Continuity of Care Starts With You

Good bedside manner means more than being nice and polite to your patients. It means being your patients' advocate as they move through this complex and often fragmented healthcare system. Making sure your patients are well cared for throughout the system is an extremely important part of every health professional's job. Frequently, during the course of an acute illness, patients move from one nurse to another, one doctor to another and one level of care to another. These transfers of care should occur smoothly and seamlessly without errors or omissions. This is called continuity of care, and unfortunately, it is one of the weakest aspects in our delivery of healthcare. Loss of continuity can sometimes result in harmful or even fatal consequences.

One patient I know recently underwent coronary artery bypass grafting. He was admitted to the cardiologist's service, had his surgery done, and was transferred to a subacute nursing facility for rehabilitation -- all outside the control of his primary care physician. A house doctor was automatically assigned to his care at the rehab facility. Unfortunately, the patient's medication orders did not get transferred along with him until much later. He spent a miserable first night at the rehab center without any pain meds and without his albuterol nebulizer, which he needed to keep his asthma under control. Furthermore, his diuretics and subcutaneous prophylactic heparin injections were omitted at the time of transfer. Over the next few days he became progressively more edematous and short of breath until he landed back in the emergency room. He had acute congestive heart failure and a pulmonary embolus, both of which might have been avoided had there been better continuity in his care related to his medications and potential post-operative problems.

As a medical student, you can help prevent such breaks in care. In the previous situation, for example, a student could have called the nurse who accepted the patient at the subacute care facility to explain the importance of getting his meds ordered on time. The student could have reviewed the list of medications and discussed any potential problems. This simple communication would have helped ease the person's transition and improved their quality of care.

Facility Transfers

When patients move from one facility to another, there should also be a transfer of information that is accurate and appropriate for the individual setting. The above case was likely caused by a lack of communication between the discharging and the accepting facilities. There was no phone call from the patient's hospital nurse to the charge nurse at the rehab facility, nor was there any communication between the discharging hospital doctor and the accepting doctor, except for a skimpy discharge summary.

Furthermore, the medication orders did not get transferred or filled by the pharmacy in a timely manner. The patient should not have had to wait nearly 24 hours for a nebulizer treatment or a pain medication.

The doctor in charge of the patient's care at the new facility didn't know the patient and didn't see him or review the records until the next day (which is actually pretty good, considering the facility allows a delay of up to 3 days before the patient has to be seen by a physician!).

In short, there was a significant lack of continuity of care between the 2 facilities, and the patient suffered for it. Unfortunately, this is a common scenario when patients are transferred to rehab facilities. It is unusual for primary care doctors to see their own patients in those facilities anymore. So, the patient ends up with providers who don't know him/her very well. Something always seems to get lost in the process.

Hospital Discharges to Home

Similarly, when a patient is discharged to the home setting, we need to be sure the caretakers at home (whether they are family or home nurses) have enough information to adequately care for the patient in that setting. Also, the physician who will be taking care of that person as an outpatient should have all the information that s/he needs to be able to issue the right orders and to know how and when to follow up.

For one reason or another, medications are sometimes not continued as intended: something gets dropped off the list, or the patient can't afford all of them, or the individual takes all meds on the new list plus all on the old list. We must make sure that when patients leave the hospital, they know exactly how they are supposed to take their medications properly.

Nursing Handoffs

Nurse-to-nurse handoffs are often too brief and sketchy to provide the accepting nurse with a sense of how ill the patient might be or even the individual's general condition. The nurse might know that the person in room 428 had her gallbladder out but will have no idea how much pain she has, for example. In a situation like that, when someone else needs to know something about the patient, the nurse who is supposed to know can't be helpful.

It is frustrating from a physician's standpoint to ask the nurse who is taking care of a particular patient whether his/her current condition is different from what it was before, only to find out s/he doesn't have any idea what the patient looked like before because she just came on, never saw the person before, and received insufficient information from the nurse on the prior shift.

In taking care of hospital patients, when a crisis occurs, the first line of communication is often between the nurse and the on-call physician. If the nurse doesn't know what's going on with the patient, appropriate care can be compromised or delayed.

Physician Handoffs

Of course, when you think about it, physician handoffs are often no better and may be even worse. Sometimes, we only tell each other about the sickest people or those we think the oncoming doctor might get called about. Worse yet, we don't get a sign-out at all. Maybe we figure the on-call doctor can just "wing it". I know it's impossible to anticipate every problem that might occur, but an inadequate handoff can potentially be dangerous due to lack of information for the covering doctor.

The physician handoff in the above story was problematic in that the accepting physician didn't know about the patient's asthma or about how much pain he was in at the time of transfer. The medication list was not entirely accurate, and it took way too long for the drug orders to be entered. In addition, no one paid attention to the patient's fluid balance and the development of edema. If the doctor and the nurses knew the patient well enough and knew what to expect after coronary bypass surgery, this might have been caught earlier.

