Evidence Summary and Recommendations for Improved Communication during Care Transitions

Abstract

Background

Communication between levels of care can be complex for any patient. For the Servicemember or Veteran with complex medical issues, who needs transitioning between multiple levels of care, this communication involves detailed, individualized information pivotal to quality clinical outcomes and patient/family satisfaction. These complex cases also typically include communication between multiple family members.

Purpose

The purpose was to summarize the evidence and present recommendations for facilitating effective transitions of patient care within the complex Veterans Affairs (VA) Polytrauma System of Care.

Design

Evidence Based Review.

Methods

Selected members of the VA Office of Nursing Service Polytrauma Field Advisory Committee conducted an evidence-based review, and queried a clinical panel of polytrauma nursing experts and direct care rehabilitation nurses.

Findings

Search results, key practice recommendations, a plan of care template, and future plans for dissemination and implementation are presented.

Conclusions

Communication is a key to success when managing many details and requires both focus and knowledge of larger systems.

Clinical Relevance

Direct communication, using a standardized approach, is recommended for successful patient transitions.

Background

The VA Polytrauma System of Care (PSC) was developed to address the unique challenges associated with polytrauma and traumatic brain injury (TBI) recovery. The PSC provides world-class rehabilitation services and ensures that Veterans and Servicemembers with polytrauma transition seamlessly between Department of Defense (DoD) and Veterans Health Administration (VHA) and back to their home communities.

The Polytrauma Rehabilitation Field Advisory Committee (PFAC) is one of ten Clinical Practice Programs (CPP) developed by VHA Office of Nursing Service to support nursing clinical practice, develop policies in coordination with other VHA program offices and to disseminate communication to the field. The PFAC was asked to review transition processes, evaluate the evidence, and provide guidance for recommendations to assure complete and effective transition of patient care occurring within the complex PSC. Members of the PFAC utilized evidence-based practice and scientific literature critical appraisal methods to evaluate the body of evidence and answer the clinical question pertaining to the most effective communication actions during patient transitions across care settings. In addition, the PFAC members queried a clinical panel of polytrauma nursing experts and direct care rehabilitation nurses. This article summarizes these findings.

Case Example Regarding Communication during a Transition in Patient Care

A 26-year-old white male was transferred across state lines and between two government facilities. The Service-member was injured several months earlier when he walked over an improvised explosive device in Afghanistan. He was healthy before injury and was planning to be a career soldier. His wife and 1-year old son were living in Georgia. His parents were living in Oregon. His mother planned to travel with him and stay in the room with him at both sites.

The Servicemember’s injuries included moderate TBI and traumatic amputation of the right arm and the right leg below the knee. He had intermittent pain that was controlled by oral medications. In the first facility, he had memory deficits and occasional agitation, but no confusion. The patient arrived from the first facility to the rehabilitation unit, unaccompanied by any family members, with a Patient Controlled Analgesia (PCA) pump and Foley catheter. He was agitated, confused, and frequently tried to get out of bed.

Immediately upon the Servicemember’s arrival to the rehabilitation facility and during the initial assessment, the admitting nurse questioned why some information was not included in the hand-off communication between the two facilities, and had the following questions:

1. When did the patient receive a PCA pump and why?

2. Why does the patient have an indwelling Foley catheter?

3. Where are the family members?

Per discussion among the clinical experts, this example highlights a common problem regarding transitions of highly complex patients as they move through any healthcare system after significant trauma and the changes that can occur rapidly, and immediately before transition, that affect the receiving transition facility. The example underscores the implications for consistently utilizing a standard, robust, evidence-based hand-off reporting communication method or tool. The complexities of this case example include the severity of the trauma, the multiple care sites involved, the transition of care between multiple agencies, and multiple family members.

Since the onset of the Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) conflict, there have been ongoing program process improvement activities at the VA PSC and within the DoD. There have also been efforts to streamline the transition between the multiple entities. One example is a transfer summary tool which was developed to facilitate transferring of patients from the acute phase of care in DoD medical treatment facilities to VA PSC for acute rehabilitation services. Another example which illustrates the improvements made in transitioning patients across care settings and levels is the advent 10 years ago of the VA/DoD Nurse Liaison position. This position is a VA employee located within the DoD medical system whose job is to work between both systems and to ensure that communications are thorough and complete.

