CAR Study Intervention

CAR Study InterventionCommunicating About ReadinessFor Hospital Discharge: An inter-professional intervention

This presentation is about the CAR study. CAR stands for Communicating about Readiness for Hospital Discharge. This presentation is designed to prepare members of the inter-professional health team for implementation of new communication processes to be implemented on the study units which are 7NT and 8NT. In order for the planned change to be effective in improving discharge communication and reducing hospital readmissions, all members of the health team need to be educated in the new process and implement it consistently for all patients being discharged.1What is CAR Study?Communication About Readiness (for discharge)Approved by the IRB and Nursing Research CouncilGoalsImprove the discharge experience of patients through improved discharge preparation communication between patients and care team membersReduce readmissions and ED visits post-discharge.Reduce unpaid costs for readmissions4 phase pre-post intervention cohort study

What is the CAR study? The CAR study, Communicating about Readiness for Hospital Discharge focuses on inter-professional communication between health team members and with patients and families. The study was approved by the IRB and the Nursing Research Council. The goals of the study are to improve the patients discharge experience through improved communication between health team members and with patients and families.. Research has shown that patients and families report poor communication among the members of the team who provide their care and inconsistencies in the information provided to the patient during discharge preparation.

The study has 4 phases and we have already completed the first 2. The study design is a pre and post intervention (or implementation) design with the cohort of patients on the 2 study units included. In the first phase, we evaluated current inter-professional communication patterns related to discharge communication. In phase 2, we collected baseline data on the outcome measures for the study, specifically patient, nurse and physician perceptions of discharge readiness, readmissions, and ED use after discharge. Based on this information, the research team have redesigned a process for communication about discharge between health team members and with patients and families. You will learn about these processes in this presentation. 2The evidence for improving health team communication and collaboration2010 - 2013: Ineffective communication among top 3 root causes of sentinel adverse events (TJC Sentinel Event Data (Root Causes by Event Type)

Poor communication and collaboration Patients: Adverse events e.g. medical errors, Patient-reported poor quality care, Preventable mortality Professional Staff: Dissatisfaction and turnover

Baggs, 1999, Martin et al., 2010, Manojlovich et al., 2007, 2009; Rosenstein & ODaniel, 2006

There is strong evidence supporting the importance of health team communication and collaboration.

The Joint Commission published data from 2010 to 2013 that indicated that ineffective communication was among the top 3 root causes of sentinel adverse event in hospitals.

Poor communication and collaboration has bees associated with patient adverse events such as medication errors, patient reports of poor quality care, and preventable mortality. When communication and collaboration are poor, professional staff are dissatisfied and more likely to leave their position.3The evidence for health team communication about dischargePatients and family caregivers:Consistently report they do not get enough preparation for discharge1/5 of patients report receiving conflicting information (Cleary et al., 2003 Nurses reportFrustration with lack of communication about discharge (Foust, 2007; Nosbusch, 2010)

In relation to discharge,Patients and family caregivers consistently report they do not get enough preparation for discharge, and one in five patients report receiving conflicting information from their doctors and nurses.

Nurse report frustration with the lack of communication about discharge with the medical team.

4The evidence for health team communication about dischargePoor preparation of patients for hospital discharge is a major contributor to readmission (Jack et al., 2009; Mistiaen et al., 2007)

Enhanced communication about discharge is a core element of effective multi-component interventions that have produced reductions in readmission (Kripalani, et al., 2014)

Poor preparation for discharge has been documented in several studies as a major contributor to readmission.

A recent article by Kripalani et al., (2014) in the Annual Review of Medicine described enhances communication about discharge as a core element of effective multi-component interventions that have produced reductions in readmissions.5Baseline dataNurses talk to nursesDoctors talk to doctorsWe dont talk to each other as much as needed

In phase one of the study, we learned that the web of communication about discharge tended to be discipline centered, with physicians primarily communicating with physicians and nurse communicating with nurses more than other disciplines. The web diagram indicates the overlapping but also non-overlapping patterns of communication that suggest that disciplines within the health care team dont talk to each other as much as needed

6Baseline data phase 2250 Froedtert patients and their discharging RN and MD completed an 8-item validated screening tool for discharge readinessResults:On the day of discharge, 17% of patients, 23% of nurses, and 13% of physicians rated patients as low readiness for discharge ( and low readiness is associated with a 6-9 fold increase in odds of readmission).For 25% of patients being discharged, there was disagreement on discharge readiness between the patient, RN, and MD.Conclusion:Patients, RNs, and MDs are not on the same page about dischargeThere is work to do to improve communication about discharge among the triad of patient-RN-MD.

In phase 2 of the CAR study, we asked more than 250 Froedtert patients and their discharging physicians and nurses to complete an 8-item validated screening tool for discharge readiness.

On the day of discharge, 17% of patients, 23% of nurses, and 13% of physicians rated patients as low readiness for discharge ( and low readiness is associated with a 6-9 fold increase in odds of readmission). For 25% of patients being discharged, there was disagreement on discharge readiness between the patient, RN, and MD.

