Based on an interview with Verna E. Reynolds, MD, MPH, CMD, Medical Director, Sentara Long Term Care Medical Associates
Based of an interview with Verna E. Reynolds, MD, MPH, CMD, Medical Director, Sentara Long Term Care Medical Associates Nursing facilities must follow state and federal regulations governing physician notification to maintain their operating licenses and receive payment from Medicare and Medicaid. However, the regulations don't specify the manner in which the physician should be contacted-and therein lies the potential for miscommunication, survey citations, and potentially poor, even disastrous, clinical outcomes.
Clinical care in the long-term care setting offers particular challenges because physicians are not always on-site. This can pose serious difficulties. For example, speaking from the physician's standpoint:
- Nursing staff has a variety of communications media to choose from, some bespeaking more urgency than others, i.e., phone, voice mail, fax, e-mail, and direct page. It can be unclear to nurses as to which medium fits which situation. If a nurse notices a developing pressure ulcer on a Friday evening or Saturday morning and sends the physician's office a fax about it, the sore might possibly evolve to stage IV by the time the physician's staff returns to work Monday morning. This condition should have been phoned in.
- Some nursing reports are required by regulation-for example, weight loss or abnormal lab results. To the nurses involved, the regulatory requirement means that these reports are "urgent." From the medical standpoint, however, they may not be urgent. That may be difficult to determine, though, for a physician who is in the midst of treating a patient in the office. If the physician responds to the "urgent" call, treatment is interrupted; if he or she doesn't respond, there is the risk of missing an important development in the nursing home.
- Inexperienced nurses and aides may give only partial information. Physicians are trained to evaluate cases based on a range of data. If the nurse reports "Mrs. Jones's blood sugar is up to 300," the physician might want to know, for example, about Mrs. Jones's diet and medications and what her blood sugar history is, among other things. Similar questions would arise with an elevated blood pressure reading, as another example.
- Different units in a facility may use different reporting mechanisms-a logbook in one unit, a box in another, a mailbox in still another. Physicians can get confused and sometimes frustrated looking for reports.
- Because physicians come in only periodically, they can find themselves either rushed, with staff unable to prepare properly, or so besieged by requests from staff desperate for immediate feedback that they're uncertain if they ever want to come back.
We began the program in two of the organization's seven facilities-six in tidewater Virginia and one in North Carolina-with in-services involving nurses, aides, and Sentara's salaried physicians. Ideas for content came from physicians, nurse practitioners, medical directors, and directors of nursing, and all were aimed at enhancing clinical communication skills. Physicians were also required to designate adequate time for making visits and receiving daily patient updates. Weekly rounding was conducted, and all nurses, including CNAs, were (and are) encouraged to participate.
Another initial step was to centralize communications as much as possible by having all medical information included in a loose-leaf logbook, sectioned into such areas as dietary, pharmacy, lab, and x-ray, and providing space to write nursing notes. The logbook is located at the nursing station for ready retrieval although, again, nursing staff and physicians must know how to use it. For example, if the physician is coming in later that day, the information should be logged in the book so it can be reviewed on-site; if he or she just left the facility, a call would be appropriate.
Guidelines for proper selection of communications media are, of course, part of this program. As a general rule, items entered in the logbook are of a "for your information" nature; no immediate response is required or implied. Nurses with important questions, however, should page the physician, particularly in our type of organization, in which salaried physicians are usually on the premises. As a matter of policy, though, we believe that the physician should initiate a daily call to the facility at a particular time each day to get updated information and field nonurgent questions. This reduces repeated and sometimes difficult-to-decipher calls and faxes to the physician's office.
We have also gone to some lengths to improve the content of the communication. Physicians have coached nurses on presenting all of the facts about a case, as I noted earlier, and we have seen staff exhibit particular pride in accomplishing this. We have also grappled with today's practical problem of English as a second language. With nurses and CNAs of overseas origin, physicians are encouraged to speak slowly and carefully, and the nurses are asked to repeat back what they've heard. Another rule: Particularly important information should be confined to writting, not trusted to verbal communication alone. True, this is more time-consuming, but it pays off in safer and more effective clinical care.