acute care transfers

[a gray man]

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Hey there, new medical director looking to get control of acute care transfers at our facility. Soliciting advice from anyone about best practices or things they did that significantly changed the transfer rate. Thanks!

 

[RangerBob]

24/7 hospitalist coverage/co-management.

We typically see patients daily (another thing that helps minimize transfers, as we catch things before they develop). IM sees them about every other day unless the patient has more acute issues going on.

Well-trained RNs as well. Daily wound inspections. It can be hard for us (the docs) to see incisions when patients are out working with therapy/moving around, but the RNs are there at the bedside 24/7 and doing the dressing changes, so if the dressing change can't be done when we're around, the RNs know to contact us for any concern for developing surgical site infections.

Quick response to bed alarms helps too, and patient sitters when needed. We don't want our TBI pts getting another TBI on rehab.

Just a few that came to mind

 

[Momentum70]

Inpatient rehab patients are getting much more unstable. The hospitals are sending them out when they look like getting better but not fully stabilized. Its too much for a pmr doc to handle by themselves. Im going to repeat some things that RangerBob said and add in others.

1) Get full admit labs night they arrive. Ive started iv abx, tranfused blood, and other interventions day of arrival

2) Get IM to co manage patients as they are complex and borderline stable

3) telemetry monitoring for new heart issues and heart surgery patients for first few days. We have caught multiple arrhythmias post CABG we are able to get ahead of before they rapid/code and leave

4) 24 hr RT coverage. My rehab had RT leaving at 11 and arriving at 7 and nursing covering their job. Its NOT the same job

5) on admit have nursing remove all dressing and take pictures of wounds and put in chart. Some wounds are already going bad when they arrive and waiting to see can lead to worse outcomes.

6) pay close attention and have pharmacy do a review of dc meds versus meds they were on in hospital. At our hospital the pharmacist was able to look into acute care system and make comparison for us. Sadly there are some acute care docs that just hit continue home meds and do not do the dc recs correctly. This can get really bad with HTN and DM meds.

 

[a gray man]

I really appreciate both of your responses, it's really valuable. A bit more info:

We currently co-manage with IM who sees the patients every day.

We have RT and they do 12 hour shifts 7 days per week. This has been very helpful and only very rarely does someone come in outside of those hours needing Bipap, capnography, etc. It may be hard for me to justify RT in house overnight.

I really like the idea of getting admit labs the moment people arrive in house. We send out our labs and sometimes it's close to 24 hours after the patient arrives before they result.

We routinely use telemetry but it's monitored remotely and frankly seems to be very hit or miss in terms of reporting. We have finally put a laptop in house so we can watch the leads but this has really only been helpful in confirming the box is transmitting. We are in the process of switching to a new monitoring service in the hopes that we actually get real time notification of arrhythmias.

We very consistently find absent meds from DC med recs. Most importantly when it pertains to ABX and AC meds. I still can't fathom how people are discharged without something like warfarin on a med rec.

We have pretty good wound care coverage although sometimes things have been missed such as dislodged diaphragmatic pacer, pacemaker leads, etc. Unreal how this can be the case but still happens.

One of our biggest things lately has been patients getting sent out in the first 24-48 hours. Obviously these patients are coming in sick and somehow getting missed in the prescreen and liaison process. Any advice you guys have on these sort of patients outside of laying eyes on them myself? Without accounting for these patients our acute care transfer rate would be very respectable.

Thanks again!

 

[piviti]

I would suggest sitting down with the liaisons and business development director routinely and educate them regarding red flags on prescreens and what a good acute inpatient rehab candidate looks like. Meeting the case managers and referring physicians in the acute care hospital with the marketing team can also help them understand your clinical capabilities as a hospital, what a good rehab candidate is, and how aggressive the therapy is in a short period of time. Do you do all the prescreens? You might have to push back on patients who you feel aren't ready to do acute rehab and be clear on what they need before they are rehab ready as the referring hospital is often trying to get a dispo ASAP. But this can be harder to do in a saturated area in which if you don't take the patient, another acute inpatient will. Alternatively you could start a consult service and possibly hire a midlevel to do the consults and lay eyes on the patients from your major referring hospitals.

