“The family doctor has seen the patient for 20 or 30 years and knows what he or she wants,” Dr. Haimowitz says. “But this patient is brand new to the hospitalist. Unless the hospitalist is really good with communication and takes the extra step to call the physician at the nursing home, I think you run the real risk of duplicating workup or actually not doing what is in the best interest of the patient.”
“While demonstrating improved quality of care for the acutely ill hospitalized patient, hospital medicine has struggled with the fact that it inherently adds more patient hand-offs into the mix,” says Bryce Gartland, MD, medical director for care coordination and director of hospital medicine for Emory University Hospital in Atlanta. “We experience this internally, within our facility and externally when transferring patients into or out of the hospital.”
There is always a potential for what has been called the “voltage drop” when hand-offs occur, agrees Dr. Cumming, whether they’re between hospitalists in the same facility or from hospitalist back to the primary care provider. “We function in a healthcare system that is very individualized,” she says. “When you’re dealing with many different community hospitals that may not be part of the same system, it’s very hard to standardize [transfer processes].”
The standard of care for transferring patients from Marin General Hospital to subacute rehabilitation facilities or to skilled nursing facilities entails a detailed inter-facility transfer form. The form includes a thorough discharge summary, with a separate medication reconciliation form, photocopies of any relevant consultations, and a list of pending lab tests. In concert with the hospital’s case managers, Dr. Cumming and hospitalists on her team also make every effort to speak with patients’ receiving providers to relay a synopsis of what has occurred during their patients’ stay in the hospital.
—Daniel Haimowitz, MD, CMD, chairman of internal medicine, Lower Bucks Hospital, Bristol, Pa.
Avoid Assumptions
Especially in the case of patients with dementia or severe illness prohibiting communication about their condition, a thorough transfer sheet or discharge summary—arriving with the patient or faxed in a timely manner—can help reduce errors and contribute to more seamless resumption of care at the next facility.
Without access to a patient’s history, the opportunity for errors increases. One of Dr. Crecelius’ pet peeves is seeing “history not obtainable” on the hospital’s patient transfer sheet. “A history is always obtainable,” Dr. Crecelius asserts. “You can call the nursing home, the family, or the patient’s physician. That phrase equals, ‘We didn’t bother to take the time.’ There is no such thing as ‘history not obtainable,’ and legally, that will not fly in a court of law.”
Missing or incomplete records necessitate communication between facilities. Dr. Crecelius has also found that hospitalists may not understand the nuances of medication prescription for the elderly—a situation that can be rectified with a phone call.
A case in point: Dr. Crecelius once prescribed theophylline for a bradycardic patient who refused a pacemaker but frequently lost consciousness when his pulse and blood pressure dropped. Although this was an obscure use of the drug, which is primarily a bronchodilator, “it worked to keep the patient’s pulse up so he was not passing out. When he went to the hospital, they stopped the drug, and it took forever to get him discharged. The patient came back to the nursing home in horrible shape. I assume the providers at the hospital thought I was crazy for prescribing theophylline to a frail old person!”