Long-Term Care Survey Alert

Provide this 'gentle reminder' in the chart for physicians, expert suggests.

1. Record hospital test results in SNF patients' medical records. When you receive hospital material for a new admission, review it and "enter all pertinent data into the clinical record," advises Marilyn Mines, RN, BSN, RAC-CT, BC, manager of clinical services for FR&R Healthcare Consulting in Deerfield, Ill. "Put the results of CAT scans and MRIs in the progress note or order sheet section as a gentle reminder for the physician," Mines suggests. Another option is to check the hospital database for recent CAT or MRI results if the physician orders either of these tests for a SNF patient, she adds.

Naushira Pandya, MD, CMD, notes that the nursing facility where she works has a section in the medical records for lab tests where clinicians "make an annotation

about MRIs" and other imaging results. "For example, if no-one makes a notation that a patient with dementia had an MRI brain scan, that may be repeated," adds Pandya.

"Another thing that can help is a cumulative diagnosis list or what I call a problem list," adds Pandya, associate professor and chair with the Department of Geriatrics at NSU College of Osteopathic Medicine in Ft. Lauderdale, Fla. For example, "we make a note that a person has had a work-up for heart failure, including an echo, so they don't get another one, if they see a cardiologist who may not be the same one they saw in the hospital," she says.

Key: Pandya points out that "it's the flow of information and noting what's already available that's important. But you tend to see very sketchy history and physicals that don't make note of things like thyroid function where a patient who has hypothyroidism got a TSH level in the hospital. And you know by that result that the person is getting adequate treatment. But if you don't make that notation, someone might order another TSH."

Problem: "Sometimes the nursing home doesn't get enough information about the testing the patient has received in the hospital or maybe a rehab hospital," says Pandya.

Solution: In such cases, facilities can "work with their referring hospitals to coordinate the information transfer from the ER as well as from case managers and social workers at discharge," says Pandya. That includes "discharge summary, tests, consults, history and physical, etc.," she adds.

2. Don't leave certain test orders open-ended. "Some medical problems may be time-limited so when labs are ordered without stop dates, they may no longer be necessary," says Daniel Haimowitz, MD, CMD, a nursing home medical director who practices in Levittown, Pa.

3. Educate those involved. That includes physicians, nursing facility staff, and families, as well as other providers caring for residents, says Haimowitz. For example, he reports having residents' families ask him to "order inappropriate repeat urinalysis and cultures for asymptomatic family members after treatment for a UTI." (For a recent article from MDS Alert on how to reduce unnecessary testing and over-treatment for UTI, e-mail the editor at KarenL@Eliresearch.com.)

Another example: Haimowitz recounts how one of his patients had a brain bleed. "And without my knowledge, the trauma doctor ... said the patient needed evaluation for a cerebral aneurysm repair and sent the patient downtown in a medi-vac to get tests. But the patient was 'no code' and would not have wanted brain surgery."

Key: "Better education and having a geriatric mindset, keeping in mind the big picture and being faithful to the patient's and family's wishes, can often prevent unnecessary tests and medications," says Haimowitz.

4. Make efforts to prevent specialists from repeating tests. "The nursing home should do their best when they send someone out to a consultant to make sure the consultant gets the information they need to best treat the patient," says Haimowitz.

Also: "If the consultant," for example, "orders an EKG and a chest x-ray, and the attending knows those tests were recently done, the attending can cancel the order," he points out.

"Ideally, the consultant would either have the results come with the patient's visit, have the test results faxed to the office -- or the attending would call and let them know the results of those tests to see if that would change their recommendations," Haimowitz relays.

The challenge: "Each individual patient situation is so different, and circumstances change where you're going to be more conservative or aggressive," Haimowitz points out. "Also, if someone goes back to the hospital, it changes the clock for ordering tests. With best practice you look at each case continually, in real time," he adds.