IF it was easy to ensure that all patients' needs were met with the highest quality of care, fewer instances of medical errors due to shift handovers and patient transfers would occur. Patients would receive services without duplication, misinterpretation, or omission as they move from one site or clinician to the next.
However, since healthcare services are continuously provided in a complex, loosely organized "system," the potential for errors due to handovers and patient transfers-collectively known as "care transitions"-is enormous. Patient safety organizations and advocates agree that a key component of reducing the incidence of medical errors is to examine the processes that patients undergo as they move from one site or clinician to another for both acute and chronic needs.
Care transitions are defined as patient transfers within one setting, for example, from the emergency department to intensive care unit, or from one care setting to another, such as from a hospital to the patient's home or skilled nursing facility. The potential for medical errors exists whenever more than 1 healthcare provider or site of care is involved in providing services. Moreover, patient safety research demonstrates that the cumulative effect of mistakes that occur during care transitions can result in significant patient harm or even death.
RESEARCH TARGETING PATIENT TRANSITIONS
Over the past 10 years, the Agency for Healthcare Research and Quality (AHRQ) has funded numerous studies that have assessed efforts to improve patient transfers from one site or one type of provider to another. These studies can be broadly categorized into the following areas:
* Using health information technology, such as electronic medical records and e-mail, to enhance clinician communication and documentation and to facilitate communication between clinician and patient
* Using care/case managers to improve chronic disease management
* Assessing the impact of tools to enable self-management and communication about the patient's health status in between visits to clinicians.
Health information technology can decrease communication errors from one site or clinician to another associated with omissions and time delays. Several AHRQ-funded studies are currently in the process of assessing the impact of a patient- and clinician-shared electronic medical record (EMR) as well as an integrated outpatient and inpatient information system to improve communication during care transitions and the quality of patient care over time.
For example, an AHRQ-funded grant at DuBois Regional Medical Center (DuBois, Pennsylvania) is testing implementation of an EMR system that allows 24-hour data sharing across 7 rural healthcare delivery sites for clinicians to access current patient information with either a personal digital assistant or Web portal. One of the key objectives of the project is to use the EMR system to improve patient safety and reduce the frequency of medical errors, such as adverse drug reactions and mistakes when physicians cover for their colleagues. The project is scheduled for completion in September 2007.
While the evidence is emerging about the use of new technologies, some findings have indicated that changes to current processes need to be considered and may serve as a hindrance to communicating information about patients1 during and after times of transition. Nursing research can be instrumental in assessing the effectiveness of these technologies in improving patient transitions.
Integration and utilization of care/case managers and tele-health technologies to improve chronic disease management is another mechanism that can be used to improve care transitions. Research in this area has included using tools to enable self-management and to communicate the patient's health status between visits to clinicians, particularly in vulnerable populations such as those in rural communities, those with multiple morbidities, and those seeking care from multiple clinicians and multiple sites of care. Because nurses play a critical role in care/case management, nursing research is needed to better understand the tools, competencies, and resources that can enable optimal care/case management, particularly during care transitions.
CHANGING NEEDS REQUIRE MORE TRANSITIONS
Patients' needs change over time. Whether chronic or acute, their conditions could reflect a new diagnosis, symptoms without a diagnosis, or a sudden change in health status. With few exceptions, healthcare operates as a continuous process involving a variety of clinicians, including nurses, physicians, pharmacists, and others who work in shift rotations and in an array of care delivery settings. Consequently, patients often move from one clinician or site of care to another, particularly when their needs are complex.
Care transition episodes frequently involve verbal or written transmission of patient information, thus increasing the potential for information to be lost or miscommunicated. Examples include the following:
* Adolescents moving from child to adult care2
* End-stage renal disease patients transitioning between dialysis and kidney transplantation3
* Shift handover and shift changeover
* Ambulance to emergency department transfer, then hospital admission
* Transferring a patient from an acute care setting to a skilled nursing facility or to home, with or without home care
* Transitions from self-care to family caregiving
* Transferring from intensive care to end-of-life and palliative care.
Quality improvement strategies for improving care transitions often require changes in the process of care delivery by nurses, physicians, and other clinicians. However, care transitions should also involve patients when appropriate. Encouraging patient involvement is a National Patient Safety Goal of the Joint Commission. Instead of treating patients as an object or a number that needs to move from one site to another, the intent should be to foster care transitions that are patient-centered, that can support patient choices and goals, and that can benefit from an interdisciplinary team approach.