Despite the above described efforts, transition communication can still be improved. Thus, the PFAC was asked to address transition communication activities and suggest ways to improve practice.

Methods

Evidence Search

An evidence-based practice, literature review strategy was utilized to evaluate this transition of care communication issue. Selected members of the VA PFAC focused the direction of the literature search by starting with a PICO question. PICO stands for: Population/problem, Intervention (if there is one), Comparison (if there is one), and Outcome of interest (Fineout-Overholt, Melnyk, & Schultz, 2005). The PICO question utilized was: For complex patients who are discharged or transferred across medical care settings [Population/Problem], does use of interdisciplinary communication written format (tool) in addition to verbal communication [Intervention], compared with verbal communication alone [Comparison] improve the clinical outcomes and satisfaction (regarding the transfer) for the Servicemember or Veteran, their family, and the receiving facility [Outome]?

A search of the literature was completed utilizing online databases including: PubMed, PubMed Clinical Queries, Cochrane Library, AHRQ (clinical practice guidelines), CINAHL, UpToDate, BioMed Central, and EBSCO host database. This search used 30 search terms: communication, continuity of patient care/organization and administration, discharge, emergency service, interdepartmental relations, interprofessional relations, leadership, medical errors/nursing, medical errors/prevention and control, medical errors/statistics and numerical data, models, nursing, needs assessment, nurse administrators/organization, nurse administrators/psychology, nurse’s role/psychology, nursing evaluation research, nursing staff hospital, outcome and process assessment, patient care planning/organization and administration, problem solving, safety management/organization, systems analysis, total quality management/organization, continuity of patient care, emergency medical technicians, humans, patient care team, patient transfer/standards and trauma centers. This search resulted in 21 articles for review. Six articles were excluded because they did not address the topic of interest and six were excluded because the articles were not well-detailed, which made it difficult to determine their quality. The nine included articles are summarized as an attachment to this article (see Appendix A).

Input from Expert Clinical Panel and VA Polytrauma Rehabilitation Nurses

To acquire additional evidence regarding this clinical question, expert opinion was sought from a clinical panel of polytrauma and rehabilitation nursing experts chosen from the PFAC. An informal query was also conducted with VA polytrauma rehabilitation nurses to obtain input regarding strategies used to assure effective hand-offs at a time of discharge to another level of care.

Findings: Evidence Review

To assist in critically appraising the evidence, an evidence-based practice (EBP) toolkit containing critical appraisal worksheets from the Critical Appraisal Skills Program and Centre for Evidence-Based Medicine were utilized. Furthermore, the Level of Evidence hierarchies designated by the Agency for Healthcare Research and Quality (AHRQ) were used to document the level of evidence in our team’s literature review matrix. (Appendix A) The Strength of Recommendation Taxonomy (SORT) method was used to evaluate the quality of each study (Ebell, 2004).

The overwhelming recurrent theme throughout the literature review and the informal suggestions by polytrauma nurses in the VA nationwide suggested that communication is the key element in any successful patient hand-off. This successful communication includes the following key components: (1) active listening, (2) thorough documentation, and (3) detailed verbal communication between involved care providers.

Numerous situational strategies are described in the literature, which have been effective in certain environments. For example, communication boards might be utilized in an emergency room or operating room. The scientific literature supports strategies developed in formats that are discipline-specific and specialty-specific to be certain all essential details are included in the transition hand-off.

Unfortunately, there were limitations to the literature search. The studies reviewed did not identify any examples specific to a transitioning rehabilitation or trauma patient within the military-VA system or in the community system. Therefore, how these findings can be generalized to the practice of rehabilitation nursing, in any setting, cannot be clearly determined.

This evidence base, along with input from the clinical panel of polytrauma nursing experts and the informal query results of direct care rehabilitation nursing staff, supports the need for effective communication during any transition. The PFAC recommends operationalizing communication effort by standardizing a transition of care process. The PFAC developed a standardized process to assure that a reliable and safe transition of care occurs for all patients. As this transition process often involves very complex Active Duty Servicemembers and Veterans in the PSC, the following practice recommendations were developed. However, these findings are not specific to just military rehabilitation but to all complex rehabilitation patients and can be applied to all rehabilitation nursing processes.