Our conclusions were that1. Patients, RNs, and MDs are not on the same page about discharge2. There is work to do to improve communication about discharge among the triad of the patient-RN-MD.

7Improvement in Discharge Communication NeededBuilding an inter-professional communication system is needed to avoid information breakdown in fast-paced contexts.

Practice based training is required, aimed at developing a deep appreciation of team member contributions. Gilardi et al., 2014

From the baseline findings, improvement in discharge communication is needed.

Gilardi et al have noted that Building an inter-professional communication system is needed to avoid information breakdown in fast paced contexts and that Practice based training is required, aimed at developing an appreciation of team member contributions.

We have taken note of these 2 points in building a new approach to communication about discharge.8Intervention Planning TeamKristi Opper, MS, RN, ACNS-BCJoe Beiler, MS, RN,ACSN-BCDr. Marianne Weiss, DNSc, RNSara Darby, BSN, RN, CMSRNDavid Huebner, BSN,RNAndrea Melenchuk, BSN, RN, CMSRNNicole Ladwig, BSN, RN, CMSRNKristi Copeland, BSN,RN,CMSRNJessica Schaeffer, ADN, RNCrystal Pietrowski, BSN, RNKaren Wilson, BSN, RNSarah Kortsch, BSN, RN

Dr. Kiran TuragaDr. Fabian JohnstonDr. Michael StadlerDr. Jenna CusicDr. Gregory LarriexKim Spitz, APNPCourtney Johnson, PA

At the end of phase 2, we convened an intervention planning group to review phase 1 and 2 data and plan for an improvement in health team communication that would augment other ongoing processes such as care coordination rounds. This slide contains the names of the intervention planning team members. In the next slides you will learn about the intervention.

The planned change in health team communication about discharge was guided by the Agency for Health Care Research and Quality (AHRQ) TeamStepps process, a national initiative to improve patient safety through improved health team communication. The newly designed communication processes are based on tools and techniques recommended by the AHRQ TeamStepps program

9

This slide shows the Communication about Readiness for Discharge process map developed by the Intervention Planning Team. The core components are as follows:

Physician Rounding: We have developed a new process for Physician rounding that will include bedside rounding with the Physician Team, the nurse caring for the patient, and the patient and the family ( if they are present at the time). For Physician Team rounding, there is a Rounding Checklist to be used to assure that all key components related to progress to discharge and discharge preparation are addressedRN to RN communication: Nurses will do bedside shift reporting at change of shift to assure appropriate communication between nurses and patients. A Briefing Checklist has also been developed to support this process.Care coordination rounds on each unit will continue with enhanced communication from inputs from participants in MD rounding and RN bedside shift report.Follow-up communication from each of the other communication processes will be key to making the communication process work. Designating need and accountability for follow-up on issues raised in the rounding process should be clearly identified.Note that the patient and family are central participants in these communication processes.

10MD Teams with RNs Rounding ProcessPurposeTo include patient and family at bedsideTo engage RN during rounds at least once every 24 hours

A key part of the intervention is changing how daily rounding will occur. The new process will include Physician Teams and Nurse together conducting bedside rounds with the patient, and family member if present. We have identified that patient do not know what to expect in preparing for discharge. As an inter-professional team, we need to work together to better communicate about what to expect in preparation for and after discharge. The purpose of daily Team bedside rounds is to have the triad of partners responsible for the success of the discharge transition to be engaged together in progress monitoring and planning for discharge needs through the course of care. Physician Team rounds at the bedside with the patient and the nurse should occur at least once every 24 hours.

11

The Physician Rounding Process has several stepsWhen the Physician Team arrives on the unit, one member of the team should use the telephone system dialing 5-2117 and announcing Broadcast to 7NT ( or 8NT) nurses physician team rounds are beginning in Room___ - and state the room number. The patients nurse or a pre-arranged substitute will join the teamWhen the Team arrives at the patient room. If the RN isnt there already, Press the MD requests RN button located near the sink. Assign responsibilities for updating the Getting Ready for Discharge Whiteboard; (2) review of the Rounding checklist; 3. the person to report outBe sure to engage the patient in the conversation about progress toward discharge and discharge goals. Have mutual respect for the contributions of all team members. And include all appropriate Briefing Checklist items in the rounding conversation at the bedside.One of the medical team members will report out on pertinent information about the patient including progress, labs, and consults. The plan for the day and any changes to the plan for the hospital stay and post-discharge care will be discussed at this time.Update the Getting Ready for Discharge WhiteboardFinally, confirm ant follow-up responsibilities or communications ( for example consults, family update, communication with other disciplines).Plan for any information that needs to be communicated back to discharge coordination rounds or to RN-RN bedside shift reports ( refer back to the communication process map on the prior slide)

12MD Team/RN Rounding Checklist

To facilitate bedside rounding, a new communication tool has been developed. It is a Rounding Checklist. The checklist will be affixed to the computer in the patient room. The Physician Team will identify who will lead the conversation with the patient. Unless otherwise assigned, the RN will have responsibility for making sure all checklist items are included in the content of the rounds.

