Over nearly the last two years, nothing has become more evident that the importance of clear and concise communication during care transitions. As health care facilities struggled to manage the burgeoning demand for inpatient beds, and in particular ICU beds, care transitions were fast and furious. To facilitate care delivery and expedite care transitions, CMS issued numerous 1135 COVID-19 Emergency Declaration Blanket Waivers. Examples (not an exhaustive list) of those blanket waivers related to required communications that may have affected the quality or safety of care during and immediately after care transitions include:
- Allowance of audio-only telehealth for certain services.
- Waiver of the requirement to authenticate verbal orders within 48 hours.
- Restrictions on patient rights regarding visitation, particularly where an outbreak of COVID exists.
- Limitations on detailed information sharing for discharge planning for hospitals and critical access hospitals.
- Extension of time within which to complete medical records following discharge.
- Expansion of role of allied health professionals, reduction in physician supervision requirements in certain settings, and
- Waiver of requirement to develop and keep current a nursing care plan for each patient.
While intended to assure the safety and quality of care during the emergency, many of these waivers reduced requirements intended for safety and quality purposes. It remains to be seen whether these blanket waivers in the rear-view mirror will be seen as effective in their intended objectives.
So how do you evaluate whether documentation and communication during a care transition has been effective? To evaluate this, it is important first to agree upon what constitutes a care transition. Following that, it is helpful to articulate the various purposes (and target audience) for communication and/or documentation. Recognizing the correlation between the accuracy and completeness of communication and the incidence of medical error is critical to underscore the importance of all forms of communication. And, lastly, understanding how the limitation and implications of poor communication in all forms affects a facility’s liability.
WHAT IS A CARE TRANSITION?
A care transition occurs when all or a part of a patient’s care is transferred from one caregiver to another, whether it involves a change of location or not. Care transitions are easier to spot when the patient physically moves, whether inside the hospital or to an outside facility. Less obvious care transitions occur when the nurse from the prior day is not on duty and a new nurse takes over the care of a patient. Even more so, a care transition occurs every time a nurse takes a lunch break, and another nurse must cover for her/him.
And discharge to home is no exception- it is a care transition even if the patient is discharged to home only with family to provide services.
Regardless, effective and comprehensive communication at the time of each care transition is essential to assure safe and timely patient care. Each care transition provides an opportunity for risk of communication errors which are often contributing factors in sentinel events. All information must be current and accurate. Written documentation is only one source of communication and should not be relied upon totally to assure immediate attention to the patient’s specific needs is rendered upon transition. Staff receiving the patient during a care transition may not have time to read the entire chart, so critical information must be immediately available and accessible.
Nationally, about 18% of all patients discharged from hospitals to nursing homes are readmitted within 30 days. The challenges associated with these transfers may contribute to that rehospitalization rate and include the need for immediately retrievable access to medication information (e.g., last dose administered, discontinued meds, etc.), infection prevention challenges (e.g., latest labs, immunocompromised status, etc.), fall risk issues (e.g., history of falls, dizziness, toileting challenges, etc.), and risk of skin breakdown (e.g., integumentary changes, prevention protocols in place, etc.).
WHO IS YOUR AUDIENCE FOR COMMUNICATION/DOCUMENTATION?
Once a care transition is recognized, it becomes clear who the target audience is. However, it is not just that immediate audience that will rely upon the information communicated at the point of each care transition. Documentation, a critical form of communication, serves myriad purposes, including:
- Continuity of care
- Written record of communication between caregivers/patients
- Record of patient’s condition and changes
- Supports reimbursement
- Serves as evidence in the event of legal action
So, your audience includes other caregivers, patients and their family members, payers, and those who will judge the care rendered. Knowing this assists the person communicating (and documenting) in determining what are the essential elements that need to be communicated and then recorded.