-We also have RT doing 12 hour shifts 7 days a week and it is a hard sell to have nighttime RT as it can be quite expensive for the hospital. Night nursing staff will just have to be trained to handle RT stuff.
-We also have telemetry but haven't really used it much to be honest. I don't think it has helped much
-Do you get the MAR sent over? This can show you meds the patient was getting in the hospital but may not have made it to the DC summary for whatever reason. We routinely see missed pain meds, antibiotics, antihypertensives, etc.
-Do you have specialists there? At our hospital we have psychiatry, palliative care, cardiology, and nephrology. We are working on getting pulmonology, orthopedics, and wound care. Cardiology, pulmonology, and nephrology are especially key. Even if they aren't there to physically see the patient everyday, you might be able to call them with questions if something were to arise.
-Do you have relationships with the ER where you send most of the patients out ACT? Sometimes you can get the patient back within the 3 midnight window (if medicare) and avoid the ACT if you have open communication with the ER and let them know what your hospital's clinical capabilities are and what you need (like a stat head CT to evaluate for new stroke or CTA for possible PE) so they can expedite it and get the patient back as quickly as possible.
-Do you have routine ACT meetings? I think including all the departments and having input from all (our hospital ACT meetings include PM&R, Internal medicine, nursing, pharmacy, RT, the business development director) really helps identify gaps in care.

We did have a high ACT rate when we first opened - the biggest things I think that helped us were really training the liaisons to spot a good rehab candidate and also hiring and training better nurses. We had to turnover almost all our nurses to get solid nursing care.

 

[a gray man]

Any thoughts about making Liasons do an additional checklist to screen for vital sign abnormalities, prn meds, etc to highlight and screen out patients who may not be appropriate?

 

[RangerBob]

Any thoughts about making Liasons do an additional checklist to screen for vital sign abnormalities, prn meds, etc to highlight and screen out patients who may not be appropriate?

We don't have a formal checklist, but our liaisons do check pt's charts/updated labs the day of admission to make sure the pt is still stable. They make sure there's nothing unusual with the prn meds.

 

[a gray man]

We don't have a formal checklist, but our liaisons do check pt's charts/updated labs the day of admission to make sure the pt is still stable. They make sure there's nothing unusual with the prn meds.

thank you

 

[a gray man]

I would suggest sitting down with the liaisons and business development director routinely and educate them regarding red flags on prescreens and what a good acute inpatient rehab candidate looks like. Meeting the case managers and referring physicians in the acute care hospital with the marketing team can also help them understand your clinical capabilities as a hospital, what a good rehab candidate is, and how aggressive the therapy is in a short period of time. Do you do all the prescreens? You might have to push back on patients who you feel aren't ready to do acute rehab and be clear on what they need before they are rehab ready as the referring hospital is often trying to get a dispo ASAP. But this can be harder to do in a saturated area in which if you don't take the patient, another acute inpatient will. Alternatively you could start a consult service and possibly hire a midlevel to do the consults and lay eyes on the patients from your major referring hospitals.

-We also have RT doing 12 hour shifts 7 days a week and it is a hard sell to have nighttime RT as it can be quite expensive for the hospital. Night nursing staff will just have to be trained to handle RT stuff.
-We also have telemetry but haven't really used it much to be honest. I don't think it has helped much
-Do you get the MAR sent over? This can show you meds the patient was getting in the hospital but may not have made it to the DC summary for whatever reason. We routinely see missed pain meds, antibiotics, antihypertensives, etc.
-Do you have specialists there? At our hospital we have psychiatry, palliative care, cardiology, and nephrology. We are working on getting pulmonology, orthopedics, and wound care. Cardiology, pulmonology, and nephrology are especially key. Even if they aren't there to physically see the patient everyday, you might be able to call them with questions if something were to arise.
-Do you have relationships with the ER where you send most of the patients out ACT? Sometimes you can get the patient back within the 3 midnight window (if medicare) and avoid the ACT if you have open communication with the ER and let them know what your hospital's clinical capabilities are and what you need (like a stat head CT to evaluate for new stroke or CTA for possible PE) so they can expedite it and get the patient back as quickly as possible.
-Do you have routine ACT meetings? I think including all the departments and having input from all (our hospital ACT meetings include PM&R, Internal medicine, nursing, pharmacy, RT, the business development director) really helps identify gaps in care.

