Lecture 2: Transitions of Care

Question 1

What are the 2 main goals during ER transfer?

Answer 1

• Transfer info
• Clarify responsibility of patient care

Question 2

What should be included in an ED transfer to the hospitalist in terms of info?

Answer 2

• Principal Dx and problem list
• Med list
• Cognitive status
• Test results/pending

Question 3

What are the 4 selection recommendations for direct admission from outpatient?

Answer 3

• Admitting Dx is certain
• Clinically stable
• Evaluated day of by PCP
• Arrives at hospital early

Question 4

What information tends to be missing in an ED transfer from a SNF?

Answer 4

• Baseline cognitive function
• Current meds
• Advance directive status

Question 5

When transferring a patient OUT of the hospital, when are they no longer under your care?

Answer 5

As soon as they step foot off facility grounds, it is the accepting provider’s responsibility.

Question 6

What is considered Outpatient or Inpatient per CMS?

Answer 6

1. Outpatient if admitting physician expects a stay of less than 2 midnights
2. Inpatient if admitting physician expects a stay of more than 2 midnights

Has to do with reimbursement

Question 7

What are the 4 main unit types of a hospital?

Answer 7

• ICUs (continuous/invasive monitoring hourly)
• Intermediate care/Step Down Units
• Telemetry Units (continuous ECG monitoring)
• Medical/Surgical Wards (Non-monitored)

Question 8

Of the 3 intrahospital handoff types, which require written documentation?

Answer 8

• Service change (permanent transfer to a new physician)
• Service transfer (change to an entire different group and different specialty/service)

Service transfer would be like PCP to cardiology

Shift change does not require written documentation

Question 9

What are the core components of handoffs?

Answer 9

• Verbal communication
• Written communication
• Transfer of Professional Responsibility

Question 10

What is the MCC of sentinel events?

Answer 10

Lack of communication

Question 11

What are the 4 core steps to the handoff process?

Answer 11

• Pre-handoff
• Arrival
• Dialogue
• Post-handoff

Question 12

What is IPASS?

Answer 12

1. Introduction
2. Patient (identifiers)
3. Assessment (problem, procedure)
4. Situation (Current status, changes)
5. Safety Concerns (critical labs, threats, alerts)

Standardized handoff

Question 13

What is SBAR?

Answer 13

1. Situation (What is going on)
2. Background (Relevant history, bkg, prior dx)
3. Assessment (What you think is going on and needed)
4. Recommendations (What you are asking the physician to do)

MC used by nurses

Question 14

What are the 4 key elements to discharge care coordination?

Answer 14

1. Appropriate discharge destination
2. Proactive scheduling of F/u
3. Careful med reconciliation
4. Engagement of pts and caregivers

Question 15

What are the MC discharge locations?

Answer 15

• Home w/ or w/o caregivers
• Home with home health services
• Inpt rehab
• SNFs
• LTAC
• Extended care

Question 16

What is the average reasonable post-discharge f/u time?

Answer 16

7-14d unless high risk.

Question 17

What is medication reconciliation and what 3 things must be explicitly noted?

Answer 17

• Process by which a patient’s med list is obtained, compared, and clarified.
• Must list meds that are ADDED, DISCONTINUED, or CHANGED during hospitalization

Question 18

What must be included in discharge instructions? (7)

Answer 18

1. Reason for hospitalization/tx/clinicians
2. Pertinent test results/pending results
3. Diet and activity
4. Meds, including changes
5. F/u appts
6. Identification of contact person
7. List of concerning symptoms and how to respond