Improving ACE Discharges to Skilled Nursing Facilities

1. Improving ACE Discharges to Skilled Nursing Facilities By Melissa Morris, RN, BSN

2. Introduction • The author of the poster noted several instances when skilled nursing facility (SNF) nurses would call the ACE unit after a patient had discharged, asking for clarification about medication orders, specifically medication indications and duration of treatment. Also, the author noted many instances on the ACE unit when nurses sought clarification about medication indications prior to giving patients medications and/or providing patients with medication education.

3. Literature Review • More than 40% of medication errors are thought to be caused by inadequate medication reconciliation during handoffs in admission, transfers, and discharges (Blank, Benyo, & Glover, 2012). • The Joint Commission implemented a regulation that went into effect on January 1, 2012 requiring that information exchanged between facilities include the patient’s name, dose, route, frequency, duration, and purpose (Blank, Benyo, & Glover, 2012). • At least one medication discrepancy was identified in 142 of 199 (71.4%) SNF admissions (Bonner, Briesacher, McGee, Terrill, & Miller, 2009). • Older adults are at a particularly heightened risk of experiencing adverse drug events due to inaccurate/incomplete medication reconciliation between care facilities (Chhabra et al., 2012). • Medication errors frequently contributed to patient readmission from skilled nursing facilities (Lu, et al., 2013). • SNF RNs reported relying heavily on written hospital discharge information to assist in effective transitions to SNFs, but frequently the discharge paperwork lacked sufficient information. Due to insufficient discharge information, patients and family members frequently thought SNF staff was unknowledgeable about the plan of care for the newly-transferred SNF patient (King, Gilmore-Bykovskyi, Roiland, Polnaszek, Bowers, & Kind, 2013). • Nurses used clinical reasoning, notes, and physician communication to assist in safe medication administration and education, and to deduce medication indications (Dickson & Flynn, 2011).

4. Objectives • To improve discharges to skilled nursing facilities (as measured by reported improvements by SNF staff during interviews and SNF staff responses to survey questions) • To increase the percentage of scheduled medications with a written indication/diagnosis • To increase the number of antibiotics and injectable anticoagulants with written start and stop dates • To improve ACE RN reported comfort with providing medication education to patients

5. Methods • The author of this poster: • Conducted formal, in-person interviews with representatives from four of the five most frequently used SNFs by ACE patients (Colorado State Vets Home, Lifecare Center of Aurora, Advanced Healthcare of Aurora, and Heritage Clubs) • Performed medication audits of all ACE 1 and ACE 2 patients each month to establish a baseline • Created and distributed a survey to ACE RNs titled “RN-Provided Medication Education” • Participated in an informal discussion with ACE providers to understand the workflow of ordering medications through EPIC, and to gauge their potential willingness to write indications for all medications • Requested from UCHealth’s Clinical Informatics Nurse Senior to add a template in EPIC from which providers could select indications for all medications

6. Results • Interviews with SNF representatives revealed a number of areas in which the interdisciplinary ACE team could work to improve discharges to SNFs. As of February 2014, only 8.6% (103 of the 1194) of audited, scheduled medications had written indications. EPIC does not currently offer providers the ability to include indications for scheduled medications without requiring providers to type in an indication; however, providers and nurses can select indications for all prior-to-admission medications using the admission tab in EPIC (so long as the medications have not yet been ordered). Through the RN-Provided Medication Education survey, 100% of ACE RNs agreed or strongly agreed with the statement, “I would feel more comfortable providing patients and family members with medication education if specific indications for scheduled medications were listed on the MAR”.

9. Results(Formal Interview Responses from SNF MDs, RNs, and Staff) • SNFs are required to have an indication or diagnosis for every medication on the MAR. • All prescriptions must be signed or cosigned by an attending physician. • SNFs require a paper, signed prescription for all controlled substances. • SNFs would like to receive the AVS and medication orders by 1200 (or earlier) the day the patient is discharged. • SNFs would like to have start and stop dates for antibiotics and injectable anticoagulants. • If the patient is on warfarin, SNFs would like to know the most recent PT/INR. • The majority of SNFs do not have pharmacies on site. All medications are filled at off-site pharmacies and delivered to the SNFs. Even STAT orders can take up to four hours to arrive. • Patient to RN ratios are different for SNFs, rehab ratios are 12-15:1, and long-term care ratios can be up to 25:1. • Psychiatric medications are heavily regulated in SNFs, and each psychiatric medication must have a corresponding diagnosis (psychiatric medications can be used only for a limited time in acute delirium).

