Kate Lloyd

Manager, Acute Care Agency for Clinical Innovation

Evidence Review

14 June 2013

Evidence Review

Overview

Communication/Engagement Communication critically important to provide safe and effective care1,2

significant barrier is the structure and geographic spread of team3

Collaboration/teamwork are associated with better patient outcomes4

Engagement poor work climates patient experience5 Employee engagement patient satisfaction, patient mortality, infection rates6

Clinical Management Plans Document with efficiency7

Document verbal communications8

Electronic / Hybrid notes – Medical clinicians (electronic notes) – Patients (paper)9 – Copying in the eMR is common10 – risk of errors1

Improving documentation

– Standardising: documentation12,13, knowledge and satisfaction12 – Checklists: length of stay, medication compliance14 – Clinical pathways15

– Evidence based medicine workshops16

Ward Rounds Benefits of IDT ward rounds – mortality17

– Length of stay / discharges18-20

– collaboration10,18,21,22

Type – Bedside rounds are preferable28,30-32, JMOs report a preference for conference room questions31

– Rounding staff should avoid jargon28

– Board rounds29

Timing – Bedside rounds take 20% longer than traditional rounds but ultimately save time30

12 minutes per patient (8-24 minutes)33, another study found 7.5 min (3-16 min)27

Improving – Variability in review of medication charts23, can be reduced through a standardised checklist24

– Collaboration through all IDT sharing at bedside25

– Junior medical officers requested that rounds feature teaching the management of patients26

– A more structured approach to communication would benefit patients27

Patient Flow Establish realistic estimated date of discharge (EDD) at admission34

EDD updated throughout journey34

Commence discharge planning within 24 hours of admission34,35

Implement separate streams for emergency and elective surgery34

Ensure patients are seen by a senior clinician34

Complex discharges: confirm discharge date 2-3 days in advance34

Communicate to all involved in a patient’s discharge34, particularly patients36

Support patients to leave the ward as early in the day as possible34

Criteria Led Discharge Criteria Led Discharge involves the identification of a patient who is signed off by a senior medical clinician as eligible for hospital discharge under agreed criteria without final medical review.

CLD has been found to: reduce length of stay37,38

increase the percentage of discharges that occur before admissions arrive37, 39

increase weekend discharges37

increase patient and staff satisfaction37

improve quality of discharge planning, resulting in improved patient care37

have no discernable impact on patient readmission rates37

CLD should 1. be integrated with and not separate from the usual discharge process 2. be conducted with a review of the whole discharge process. 3. include outcome measures (e.g. use and accuracy of EDD, last medical review, time

of actual discharge)40

Transfer of Care Clinical handover or transfer of care is the: …transfer of professional responsibility and accountability for some or all aspects of care for a patient… to another person or professional group on a temporary or permanent basis41

Interventions are multi-component42

Health professionals have differing expectations43,44

Introducing a multidisciplinary care coordination team reduced hospital admission rates and improved stakeholder satisfaction45

Transfer of care checklist increased staff satisfaction48

Transfer of Care Recommendations for General Practice to Hospital (bi-directional) 1. Clear, succinct communication is essential for safe transfers of care.

Clinical judgement will be required to determine the appropriate method.

2. A patient must leave the hospital with a copy of discharge communications.

3. GPs access to electronic patient results in the hospital.

4. Medication reconciliation should occur at every transition of care

5. The patient, their family and carer must be involved as a partner

Patient Centered Care 3 tenets: 1. The needs of the patient come first49

2. Nothing about me without me14, 33, 49-51, 53, 54

3. Every patient is the only patient49

Important features: Empowerment52-54

Shared decision making52 Partnership 52, being heard58

Verbal communication, including between inpatient and outpatient providers57

Information about lifestyle changes57

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the Association of American Medical Colleges. 2004;79(2):186-94. Epub 2004/01/28.

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4. Davenport DL, Henderson WG, Mosca CL, Khuri SF, Mentzer RM, Jr. Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. Journal of the American College of Surgeons. 2007;205(6):778-84. Epub 2007/11/24.

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12. Grogan EL, Speroff T, Deppen SA, Roumie CL, Elasy TA, Dittus RS, et al. Improving documentation of patient acuity level using a progress note template. Journal of the American College of Surgeons. 2004;199(3):468-75. Epub 2004/08/25.

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note template. Journal of the American College of Surgeons. 2004;199(3):468-75. Epub 2004/08/25.

13. Kargul GJ, Wright SM, Knight AM, McNichol MT, Riggio JM. The hybrid progress note: semiautomating daily progress notes to achieve high-quality documentation and improve provider efficiency. American journal of medical quality : the official journal of the American College of Medical Quality. 2013;28(1):25-32. Epub 2012/06/12.

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15. Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J, et al. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database Syst Rev. 2010;3(3).

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18. O'Mahony S, Mazur E, Charney P, Wang Y, Fine J. Use of multidisciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of stay. J Gen Intern Med. 2007;22(8):1073-9. Epub 2007/05/09.

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20. Ahmad A, Purewal TS, Sharma D, Weston PJ. The impact of twice-daily consultant ward rounds on the length of stay in two general medical wards. Clinical Medicine, Journal of the Royal College of Physicians of London. 2011;11(6):524-8.

21. Vazirani S, Hays RD, Shapiro MF, Cowan M. Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. American journal of critical care : an official publication, American Association of Critical-Care Nurses. 2005;14(1):71-7. Epub 2004/12/21.

22.

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