research Center and Medicare Rural Hospital Flexibility Program. Additionally, she has worked on projects related to population health, public health quality improvement, chronic illness and disability, health policy payment reform, and other federal and state-funded research and technical assistance projects in the Muskie School. Andrew F. Coburn, PhD, Research Professor and Associate Dean, Muskie School of Public Service, University of Southern Maine, Portland, ME. A national expert on rural health, his rural research and publications have focused on rural hospital patient safety, the patterns of health insurance coverage for rural populations, rural health clinics, and the Medicare Rural Hospital Flexibility Program. He has testified frequently before Congress on rural health policy issues and served on the Institute of Medicine’s Committee on the Future of Rural Health Care. For more information on this article, contact Judith B. Tupper at [email protected] Supported by grant number R18HS019064 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. The authors declare no conflicts of interest.


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