Recommendations for Practice

1. It is essential that effective hand-off communication occurs in such a manner that the transferring and receiving parties have the opportunity to clarify patient care needs by asking and responding to pertinent questions. Therefore, this communication needs to take place in real time, which is the quality standard designated within the PSC.

   1. Hand-off communication is to be done face-to-face or in-person via video teleconferencing or by telephone. Recorded messages, faxed information, e-mail, text messages, and hand-written notes do not fulfill this quality standard for effective communication.
   2. A mutually agreed upon time for communicating this care information among clinical staff members needs to be established.
   3. This hand-off time should be protected and in a designated area to minimize interruptions. Interruptions during this communication time must be kept to a bare minimum to enhance the accuracy and comprehensive information exchange.
   4. The information exchange should be done RN to RN and/or with other designated members of the professional healthcare team that have an extensive knowledge of the patient.
   5. We propose the ISBAR (Identification, Situation, Background, Assessment and Recommendation; ISBAR, n.d.) as the framework for this communication exchange. This inclusive framework review should establish that the patient’s clinical status is stable and thereby able to sustain care at the next level of transition along the road to recovery. For instance, transition to an acute rehabilitation setting will require planned participation in a minimum of three hours of therapy per day.
2. Hand-off communication is required at all levels of transition, such as transitioning between an inpatient rehabilitation center, a community transitional program, a day program, or an out-patient clinic site.

   1. The choice of transition facility is dependent on services needed by the patient, with consideration given toward transitioning to a VA facility close to the patient’s home.
   2. Hand-off communication is also the recommendation for discharge to long-term care facilities, assisted living facilities, community living centers, hospice, or home.

3. Patient/family participation in the process is essential at each stage of transition. This provides an opportunity to introduce the point-of-contact at the receiving unit, as well as to the transferring patient and family, to ease the stress of the transition. Specifically, patient/family participation facilitates the review of short- and long-term goals, assures sufficient understanding of realistic expectations, and promotes understanding of the services offered at the receiving facility.

4. A plan related to the specifics of care for the individual patient should be utilized as a communication tool for all clinicians involved in the process. For example, in the VA, the standardized Polytrauma-TBI Individualized Rehabilitation Reintegration Plan of Care (Appendix B) is the written format that should be utilized in the transition communication. Nursing information should be integrated into this interdisciplinary document. While the responsibility for completing this document often falls to the case manager, additional nursing discharge documents (site specific) may also be utilized to include more detailed nursing care information. An example of such a document utilized by the San Antonio VA is the “Rehabilitation Nursing Report Outline” (Appendix C), which provides a suggested format for nursing-to-nursing communication during the transition process.

5. The transition communication includes all follow-up outpatient clinic appointments scheduled as necessary, with this information provided in writing to the patient/family and receiving facility before the transfer.

6. It is expected that both the discharge and transition planning process begins at admission.

Evidence Dissemination

The PFAC and the work group that developed these recommendations are part of the CPP. The CPP was developed by the VHA Office of Nursing Service (ONS) to support nursing clinical practice, develop policies in coordination with other VHA program offices and to disseminate communication to the field. The following activities demonstrate ways members have disseminated the findings from this project with the nursing community:

1. A fact sheet was developed based on the findings of the group with recommendations and posted on the PFAC SharePoint and the ONS CPP products page. All VHA nurses have access to these intranet web pages.

2. Findings and recommendations were presented to the following:

   1. National Nursing Practice Council and direct care staff in March, 2013.
   2. Edward Hines, Jr. VA Hospital’s Evidenced-Based Practice Council in April, 2013.
   3. National Polytrauma Nurses group in May, 2013, via webinar.
   4. VHA National Nurse Executives and Nursing Practice Transformation Goal group in January, 2014.
3. Posters were presented on the findings and recommendations at the following:

   1. The Future Trends Conference in Richmond, Virginia at the Hunter Holmes McGuire VA Hospital in October, 2013.
   2. Virginia Nurses Association Legislative Day Conference in February, 2014.
   3. Edward Hines, Jr. VA Hospital Nurses’ Week Poster Presentation in May, 2014.
   4. The 9th Annual Brain Injury Rehabilitation Conference in May, 2014.
   5. The 40th Annual ARN conference in October, 2014.

The PFAC will continue to support nursing clinical practice, develop policies in coordination with other VHA program offices, and disseminate recommendations to the field.

