General

Guideline Title

Care transitions.

Bibliographic Source(s)

  • Registered Nurses’ Association of Ontario (RNAO). Care transitions. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2014 Mar. 88 p. [146 references]

Guideline Status

This is the current release of the guideline.

This guideline meets NGC’s 2013 (revised) inclusion criteria.

Recommendations

Major Recommendations

The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the “Major Recommendations” field.

Practice Recommendations

Assessment

Recommendation 1.1

Assess the client’s current and evolving care requirements on admission, regularly throughout an episode of care, in response to a change in health status or care needs, at shift change and prior to discharge.

(Level of Evidence = Ia)

Recommendation 1.2

Obtain a “best possible medication history” during care transitions by using a structured and systematic process to collect client medication information that includes dose, frequency and route.

(Level of Evidence = IIb)

Recommendation 1.3

Assess the client for physical and psychological readiness for a care transition.

(Level of Evidence = III)

Recommendation 1.4

Assess the client, their family and caregivers for factors known to affect the ability to learn self-care strategies before, during and after a transition.

(Level of Evidence = III)

Recommendation 1.5

Assess the learning and information needs of the client, their family and caregivers to self-manage care before, during and after a transition.

(Level of Evidence = III)

Planning

Recommendation 2.1

Collaborate with the client, their family and caregivers and the interprofessional team to develop a transition plan that supports the unique needs of the client while promoting safety and continuity of care.

(Level of Evidence = Ia)

Recommendation 2.2

Use effective communication to share client information among members of the interprofessional team during care transition planning.

(Level of Evidence = III)

Implementation

Recommendation 3.1

Educate the client, their family and caregivers about the care transition during routine care, tailoring the information to their needs and stage of care.

(Level of Evidence = III)

Recommendation 3.2

Use standardized documentation tools and communication strategies for clear and timely exchange of client information at care transitions.

(Level of Evidence = IIb)

Recommendation 3.3

Obtain accurate and complete client medication information on care transition.

(Level of Evidence = IV)

Recommendation 3.4

Coach the client on self-management strategies to promote belief in their ability to look after themselves on care transition.

(Level of Evidence = IIb)

Evaluation

Recommendation 4.1

Evaluate the effectiveness of transition planning on the client, their family and caregivers before, during and after a transition.

(Level of Evidence = IV)

Recommendation 4.2

Evaluate the effectiveness of transition planning on the continuity of care.

(Level of Evidence = Ia)

Recommendation 4.3

Evaluate the effectiveness of communication and information exchange between the client, their family and caregivers and the health-care team during care transitions.

(Level of Evidence = IV)

Education Recommendations

Recommendation 5.1

Health-care professionals engage in continuing education to enhance the specific knowledge and skills required for effective coordination of care transitions.

(Level of Evidence = Ia-IV)

Recommendation 5.2

Educational institutions and programs incorporate the guideline Care Transitions into basic and interprofessional curricula so all health-care professionals are provided with the evidence-based knowledge and skills needed for assessing and managing client care transitions.
(Level of Evidence = IV)

Organization and Policy Recommendations

Recommendation 6.1

Establish care transitions as a strategic priority to enhance the quality of client care and safety.

(Level of Evidence = III)

Recommendation 6.2

Provide sufficient human, material and fiscal resources and adopt organization-wide structures necessary to support the interprofessional team with client care transitions.

(Level of Evidence = III)

Recommendation 6.3

Develop organization-wide standardized policies and structured processes for medication reconciliation on care transition.

(Level of Evidence = III)

Recommendation 6.4

Establish organization-wide systems for communicating client information during care transitions to meet all privacy, security and legislated regulatory requirements.

(Level of Evidence = IV)

Recommendation 6.5

Include care transitions when measuring organization performance to support quality improvement initiatives for client outcomes and interprofessional team functioning.

(Level of Evidence = III)

Definitions

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic reviews of randomized controlled trials

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies

IV Evidence obtained from expert committee reports or opinions or clinical experiences of respected authorities

Note : Adapted from “SIGN grading system 1999-2012,” by the Scottish Intercollegiate Guidelines Network (SIGN). (2012). In: SIGN 50: A guideline developer’s handbook. Available from: http://www.sign.ac.uk/guidelines/fulltext/50/ .