A better scenario would have been for the primary care physician to follow the patient all the way through -- from the office, through the hospitalization, and into the rehab facility. The orders would have gone through that physician who knew the patient, knew what problems to anticipate, and could implement the orders to prevent those problems. I'm sure it would have gone more smoothly, and the patient probably would not have had to be readmitted or to suffer as much as he did.

Some skilled nursing facilities do not allow the primary care doctors to come in and see their own patients. Rather, they require their own house doctors to admit all the patients. This, in itself, disrupts continuity. The priority for nursing facilities is to make sure all the proper paperwork gets done so they get reimbursed by insurance. If their own doctors are taking care of the patients, the paperwork is more regularly completed on time.

I had another patient with severe chronic lung disease who was transferred to a rehab facility after a long hospitalization. I was not permitted to take care of her there, but I visited her anyway twice a week. I could see that she was deteriorating and made suggestions to the attending physicians, which were mostly ignored. She ended up with severe pneumonia and belatedly got transferred back to the hospital in a comatose state where she died the next day. It may not have made any difference, but I knew when she was getting worse because I knew what she looked like when she was healthy. They were not as aware of it as I was.

Rotating Doctors

Another situation that interferes with continuity of care is a method of making hospital rounds that is used by groups of hospitalists or specialists. This occurs when members of a group decide that they can be more efficient by having the physicians of the group rotate responsibilities. A different doctor rounds on all the group's patients every day while the other members of the group take care of patients in the office. This can cause major inefficiencies and disorganization in patient care.

One patient I had came into the hospital with an arrhythmia. On Tuesday, one cardiologist said he thought the patient should have a pacemaker. On Wednesday, a different cardiologist said that only "maybe" he would need one. Thursday, a third cardiologist said, "Yes let's go ahead and schedule it for Monday." When Monday came around after the patient waited in the hospital for almost a week for a pacemaker, the electrophysiologist came by and said that the patient didn't need one. The patient went home. In this case, no harm came to the patient, but it was a very inefficient use of hospital time and resources.

In addition to the inefficiencies of this approach, patients often become very confused about what's going on. They don't know who their doctor is. The information they receive is often contradictory. They come out of the hospital not really knowing what was done or why.

How Can We Improve Continuity of Care?

In the past, the primary care doctor usually remained the attending physician when one of his/her patients went into the hospital or nursing facility. There are many reasons why this has gone by the wayside in recent years, and I don't think it is likely to return in the future. In the current setting, we just have to be sure that critical information is passed from one level of care to another.

Continuity of care is discussed frequently because everyone knows its importance. However, on a priority scale, it sometimes falls lower than it should. From a practical standpoint, implementation is often difficult and requires extra time and effort.

In an ideal world, primary care physicians would follow their own patients wherever they are – whether in the hospital, in the nursing home, in assisted living or even at home if they are homebound. Of course, the primary care provider would be accessible at all times, no matter what day or hour and even if s/he is on vacation. The patient would always be assured that the doctor who knows him/her the best would always be there when needed. This is not possible in real life. We all need time off. However, even though we can never be perfect, we can always try to improve continuity of care as much as possible.

First of all, I think we should be mindful of the fact that the less the continuity, the lower the quality of care, and the higher the likelihood of harmful mistakes along the way. We should always be on the alert for ways to avoid these problems and look for ways to improve on current practices.

What are some specific things that can be done?

We need better sign-outs at the bedside, where providers can actually see how the patients look and where more detailed information can be transferred. A 1-hour overlap in shifts might help accomplish this. As a medical student, you should be present at sign-outs whenever possible to assist with important details about the patient that might otherwise be overlooked.
We need mandatory notification of primary care providers when their patients are admitted and discharged. This helps ensure that vital information can be forwarded to the physician in charge.
We should avoid rotating doctors and nurses whenever possible so that a different provider isn't seeing the patient every day. However, as a med student, you may be the only one who sees the patient every day -- which makes you ideally situated to help close any gaps in communication that occur with rotating providers.
Hospitals and nursing facilities should communicate with each other when patients are transferred from one to another. Medication orders should be sent ahead of time so they will be there when the patient arrives – not 24 hours later. One of the students assigned to a patient could call the nurse accepting that patient in the transfer facility to explain the situation and review medications and potential problems. The student could also make sure the facility has accurate and complete discharge summary and orders -- well ahead of the patient's arrival.
Primary care providers should stay involved with their patients when they go to the hospital, assisted living, or nursing home facilities. If they are unable to have a physical presence there, they should at least stay in touch with the patient or the family. Even a call to or from the hospitalist for a follow-up now and then would be very helpful.
Everyone involved must ensure that the documentation in the record is complete so that critical information will be available to the on-call physician when needed.

Our patients deserve the best care that we can deliver. I'm sure we would all want that for our family members if one of them became ill. Good care starts with a good history and the recognition that all other caregivers involved need to know the critical parts of that history.