Summary and Conclusion

Communication is a key to success when managing many details and requires both focus and knowledge of larger systems. Assuring that all information specific to an individual patient is communicated during a period of transition is crucial to a successful care process. Patients who are in a trauma or rehabilitative setting typically have care provided by many professionals using an interdisciplinary team approach. Thus, there is a need for complex and detailed information to be shared with receiving teams during any transition.

Transitions occur between many types of settings and can also occur across many miles. Patients and families are reliant on clinical staff to be certain all details and preferences are communicated and managed across various programs and communicated to all necessary professionals. This can be a large task for patients with complex medical needs. Direct communication, using a standardized approach, is recommended between like clinicians. This approach assures that all details are included in the discussion and patient preferences and individual needs are incorporated.

The PICO question raised in this review will require additional study to determine if implementation of this more systematic approach to transfer communication actually improves patient outcome and patient satisfaction.

Key Practice Points.

• Communication is a key to success while managing many details and requires focus and knowledge of larger systems.

• Establish a safe, patient-centered, standardized set of communication actions to ensure critical coordination, continuity, and optimal healthcare outcomes for Service-members and Veterans as they transition from one care site to another.

• Ensure effective communication by utilizing a template providing a two-way dialog for critical information that affords the opportunity to ask and respond to questions in real time.

• Use of a standardized set of communication actions and Interdisciplinary Team (IDT) information are the key elements in any successful patient hand-off.

Earn nursing contact hours.

Rehabilitation Nursing is pleased to offer readers the opportunity to earn nursing contact hours for its continuing education articles by taking a posttest through the ARN website. The posttest consists of questions based on this article, plus several assessment questions (e.g., how long did it take you to read the articles and complete the posttest?). A passing score on the posttest and completing of the assessment questions yield one nursing contact hour for each article.

To earn contact hours, go to www.rehabnurse.org and select the “Education” page. There you can read the article again, or go directly to the posttest assessment by selecting “RNJ online CE.” The cost for credit is $10 per article. You will be asked for a credit card or online payment service number.

The contact hours for this activity will not be available after June 30, 2018.

The Association of Rehabilitation Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation (ANCC-COA).

