Improved Pre-hospital

Communication

Clinical Group F: Sai-Han Ackerman, Scott Demar, Natalie Drorbaugh, Elizabeth Farr, David Fuentes, Emily Groves, Whitney Ligon, Meredith

Pelty, Tricia Salls, & Athena Watkins

Factors Influencing ED Admits From Nursing Homes

• Nursing home residents account for more than 2.2 million emergency department (ED) visits annually in the United States.▫40% of Nursing Home (NH) admits are preventable▫84% are discharged back to NH▫ED length of stay was ~5 hours

• Emergency admits were more likely during “out of hours”

• Lack of proactive care for residential home▫Staff had no reference to medical advice

• Fall related injuries most common for ED visit

(Wang et al., 2011, Gillie, 2010, Evans, 2010)

Our Situation• Skilled Nursing Facility (SNF) across the street

from major ED• There is high flow of patients from SNF to ED• Increased ED burden has resulted in higher

levels of boarding• Increased patient visits from SNF to ED has

results in problematic patient weight times

Our Expansion Project

• Partnership between SNF and hospital• NP from hospital staff

▫Daily rounds to SNF▫On call after hours

• Will visit SNF to examine patients▫Dx and Tx for non-acute issues▫Refer non-acute issues to physicians and NPs

during regular hours▫Refer acute cases to ED with detailed information

Call ED to give support and coordinate beginning of admission process

Two Departments Most Affected

• Emergency Department (ED)▫ Goal: Decrease influx of patients and crowding in the ED▫ Decreased crowding, wait times, and influx will

Improve patient satisfaction Increase patient safety Save the ED money by decreasing resource wasting

• Skilled Nursing Facility (SNF)▫ Currently patients admitted to the ED from the SNF

account for a large number of patients seen in the ED▫ SNF will need to communicate with NPs on call to assess

potential admits▫ SNF will be responsible for establishing transport for

nursing home patients that may be admitted

• Unit Director

• Nurse Practitioner

• Staff Nurse

• Community Relations/PR

• Nurse Administrator (CNL)

• Director

• Nurse Assistant

"Relaying Help" Task Force

Emergency Departmen

t

Hospital Administration

Skilled Nursing Facility

Shared Governance Council

Hospital Staff• Community Relations/PR

▫ Mediator for ED and SNF▫ Spread the Word

• ED Unit Director▫ Train staff▫ Increase awareness in ED

& hospital• Nurse Administrator (CNL)

▫ Possible changes▫ Cost=benefit▫ Evidence based practice▫ Compare baseline &

interventions

• Nurse Practitioner▫ Primary care at the SNF▫ Dx, Tx, & referrals

• Staff Nurse from ED▫ Representative of staff

nurses▫ Provide input to improve

continuity of care

Shared Governance Council

Skilled Nursing Facility• Director from SNF

▫ Collaborates with the hospital

▫ Give suggestions to decrease ED visits and background information

• Nurse Assistant ▫ Provide insight on

patients ▫ Identify needs of staff▫ Give insight and input

Task Force Meetings

•Meetings will be bi-monthly▫Every 2nd and 4th Wednesday of the month

from 12:00 – 14:00•Include all members of the task force

Meeting 1:"Relaying Help" Agenda• Goal of the meeting: To establish task force goals

• I. Introductions• II. Action items from previous meeting• III. Agenda Items

▫ Purpose of the task force▫ Establish goals of project▫ Discuss current issue of SNF residents coming to ED

• IV. New Action Items▫ Review the literature on SNF-ED relationship and other interventions▫ Interview ED staff about what they believe the problems are and how

they think these problems can be solved▫ Determine reasons why SNF residents come to the ED

• Future meeting goals:▫ Understand the problems and discuss solutions

Goals of the Project

1. Decrease the inappropriate use of the ED

2. Save the hospital time and money

3. Free up ED beds that are unnecessarily used

Throughput Issues - ED

•Patients arriving from SNF will come with more complete H&P workup▫But some Dx tests may still be needed

•ED will still need to find beds for these patients in the hospital—deal with bed control▫Possible backup of patients that are known

to need admission depending on availability of beds

•Expected decrease in non-acute patients

Action Plan for ED Issues•NP will evaluate acuity level & provide

thorough H&P of the SNF resident for those that need to be sent to ED▫Will call in report to ED, give report &

recommendations to ambulance personnel (and ED charge nurse via phone)

▫This will help decrease ED diagnostic time so patients are admitted more efficiently

