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Development and testing of a standardized communication form to improve transitions for nursing home residents
Greta Cummings, RN, PhD, FAAN, FCAHSUniversity of Alberta
Webinar SeriesMay 25, 2016
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Welcome to the CFNWebinar Series
Development and testing of a standardized communication form to improve transitions for nursing home residents
Webinar & slides posted on CFN website: www.cfn-nce.ca
Carol BarrieExecutive Director
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25/05/2016 Footer text for the presentation
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Q-&-A session
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2016-04-06
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Presenter
• Centennial Professor in the Faculty of Nursing at the University of Alberta
• Leads the CLEAR (Connecting Leadership, Education & Research) Outcomes research program and within it, the Older Persons’ Transitions in Care (OPTIC) research program. This research program examines the quality of transitions of frail elderly clients across three care settings: Continuing Care facilities, Emergency Medical Services, and Emergency Departments
• Dr. Cummings has published over 160 papers and is a 2014 Highly Cited Researcher in Social Sciences(Thomson Reuters). Dr. Cummings’ has received the Canadian Nurses Association Order of Merit for Research, and in 2015 was inaugurated into the Sigma Theta Tau International Nurse Researcher Hall of Fame.
Development and testing of a standardized communication form to improve transitions for nursing home residents
Greta Cummings, RN, PhD, FAAN, FCAHS
2016-04-06
OPTIC IMPACT (Improving Communications during Aged Care
Transitions 2014-2015) CFN Webinar
Dr. Greta G. Cummings RN PhD FAAN FCAHS
With slides by Patrick McLane & Matthew Pietrosanu
(OPTIC) Older Persons’ Transitions in Care Research Program in partnership with Alberta Health Services
TeamPrincipal InvestigatorGreta G. Cummings, Professor, Faculty
of Nursing, U of A
Co InvestigatorsColin Reid, Assistant Professor, Health
and Exercise Sciences, U of BCCarole Estabrooks, Professor, Faculty of
Nursing, U of ABrian Rowe, Professor, Department of
Emergency Medicine, U of AAdrian Wagg, Professor, Healthy
Ageing, Faculty of Medicine and Dentistry, U of A
Garnet Cummings, Associate Professor, Education/Disaster Medicine, U of A
AHS Decision-MakersCarol Anderson, Executive Director,
AHS, Continuing CareKaren Latoszek, Senior Patient Care
Manager, UAH Emergency DepartmentGarnet Munro, Director, EMS Clinical
Operations, Edmonton MetroAnn Chiovetti, Manager, Quality & Patient
Safety, EMS Central Zone Research StaffSarah Cooper, Master’s of Nursing-Nurse
Practitioner Student, U of APatrick McLane, CLEAR Outcomes
Research AssociateKaitlyn Tate, Honours Student, CLEAR
Outcomes ProgramMatthew Pietrosanu, CLEAR Outcomes
Program, Data Analyst
Funding
This research is funded by TVN, which is supported by the Government of Canada through the Networks of Centresof Excellence (NCD) program.
OPTIC Program mission
To improve care of long term care residents across the healthcare continuum
To avoid unnecessary transitions and improve those that are necessary
OPTIC Settings This study was conducted in Edmonton, Alberta and
Kelowna, British Columbia July, 2011 – July 2012
26 LTC facilities in Alberta, 12 in British Columbia
2 Emergency Departments
1 Emergency Medical Services
OPTIC 1 results showed significant gaps in documentation and availability of information about the resident to all healthcare providers during the transition of care.
Documentation of assistive devices (glasses, dentures,
etc.) accompanying the resident across the transition
was lacking.
Implications for quality of life/moment, policy, and
resources
Quality of Life for Seniors –Assistive Devices
6
Definition: Safety of Older Persons’ Transitions in Care
Embargoed Do Not Share
IMPACT Study Purpose
To test a standardized two-page evidence-informed Inter-Facility Patient Transfer form to improve communication between Long Term Care (LTC), the Emergency Department (ED) and Emergency Medical Services (EMS).
IMPACT Objectives1. To pilot test the new AHS Inter-Facility Patient Transfer
form.