HOW COMMUNICATION/DOCUMENTATION AND ITS LIMITATIONS AFFECTS LIABILITY
To be effective, documentation must be accurate, relevant, and consistent. But it also must be clear and concise. Conflicting with that edict is the need for comprehensive and complete records that are contemporaneously made and sequential. Each of these requirements contributes to whether the documentation is readily accessible and retrievable at the moment it is needed immediately following each care transition. Some of the CMS Section 1135 Waivers may have impacted whether records were contemporaneously made and whether delays in recording key information may have contributed to adverse outcomes may not have been discovered yet. Frequently, we have observed that health care providers are unable to recall key information concerning the care delivered to a patient if it is not recorded at the time the care is rendered. Yet another issue in written documentation is the routine use of subjective notes as opposed to objective assessments of the patients. Examples that demonstrate that disparity are included in the chart below:
|Appears confused||Patient found in lobby, stated he thought he was at the airport|
|Medicated for pain
(1/2 hour later) Reports relief
|Patient states incisional pain at a level 7 on 1-10 scale; patient medicated; (1/2 hour later) patient states pain at a level 2|
|Voiding qs||Voided 300 mL clear yellow urine|
|Pedal pulses present||Peripheral pulses in both legs 2+/4+|
|Taking oral fluids well (1000)||Drank 1,000 mL since 0700|
|Nervous||Patient asked several times about length of hospitalization, expected discomfort and time off work.|
|Breath sounds normal||Breath sounds clear to auscultation all lobes. Chest expansion symmetrical- no cough. Nail beds pink.|
Given the above, is it more likely that electronic medical records systems have had a positive or negative effect on the quality of documentation (and thereby overall communication) during care transitions? Reliance on an EMR can present issues. EMRs force choices and offer limitations in drop-down menus. A colleague of mine once referred to this as the “video game mentality.” The player wants to know the fastest way to get to the next level.
Some research suggests implementation of an EMR may result in improved and more efficient care, care coordination, and patient safety. But other findings indicate that while use of EMR may decrease the rate of “things falling through the cracks,” it is also associated with more frequent medication errors, fair/poor quality of care, and poor confidence in patients’ readiness for discharge? Why? Significantly, it seems that we become accustomed to drop-down menus and workarounds (to account for the IT programmer who did build the most direct path). We prefer to avoid free text whenever possible (preferring to use unapproved abbreviations and emoticons in our communications). This might be a contributing factor to reduced accuracy and comprehensiveness of medical records.
Moreover, we have also become a system that relies on standardization and protocols, to the point that we distribute (without reviewing with the patient) standard patient discharge protocols. Similarly, we present forms to the patient to sign at various stages of admission and discharge, without reviewing those forms and allowing patients to ask questions, saying “just sign here.” These rote processes where patients and families are not adequately informed and included in the health care process are often cited by patients and their families as the basis for dissatisfaction with the health care system, the care rendered, and ultimately contribute to the decision to bring a lawsuit.
Adding to the confusion is the attempt by some organizations to adopt charting by exception. But, as we all know, “if it is not documented, it did not happen.” Absent well-defined guidelines and standards of care with consistent execution and enforcement, CBE is not a panacea for our medical records woes.
Reviewing a medical record after a lawsuit or claim has arisen is like having 20/20 hindsight, not rose-colored glasses. A significant number of malpractice cases are “won/lost” on documentation alone. Absent that documentation, a care provider is not likely to remember accurately a particular patient, what happened, how and who was present. Inevitably, documentation viewed with that 20/20 hindsight is often judged to be inadequate to defend the care rendered. However, it is possible to mitigate the likelihood of a claim. Studies have shown improved communication and increased transparency around the care rendered and the health care process overall reduces the risk of being sued.
IMPROVING CARE TRANSITION COMMUNICATIONS
Improving care transition communications requires a recognition of all of the individuals with whom the information is being shared, including the patient and family. It requires identifying key patient information to share and deciding when and how that information should be shared. Collaborating among local care facilities, it may be possible to adopt standardized hand-off forms. Developing a standardized approach to care transitions requires outreach to key stakeholders, collaboration as to those critical elements of information, and periodic evaluation and adjustment of the process. Regardless, early and frequent communication between all care providers contributes to improved communications. In each case, it is important to consider:
- What is/are the most important thing(s) the next caregiver needs to know about a particular patient?
- How will that information be communicated?
- Does the medical record documentation reflect that?
- Is there a “right place” to record that information?