The checklist identifies areas that must be covered in every instance of team rounding:Enter the room and make introductionsObtain patient subjective information: Ask for patient how he/she is doing (for example with pain, nausea, or other concerns. Ask the patient what they will need to be ready to go home.Review objective data with the patient: Review current status, symptoms, and other condition specific information.Review Lab and test results and new labs/tests to be completed Inform the patient how and when he/she will receive results of pending tests. Inform patient about labs/tests/procedures that need to be completed after discharge and make patient aware of how and when to schedule these.Review the plan of care for the day. Include progression of care toward discharge (IV PO, diet, activity, etc.Review the medical milestones in progress toward discharge. Identify for the patient the milestones that need to be achieved to be ready to go home, such as tolerate diet, BM, pass therapy, etc). Identify teaching needs to prepare for discharge. Patients need to know what they need to learn for successful recovery at home, for example, drains, wound care, S/Sx when to call MD, new medications, etc.Discuss destination at discharge. Early and frequent discussion of where the patient will go after leaving the acute care hospital is critical for patients and families to plan ahead for care needs at home or placement decisions and arrangements. Patients need a say on their next level of care whether it is Home[w/HHC or family member and/or with palliative or hospice care), inpatient rehab, Skilled care facility, or a nursing home.Close the loop for follow-up. Assign responsibilities for any items needing attention after rounds are completedUpdate the Getting Ready for Discharge Whiteboard so the information is available during the day to the patient and family

13Bedside Communication Board

Update:During MD Rounds

During Bedside Shift Report

Anytime there is a change in the plan

A tool to complement the Bedside Rounding Checklist is the Bedside Communication Board called the Getting Ready for Discharge Whiteboard. The whiteboard, located in the patients room, is a way to assure 3 way communication between physicians, nurses on all shifts, and the patient and family. The whiteboard is laminated and can be written on with erasable markers. Each day, a member of the team will update the board so that the physician/nurse/patient triad are all on the same page about goals to progress to discharge, and preparation needs.

There are 2 columns:The first column where you are now identifies current day status and plan. Give details here about current and plan for the day for diet, activity, pain, teaching, and preparations for support at home. In the second column Discharge Plan write the goals to be achieved The items on the whiteboard are topics covered in the Physician Team Rounding process

14DemonstrationVideo demonstration of MD Team - RN - patient rounding

This video is a enactment of the Physician Team Rounding Process. To open, left click on the link. When the video is over, close the window and you will return to this slide.

A video demonstration of the joint MD team- RN rounding procedures using the Rounding Checklist and the Getting Ready for Discharge whiteboard is provided here.All physician and nurse team members should watch this video.

15Next StepsImplementation of MD Team RN roundingRN-RN Bedside shift rounding

Real-time coaching by CAR team members

Once all health team members are trained in the new rounding procedures, we will begin implementation of the MD Team rounding process.When implementation begins, the CAR team members will conduct real-time coaching with the rounding teams to assist with applying the new rounding approaches in real patient situations.

16RN to RN Bedside Shift Report Checklist

Another important component of the redesigned Discharge Communication process is RN to RN Bedside Shift Report. To facilitate RN to RN bedside shift report, a new communication tool has been developed. It is also a Briefing Checklist. The checklist will be affixed to the computer in the patient room. This bedside shift report assures communication between all shifts. At change of shifts, nurses will conduct change of shift report at the patient bedside using the following steps:

Enter the room and make introductionsUpdate the oncoming nurse and the patient on the content of Physician rounds with specific attention to plan of care, medical milestones achieved and to be achieved, teaching needs to prepare for discharge, and discharge destination and planning needs regarding care at home.Review new orders and clarify any patient questionsCheck pumps and perform safety checksClose the loop for any follow-up needed. Assign responsibilityUpdate the Getting Ready for Discharge whiteboard. 17DemonstrationVideo Demonstration of RN -RN bedside shift report

This video is a enactment of the RN-RN Bedside Shift Report Process. To open, left click on the link. When the video is over, close the window and you will return to this slide.

A video demonstration of the RN to RN bedside shift report procedure is provided here. All RNs should watch this video.

18Next StepsImplementation of MD Team RN roundingRN-RN Bedside shift rounding

Real-time coaching by CAR team members

Once all RN team members are trained in the new bedside shift report procedures, we will begin implementation of the MD Team-RN rounding and the RN-RN bedside shift rounding at the same time.

When implementation begins the CAR team members will conduct real-time coaching with the rounding teams to assist with applying the new rounding approaches in real patient situations.

19CAR contactsIf you have questions about the new rounding and bedside shift reports, please contact the CAR study lead on your unit:

Kristi Opper, Clinical Nurse Specialist 8NTJoe Beiler, Clinical Nurse Specialist, 7NT

Thank you for helping to improve discharge communication for our patients and families. 20