Clinical Algorithm(s)

None provided

Scope

Disease/Condition(s)

Any disease/condition requiring transitions in care

Guideline Category

  • Counseling
  • Management
  • Risk Assessment

Clinical Specialty

  • Nursing

Intended Users

  • Advanced Practice Nurses
  • Hospitals
  • Nurses

Guideline Objective(s)

To provide evidence-based recommendations for nurses and other members of the interprofessional team who are assessing and managing clients undergoing a care transition

Target Population

Patients experiencing a change in health status, care need, health-care provider or location (within, between or across settings)

Interventions and Practices Considered

  1. Obtainment of a best possible medication history
  2. Assessment of client’s, family’s and caregiver’s * Readiness for care transition * Ability to learn self-care strategies * Information needs
  3. Collaboration with the client, family and caregivers to develop a transition plan
  4. Education of the client, family and caregivers about the care transition
  5. Use of standardized documentation
  6. Coaching the client on self-management strategies
  7. Evaluation of the effectiveness of transition planning, communication and information
  8. Continuing education for health-care professionals
  9. Establishment of priorities, organization-wide structures, communication systems and performance measures for support of care transitions

Major Outcomes Considered

  • Attendance at follow-up appointments with primary care providers
  • Client satisfaction with transition process
  • Knowledge of warning signs and symptoms that require immediate follow-up by health-care provider and less misinformation
  • Reduction in the risk for readmission

Methodology

Methods Used to Collect/Select the Evidence

  • Hand-searches of Published Literature (Primary Sources)
  • Hand-searches of Published Literature (Secondary Sources)
  • Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Guideline Search Strategy

Structured Web Site Search

A member of the Registered Nurses’ Association of Ontario (RNAO) guideline development team (project coordinator) searched an established list of Web sites for guidelines.

Guidelines were selected based on the following criteria:

  • Focus on topic of transitions in care (terms include: care transitions, discharge planning, handovers, hospital to home and community and residential, group home, other transitional facilities such as mental health, rehabilitation, long-term care, transitions) which includes:
    • Assessment
    • Management
    • Client safety and transitions
    • Education or training requirements for nurses
    • Organizational and health-care system responsibilities or support for transitions
  • Published no earlier than January 2002
  • Published in English, national and international in scope
  • Accessible for retrieval

Refer to the search strategy document (see the “Availability of Companion Documents” field) for a list of Web sites searched, search term, and inclusion/exclusion criteria.

Hand Search

RNAO expert panel members were asked to review personal libraries to identify and submit potentially relevant guidelines. Guidelines submitted for consideration by RNAO expert panel members were integrated into the retrieved list of guidelines if they had not been identified by the on-line guideline search and met the inclusion criteria.

Guideline Review

Members of the expert panel critically appraised 12 international guidelines using the Appraisal of Guidelines for Research and Evaluation Instrument II. From this review, six guidelines were selected to inform the review process.

Systematic Review

Concurrent with the review of existing guidelines, a search for recent literature relevant to the scope of the guideline was conducted with guidance from the chair of RNAO’s expert panel. The systematic literature search was conducted by a health-sciences librarian. The search, limited to English-language articles published between January 2002 and August 2012, was applied to CINAHL, EMBASE, DARE, Medline, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, ERIC, Joanna Briggs, and PsycINFO databases. The initial search for relevant studies pertaining to questions 1 and 2 returned 7937 articles. Due to the volume of research, the inclusion criteria for study methodology was changed and limited to meta-analysis, systematic reviews, integrative reviews, randomized controlled trials and qualitative evidence syntheses. Detailed information about the search strategy for the systematic review, including the inclusion and exclusion criteria as well as search terms is available in the search strategy document (see the “Availability of Companion Documents” field). Two research associates (master’s prepared nurses) independently assessed the eligibility of studies according to the established inclusion and exclusion criteria. RNAO’s best practice guideline program manager working with the expert panel, resolved disagreements.

Number of Source Documents

6 guidelines and 127 records were selected to inform the review process. See Appendix C in the original guideline document for flow diagrams of the guideline and article review process.

