Communication, Documentation, and Preparation for Patient Transfer

1. Communication, Documentation, and Preparation for Patient Transfer Andrea O’Flahrity BSN, RN, CCRN, CFRN Adult Trauma Program Manager, UWHC

2. Objectives Describe communication that must take place during patient transfer Describe the documentation that must be present and sent with the patient Describe how to prepare and package patient for transfer

3. Communication • Why is it important? • The Joint Commission reports that communication issues were the root cause of ~65% of all sentinel events from 1995-2004 (2966 events) (Groah, 2006, p. 227) • Intra-facility vs. inter-facility • Study of intra-facility transfers • 32 transfers over 37 days • 14 incidences were observed (44%) • Several near extubations, lines being pulled out. Higher incidence in CT (Winter, 2010, p. 548) • Who are you talking to? What does the other person need to know? • Rossi et al. (2009) communication study • Levels III-V: common communication problems included hostility, condescension, and dismissiveness • Levels I-II: reported wasted time based on ineffective communication and exchange of extraneous information (Avtgis, Polack, Martin, & Rossi, 2010, p. 284) • What does your patient need to know?

4. Giving Report • Structure • Many authors recommend a standardized communication process to reduce error (SBAR, SHARED). Joint Commission Patient Safety Goal: Standardization of hand-off communications (Carter, Silverman, & Carter, 2008, p. 155) • What to include? • Who is your audience and what do they need to know to care for your patient? • How much is too much? • How much is not enough?

5. Giving Report • Quick explanation of what happened • If coming from the ED (<24 hrs after the injury) this will help determine if pt needs to be activated • Accident speed/rollover/ejection, Fall Height, skull/pelvic fractures • If coming from the inpatient side >24 hours after the injury happened • Patient will not be activated unless they continue to be unstable

6. Giving Report • Important points by body system • Name/DOB/Allergies/Family/Code Status (paperwork?) • What will the receiving facility need to know so they can compare what they are seeing to the report……. • Neuro • GCS if appropriate • Pupillary assessment if appropriate • Injuries/Medications? • Cardiac • Blood Pressure trend (CVP and others if applicable) • HR and rhythm • Venous and arterial access: Do they draw and flush? • Fluid/Blood Products Given • Injuries? • Medications running?

7. Giving Report • Pulmonary • RR • Lung sounds • Suctioning needs • Injures/chest tubes? • GI/GU • N/V/D – Medications given? • Urine output and over what period of time • Injuries? • Skin • Temperature/color/condition • Injuries? Repairs? Surgical incisions?

8. Giving Report: The Wrap-Up • Medications and time given • Blood glucose and insulin given • ABX • Pain • Injuries not previously mentioned • Ortho and other • Remaining Questions……get name and call-back number

9. Documentation • Facility Specific • What to send? • EMS sheets – any and all • ED documentation • Inpatient documentation • DNR/Living Will Paperwork • EMTALA required forms

10. What is EMTALA?? • Emergency Medical Treatment and Active Labor Act (1986) • Applies to hospitals participating in Medicare (which is 98% of us)(Zibulewsky, 2001, p. 340) • A hospital with an Emergency Department is required to screen and stabilize any patient presenting with an emergency medical condition • Physician must get patient consent and explain risks and benefits. All lab and radiological tests must be copied and sent with the patient • Must find an accepting physician • Appropriate transport must be arranged

11. EMTALA • Elements required by EMTALA • Certificate signed by physician including reason for transfer and discussion of risks/benefits • Documentation that the patient was informed of and accepts the risks and benefits of transfer • Medical Records must be sent with the patient

12. Also required by EMTALA Vital signs taken 15-30 minutes before patient departure from your hospital Medical history (screening) and if patient is stable or not Name of accepting physician Condition of patient at time of transfer Implementing EMTALA: Strategies for Compliance by Susan Dill, RN, MSN, JD

13. Elements required by the State of Wisconsin • The Transferring physician is responsible for: • Stabilizing the patient (within the capacity of the facility) • Performing a risk/benefit analysis of transfer • Determine mode of transfer based on patient acuity, distance, weather and consultation with the receiving facility physician • Determining the medical needs of the patient during transfer and the qualifications of the medical personnel required to meet that need • Recognizing the limitations/scope of practice of the transport service • Determining the credentials and capabilities of any personnel providing transport • Ensuring on-line medical control is available by voice contact within 3 minutes (State of Wisconsin Bureau of Local Health Support and Emergency Medical Services [State of WI], 2006)

14. Not a bad idea to include either….. Recent neuro exam Temp Medications given recently or currently hanging Contact information for the family if available

15. Finally….Patient Transfer • Is your transport appropriate? • Transfer to a tertiary trauma center was associated with a significantly lower 30-day mortality compared to admission in a non-tertiary trauma center (Garwe et al., 2010, p. 1223) • Do you have copies of everything? • If patient is critical, send what you can and fax the rest

16. The Patient • Let them know what is going on • Make sure your IVs are patent • Don’t delay transfer for tests • If you get results back after the patient leaves, fax them • The American College of Surgeons Committee on Trauma (ACS COT) recommends a CT scan not delay patient transport • Computerized PACS system helps. Decreases number of repeat scans (Young, Meyers, Wolfe, & Duane, 2012, p. 675)

17. The Family Make sure they are aware of the transfer Do they have directions? Make sure they have a contact number for the receiving facility. Are they safe to travel? Make sure they get a chance to say goodbye, even if it is quick

18. Helpful for Everyone IV lines labeled? Appropriate pain control or sedation for the transfer? Belongings accounted for?

