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Dangerous handoffs with elders must end
Information often inaccurate
There is no question that handoffs between long-term care facilities and EDs are high-risk times for elder patients. "Transfers because of an acute deterioration of the patient can result in a lack of communication related to pertinent history, medications, allergies, and code status," says Samuel Shartar, RN, CEN, director of the ED at Emory University Hospital in Atlanta.
Patients from long-term care facilities are often fragile, and a clear, accurate report is essential, says Judy Maxwell, RN, an ED nurse at Cheyenne (WY) Medical Center. "If we have a clear picture of the situation, we can proceed with definitive care. Because the elderly are compromised, they can get septic from the tiniest infection. Care needs to be aggressive and definitive."
Getting the "whole picture" of the patient might mean a better outcome, Maxwell says. "All who take care of the patient should consider this a team effort," she says.
Elders might be poor historians due to their cognitive status. Kelly Chasteen, RN, associate chief nursing officer at Wesley Woods Geriatric Hospital in Atlanta, says, "Their ability to advocate for themselves or give correct information may be limited."
Information from the long-term care facility might be incomplete, have too much detail so that important information is easily overlooked, or it might come in a different format than the ED uses, either electronic or manual. "The patient may also have multiple care providers and care settings," Chasteen says. "They may go offsite for some portion of their care, or practitioners may come to the facility. It's not one-stop shopping for all their information."
Information from long-term care facilities, whether verbal or written, might not be complete. Karen Smith, MS, RN, CEN, director of emergency services at Newport (RI) Hospital, says, "We can get some inaccurate assessments from the staff. Validate what they've said with what you see on arrival."
Reports might lead ED nurses to believe a patient is in an emergency situation, but the patient is stable on arrival. "Or, we can get a report that says that the patient is basically in good shape but had a little difficulty breathing, and they are just about ready to code when they get here," says Smith. "There are sometimes things we would have expected to hear about that get skipped. Medication sheets may be very difficult to read."
Staff at the facility might lack essential information about the current status of the patient, or the information might be misunderstood, says Jacquelyn Byrd, MSN, RN-BC, an ED clinical nurse specialist at Emory University Hospital -- Midtown, in Atlanta. "A formal handoff usually does not occur between the ED staff and the long-term care facility," says Byrd. "Often, the information that you receive is coming 'second-hand' from emergency medical service [EMS] personnel transporting the patient." EMS, though, might have only information regarding the current reason why the patient is being sent to the ED, without any additional history.
Eileen Brassil, RN, clinical coordinator for the ED at Northwestern Memorial Hospital in Chicago, says, "Sometimes when we take a call from a facility, the person giving the report can't provide an adequate history on the patient or why they're coming. You have to hunt for that information. It can really slow down the overall process."
Use of formal transfer forms can help to obtain necessary information consistently. Shartar says, "These can be faxed to the ED after EMS has left, to prevent transport delays in an emergency."
Sources & Resources
For more information on handoffs from long-term care facilities, contact:
On the phone, obtain this info
When taking a phone report about an elder patient being transferred to your ED, you might find yourself frustrated. One reason is that the skill set or knowledge of the long-term care facility employees might be lacking.
"They might not have a RN-heavy facility. So when they give a patient's history, they might get terms incorrect or trip up over medical language," says Eileen Brassil, RN, clinical coordinator for the ED at Northwestern Memorial Hospital in Chicago. Here are some good approaches for this scenario:
"And, get the name and direct phone number of the person giving the report. Follow up with them should additional questions arise," says Brassil.
For example, ask if they have tried giving acetaminophen to relieve pain, says Brassil.
Jacquelyn Byrd, MSN, RN-BC, an ED clinical nurse specialist at Emory University Hospital -- Midtown, in Atlanta, says, "Gather pertinent information about the patient, including mental status and level of alertness. When possible, speak directly with the primary care provider for the patient."
Good assessment led to good outcome
Recently, Judy Maxwell, RN, an ED nurse at Cheyenne (WY) Medical Center, cared for a woman brought by ambulance from a long-term care facility. She was told only that the patient had started running a fever that progressively got worse.
"Tylenol was not helping, and the patient's mental status was now changing," says Maxwell. "Upon admission, she had a fever of 103." ED nurses did these interventions:
"The care of the patient took just a little over an hour. The patient was then admitted to the intensive care unit," says Maxwell. "After one week, the patient returned to her nursing home."
Get 'must-have' info on elders in the ED
To obtain "must have" information for handoffs involving transferred elders, Kelly Chasteen, RN, associate chief nursing officer at Wesley Woods Geriatric Hospital in Atlanta, recommends using an abbreviated form.
"You need to get a complete picture of what is going on with the patient," Chasteen says. The form should give you:
An in-person or phone consultation can be done as needed. "If the patient is unable to make decisions for him or herself, you need to know the appropriate spokesperson," says Chasteen.
"This is often ambiguous, and you need to know their wishes," Chasteen says.
Elder patients might have complex histories and multiple comorbid conditions. "With more factors to consider, history taking is more difficult," says Chasteen.