2. To measure healthcare providers’ (HCP) assessment of feasibility of use, usefulness and applicability of information included in the form to their practice.
3. To assess rates of form and data element completion.
Learning Objectives1. IMPACT was a joint project between the CLEAR
Outcomes Program and Alberta Health Services, intended to improve communications between sites involved in older persons’ transitions in care.
2. Healthcare staff turnover and research fatigue presented major challenges to implementation of study protocols.
3. Multi-site/multi-provider implementation projects must consider best practices for implementation of new initiatives, and burden/benefit for each setting.
IMPACT Transition ProcessLong Term
Care Facility
Emergency Medical Services
Emergency Department
Emergency Medical
Services/ Inter-Facility
Transfer
ONE STANDARDIZED INTER-FACILITY
PATIENT TRANSFER FORM
INTER-FACILITY PATIENT TRANSFER FORMPage 1 Page 2
Green area completed by LTC facility
Brown area completed by EMS
Red area completed by ED
Document Process FlowLong Term Care (LTC)
Document originates at LTC
LTC nurse completes area outlined in green
Keeps ‘canary coloured’ copy for resident’s chart
Provides original to EMS
Document Process Flow EMS
EMS completes brown outlined area at the time of pick-up
Original goes with the resident to ED
Document Process Flow ED
ED nurse completes the Receiving Facility section; 1st
red outlined area.
Upon completion of care, the Return trip section (2nd red outlined area) is completed by hospital nurse.
Document Process FlowIFT\EMS Return
IFT\EMS will complete the 2nd and final brown outlined area.
Sample 11 of the 15 LTC sites that transferred the highest numbers of
residents to the participating ED during the original OPTIC study participated in IMPACT.
These LTCs are a mix of public sites, private for profits and private non-profits.
1 Alberta Health Services ED was enrolled.
Edmonton EMS (part of Alberta Health Services) participated.
Methods Training on the new transfer forms was provided to night and day
shift staff in the ED and participating LTCs.
Training was provided to Edmonton EMS staff through emailed training materials and orientations conducted by EMS managers.
RAs collected forms from the ED and again on patients’ return to the LTC.
Pre and Post surveys were conducted with staff in all settings.
Challenges Participating sites and individuals suffered from “research fatigue,”
having been involved in many recent studies.
High staff turnover in LTCs meant that many new staff responsible for completing the form never received training.
Research assistants frequently encountered healthcare staff in participating sites who were unaware of the study despite training.
Site staff frequently resisted the new form, especially where sites already had either paper or electronic transfer forms in use.
Results - Form Use The form was used in 90 of 247 resident transitions captured by
data collectors across the 11 participating LTC facilities over an eight month period, February 25 – October 30, 2015.
This is 36.4% form uptake.
Uptake varied dramatically by site and setting.
Form use by LTC Facility23
18
9
0
2
5
2
6
5
20
0
0
5
10
15
20
25
10 11 12 13 14 15 16 17 19 20 21
March 1 - October 31 2015
# of IFPT Forms sent with residents to ED
Return of forms to LTC 2 forms in our sample of 90 were never sent from the
LTC to the ED.
Of the 88 forms sent to the ED, 69 (78%) were not returned to the LTC.
11 of these 69 (15%) were not returned because the patient was deceased in hospital.
Form Completion• In 57 cases, only the sending LTC completed
information on the form. In 14 of these cases, less than 10 items were complete.
• In 16 cases, one of the two pages was found to be missing.
• EMS completed information on the form in 15 cases.
• ED completed information on the form in 5 cases.
• In 1 case, all provider sections of the form were complete.
Results: Item Completion
Page 1 - Item Completion• Reason for Transfer was filled out in 79% of cases.
• Principal Diagnosis in 69% of cases.
• Next of Kin Name in 54% of cases (phone # 51%).
• Physician Name in 51% of cases (phone # 22%).
• Goals of Care Information in 72% of cases.
• Allergies in 81% of cases.
• Sending Practitioner in 69% of cases (phone # 49%).