Appendix A

Evidence summary table

Levels of Evidence used in this summary were obtained from:
Agency for Healthcare Research and Quality (AHRQ)
Level I			Meta-Analysis (Combination of data from many studies)
Level II			Experimental Designs (Randomized Control Trials)
Level III			Well-designed Quasi Experimental Designs (Not randomized or no control group)
Level IV			Well-designed Non-Experimental Designs (Descriptive-can include qualitative)
Level V			Case reports/clinical expertise
Reference	Study Design or Method/Sample/ Setting/Process Description	Major Themes	Limitations	Recommendations or Findings	Level of Evidence/ Strength of Recommendation	Findings Supported by Expert Panel?
Calleja, P., Aitken,  L.M., & Cooke, M.L.  (2011). Information  transfer for multitrauma  patients on  discharge from the  emergency  department: Mixedmethod  narrative  review. Journal of  Advanced Nursing,  67, 4–18.	Mixed methods  narrative review of  316 articles from 12  online data bases (45  research articles, four  literature reviews,  and one policy  statement) from the  years 1990 through  2009	Impact of Trauma teams Communication Documentation Clinical Handover	1. Limited number of  papers directly  applicable so similar  issues in other care  contexts were reviewed  and links to trauma care  presented; 2. Limited to  papers in English, no  studies investigating  effectiveness of  communication  strategies in trauma  specific handovers	If strategies can be  developed to help  reduce barriers and  prevent communication  breakdown, there is  great potential to  improve patient care.	III-IV/B	Yes
Roberts, M., Putnam,  J. & Raup, G.H.  (2012). The  Interdepartmental  Ticket (IT) factor:  Enhancing  communication to  improve quality.  Journal of Nursing  Care Quality, 27, 247  –252.	Evidence-based  improvement project  implemented in one  facility. Utilized Iowa  model as project  framework. The plan  –do–check–act  (PDCA) process was  used by the EBP  Council and  integrated into the  Iowa model; the  PDCA served as the  step-by-step method  they used to evaluate  the practice change  1-year post  implementation.	Use of standardized  communication  procedures with a  structured method such  as the IT tool appears to  facilitate collection and  transfer of critical safety  data that otherwise  might be lost using  traditional nursing  communication  practices.	This article did not  present specific  limitations of their  project. Because this  was a local improvement  project, the project has  been limited.	Use of standardized  communication  procedures with a  structured method such  as the IT tool appears to  facilitate collection and  transfer of critical safety  data that otherwise  might be lost using  traditional nursing  communication  practices.	IV/B	Yes
Coleman, E. & Boult,  C. (2003). Improving  the quality of  transitional care for  persons with complex  care needs. Journal  of the American  Geriatrics Society, 51,  556–557	The consensus article  was based on an  evaluation of work  dating from 1988  through 2002. The  studies that were  summarized include  qualitative research,  and randomized  control clinical trials.	The article recommended  five positions supported  by the American  Geriatric Society: Patients and caregivers need to be actively involved in the transfer process. Bidirectional communication is essential between clinical professionals. Policies should be devel oped to promote high quality transitional care. Education in transitional care is needed for healthcare professionals involved in patient transfers. Future research is needed on how to: empower patients and caregivers, improve effective training of professionals, design and test systems of care focused on transitions, development of performance indicators and quality improvement technologies focused on transitional care.	The studies that were  reviewed were not  current. The paper was  aimed at long-term care  and assisted living care  settings and transfers  involving these areas.  There was no  description of the  specific patient  populations reviewed in  the supporting studies.  There was a lack of  detail whether the five  positions are applicable  to all patient  populations. The basis  and rationale for the five  positions was not clearly  defined.	There are clearly  identified potential risks  when critical elements  of transitions are  omitted and these  critical elements are the  responsibilities of both  senders and receivers of  transitional care. The  article emphasizes the  importance of the  patient-centeredness of  the process.	IV/B	Yes
Kripalani, S., LeFevre,  F., Phillips, C.,  Williams, M.,  Basaviah, P. & Baker,  D. (2007). Deficits in  communication and  information transfer  between hospitalbased  and primary  care physicians:  Implications for  patient safety and  continuity of care.  Journal of the  American Medical  Association, 297, 831  –841.	This article was a  systematic review  based on 73 studies  of which 55 were  observational and 15  were controlled  intervention trials  (three randomized,  seven nonrandomized  with  concurrent control  and eight with pre–  post design). The 55  observational studies  were published  between 1970 and  2005.	The purpose of most of  the observational studies  was to investigate  communication and  information transfer at  hospital discharge,  whereas the controlled  intervention studies  evaluated the efficacy of  interventions aimed at  improving information  transfer.	The limitations of this  review are reflected in  the high degree of  variability among the  studies in patient  populations, outcome  measures and types of  interventions tested. In  addition, they reported  limited outcome data  and different metrics to  measure these  outcomes.	Despite the above cited  limitations, conclusions  drawn unanimously  noted that deficits in  communication and  information transfer at  hospital discharge are  common and may  adversely affect patient  care and outcomes.  Standardized formats  and computer-generated  summaries may facilitate  more timely, pertinent,  consistent, and inclusive  information needed for  follow-up care.	II	Yes