19. The trauma center • Our registry captures all of our trauma patients. We need as much EMS and referring facility documentation as possible. • Patient transfer is a risk….but the benefits of transfer to a trauma center can outweigh the risk • State of Massachusetts reports that patient death rates are 10 times lower during the transfer process from scene to trauma center than they are for inter-facility transfer because of increased transfer times (Avtgis, Polack, Martin, & Rossi, 2010, p. 283)

20. UW Hospital: Main Number: 608-263-6400 Access Center: 608-262-5546 ER: 608-262-2398 ER Fax: 608-263-9991 Preferred Ambulance: Main Number:608-555-5555 Secondary Ambulance: Main Number: 608-555-5555 Transfer Forms: Physician Certification Accepting MD Stable/Not-Stable Risk/Benefit MD Signature Patient/Family Consent Medical Record H&P Radiology EMS records Lab Results Nursing Documentation Living Will/DNR/DNI Report/Communication: Name/DOB Code Status Allergies/Pertinent Meds Mechanism Neuro: GCS, Pupils Cardio: Vitals, Lines, Drips, Fluid/Blood given Pulmonary: Airway, Chest Tubes, O2 Requirements GI/GU: N/V, Urine Output Skin: Color/Temp/Condition Injuries Meds Given Family: Report Called to: Call Back Number: Documentation Needed: Vitals with temp within 30 min of transfer Assessment within 30 min of transfer Neuro: GCS Cardio: Lines, Drips, Fluids Pulmonary: Airway, Breathing GI/GU: Urine Output Medications Pain Patient and Family: Receiving Hospital/Floor Address and Phone Number Directions Belongings Questions Answered

21. In Conclusion • Communication: • The report • Intra-facility vs. inter-facility • Structure • Who are you talking to and what do they need to know

22. In Conclusion • Documentation • Required documentation per EMTALA and the State of Wisconsin • Recent vitals • Copy everything • Send everything….but don’t delay transfer

23. In Conclusion • Patient transport • Keep the patient and family informed • Make it as safe as possible • Don’t delay transfer for extra tests

24. Thank You! Andrea O’Flahrity Adult Trauma Program Manager UW Hospital and Clinics AOFlahrity@uwhealth.org 608-262-5059

25. References Avtgis, T. A., Polack, E. P., Martin, M. M., & Rossi, D. (2010, July). Improve the communication, decrease the distance: The investigation into problematic communication and delays in inter-hospital transfer of rural trauma patients. Communication Education, 59(3), 282-293. Retrieved from https://ehis.ebscohost.com Carter, J. C., Silverman, F. N., & Carter, S. J. (2008). A blueprint for reducing patient hand-off errors. International Journal of Business Research, 8(4), 155-160. Retrieved from https://ehis.ebscohost.com Garwe, T., Cowan, L. D., Neas, B., Cathey, T., Danford, B. C., & Greenawalt, P. (2010, November). Survival benefit of transfer to tertiary trauma centers for major trauma patients initially presenting to nontertiary trauma centers. Academic Emergency Medicine, 17(11), 1223-1232. Retrieved from https://ehis.ebscohost.com Groah, L. (2006, January). Hand offs: A link to improving patient safety. AORN Journal, 83(1), 227-230. Retrieved from https://ehis.ebscohost.com State of Wisconsin Bureau of Local Health Support and Emergency Medical Services. (2006). Interfacility transport guidelines. Retrieved from http://www.dhs.wisconsin.gov/ems/emsunit/wi_interfacility_transport_guidelines_2006.pdf Winter, M. W. (2010, May). Intrahospital transfer of critically ill patients; A prospective audit within Flinders Medical Centre. Anaesthesia and Intensive Care, 38(3), 545-549. Retrieved from https://ehis.ebscohost.com Young, A. J., Meyers, K. S., Wolfe, L., & Duane, T. M. (2012, June). Repeat computed tomography for trauma patients undergoing transfer to a level I trauma center. The American Surgeon, 78(), 675-678. Retrieved from https://ehis.ebscohost.com Zibulewsky, J. (2001, October). The Emergency Medical Treatment and Active Labor Act (EMTALA): What is is and what it means for physicians. Baylor University Medical Center Proceedings, 14(4), 339-346. Retrieved from http://www.ncbi.nlm.nih.giv/pmc/articles/PMC1305897/