Methods Used to Assess the Quality and Strength of the Evidence

  • Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic reviews of randomized controlled trials

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies

IV Evidence obtained from expert committee reports or opinions or clinical experiences of respected authorities

Note: Adapted from "SIGN grading system 1999-2012," by the Scottish Intercollegiate Guidelines Network (SIGN). (2012). In: SIGN 50: A guideline developer's handbook. Available from: http://www.sign.ac.uk/guidelines/fulltext/50/.

Methods Used to Analyze the Evidence

  • Review of Published Meta-Analyses
  • Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Quality Appraisal and Data Extraction

To determine interrater reliability, 10% of included studies from the relevance review were independently quality appraised by both research associates (RAs). A sufficient kappa score (κ=0.71) was achieved, allowing the remaining studies to be divided equally between the 2 RAs for independent quality appraisal. The methodological quality of the studies was evaluated as follows: the Assessment of Multiple Systematic Reviews (AMSTAR) tool (http://amstar.ca/) was used to appraise all systematic reviews and meta-analyses, whereas Critical Appraisal Skills Program (CASP) tools that were developed in the United Kingdom (http://www.casp-uk.net/find-appraise-act/) were used to appraise case-control studies, cohort studies, cross-sectional studies, qualitative studies, and randomized controlled trials. Studies were rated as strong (>85%), moderate (65% to 80%), or weak (<60%), based on their rounded score. Studies were data extracted and organized into data tables by research question.

Methods Used to Formulate the Recommendations

  • Expert Consensus

Description of Methods Used to Formulate the Recommendations

For this new guideline, the Registered Nurses’ Association of Ontario (RNAO) assembled an expert panel of health-care professionals with particular expertise in this practice area. A systematic review of the evidence took into consideration the purpose and scope of the guideline and was supported by six clinical questions. It captured relevant literature and guidelines published between January 2002 and June 2012. These are the research questions that guided the systematic review:

  1. What are the most effective assessment and management strategies to ensure continuity of care and safe optimal client outcomes during care transitions?
  2. What safety and monitoring strategies should be considered to ensure continuity of care and safe optimal client outcomes during care transitions?
  3. What educational supports do nurses and other health-care providers require to effectively assess and manage client care transitions?
  4. What organization characteristics support nurses and other health-care providers to effectively assess and manage client care transitions?

This new guideline, Care Transitions is the result of the expert panel’s work to integrate the most current and best evidence and ensure the validity, appropriateness and safety of the guideline recommendations with supporting evidence.

The comprehensive data tables and summary were provided to all RNAO’s expert panel members. In October 2012, the expert panel convened to develop and achieve consensus on guideline recommendations and discussion of evidence.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

  • External Peer Review
  • Internal Peer Review

Description of Method of Guideline Validation

Stakeholders representing diverse perspectives were solicited for their feedback.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the “Major Recommendations” field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

  • Avoidance of repetition, duplication or omission of critical client information during information exchanges between settings or health-care providers
  • Streamlining and standardization of discussion and documentation to ensure clear and accurate transfer of information

Potential Harms

One study cautions that giving clients too much information at once is not effective.

Qualifying Statements

Qualifying Statements

  • These guidelines are not binding on nurses or the organizations that employ them. The use of these guidelines should be flexible, and based on individual needs and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work.
  • This nursing best practice guideline is a comprehensive document providing resources for evidence-based nursing practice and should be considered a tool, or template, intended to enhance decision making for individualized care. The guideline is intended to be reviewed and applied in accordance with both the needs of the individual organizations or practice settings and the needs and wishes of the client ( throughout the guideline, the word “client” is used to refer to patients, persons, residents, or consumers; that is the client, their family and caregivers, or parents, or substitute decision makers being cared for by the interprofessional team ). In addition, the guideline provides an overview of appropriate structures and supports for providing the best possible evidence-based care.
  • Nurses, other health-care professionals and administrators who lead and facilitate practice changes will find this document invaluable for developing policies, procedures, protocols, educational programs and assessments, interventions and documentation tools. Nurses in direct care will benefit from reviewing the recommendations and the evidence that supports them. The RNAO particularly recommends practice settings adapt these guidelines in formats that are user-friendly for daily use.

Implementation of the Guideline

Description of Implementation Strategy

Implementation Strategies

Implementing guidelines at the point of care is multifaceted and challenging; it takes more than awareness and distribution of guidelines to get people to change how they practice. Guidelines must be adapted for each practice setting in a systematic and participatory way, to ensure recommendations fit the local context. The Registered Nurses’ Association of Ontario (RNAO) Toolkit: Implementation of Best Practice Guidelines (2nd ed.) provides an evidence-informed process for doing that.

