Before St. Mary's Health Center in St. Louis, Mo., launched its morning handoff meetings, nurses often complained that the first time they heard about a patient being discharged was when they saw the signed order. A flurry of activity would then ensue as nurses, social workers and case managers scrambled to put together a last-minute discharge plan, but the process was chaotic and often contributed to the same patients being readmitted weeks or months later.
The 9 a.m. meetings, initiated in June 2008, have changed that dynamic. Now, a social worker, case manager and nurse team leader meet daily with attending physicians to go over all potential discharges on the 33-bed unit. Physicians offer an estimated discharge date soon after the patient is admitted and the entire team has input.
“The standard stereotype is you see the patient and say, ‘Hey, you can go home today,’ and everyone is thrown into a tizzy because no one has communicated that to them or to the family,” said Peter F. Shawki, ACP Member, a staff hospitalist. “You have to give everyone a sense of the timing so it isn't sprung on them.”
The collaborative approach replaced a silo mentality that wasn't productive and potentially disastrous, added Philip B. Vaidyan, FACP, director of the unit.
“In the past, physicians have had sporadic contact with others. Everyone had their own plan,” he said. “But discharges are potentially dangerous events. It's like landing a plane—you have to have a plan, you can't just crash land.”
Good communication doesn't just happen
Including staff other than physicians in daily handoff conferences is a relatively recent development at most hospitals, but they're catching on as a way to smooth discharges, increase patient satisfaction and improve relationships among health care team members. The sessions can be brief—as short as 15 minutes—and can play a key role in reducing preventable readmissions.
Reducing readmission rates became a priority for hospitals after an analysis in the April 2, 2009 New England Journal of Medicine reported that 20% of all Medicare patients are readmitted within 30 days after discharge. The readmission rate for patients discharged with medical conditions was much higher (67%) and just over half of those discharged after surgery were rehospitalized or died within the next year, according to the study.
The morning conference has helped improve those statistics at St. Mary's, where it is a key part of the larger Project BOOST (Better Outcomes for Older Adults through Safe Transitions). The unit's readmission rate dropped from 17% when the program began in June 2008 to 7% in September 2009, said Dr. Vaidyan.
Everyone agrees that keeping nurses, social workers and other team members in the loop contributes to better outcomes, but communication can be haphazard without a formal system to get everyone in the same room at the same time.
“If someone is going to be discharged in three days but has no family or nowhere to go, I need to start working on that. I need to find out who needs what and when,” said Rachel Protzel, staff social worker for the hospitalist unit at St. Mary's. “Having that scheduled meeting with the physicians every day means that I'm always informed and they can always find me.”
A similar strategy is under way at the University of California San Francisco Medical Center, where attendings for the eight medical teams meet daily for 15-minute multidisciplinary sessions (two or three attendings per session) to go through 40 to 50 patient charts and discuss discharge plans. Besides physicians, the meetings include charge nurses, case managers, social workers, pharmacists, dieticians, and occupational and physical therapists. A nurse manager or clinical nurse specialist helps facilitate the rounds to make sure all patients are covered in the allotted time. These multidisciplinary rounds have now been implemented on all units across the hospital.
The meetings end up saving time by having everyone in one room for short periods, said Niraj L. Sehgal, FACP, a USCF staff hospitalist and associate chair for quality and safety in the department of medicine. For example, a physician at the meeting might indicate that a patient is ready to be discharged, but the bedside nurse says that the patient cannot walk independently and needs physical therapy. The physical therapist is then brought into the conversation to develop a plan that meets the patient's needs.
“It gets everyone up to speed on what's going on with the patient in real time,” said Julie Koppel, RN, nurse manager on the medicine unit at UCSF. The bedside nurse often conveys updated information that can impact the discharge decision, she added, such as that a patient just fell or had an acute change in mental status.
Face-to-face contact between physicians, nurses and others on the care team facilitates a better working environment and greater accountability among team members, said P.J. Brennan, ACP Member, chief medical officer and senior vice president of the University of Pennsylvania Health System in Philadelphia. Dr. Brennan, along with Victoria Rich, RN, chief nursing executive at the Hospital of the University of Pennsylvania, spearheaded the use of leadership teams, each consisting of a physician, nurse leader and quality project manager, in all of its hospitalist units.
Before the leadership program was launched in 2006, hospitalist units did not have designated medical leaders and tended to lack conformity and accountability, said Dr. Brennan. “All of this was predicated on the recognition of unprofessional behavior in the past, such as housestaff rotating through without knowing anyone's names, doctors acting out and nurses retaliating,” he said.
Improving communication between physicians and nurses is central to the goal of preventing readmissions, said Dr. Brennan. To that end, residents attend an orientation with nurses as soon as their shift begins and nurses are brought into multidisciplinary rounds on medical-surgical units. “We learned from the ICU, where their motto is ‘If the nurse doesn't know the care plan, there is no plan,’” noted Dr. Brennan.
In the past, physicians often devised care plans on their own with sporadic input from nurses, he added. Multidisciplinary teams have changed that dynamic and, not surprisingly, nurses report being much more satisfied with their relationships with physicians.
“It's been very catalytic,” said Dr. Brennan of the leadership model. “What we're seeing now is pharmacists, social workers and discharge planners are asking to be part of these teams and the administration is looking to teams as solutions to a variety of problems.”
Making it work
Even if all the participants buy into the idea of regular team meetings, logistics can pose a challenge. Especially important is whether physicians' patients are located in one place or spread among several units in the hospital, said Dr. Sehgal at UCSF.
“Nurses are almost always unit-based while doctors are often service-based, meaning they may have patients on several different units on a given day,” he explained. At UCSF's main teaching hospital, multidisciplinary sessions focus on two units where the majority of hospitalists' patients are located. For patients outside of those units, physicians communicate with a single case manager but do not attend formal team meetings on the other units.
Team meetings are easier to implement when patients are geographically organized on one unit, which is the case at UCSF's smaller Mt. Zion campus, where Dr. Sehgal had served as inpatient director. Mt. Zion's daily 30-minute multidisciplinary rounds include the two hospitalists on service plus a charge nurse, physical therapist, occupational therapist, nutritionist, chaplain, case manager and social worker. Each nurse has five minutes to report on his or her patients for that day.
At Mt. Zion, the bedside nurse, rather than the hospitalist, drives the rounding schedule, said Dr. Sehgal. The two hospitalists stay in the room for the entire meeting, while nurses rotate through to report on their patients. The case manager summarizes action items at the end of each presentation.
“A key piece is having action items at the end because the next day the patient gets presented and it may be a different hospitalist or nurse,” said Dr. Sehgal. Because a standardized tracking form was created the previous day, the case manager can report, for example, that the team is waiting to hear back from a family member about a certain issue or that they need to confirm whether equipment was delivered to a patient's home.
It also helps to have strong administrative support for the team approach, noted Dr. Vaidyan at St. Mary's. For example, his unit has a designated conference room equipped with cutting-edge technology, including a flat screen with computer capability so the whole team can easily go over X-rays and medication lists.
Engaging physicians isn't easy because they tend to have an independent practitioner mentality, said Dr. Vaidyan. But if you can get them to buy into the concept, the benefits often transcend statistical outcomes.
“The most important thing I see is the relationship building between hospitalists, nurses, social workers and case managers so that we all function as a team,” he said. “The egos are out the door. You can't measure that, but I consider it to be huge.”