Strategies for Seamless Patient Care Transitions

Transitions of care refers to patients being moved between different caretakers, clinicians, or facilities as their condition or needs change.¹ Formal training in communication during patient transferrals has not been standard practice,² even though human medicine studies have shown poor communication is the leading cause of inaccuracies, which in turn have led to twice as many deaths as clinical errors.^1,2

Developing strategies to prevent miscommunication during patient transitions is clearly essential to help prevent medical errors.

Patients may be transferred between veterinarians, veterinary nurses, practice departments, and even practices. For example, a canine patient may present to his regular veterinarian with a problem that prompts the veterinarian to refer the dog to an emergency practice. After admission to the emergency practice, the dog may be transferred to a veterinarian in a specific department (eg, internal medicine) for appropriate management. Seamless communication is essential to ensure continuous and effective care.

Communication Models

Understanding the information that is necessary to convey and how to present it in a way that is easily understood is essential for excellent patient care. Veterinarians and veterinary nurses should not only have a clear plan for the pertinent information they will gather when admitting a new patient but should also be prepared to pass on the information as the patient is transitioned to another’s care. Many models are available to help gather and convey information effectively and efficiently.

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TeamSTEPPS

The TeamSTEPPS program—produced by the Agency for Healthcare Research and Quality, an agency within the US Department of Health and Human Services—is a program to improve patient safety and communication among healthcare providers.³ TeamSTEPPS (ie, Strategies and Tools to Enhance Performance and Patient Safety) uses communication techniques such as SBAR (ie, Situation, Background, Assessment, Recommendation) to identify discussion points in a clear, organized format.^3,4

SBAR

The goal of the SBAR technique is to ensure that communication during each transition:

• Addresses any concerns about the patient (eg, the initial/primary concern)

• Provides all the important facts about the patient (as they relate to the primary concern)

• Includes specific details in the patient summary (eg, a general assessment of how the patient is doing, the owner’s state of mind)

• Recommends and encourages the team member to use critical thinking and suggest how to proceed 

For example, when a caretaker is communicating a concern about the patient, he or she can follow the SBAR dialogue to identify the patient, location, scenario, and problem and offer suggestions. Here is an example of an SBAR interaction between a veterinary nurse and a veterinarian. 

• Situation: Good morning, Dr. Doe. This is Jane in CCU. I am calling regarding your patient, Lucky, who was admitted through the emergency service after he was struck by a car this morning. He seems to be having increased respiratory effort.

• Background: He has become increasingly restless and tachypnic despite oxygen administration, and I have auscultated decreased breath sounds bilaterally.

• Assessment: I am concerned that Lucky may have a pneumothorax.

• Recommendation: I think we may need to perform a thoracocentesis. Would you be able to evaluate Lucky now?

As well as the SBAR technique, the I-PASS and SHARE methods, which were developed to specifically address patient handoffs, can also be used to ensure good continuity of care.^4,5 These methods ensure necessary information will be exchanged clearly and concisely among patient-care team members and prevent team members from becoming distracted by unrelated topics when exchanging information.

I-PASS 

The I-PASS (Illness Severity, Patient Summary, Action List, Situation Awareness and Contingency Planning, Synthesis by Receiver) method is another form of dialogue.⁵ Here is an example of a conversation when a patient is being transferred from one veterinary nurse to another: 

The Transferring Veterinary Nurse

• I: Lucky is a 4-year-old neutered Labrador retriever who was struck by a car yesterday morning.

• P: On presentation, he was anxious but alert and ambulatory, with multiple mild abrasions on his front and rear legs. We administered an IV fluid bolus and hydromorphone for pain, and he was admitted to the critical care unit. Shortly after presentation, decreased breath sounds were noted and thoracocentesis was performed bilaterally. One hundred mL of air was aspirated from his left side and 250 mL of air from the right side. He vomited once after admission, with no evidence of pneumothorax recurrence. His pain is controlled with buprenorphine and his abrasions kept clean and dry. He is maintained on maintenance crystalloid IV fluids and his vitals and respiratory pattern are being monitored. His respiratory rate has remained within normal limits with minimal effort. Radiographs confirmed some lung contusions, but Lucky has been resting comfortably with no complications. 

• A: The plan is to transfer him to the intermediate-care ward, wean him off fluids, and switch him to oral medications if he begins eating and remains comfortable. Thoracic radiographs will be taken again in the morning and Lucky will be sent home if no complications arise. 

• S: If Lucky vomits again or becomes dyspneic or distressed, he will be kept in the critical care unit and the plan will be reevaluated.

The Receiving Veterinary Nurse

• S: Lucky has remained stable and comfortable after a single thoracocentesis yesterday. His fluids are being decreased, and he is being encouraged to eat and transitioned to oral medications. If he eats and does well, repeat radiographs will be evaluated tomorrow and he will be discharged. If he vomits again or has any respiratory effort, the veterinarian will be notified and radiography may be repeated earlier.

SHARE

The SHARE method includes these guidelines that caretakers should follow⁶: 

• Standardize Critical Content: Provide details regarding patient history and status, emphasizing any particular concerns. 

• Hardwire Within the System: Use standard systems or forms (ie, SBAR) in an appropriate environment and ensure proper documentation.

• Allow the Opportunity to Ask Questions: Collaborate with team members on information using critical thinking skills.

• Reinforce Quality and Measurement: Promote accountability among team members and monitor the outcome of transferred cases.

• Educate and Coach: Emphasize the importance of communication during rounds and transfers, ensure team members are properly trained, and review and practice frequently.

Conclusion

Poor communication is one of the most common causes of errors in medical practice, so using a standard communication technique that helps facilitate an easy transition of care by providing an outline of pertinent information, conveyed in an organized format, is essential. Maintaining current, accurate medical records with appropriate documentation of the patient’s condition and interventions is also important. The records should be accessible to everyone attending to the patient. 

Establishing a designated area where cases can be discussed without any distractions can also be helpful to ensure open dialogue between the veterinarians and veterinary nurses caring for the patient and to reinforce the importance of the information being understood. Patients will receive better continuity of care when good communication skills are employed.