We did have a high ACT rate when we first opened - the biggest things I think that helped us were really training the liaisons to spot a good rehab candidate and also hiring and training better nurses. We had to turnover almost all our nurses to get solid nursing care.

This is great information, The main issue has been pressure to admit due to census low and poor referral flow the last two months. I am hoping to prioritize medical stability over census in the future

 

[Iamnew2]

I really appreciate both of your responses, it's really valuable. A bit more info:

We currently co-manage with IM who sees the patients every day.

We have RT and they do 12 hour shifts 7 days per week. This has been very helpful and only very rarely does someone come in outside of those hours needing Bipap, capnography, etc. It may be hard for me to justify RT in house overnight.

I really like the idea of getting admit labs the moment people arrive in house. We send out our labs and sometimes it's close to 24 hours after the patient arrives before they result.

We routinely use telemetry but it's monitored remotely and frankly seems to be very hit or miss in terms of reporting. We have finally put a laptop in house so we can watch the leads but this has really only been helpful in confirming the box is transmitting. We are in the process of switching to a new monitoring service in the hopes that we actually get real time notification of arrhythmias.

We very consistently find absent meds from DC med recs. Most importantly when it pertains to ABX and AC meds. I still can't fathom how people are discharged without something like warfarin on a med rec.

We have pretty good wound care coverage although sometimes things have been missed such as dislodged diaphragmatic pacer, pacemaker leads, etc. Unreal how this can be the case but still happens.

One of our biggest things lately has been patients getting sent out in the first 24-48 hours. Obviously these patients are coming in sick and somehow getting missed in the prescreen and liaison process. Any advice you guys have on these sort of patients outside of laying eyes on them myself? Without accounting for these patients our acute care transfer rate would be very respectable.

Thanks again!

Good advice overall.
I think ACTs are a battle everywhere.
As others have mentioned -
1-admission labs on everyone - the ability to have in house labs is essential particularly for patients that are not super stable or have questionable labs in acute care
2 - strong IM that truly follows patients closely
3- ID!!!! cannot tell you how important it is to have a good ID physician round on patients.
4- good wound care - we see wounds generally several types a week, take pics on admission and when we see them. Nursing does a full skin check/wound check when admitted and takes pictures. Helps not only for patient care but from a medicolwegal perspective
5-good access to surgical teams - when wounds/surgeries are not going well, important to be able to discuss with surgeons and send back for evaluation
6-good nursing!!! cannot be stressed enough. if nurses are not strong they will not pick up on patients going south.
7-prompt response - when patients start going south (starting to desaturate, etc) start work up quickly!!

we have also had issues with acute care hospitals sending patients too quickly and not stable
we have rules in place to have labs at least 48hrs prior to admission to rehab and our liaisons will reach out if labs look questionable for clearance
having pictures of wounds that are questionable sent prior to admission is also important - it can save you transferring a patient that at times cannot be managed particularly if you are at a lone standing IRF not attached to a hospital

 

[piviti]

Good advice overall.
I think ACTs are a battle everywhere.
As others have mentioned -
1-admission labs on everyone - the ability to have in house labs is essential particularly for patients that are not super stable or have questionable labs in acute care
2 - strong IM that truly follows patients closely
3- ID!!!! cannot tell you how important it is to have a good ID physician round on patients.
4- good wound care - we see wounds generally several types a week, take pics on admission and when we see them. Nursing does a full skin check/wound check when admitted and takes pictures. Helps not only for patient care but from a medicolwegal perspective
5-good access to surgical teams - when wounds/surgeries are not going well, important to be able to discuss with surgeons and send back for evaluation
6-good nursing!!! cannot be stressed enough. if nurses are not strong they will not pick up on patients going south.
7-prompt response - when patients start going south (starting to desaturate, etc) start work up quickly!!

