Spotlight

1. Spotlight A Room Without Orders

2. Source and Credits • This presentation is based on the January 2016AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Amy Vogelsmeier, PhD, RN, Sinclair School of Nursing; and Laurel Despins, PhD, RN, Sinclair School of Nursing • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Kiran Gupta, MD, MPH • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Review a common process for planned direct hospital admissions • Describe challenges of prioritizing day-to-day patient care activities with additional workload of patient admissions • Discuss poor communication as a potential underlying cause of safety risks, including missed nursing care • Identify strategies for improving communication to facilitate direct patient admissions, including reducing risk of missed nursing care

4. Case: A Room Without Orders A 56-year-old man with acute lymphoblastic leukemia and diabetes mellitus was admitted to the hospital for a scheduled cycle of chemotherapy. He had no acute complaints. The patient arrived directly to the medical unit on a busy afternoon and waited in a nearby area for his assigned room. At shift change, the patient's room was ready, but the nurse who had initially greeted him on arrival had been replaced by a new nurse, who escorted the patient to his room. The nurse completed the usual check-in process later in the evening but did not contact the admitting provider, making the assumption this occurred several hours ago. Therefore, no admitting orders were written.

5. Case: A Room Without Orders (2) The patient spent the night in the hospital and took his own insulin, which he had brought from home. No evening meal was delivered; the patient thought this was part of his chemo regimen so he didn't question this. Since he wasn't complaining of any symptoms and takes few medications at home, he didn't prompt the need for any orders overnight.

6. Case: A Room Without Orders (3) The following morning, the new nurse (the third in his care so far) noted the patient was difficult to arouse. She went to review existing orders and discovered they were completely absent. She paged the on-call team who immediately evaluated the patient and successfully treated him for symptomatic hypoglycemia, which had been caused by the patient's insulin kicking in while he failed to consume calories. The case prompted a formal review as, in addition to the preventable episode of hypoglycemia, there was a delay in the initiation of his scheduled chemotherapy.

7. Background: Hospital Admissions According to the American Hospital Association, there are 35.4 million admissions to US hospitals each year About 16 million of these admissions come through the emergency department, implying that the majority of admissions are direct admissions Direct admissions may be planned or unplanned

8. Background: Direct Admissions Planned direct admissions occur when a patient is pre-scheduled for a procedure or treatment that requires an inpatient stay (e.g., chemotherapy described in the case above) Unplanned direct admissions occur when an ill patient presents to the physician's office and is determined to require inpatient care but is sent directly to an inpatient floor as opposed to the emergency department

9. Direct Admissions: Processes Involved When a direct admission is to occur, the ordering outpatient physician communicates to a nurse assigned to locate an appropriate bed for the patient This nurse may be an admissions coordinator or a nurse supervisor Nurse supervisors are often aware of patient flow and bed availability as well as patient acuity and nurse staffing ratios in order to ensure that admissions can be accommodated appropriately

10. Direct Admissions: Processes Involved (2) Directly admitting a patient is a complex process involving many steps Upon patient arrival, the admissions coordinator/nurse supervisor triages the patient and communicates with the nurse manager or charge nurse on the unit where the patient is being admitted Nurse managers/charge nurses then assign a unit-based staff nurse to perform the admission

11. Risk of Missed Nursing Care Staff nurses must balance providing care to existing patients with admitting, discharging, and transferring other patients Complexity of the health care environment and high acuity level of hospitalized patients requires nurses to continuously reprioritize which tasks are most important

12. Risk of Missed Nursing Care (2) • Missed nursing care is an error of omission • Occurs frequently among staff nurses • Reported reasons for missed nursing care include: • Limited labor resources • Insufficient material resources • Communication issues

13. Communication as a Contributor to Error Inadequate communication is a well-established cause of safety issues in the hospital—including missed nursing care With regard to direct admissions, clear communication among all providers and the patient is essential to ensure that everyone has a clear understanding of the treatment plan and tasks that need to be performed

14. Strategies to Improve Communication Convene a morning huddle with key staff to discuss planned admissions, discharges, and transfers Institute a centralized bed management system Establish daily multidisciplinary rounds to discuss new admissions, discharge readiness, and anticipated discharge dates as well as potential transfers and planned admissions

15. Strategies to Facilitate Teamwork Establish routine shift-to-shift communication about admissions Establish walk rounds to facilitate handoff communication at shift change Develop checklists for admission processes Foster a collaborative environment so nursing staff work together Include the patient in all aspects of care

16. Hospital-based Technology • Information technology (IT) offers tools that can enhance patient throughput and associated workflow and communication • For example, electronic bed board applications facilitate tracking of patients through the hospital • Nurses have reported improved sense of control over their workload after using a LEAN process, which enabled them to prioritize transfers and decrease incidence of multiple patients arriving simultaneously

17. Hospital-based Technology (2) Software applications can send user alerts to notify the admitting provider of patient arrival Pre-completed admission order sets for planned admissions for procedures and scheduled treatments can be entered in the EHR prior to admission and initiated by the admitting nurse EHRs provide point-of-care access to previous encounters, imaging, lab results, and provider orders, promoting improved information exchange during handoffs

18. Limitations of Technology Implementation of new IT tools should be monitored for unintended consequences Clear understanding of the limitations of the electronic tool as well as the workflow process into which it is to be integrated is essential for successful use

19. This Case • In this case, to prevent the hypoglycemia and delay in chemotherapy administration that resulted from a lack of admission orders and missed nursing care: • The outgoing staff nurse who initially greeted the patient on admission should have notified the oncoming staff nurse that she had not verified the admission orders • The oncoming staff nurse should have contacted the admitting provider for orders • The treatment plan should have been communicated clearly to the patient, including instructions not to take his home insulin • If the night was particularly busy, the unit charge nurse could have checked in with the staff nurse to ensure that everything was in order for the new admission

20. Take-Home Points Planned direct admissions are complex processes involving information exchanges between clinicians at multiple points in time Standardizing the patient throughput process by establishing specific communication checkpoints promotes effective, efficient information distribution Information technology tools are likely to enhance patient throughput and communication, but must be integrated within the context of the clinician's workflow and closely monitored for unintended consequences