The Toolkit is based on emerging evidence that successful uptake of best practice in health care is more likely when:

  • Leaders at all levels are committed to supporting guideline implementation
  • Guidelines are selected for implementation through a systematic, participatory process
  • Stakeholders for whom the guideline is relevant are identified and engaged in the implementation
  • Environmental readiness for implementing guidelines is assessed
  • The guideline is tailored to the local context
  • Barriers and facilitators to using the guideline are assessed and addressed
  • Interventions to promote use of the guideline are selected
  • Use of the guideline is systematically monitored and sustained
  • Evaluation of the guideline’s impact is embedded in the process
  • There are adequate resources to complete all aspects of the implementation

The Toolkit uses the “Knowledge-to-Action” framework to demonstrate the process steps required for knowledge inquiry and synthesis. It also guides the adaptation of the new knowledge to the local context and implementation. This framework suggests identifying and using knowledge tools such as guidelines, to identify gaps and to begin the process of tailoring the new knowledge to local settings.

RNAO is committed to widespread deployment and implementation of their guidelines. RNAO uses a coordinated approach to dissemination, incorporating a variety of strategies, including the Nursing Best Practice Champion Network®, which develops the capacity of individual nurses to foster awareness, engagement and adoption of Best Practice Guidelines (BPGs); and the Best Practice Spotlight Organization® (BPSO®) designation, which supports implementation at the organization and system levels. BPSOs focus on developing evidence-based cultures with the specific mandate to implement, evaluate and sustain multiple RNAO best practice guidelines. In addition, RNAO offers capacity-building learning institutes on specific guidelines and their implementation annually.

Information about RNAO’s implementation strategies can be found at:

Implementation Tools

  • Audit Criteria/Indicators
  • Foreign Language Translations
  • Mobile Device Resources
  • Patient Resources
  • Resources
  • Slide Presentation
  • Tool Kits

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

  • Getting Better
  • Staying Healthy

IOM Domain

  • Effectiveness
  • Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)

  • Registered Nurses’ Association of Ontario (RNAO). Care transitions. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2014 Mar. 88 p. [146 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2014 Mar

Guideline Developer(s)

  • Registered Nurses’ Association of Ontario - Professional Association

Source(s) of Funding

This work is funded by the Ontario Ministry of Health and Long-Term Care.

Guideline Committee

Registered Nurses’ Association of Ontario Expert Panel

Composition of Group That Authored the Guideline

Expert Panel Members

Nancy Pearce, RN, PhD
Expert Panel Chair
Clinical Nurse Specialist
Grand River Hospital
Kitchener, Ontario

Nancy Boaro, BScN, MN, CNN(C), CRN(C)
Manager, Professional Nursing Practice
University Health Network
Toronto, Ontario

Gwen Brown, RN, BA, BEd, MA
Regional Community and Long Term Care Coordinator
Stroke Network of Southeastern Ontario
Kingston General Hospital
Kingston, Ontario

Heather Campbell, RN, BN, MS
Director, Nursing Practice and Education
St. Michael’s Hospital
Toronto, Ontario

Susan Cymbaluk, RN
Operations Manager-Clinical
OMNI Health Care
Peterborough, Ontario

Julie Desmarais, RN, BHSc(N)
Clinical Manager/Site Administrator
Sydenham Campus Medicine and
Complex Continuing Care Units
Chatham Kent Health Alliance
Chatham, Ontario

Danielle Dorschner, RN, MScN
Director, National Client Services
Accreditation Canada
Ottawa, Ontario

Tamara Dus, RN, MN
Director Cancer Services
Durham Regional Cancer Centre
Oshawa, Ontario

David Fry, BSc(OT), MHSc
Director of Client Services
Ontario Association of Community
Care Access Centres (OACCAC)
Toronto, Ontario

Margaret Gehrs, RN, BSc(HK), BScN, MScN, CPMHN(C)
Director, Interprofessional Practice
Centre for Addiction and Mental Health
Toronto, Ontario

Cindy Hollister, RN, BHSc(N), CPHIMS-CA
Clinical Leader, Clinical Adoption
Canada Health Infoway
Toronto, Ontario

