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Evidence Summary and Recommendations for Improved Communication during Care Transitions

Jackson, Patricia D. MS, RN, CRRN1; Biggins, Mary Sue MBA, BSN, RN, CRRN2; Cowan, Linda PhD, ARNP, FNP-BC, CWS3; French, Brenda MSN, CRRN, CBIS, VHA-CM, RN-BC4; Hopkins, Sherry L. MSN, BSN, RN-BC, CCM, CRRN5; Uphold, Constance R. PhD, ARNP, FAAN3

Rehabilitation Nursing Journal: May 2016 - Volume 41 - Issue 3 - p 135–148
doi: 10.1002/rnj.230
Current Issues: CE ARTICLES
Continuing Education

Background: Communication between levels of care can be complex for any patient. For the Servicemember or Veteran with complex medical issues, who needs transitioning between multiple levels of care, this communication involves detailed, individualized information pivotal to quality clinical outcomes and patient/family satisfaction. These complex cases also typically include communication between multiple family members.

Purpose: The purpose was to summarize the evidence and present recommendations for facilitating effective transitions of patient care within the complex Veterans Affairs (VA) Polytrauma System of Care.

Design: Evidence Based Review.

Methods: Selected members of the VA Office of Nursing Service Polytrauma Field Advisory Committee conducted an evidence-based review, and queried a clinical panel of polytrauma nursing experts and direct care rehabilitation nurses.

Findings: Search results, key practice recommendations, a plan of care template, and future plans for dissemination and implementation are presented.

Conclusions: Communication is a key to success when managing many details and requires both focus and knowledge of larger systems.

Clinical Relevance: Direct communication, using a standardized approach, is recommended for successful patient transitions.

1 Veteran Affairs, Lexington, KY, USA

2 Veteran Affairs, Hines, IL, USA

3 North Florida/South Georgia Veterans Health System, Gainesville, FL, USA

4 Veteran Affairs, Richmond, VA, USA

5 Veterans Affairs, Grand Island, NE, USA

Accepted June 23, 2015


Patricia Jackson, Polytrauma Nurse Coordinator, Veterans Administration, Physical Medicine & Rehabilitation (117B-LD), 1101 Veterans Drive, Lexington, KY 40502.


© 2016 Association of Rehabilitation Nurses.
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