Page 2 – Item Completion Personal Items – Glasses noted in 12% of cases
Personal Items – Dentures noted in 14% of cases
Name of Transport Staff – From LTC - 11%
Name of Receiving Practitioner at Hospital - 2%
Return Trip (Sending Back) Practitioner Name - 3%
Return Trip - Transport Staff Name - 2%
Healthcare provider surveys Responses measured on a Likert scale from 1 (“never”)
to 5 (“always”)
13 statements – on specific item identifiability
Pre survey – identifying information in standard health care record
Post survey – identifying information in a) standard health care record (without form)b) Using transfer form
Post-Survey Response Rate Post survey response rate was 83%. n=265/318
Relatively few respondents experienced a transfer where the IMPACT form was used (68/265, 26%).
Survey Results: All Settings
Wilcoxon signed-rank tests performed on responses from individuals answering both with form and without form surveys (paired responses) in the ED, EMS, and LTC settings
Descriptive statistics for all respondents are shown for some survey items where the test found paired responses significantly different (𝑝𝑝 < 0.05) than what we would expect if respondents had no preference to transfers with or without the form
Responses about transfers with the form often had higher means and/or medians than responses about transfers without the form
Survey Results: All SettingsSurvey Item N Mean SD MedCode status was easily identifiable. Without 242 3.44 1.06 3.00
With 68 3.63 1.13 4.00Baseline mental status was easily identifiable.
Without 240 2.72 1.04 3.00With 68 3.24 1.19 3.00
Changes to baseline mobility were easily identifiable.
Without 241 2.56 1.01 2.00With 66 3.05 1.15 3.00
I found the transfer information needed to care for the patient in less than 2 minutes.
Without 240 2.47 1.13 2.00With 65 3.08 1.25 3.00
Accessing information allowed me to provide more personalized care to this patient.
Without 231 3.21 1.08 3.00With 60 3.58 1.15 4.00
Range = 1 (“never”) to 5 (“always”)
Survey Results: EMS SettingSurvey Item N Mean SD MedReason for transfer was easily identifiable.
Without 88 3.10 0.91 3.00With 18 3.44 0.98 3.00
Baseline mental status was easily identifiable.
Without 88 2.47 0.95 2.00With 18 3.22 1.16 3.00
Changes to baseline mobility were easily identifiable.
Without 88 2.32 0.94 2.00With 18 3.00 0.84 3.00
The labs/tests/x-rays completed were easily identifiable.
Without 88 2.47 0.84 2.50With 18 2.33 0.90 2.50
Accessing information allowed me to provide more personalized care to this patient.
Without 87 3.06 1.13 3.00With 18 3.89 0.90 4.00
Range = 1 (“never”) to 5 (“always”)
Survey Results: EMS SettingSurvey Item N Mean SD MedReason for transfer was easily identifiable.
Without 88 3.10 0.91 3.00With 18* 3.44 0.98 3.00
Baseline mental status was easily identifiable.
Without 88 2.47 0.95 2.00With 18* 3.22 1.16 3.00
Changes to baseline mobility were easily identifiable.
Without 88 2.32 0.94 2.00With 18* 3.00 0.84 3.00
The labs/tests/x-rays completed were easily identifiable.
Without 88 2.47 0.84 2.50With 18 2.33 0.90 2.50
Accessing information allowed me to provide more personalized care to this patient.
Without 87 3.06 1.13 3.00With 18* 3.89 0.90 4.00
Range = 1 (“never”) to 5 (“always”)*Paired mean responses were significantly higher in form use - Wilcoxon test
n=16 without 3.06
with form 3.56p=.01
Survey Results: ED SettingSurvey Item N Mean SD MedBaseline mental status was easily identifiable.
Without 65 2.54 0.77 2.00With 17* 3.35 0.78 3.00
Allergies were easily identifiable. Without 64 3.45 0.81 3.00With 17* 4.35 0.70 4.00
Medical history list was easily identifiable.
Without 65 3.17 0.76 3.00With 17* 4.18 0.72 4.00
Changes to baseline mobility were easily identifiable.