Coleman, E., Parry, C.,  Chalmers, S. & Min,  S. (2006). The care  transitions  intervention. Archives  of Internal Medicine,  166, 1822–1828.	The article reported  results of a  randomized  controlled trial  conducted between  September 1, 2002,  and August 31,  2003, within a large  integrated delivery  system in Colorado.  The subjects were  community dwelling  adults 65 years and  older, admitted to  the hospital with one  of 11 selected  conditions. Total  number of subjects  was 750.	The intervention subjects  received (1) tools to  promote cross-site  communication, (2)  encouragement to take  a more active role in  their care and assert  their preferences, and  (3) continuity across  settings with guidance  from a “transition coach.”  Rates of rehospitalization  were measured at 30, 90,  and 180 days.	Limitations of the study  dealt with measuring  the costs of the  interventions and  productivity with the  cost-effectiveness  analysis being beyond  the scope of the study.  The study was limited to  a single hospital in  Colorado and a subject  age group of 65 years  and older.	Conclusions of the study  note statistical  significance in the  reduced rates of hospital  readmissions, with the  suggestion that this may  be attributable to the  focus on meeting  communication needs  during the vulnerable  transition period.	II	Yes
Manser, T. (2009).  Teamwork and  patient safety in  dynamic domains of  healthcare: A review  of the literature. Acta  Annaesthesiologica  Scandinavica, 53,  143–151.	One hundred and one  publications  (between 1998 and  2007) were selected  for review. The  purpose of this  review was to  identify aspects of  teamwork that have  been linked to safety  and quality of care.	Three domains were  identified as providing  evidence that suggests  being necessary to  assure quality and safety  related to patient care.  These include: (1)  teamwork plays an  important role, (2)  healthcare providers  perception of teamwork,  and (3) patterns of  communication among  high performing teams.  The article describes  effective teamwork as a  necessary part of patient  safety in highly dynamic  healthcare environments		Conclusions indicate  teamwork is an  important contributing  factor to assuring  patient safety and  preventing adverse  events. Coordination of  healthcare teams is an  important process as  patients move through  the healthcare system.  Communication and  leadership are both  necessary components  of effective teamwork.	Level II	Yes
Shendell-Falik, N.,  Feinson, M. & Mohr,  B.J. (2007).  Enhancing patient  safety: Improving the  patient handoff  process through  appreciative inquiry.  Journal of Nursing  Administration, 37,  95–104.	Qualitative study of  one hospital’s  experience.	This article was one  hospital’s experience in  making measurable  improvements in the  hand-off process using  an unconventional  approach to change called  appreciative  inquiry (AI).	There were no stated  limitations or strengths  in the article. However,  it was implied that if  change is sought at a  quantum level not an  incremental level then  the AI was a good  choice.	Using the five basic  processes of the AI  method they achieved  short and intermediate  outcomes and stated  long-term goals.	IV/B	Yes
					IV	Yes
Camicia, M., Black, T.,  Farrell, J., Waites, K.,  Wirt, S., & Lutz, B.  (2013). The essential  role of the  rehabilitation nurse in  facilitating care  transitions: A white  paper by the  Association of  Rehabilitation Nurses.  Rehabilitation  Nursing, 39, 3–15.	Members of the  Association of  Rehabilitation Nurse  leadership wrote a  white paper  (consensus  statement) in  response to a review  of the literature that  reveals significant  problems with  transitions to postacute  care settings.	A nurse with  rehabilitation nursing  training, knowledge,  and experience is the  healthcare professional  who is best able to  coordinate, support, and  oversee the discharge  transition process to  promote quality  outcomes and cost-effective  care for  individuals with disabling  conditions.	Studies are needed to  evaluate the impact of  rehabilitation nurses on  the healthcare delivery  system.	Care transitions must be  facilitated by nurses with  training, knowledge and  experience. The role of  the rehab nurse is to  educate and inform  regarding services  available. Nurses must  be involved in public  policy and research.
Dossa, A., Bokhour, B  & Hoenig, H. (2012).  Care transitions from  the hospital to home  for patients with  mobility impairments:  Patient and family  caregiver  experiences.  Rehabilitation  Nursing, 37, 277–  285.	This is a qualitative,  longitudinal study.  Nine Caucasian men  between the age of  70–88 with either a  medical or surgical  diagnosis. The nine  patients and nine  female caregivers  interviewed at  2 weeks, 1 month,  and 2 months  postdischarge. The  patients all had a  recommendation for  follow-up  rehabilitation and an  involved caregiver.	Four areas that had an  impact on continuity of  care and patient  recovery following  discharge all had to do  with communication.  Poor communication  between provider and  patient regarding home  care, whom to contact  postdischarge, responses  from providers following  discharge and provider  to provider  communication.	Limited by inclusion of  only patients who were  cognitively able to  participate in interviews  and who had caregivers.  Only interviewed  patients and caregivers  not the providers.  Sample size was limited.	Improved systems are  needed to address  patient concerns after  discharge. Better  communication is  needed to coordinate  care, facilitate recovery  and prevent potential  adverse outcomes.	IV/B	Yes

