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Special Report: Improving care transition communication
Hospitals could use TMDS to convey data
Study shows improvement with its use
One important obstacle to clear, effective care transition communication is the format in which information is conveyed. If information about hospital patients is sent electronically, what should be included? Which fields are essential? And is it possible to include flexibility in an electronic form or data set?
Researchers at the MGH Institute of Health Professions in Boston have developed a transitional minimum data set (TMDS) that might serve as a model that addresses and resolves these issues. The TMDS tool was developed based on a literature review and an expert panel's suggestions. A study of the TMDS in use found that it was associated with marked improvement in the transfer of essential clinical information, although additional educational efforts were needed to improve consistency in its use.1
"Our focus was to help avoid hospital admissions for elders who go to the emergency room from long-term care facilities," says Diane Feeney Mahoney, PhD, ARNP, BC, FGSA, FAAN, a Jacques Mohr professor of geriatric nursing research at the MGH Institute of Health Professions.
Mahoney and co-authors sought to make the encounter in the emergency department more productive.
"Many elders who come to the emergency department are confused," Mahoney says. "So you need to know how they were normally; were they alert or confused? How did they normally function? Also, what are their risks for falls, aspirations, wandering, and seizures?"
The TMDS collects these details, giving clinicians a broader picture of who the patient is and what a particular patient's "normal" should look like.
"The emergency department staff loved it," Mahoney notes. "They felt the data set helped save them time, and they could more quickly focus on the issue at hand."
The form's usage rate was 91%, indicating it was widely adopted in clinical practice.1
Such a data set also can include information about the nursing home or other provider to which the patient will be transferred. For instance, the data set could show hospital discharge providers that a particular nursing home does not provide access to acute rehabilitation, which the patient will need, Mahoney says.
"This checklist appears to work, and it improved communication in the study, despite the fact that it was new and a pilot effort," she says.
One area that did not improve with the use of the data set was the reporting of the patient's tetanus/diphtheria vaccination status, Mahoney notes.
"We were surprised this part didn't improve, and it was the only thing that didn't," she says. "The emergency department staff really wanted to know someone's tetanus/diphtheria status, and that was on the form as a critical area, but only 3% had sent that information before and only 5% sent it with the TMDS form."
This is a communication deficit that nursing homes should address since it's critical to hospitals, and emergency medicine clinicians do not have time to search through hundreds of pages of documentation to find the answer, Mahoney adds.
A potential solution would be a better graphic design of the TMDS, making it easier for nursing home staff to see the question and provide an answer, she suggests.
An electronic transitional minimum data set also could be pre-populated with basic information, making it easier and faster to complete. For instance, the names and numbers of key staff, such as social workers and medical directors, could be pre-populated in the form.
"This is so people don't have to fill out everything under a crisis," Mahoney says.
Another way the TMDS could be improved is if the data set were embedded in an electronic medical record (EMR) as part of a standard form used at times of care transition. The EMR would not let users proceed until they answer all of the essential questions, she says.
With a data set embedded in an EMR, the pre-populated information could include the patient's basic demographics and family contacts.
"If they do not know the patient's tetanus vaccination status, then they can put in the form that it's unknown," Mahoney explains.
While MGH Institute's data set form was used solely from the nursing home to the emergency department, it easily could be created for hospitals to use and send to community providers, she says.
"I would think nursing homes would want to know how the medications were changed and what were any new diagnoses or new syndromes or exacerbation of syndromes," Mahoney says. "They'd need to know more about how to manage the patient's symptoms, and they could learn which information from the hospital could help the nursing home prevent readmissions."
Hospitals using such a data set could seek input and buy-in from the community providers who will be using it.
"They could educate nursing homes as to the utility of the form," Mahoney suggests.
The TMDS study followed hospital admissions from a 140-bed nursing home. There were 33 cases in the baseline comparison group and 41 cases in the post-TMDS group, she says.
The skilled nursing facility averaged 17 emergency department transfers per month. Investigators determined the effectiveness of the TMDS tool by measuring the proportion of TMDS items received by the emergency department after implementation of the TMDS when compared with prior care.1
The TMDS tool had 30 items, but its length did not appear to be a barrier to its adoption by clinicians, Mahoney says.
Users of the tool suggested that it list why the patient was being transferred, providing space for more detail or an open-ended question, she says.
Hospitals and other health care providers increasingly will find they need to use tools and checklists to improve communication during care transition, Mahoney says.
"The regulatory side wants it; the technology side can do it, and now there are more financial incentives for facilities to adopt the technology that makes it possible," she explains. "Everybody knows issues get dropped."
So it's important to determine the critical elements that will make the transition safe and successful, and these elements need to be collected quickly and efficiently, she adds.
The purpose in having a TMDS tool is that it asks the right questions for the provider receiving the patient. This provides a greater understanding of the situation since each provider has different priorities and the nursing home might need to know different information than do emergency department physicians.
"The patient's status is a moving target, and it's critically important that we keep that information about him easily achievable," Mahoney says.
For instance, a nursing home patient's data set might indicate he was walking to dinner, sitting with friends, and having conversations a couple of months earlier. So the dementia noted when he was brought into the hospital might be delirium caused by a recent infection or new medications, and it's been misidentified as Alzheimer's disease, she explains.
With the correct information readily available to hospital clinicians, the patient's care plan and goals are adjusted with the hope of returning the patient to his former level of function.
"We want to get patients back to their pre-existing best optional functional level," Mahoney says.
1. Kelly N, Mahoney DF, Bonner A, et al. Use of a transitional minimum data set (TMDS) to improve communication between nursing home and emergency department providers. J Am Med Dir Assoc. 2011;[Epub ahead of print.]
Diane Feeney Mahoney, PhD, ARNP, BC, FGSA, FAAN, Jacques Mohr Professor of Geriatric Nursing Research, MGH Institute of Health Professions in the graduate program in nursing, Charlestown Navy Yard, 36 1st Ave., Boston, MA 02129-4557. Telephone: (617) 643-2745.