Decreasing LTC and acute care transfers by recognizing early warning signs

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Brian Yeaman
Brian Yeaman
As the principal investigator of a three-year Office of the National Coordinator (ONC) Challenge Grant, Yeaman Consulting is focusing on improving transitions of care between hospitals and long-term care (LTC) facilities by implementing electronic health information exchange to support resident care during and after transfers. As part of the pilot phase of this project, we are currently working with a group of five LTC facilities in Oklahoma all serviced by the Norman Regional Health System.

One way that we are achieving our goal is by empowering nursing assistants to maximize their skill set and capabilities with health information technology. Having a nursing assistant at the bedside is critical to daily patient care and the quality of care that facilities can provide.

At the five LTC facilities involved in this project, we have been able to implement real-time documentation at the bedside for 98% of patients over the last eight months. By using Cerner's lightweight CareTracker® system and a simple touch-screen kiosk methodology, nurses have been able to enter more information for the Activities of Daily Living (ADL) and condition status of patients rapidly and in real time, creating an opportunity to expand the use of this information.

The information produced by the CareTracker system is then applied to sophisticated algorithms we call health alerts. Through interpretation of these algorithms we can analyze early warning signs in a change of status for each patient to determine if they need closer monitoring or if a charge nurse or medical director needs to be notified. This results in measurable decreases in the number of transfers between the long-term care facility and the acute care setting.

This means happier patients, happier families and better outcomes for our patient.

Beyond decision support, we have also been able to empower the creation of an electronic SBAR report. SBAR stands for situation, background, assessment, and recommendation. These reports are modified in order to customize them for the workflow of the facilities and are being used routinely as handoff tools between shifts at the facility and to relay need-to-know messages which highlight the critical issues when a patient is transferring from the LTC facility to an acute care hospital. Most of these reports are populated by information from the CareTracker system, creating a win-win for documentation and workflow that all begins with the nursing assistant.  Beyond the SBAR, the universal transfer form is also created and primarily populated with documentation from the nursing assistant and from baseline MDS information.

Through use of technology we have successfully demonstrated that the nursing assistant can rapidly learn these tools with less than two hours of training and can implement and use them at a high level of sophistication through simple user interfaces that create tangible changes at the bedside, improving outcomes and patient satisfaction.

I encourage you to see our solution in action at the 2013 Healthcare Information and Management Systems Society (HIMSS) Conference from March 3-7.  We will be presenting in the ONC Interoperability Showcase located on the second floor La Nouvelle Ballroom.

Brian Yeaman, M.D., is a highly recognized national and international thought leader in health Information Exchange and health care delivery mechanisms that merge technology and the patient's bedside.

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