Posted June 21, 2017

It’s Not Just About Discharge: The Other Transitions of Care

By Debbie Caskey, RN Diana Topjian, RN, MSN, DM, C-ENP

The Transition of Care domain has recently become the center of many conversations about safety, patient experience and readmission rates. Mark Chassin, MD, president of The Joint Commission, has said, "There are 4,000 handoffs a day in a typical teaching hospital. If 90 percent go flawlessly, that's still 400 failures per day."

Often, when discussing transitions of care, the focus is on the discharge process - when a patient leaves the hospital or health system. While this is certainly a significant transition and clearly the focus of the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) survey, heading home is not the only transitional risk our patients may face. Consider the move from the emergency department to an acute care unit or acute care to a higher level of care. All of these shifts place our patients at risk and warrant focused attention, clear communication amongst providers, and engagement of the patient (and family) to facilitate post-discharge self-care and manage expectations.

The focus of this article is specifically on the intra-hospital episodes of transition. Transfers among inpatient units can be very frightening for patients and their families. Consider a patient moving from an Intensive Care Unit (ICU) to a step-down or acute care unit. Unlike in the ICU, the need for the extensive monitoring equipment and intense observation is reduced because the patient's condition has already been assessed. If we don't communicate well and prepare patients and families for the next step in the recovery process, we as providers have failed to effectively manage expectations and set up the receiving department for success.

Learn how a focus on care transitions can help reduce readmissions and improve financial pressures. This infographic includes 8 techniques you'll want to ensure are on your readmission prevention checklist. Read more.

When thinking about care transitions, we should also consider our ingress points. For example, think about emergency department to inpatient unit transitions or post-anesthesia recovery to an inpatient unit. How well do we prepare patients and manage up the receiving department to reduce patient anxiety? How well do we communicate key clinical information among care providers to ensure the safety of our patients as part of the handover?

There are tactics and key words healthcare professionals can use to reduce the risk of harm to patients while also managing expectations during this critical care transition period.

Communication tools such as SBAR (Situation, Background, Assessment, Recommendation) and AIDET® (Acknowledge, Introduce, Duration, Explanation, and Thank you) are two powerful communication frameworks that effectively reduce anxiety and share critical clinical information. SBAR is used very effectively between care providers to assure critical information is succinctly provided and key elements are not missed. This should include review of orders received and level of completion during the patient's stay in the transferring area. If the transferring area is an inpatient department, such as the intensive care or other inpatient nursing unit, review of orders from the beginning of the current shift to the time of transfer should be reviewed.

AIDET should be used by the oncoming team to help alleviate the anxiety of the patient. For example, quickly acknowledging the patient and his/her family upon arrival to the department (preferably meeting them in the patient room) is important. Below is an example of an AIDET dialogue following the first step, Acknowledge (A of AIDET):

'I am Diana and I will be your nurse for the next 5 hours. Debbie will be your nursing assistant and together we will take excellent care of you. We've worked together on many patients who were here for the same reason as you. To ensure we are covering all the areas that are important to your care and progress, I am going to do a brief assessment and ask you some questions so we have all the information we need to take great care of you. This will take about 15 minutes, and then we will let you rest. Debbie and I will round with you approximately every hour to make sure you are comfortable and determine if you need anything, including the restroom. We will also make sure your communication board remains updated so that you know the plan for the day and any other information to get you ready for discharge. Is there anything you need before we get started?'

In addition to AIDET, clear communication of medications using the medication reconciliation process helps improve safety and further manage family/patient expectations.

It is important to consider transitions of care in all aspects of the health care continuum. Recognizing that these are high-risk periods for our patients will assist in minimizing the threat. Tools and tactics for effective communication have been proven to aid in successful transitions across the continuum of care.

In "Transitions of Care: Moving from Acute Care to Home with Comprehensive Care Plans" we discuss transitions or hand-overs from the hospital or health system to the next level of care (either home or to another facility).

Diana Topjian, RN, MSN, DM, C-ENP is a Studer Group coach with more than 30 years of experience ranging from direct line staff nurse to executive leadership roles in both academic and community-based hospitals.

Debbie Caskey, RN has been a registered nurse and healthcare leader for more than 40 years. In her role as a Studer Group coach and account manager she specializes in helping rural and community hospitals improve results.


  • Debbie Caskey

    Debbie Caskey, RN

  • Diana Topjian

    Diana Topjian, RN, MSN, DM, C-ENP

Print Page