Best Practices for Good Communication between ED Physicians and Long-Term Care Staff

Transfers of older adults between long-term care and emergency departments occur frequently.  Unfortunately, they are often not successful.  While this fictional exchange is an extreme example of an unsuccessful transfer, it alludes to some of the many opportunities for improving this important part of care for complex older adults living in long-term care.  Transfers of care in any setting are always complicated and fraught with risks, especially when there is a culture-gap between the two parts of the transfer.  It can be helpful to keep a few basic points in mind when transferring care between LTCH and EDs.   

Bridging the Communication Gap

Long-term care homes are staffed by a small number of clinically focused nurses and many care aids and support workers who have limited clinical training.  The focus for all of them is on providing a “home” for people with mostly stable conditions.  The pace is slow, quiet, and home-like.  Emergency departments are staffed by nurses and doctors with a fairly narrow clinical focus targeting the identification and stabilization of acute illness.  The pace is fast, loud, and constantly changing.     

For long-term care: 

• In your transfer note, try to be as specific as possible about the reason for the transfer.  Don’t just say “Mrs. X had a fall”; try to say, “Mrs. X had a fall and I’m worried she might have broken something because she is not using her right hand now.”  Or “Mrs. X had a fall and is on blood thinners so we would like a CT head to confirm she doesn’t have a bleed.”  The more information you can provide at this step, the more likely you are to get what you need in the care of your resident.   
• Include basic information in the transfer.  Helpful things are:  
  • a brief description of what led up to making the transfer and any specific requests;  
  • a brief description of baseline function and cognition and changes you have noted with a timeline (hours?  Or weeks?);  
  • reliable medication record including any recent changes;  
  • any information about goals of care even if it is “there are no advance care plans”;  
  • substitute decision makers with contact information. 
• The most helpful thing you can include is a direct phone number to the person who can provide more information (not just a general number for the institution.) 

For ED staff: 

• The patient from a long-term care almost certainly has cognitive impairment.  Your only reliable source of clinically relevant information is the people who provide daily care.  EDs generally make a lot of effort to get a reliable history before starting a work-up.   Pick up the phone and spend the 6-8 minutes you usually spend on your history by getting reliable information.   
• Make sure you’re talking to the LTCH staff who knows the person well.  Sometimes that might be the care aid who was with the patient when she fell.  Sometimes it will be the care manager who spoke to the doctor who requested the transfer.     
• Remember the LTCH staff you’re talking to is not focussed on critical care or complex medical conditions (you’re not talking to the ICU!)  Taper your language appropriately
  • Not “what’s her creatinine clearance”; but rather:  “does Mrs. X have any kidney problems?”. 
  • Not “what’s her code status?”; but rather:  “have there been any discussions about what the patient and her family want?”
• Maintain a friendly collegial congenial tone.  Remember that everyone here is doing their best to ensure a good outcome for this vulnerable older person.  What tone of voice would you use if the LTCH staff person was your sister or mother or close friend? 
• Record the name of the LTCH staff you spoke to so that you don’t have to start all over if you need to call again.   
• If you work in a department with a geriatric-focused care team, you can engage them.  But remember that ultimately this is clinical decision-making, and you may feel more comfortable gathering the information yourself.