10. Results(Formal Interview Responses from SNF MDs, RNs, and Staff) • SNFs require an approved diagnosis for Foley catheters (BPH, neurogenic bladder, Stage IV pressure ulcer); they request that catheters be discontinued prior to transfer. • If a patient has an infection, and cultures have been sent, SNFs would like to know the organism. • MDs of SNFs report very limited access to acute care providers who provided direct care to patients transferred to SNFs. • SNF MDs request the discharge summary be faxed as soon as possible. • Some SNFs reported that therapy, diet, and speech orders are not always accurate on the AVS. • SNF staff request to know as soon as possible if a patient has a scheduled appointment for the day after discharge so that SNF staff can arrange transport appropriately. • SNFs would like to know if flu and pneumococcal vaccines were given or reported in a patient’s history.

11. Conclusions • ACE providers, nurses, and social workers can all have a role in improving discharges to skilled nursing facilities. SNF representatives provided the author with a number of suggestions to help facilitate successful discharges to their facilities. The author has listed a number of possible provider and nurse interventions to help facilitate discharges to SNFs. As the suggested interventions to improve discharges to SNFs are numerous, the author predicts that if the interdisciplinary ACE team focuses on these interventions, and focuses on improving discharges to SNFs, improvements will be seen in all project objectives.

12. Possible MD Interventions • Write indications/diagnoses for all medications (especially discharge medications for patients discharging to SNFs) • Begin the AVS the day/night before a patient is to be discharged to a SNF; have all SNF transfer AVSs completed by 1000 or earlier on the day of discharge • Inform the RN of the completed AVS prior to signing it and having it faxed by social work • Request that attending physicians sign or cosign all prescriptions sent to SNFs • Write start and stop dates for all injectable anticoagulants and antibiotics • Provide SNF MDs/NPs/PAs with contact information of a UCH provider who has directly cared for the patient during the inpatient stay • Increase communication with SNF providers

13. Possible RN Interventions • Review the AVS of patients discharging to skilled nursing facilities before the AVS is faxed over to the SNF by social work • Night RNs review the AVSs for patients expected to discharge to SNFs the next day; inform day RNs of needed corrections (review activity, speech, and diet orders in the AVS, compare to the inpatient orders in EPIC; review medication lists). • Day RNs perform a final review of the AVS prior to it being faxed to a SNF. • Review medications listed in the AVS • Request that start and stop dates for antibiotics and injectable anticoagulants be added to the AVS • If a patient is discharging on warfarin, request the most recent PT/INR be added to the AVS

14. Possible RN Interventions • Use the “ACE Medicine Quick Guide to SNF Nurse-to-Nurse Report” tool when giving SNF nurses report • This tool was created based on information gathered during SNF interviews and edited based on feedback from SNF representatives. • Ensure paper prescriptions for controlled substances have been signed by an attending physician, and that the signed prescription is included in the discharge packet • Discuss changes in patient mental or social status with the SNF RN • If applicable, inform the SNF of the last time a patient required a sitter, mitts, or restraints. • Pre-medicate patients prior to discharge if they require frequent pain medications

15. Call to Action • The author is challenging ACE providers and nurses to select at least one suggested intervention each week to focus on during discharges to skilled nursing facilities. The author requests feedback from the interdisciplinary team to assess the workability of the interventions throughout this project. The author will continue to collect information through July 2014 from medication audits, surveys, and interviews with SNF representatives to assess if the interventions have affected the objectives.

16. References • Chhabra, P.T., Rattinger, G.B., Dutcher, S.K., Hare, M.E., Parsons, K.L., Zuckerman, I.H., (2012). Medication reconciliation during the transition to and from long-term care settings: a systematic review. Research in Social and Administrative Pharmacy 8(1), 60-75. LOE 1. • Dickson, G.L., & Flynn, L. (2011). Nurses’ clinical reasoning: processes and practices of medication safety. Qualitative Health Research 22(3), 3-16. LOE 6. • King, B.J., Gilmore-Bykovskyi, A.L.. Roiland, R.A., Polnaszek, B.E., Bowers, B.J., & Kind, A.J.H. (2013). The consequences of poor communication during hospital to skilled nursing facility transitions: a qualitative study. Journal of American Geriatric Society 61(7), 1095–1102. LOE 6. • Laura J. Blank, L.J., Benyo, E.M., Glover, J.U. (2012). Bridging the gap in transitional care: a closer look at medication reconciliation. Geriatric Nursing Journal, 33(5), 401-409. LOE 7 • Lu, Y., Clifford, P., Bjorneby, A., Thompson, B., VanNorman, S., Won, K., & Larsen, K. (2013). Quality improvement through implementation of discharge order reconciliation. American Journal of Health-System Pharmacy 70, 815-820. LOE 4. • Tjia, J., Bonner, A., Briesacher, B.A., McGee, S., Terrill, E., Miller, K. (2009). Medication discrepancies upon hospital to skilled nursing facility transitions. Journal of General Internal Medicine 24(5), 630–635. LOE 4.