Patient-centered transitions also could enable patient education and participation by eliciting goals and preferences. Because quality improvement strategies that seek to improve transitions can involve nurses, physicians, managers, and patients, it is important to establish performance standards and measures, demonstrating improvement and providing assurance of continued quality of care delivery.
MULTIPLE CARE PROVIDERS, CARE SETTINGS REQUIRE COORDINATION
With multiple care providers and settings further complicated by varying insurance coverage and geographic locations, patients are likely to visit numerous locations for acute, postsurgical, and chronic disease care. Coordinating care to ensure high quality is challenging because it often involves multiple individuals-the patient, a clinician, a friend, or family members.
Transitions among settings pose even more chances for error, as key information may be lost during transfers from or to clinics, nursing homes, and acute care settings, and during shift changes on hospital floors. For example, a 28-year-old man who sustains a tear of an anterior cruciate ligament while skiing may require treatment from a minimum of the following 13 people or care teams:
* The snow patrol rescue team on the slopes
* Emergency medical technicians during transport to the hospital
* Physicians and nurses in the emergency department
* Nurses, orthopedic surgeons, and anesthesiologists before and during surgery
* Physicians, nurses, and physical therapists following surgery, and
* Physical therapists, nurses, and orthopedic surgeons in ambulatory settings.
As patients move from one care setting to another, the role of nursing in the care and decision-making process across settings can be critical for patients. Yet the measurable impact of nursing during transitions is not fully understood.
Another potential gap in the continuity of care can occur owing to medication errors associated with admission, transfer, and discharge.4 To reduce the likelihood of this problem, organizations are putting medication reconciliation programs into place that double-check patient records and orders to verify proper medication use and identify potential unintended variances. Medical reconciliation, together with health information technology, can enable nurses and other clinicians to avert many medication errors.
In one study, 75% of potential medication errors at the time of a patient's transition to or from the hospital were intercepted because of a standardized medication reconciliation process.5 Since nurses perform a variety of roles involving dispensing medications to patients, they also can be active participants in a hospital's medication reconciliation process. Nurses are typically involved in coordinating how medications are ordered (with physicians and nurse practitioners), filled (with pharmacists), and administered (with other nurses and patients).
NEED FOR ACCURATE, TIMELY INFORMATION
As patients move from one clinician or one site of care to another, active communication-during which participants take responsibility for accurate, 2-way communication-provides nurses with an adequate knowledge base with which to deliver quality care. This type of information transfer should be the standard during patient and shift handoffs to reduce or eliminate the potential for errors due to missing or inaccurate information. In acute care and other settings where changes in a patient's condition or needs can occur on a daily or hourly basis, clear and up-to-date information is critical.
However, communication failures have been found to be the root cause of failure in almost 70% of all sentinel events reported to the Joint Commission.6 The quality and safety of the handoff process has been shown to be variable, unstructured, and error-prone.7,8
Reasons for these failures vary. Clinicians may not possess effective written or verbal skills, or they may lack formal training in effective handoffs. The handoff process also has not been standardized, allowing clinicians to provide inconsistent levels and quality of information.
The Joint Commission's Second National Patient Safety Goal addresses staff communication by introducing standardized forms of communication to improve clarity and reduce ambiguity, including:
* Using "read backs" by the receiver of information for all telephone orders and reports of critical test results,
* Using the Situation-Background-Assessment-Recommendation (SBAR) technique to communicate about a patient's condition,
* Consistently using briefings and debriefings,
* Avoiding interruptions and minimizing distractions during all handoffs, and
* Monitoring and giving feedback on handoff performance and skills.9
In addition to using effective communication skills and techniques, clinicians need access to and proficiency in health information technology. EMRs that are comprehensive, current, and accessible are important tools that quickly enable the summarizing of medical histories and provide clinicians with up-to-date information on patients' conditions at key care transition points.
REMAINING CHALLENGES
Despite the growing adoption of processes such as medication reconciliation and the SBAR technique by organizations seeking to reduce errors during care transitions, 3 key challenges remain:
* Immediately translating evidence into everyday practice
* Improving all care transitions, especially because more care is moving out of inpatient settings and depends on self-care or family caregiving9
* Targeting future research to advance transition quality measures10 and to examine the factors involved in transition inefficiencies.
Effective healthcare transitions involve nurses as well as patients and are vital to the delivery of quality healthcare that we provide and may receive.
REFERENCES