Appendix B

Polytrauma-TBI Individualized Rehabilitation/Reintegration Plan of Care (Modified by Category)

1. Note Type ___ Initial ___ Interim ____Discharge

2. History of present illness/interim history since last team note

3. Current problems with patient input

4. Interdisciplinary Treatment Team evaluations: (including family education and family support needs)

5. Interdisciplinary Treatment Team Goals

6. Rehabilitation and reintegration plan (Types of services, frequency/duration of treatment, planned follow-up, etc.)

7. Consults requested and/or follow-up on consults

8. Proposed time/frame for IDT follow-up conference

   1. Plan of care communicated: Yes No
   2. Mode of communication: In person, telephone, mail, secure messaging

9. Physician responsible for managing the treatment plan

10. Polytrauma-TBI Case Manager responsible for monitoring implementation

11. Date care plan will be reviewed

12. Additional Information

Appendix C

Rehabilitation Nursing Report Outline

History is to include: 1.

Patient’s Name, 2. Last 4 SSN, 3. Age/DOB, 4. Sex, 5. Date Admitted, 6. Diagnosis/Chief Complaint, 7. Pertinent History (Diabetes, CHF, Surgeries, etc.), 8. Allergies, 9. Precautions (sternal, hip, weight bearing…)

Daily Report is to include:

Identify the Active Desired Outcomes from the nursing diagnoses.

Then go into the system by system report that follows for anything not addressed in the above

Format for Rehabilitation Patients: GENERAL RULE - IF SYSTEM IS “WNL” DO NOT DISCUSS IT.
Labs, x-rays and other test results can be given under appropriate body system
REPORT CATAGORIES	STATUS DO NOT REPORT NORMALS	STATUS REPORT ALL: ABNORMALS	PLAN REPORT:
1. Identification	Patient’s Name, Last 4 SSN#,  Room #, Age/DOB, Code Status
2. Neuro	Alert, Oriented	Confused, agitated, combative,  lethargic, eyeglasses	For ABNORMAL  FINDINGS:  Report a “PLAN”
3. Cardiovascular	VS, apical pulse, rhythm	Edema, H&H, vital signs,  chest pain
4. Respiratory	Lung sounds	Lung sounds, oxygen, chest tubes,  suction, sputum
5. Endocrine		Diabetes, accu-check schedule
6. Gl/Nutrition	Diet, bowel sounds,  calorie count	NPO (even if after certain time period),  feeding assistance, how do  they take their meds?  Constipation/diarrhea, N/G tube,  N/V, significant weight change,  last BM  Denture use
7. GU	Voiding
		Foley, incontinence, straight cath,  bladder management (last cath,  bladder scans), level of patient  independence with bladder mgmt,  irrigation, dialysis
8. Integumentary	Skin intact	Decubitus, rashes, wounds  (give location & dressing type/time)
9. Infectious  Disease/Hematology	Labs WNL, no isolation	Any abnormal cultures/labs.  isolation precautions. Blood  Transfusions with s/p lab results
10. IV sites	Location, type,  date of insertion	Changed on your shift, any  recent infiltrates/infections.  Include IJ, Femoral, PICC, CVC,  Vascath, Ports
11. I&O		Fluid restrictions, force fluids,  drains, 24 hour balance
12. Pain Management	Location and type of pain	Rating on pain scale, medication  and how often. Last given?  When due again? Did it help?  If not, did you notify physician?
13. Pt Safety	Activity, LOC	Falls Risk and interventions,  restraints/type, suicide precautions,  assistive devices (cane, walker,  commode, wheelchair,  overhead trapeze). Have they  fallen? May go off unit  unattended or with family?	For ABNORMAL  FINDINGS:  Report a “PLAN”
14. Transfers	Independent	Amount of assistance with transfers.  Uses assistive devices with transfers..
16. Psychosocial	Family involved	Family meeting report
17. Behavioral  Management	No Problematic behaviors  that need to be managed	Behavior plan  needed/started/implemented  Describe behavior: restless,  wandering, irritability,  escalation from internal  or external stimulation.  Agitation, physically aggressive  Combative: pushing,  shoving, swinging, hitting,  pinching, spitting, biting  Sobbing loudly  Loud, hostile voice, swearing  Abusive language  Hateful comments  Inappropriate sexual remarks  Argumentative  Becoming stuck on an  inappropriate behavior  Refusing tasks, meds, treatment  Noncompliance
15. Pt Education/Discharge  Planning	What info, has been given,  expected LOS/discharge date	Specific needs. Bowel/bladder  management, safety, transfers,  medications, diabetic,  what to do in an emergency
16. Therapy		Schedule, tolerance, level of  participation, issues
17. Miscellaneous	Any helpful hints in caring  for this patient that you  would want to know  as his/her caregiver	Any special tests/procedures  pending.