Without 65 2.29 0.70 2.00
With 17* 3.29 0.98 3.00
I found the transfer information needed to care for the patient in less than 2 minutes.
Without 64 2.08 0.91 2.00
With 17* 3.76 0.97 4.00
Range = 1 (“never”) to 5 (“always”)*Paired mean responses were significantly higher in form use - Wilcoxon test
Survey Results: ED SettingSurvey Item N Mean SD MedBaseline mental status was easily identifiable.
Without 65 2.54 0.77 2.00With 17* 3.35 0.78 3.00
Allergies were easily identifiable. Without 64 3.45 0.81 3.00With 17* 4.35 0.70 4.00
Medical history list was easily identifiable.
Without 65 3.17 0.76 3.00With 17* 4.18 0.72 4.00
Changes to baseline mobility were easily identifiable.
Without 65 2.29 0.70 2.00
With 17* 3.29 0.98 3.00
I found the transfer information needed to care for the patient in less than 2 minutes.
Without 64 2.08 0.91 2.00
With 17* 3.76 0.97 4.00
Range = 1 (“never”) to 5 (“always”)*Paired mean responses were significantly higher in form use - Wilcoxon test
without 2.53 with form 3.76
p=.003
Survey Results: LTCSurvey Item N Mean SD MedReason for transfer was easily identifiable.
Without 89 3.43 1.13 4.00
With 33* 2.91 1.25 3.00Current medication list was easily identifiable.
Without 88 3.70 1.17 4.00With 32* 3.44 1.50 4.00
Contact information was easily identifiable.
Without 83 2.82 1.20 3.00With 24* 3.00 1.47 3.50
The documents listed as send were sent.
Without 83 3.76 1.05 4.00With 25 3.28 1.30 4.00
Accessing information allowed me to provide more personalized care to this patient.
Without 82 3.44 1.05 3.00With 25 3.12 1.30 3.00
Range = 1 (“never”) to 5 (“always”)*paired mean responses were higher with the form, but not significant
Example Data VisualizationThe reason for transfer/return was easily identifiable.
Survey Results: Summary Taking all settings together, mean scores were higher
when the Interfacility Patient Transport Forms were used.
Mean LTC satisfaction was lower for nearly all survey items when the form was used than when it was not.
In the paired data, any significant preferences in ED and EMS were in favour of the transfer form; no significant preferences were found in the LTC setting.
Selected Open Ended Survey Responses (LTC)
“As I have never received a form back from hospital it was discouraging because I did all this extra paper work that seemed to have gone unnoticed.”
“The form requires too much information from the sending site in comparison to what is provided to us on return.”
“I find it time consuming, especially in an emergency situation its hard to get the form filled out before EMS arrives.”
“Filling this form while dealing with patient and EMS is not practical.”
Summary Overall, uptake and completion of the form were
relatively low. 2 of 11 participating LTC sites did not use the form at all.
ED and EMS staff scored transfers where the form was used higher than transfers where the form was not used, but rarely completed the form in practice.
LTC staff completed the form more often than EMS and ED staff, but survey scores were overall equivocal
LTC staff reported finding the form burdensome in light of the time and effort they invested in completing it.
Discussion Future efforts to enhance communication around older
persons’ transitions in care should balance the work load required between sites/providers, and the benefits that the intervention offers to sites/providers.
Site and healthcare practitioner engagement should be a major focus at the outset and throughout the lifecycle of an implementation project.
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Survey and Future Webinars
Upcoming webinars – register on twitter @CFN_NCEWednesday, June 1, 2016 at 12 noon ET
Describe care received by frail elderly patients nearing EOL in Canada – results of CFN-funded environmental scan – Anik Giguère, Laval University
Wednesday, June 15, 2016 at 12 noon ETDecision-making and communication tools for hospitalized patients (DECIDE-2-COMMUNICATE) – results of CFN-funded catalyst grant – James Downar, University of Toronto
Brief survey will pop up on your screen within next few seconds. Your responses provide us with feedback on how we can improve the webinar series.
Webinar slides & video available after the webinar at: cfn-nce.ca/news-and-events/webinars
2016-04-06