Throughput Issues - SNF

• Space for NP to work may be needed• Changes in processes will be needed

▫SNF staff call NP instead of sending to ED• Non-critical patients will remain in the SNF

▫More staff may be needed in SNF▫SNF staff will be needed who are qualified for

dressing changes, IV antibiotics, etc.• Transport may be issued for patients needing

outpatient follow-up rather than ED care• Less back & forth movement of patients as

noncritical issues addressed by NP on site

Action Plan for SNF Issues

•SNF staff orientation & training▫Explanation of rationale for change,

benefits to SNF and patients▫Training s/s to look for to call NP

How to report s/s to NP on call▫Case studies/scenarios

•Development of space for NP to work and see patients

•Checklists & Decision Trees

Action Plan for Expanding the Usage of SBAR

•What is SBAR?

•Why SBAR?

•SBAR Training

•Implementing SBAR

What is SBAR?

•Situation▫What is going on with the patient?

•Background▫What is the clinical history of the patient?

•Assessment▫What are the assessment issues, what is the

problem?

•Recommendation▫What is the plan of care?

Dayton & Henriksen, 2007

Why SBAR?

•SBAR endorsed by:▫The Institute for Healthcare Improvement▫The Joint Commission

•Reduces the risk of:▫Communication errors▫Misinterpretation of information

•Improves patient safety

Dunsford, 2009

SBAR Training

• The NP and ED staff will be required to attend an 8-hour workshop ▫Presentation

Rationale for use of SBAR Practice exercises with demonstration of effectiveness

▫Video Vignettes▫Clinical Scenario's▫Discussion of exact implementation date▫Expectations

NP and ED will be required to use SBAR for any and all patient reporting

All patients arriving from SNF to ED will be sent with an SBAR report from the NP

Veltman & Larison, 2009

Implementing SBAR

•Aids to Implement SBAR in the ED:•Worksheet•Poster•Items with SBAR on them:

▫name tag▫mouse pads▫pins

•DVD with video examples

Compton, Copeland, Flanders, Cassity, Spetman, Xiao, & Kennerly, 2012

Veltman & Larison, 2009

Team Strategy Approach Issues• Overworking the Nurse Practitioner

▫High time demand for the NP▫Result: SNF gets backed up due to the NP backup▫Can cause patients to stay in the SNF for too long,

especially if they need to go to the ED• Lack of Resources

▫Resulting in a high volume of patients still being transferred to Ed (Ex: CT to R/O pneumonia)

• Backup in the ED ▫No bed placement on other floors▫Pts from SNF still taking up beds in the ED as they

wait for placement.

Team Strategy ApproachSolutions• Overworking the Nurse Practitioner

▫Hire more Nurse Practitioners This will help prevent backup

• Lack of resource▫NP can establish the infection via urine test▫Send pt to radiology or diagnostic imaging instead of

the ED Bypass the ED

• Backup in the ED▫Keep patient at the SNF until a bed is available.▫Future- more portable equipment to prevent backup in

the ED Ex: portable beds

References• Compton, J., Copeland, K., Flanders, S., Cassity, C., Spetman, M., Xiao, Y., &

Kennerly D. (2012). Implementing SBAR across a large multihospital health system. The Joint Commission Journal on Quality and Patient Safety, 38(6), 261-268. Retrieved from http://docserver.ingentaconnect.com/deliver/connect/jcaho/15537250/v38n6/s3.pdf?expires=1354291174&id=71750911&titleid=11231&accname=UCLA+Library&checksum=8DA55D50E1D7DA4DC70BF9D2FD598132

• Dayton, E., & Henriksen, K. (2007). Communication failure: Basic components, contributing factors, and the call for structure. Joint Commission Journal on Quality and Patient Safety, 33(1), 34-47. Retrieved from http://docserver.ingentaconnect.com/deliver/connect/jcaho/15537250/v33n1/s6.pdf?expires=1354258357&id=71742936&titleid=11231&accname=UCLA+Library&checksum=1C1BBB35834084AE6C26D195DB7D5EF5

• Dunsford, J. (2009). Structured communication: Improving patient safety with SBAR. Nursing for Women’s Health, 13(5), 384-390. doi: 10.1111/j.1751-486X.2009.01456.x

• Veltman, L., & Larison, K. (2009). PURE conversations: Enhancing communication and teamwork. Journal of Healthcare Risk Management, 27(2), 41-44. doi: 10.1002/jhrm.5600270208