we have also had issues with acute care hospitals sending patients too quickly and not stable
we have rules in place to have labs at least 48hrs prior to admission to rehab and our liaisons will reach out if labs look questionable for clearance
having pictures of wounds that are questionable sent prior to admission is also important - it can save you transferring a patient that at times cannot be managed particularly if you are at a lone standing IRF not attached to a hospital

How did you find ID to round at your hospital? Do you consult them on all complicated infections/leukocytosis/fevers?

Highly agree about getting complicated wound pics prior to admit as it also helps the staff get prepared and allows you to know if you can take care of it, if they need time in a SNF to get it healed more, or if it needs to be debrided. Wound pics on arrival also helps protect the hospital if a wound goes south before the patient reaches your rehab unit you have proof of what it looked like on admit vs what its supposed to look like. We've been in situations where a surgical wound arrives to our unit dehisced and we have proof that it was not our doing.

Also agree about having the labs done prior to admit - I often ask the liaisons for vitals and labs the day of admit for complicated patients.

 

[piviti]

This is great information, The main issue has been pressure to admit due to census low and poor referral flow the last two months. I am hoping to prioritize medical stability over census in the future

That will be tough to do as admin will prioritize census over medical stability. It'll probably be best to hunt for referrals and consults, which could actually improve your ACT rate as your patient pool will expand.

 

[Iamnew2]

How did you find ID to round at your hospital? Do you consult them on all complicated infections/leukocytosis/fevers?

Highly agree about getting complicated wound pics prior to admit as it also helps the staff get prepared and allows you to know if you can take care of it, if they need time in a SNF to get it healed more, or if it needs to be debrided. Wound pics on arrival also helps protect the hospital if a wound goes south before the patient reaches your rehab unit you have proof of what it looked like on admit vs what its supposed to look like. We've been in situations where a surgical wound arrives to our unit dehisced and we have proof that it was not our doing.

Also agree about having the labs done prior to admit - I often ask the liaisons for vitals and labs the day of admit for complicated patients.

We are part of a larger hospital network with multiple hospitals, and some of the ID docs that round at other places also round at our hospital. They are awesome and a lifesaver. We couldn't manage the super complex patients, particularly the complex post op patients we see without their help.

Yeah our protocol at our hospital is to have pics when they come in of any wounds - not only for patient safety but obviously for medicolwegal purposes also. We also see wounds regularly as physicians to make sure things are going well and promptly reach out to our surgical teams if wounds start looking like they are not doing well. Has incredibly improved our ACT transfer rates

 

[a gray man]

That will be tough to do as admin will prioritize census over medical stability. It'll probably be best to hunt for referrals and consults, which could actually improve your ACT rate as your patient pool will expand.

I am pretty busy so far but could probably squeeze in a few hours of consults 1-2 days per week. How much time is necessary for something like this and is the juice worth the squeeze

 

[Momentum70]

I am pretty busy so far but could probably squeeze in a few hours of consults 1-2 days per week. How much time is necessary for something like this and is the juice worth the squeeze

As far as juice worth the squeeze issue, I would focus on things not able to come to you. Typically you can get in the straight medicare easily, but the managed medicare patients get denied ipr a lot. If you can consult on those and overturn the denials it will increase your census and make the acute care case managers and doctors happy. We are better at peer to peer than acute hospitalists. For instance at my hospital they started trying to send all amputees to snfs. I started consulting for vascular surgeons who dont have time and dont want to do the peer to peers. Same thing for some of the managed medicare strokes and brain injuries. Dont waste time on the simple ortho stuff because nothing you say or do will overturn the hip fracture denials from united and humana.