An “F” for Quality

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An "F" for Quality Aug 27th 2013, 17:06, by Ken Covinsky, MD By Ken Covinsky, MD 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.   Ken Covinsky, MD is a professor of geriatrics and clinical researcher at the UCSF School of Medicine. He blogs at GeriPal, where this post first appeared.

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