Pam Hubley, RN, MSc
Chief, Professional Practice and Nursing
Hospital for Sick Children
Toronto, Ontario

Andrea Lauzon, NP-PHC, CPMHN(C)
Nurse Practitioner, LIFEspan
Holland Bloorview Kids Rehabilitation Hospital
Toronto, Ontario

Dianne Leclair, RN
Care Coordinator
CCAC HNHB Niagara
Port Colborne, Ontario

Margaret Millward, RN, MN
Specialist, Capacity Building and
Quality Improvement Plans
Health Quality Ontario
Toronto, Ontario

Margot Mitchell, MSW, RSW
Social Worker
University Health Network
Toronto General Hospital
Toronto, Ontario

Connie Stamp, RN, CRN(C), ONC(C), CHPCN(C)
Patient Care Manager, Supportive Care
Lakeridge Health
Oshawa, Ontario

Kim Stelmacovich, MH Sc, BSc(OT)
Senior Regional Director (Ontario)
Canadian Patient Safety Institute (CPSI)
Toronto, Ontario

Anne Stephens, RN, BScN, MEd, GNC(C)
Clinical Nurse Specialist
Toronto Central,
Community Care Access Centre
Toronto, Ontario

Gina Tomaszewski, RN, MScN
Regional Stroke Acute Care Coordinator
South Western Ontario Stroke Network
London Health Sciences Centre
London, Ontario

Stephanie Vandevenne, RN, COHN
Care and Service Manager – Clinical Nursing,
Occupational Therapy and
Chronic Pain Programs – ESC
Victorian Order of Nurses
Sombra, Ontario

Stephanie van Rooy, NP-Adult, MN
Nurse Practitioner
University Health Network,
Toronto Western Hospital
Family Health Team
Toronto, Ontario

Financial Disclosures/Conflicts of Interest

Declarations of interest and confidentiality were made by all the members of the Registered Nurses’ Association of Ontario (RNAO) expert panel.

Further details are available from RNAO.

Guideline Endorser(s)

  • Accreditation Canada - Nonprofit Organization

Guideline Status

This is the current release of the guideline.

This guideline meets NGC’s 2013 (revised) inclusion criteria.

Guideline Availability

Available in English and French from the Registered Nurses’ Association of Ontario (RNAO) Web site.

Availability of Companion Documents

The following are available:

  • Dusek B, Pearce N, Harripaul A, Lloyd M. Care transitions: a systematic review of best practices. J Nurs Care Qual. 2015 Jul-Sep;30(3):233-39. Available to subscribers from the Journal of Nursing Care Quality Web site.
  • Toolkit: implementation of best practice guidelines. Second edition. Toronto (ON): Registered Nurses’ Association of Ontario (RNAO); 2012 Sep. 154 p. Available from the RNAO Web site.
  • Registered Nurses’ Association of Ontario – Nursing Best Practice Guidelines Program: care transitions. Guideline search strategy. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2014 Mar. 5 p. Available from the RNAO Web site.
  • Registered Nurses’ Association of Ontario – Nursing Best Practice Guidelines Program: care transitions. Bibliography. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2014 Mar. 11 p. Available from the RNAO Web site.

In addition, a care transitions webinar (slide presentation) is available from the RNAO Web site.

The appendices of the original guideline document contain an example framework (“Timing it Right”), example structures in organizations to support care transitions and a list of care transitions tools and resources Web sites. Structure, process and outcome indicators for monitoring and evaluating the guideline are available in Table 4 in the original guideline document.

Mobile versions of RNAO guidelines are available from the RNAO Web site.

Patient Resources

The following is available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather the Registered Nurses’ Association of Ontario (RNAO) urges patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline’s content.

NGC Status

This NGC summary was completed by ECRI Institute on September 25, 2015. The information was verified by the guideline developer on November 6, 2015.

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced and published in its entirety, without modification, in any form, including in electronic form, for educational or non-commercial purposes. Should any adaptation of the material be required for any reason, written permission must be obtained from the Registered Nurses’ Association of Ontario. Appropriate credit or citation must appear on all copied materials as follows:

Registered Nurses’ Association of Ontario (2014). Care Transitions. Toronto, ON: Registered Nurses’ Association of Ontario.

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