Nurses Are Key to Referrals to Inpatient Integrative Medicine Services

In a review of referrals to integrative medicine services at Abbott Northwestern Hospital in Minneapolis, Minnesota, researchers found that most doctors are supportive or neutral about referring patients to the integrative medicine (IM) services offered. This National Institute of Health (NIH)-funded study found that levels of engagement ranged from ordering the services for all patients, with allowance for patients to opt out, to relying on nurses and mid-level practitioners to suggest which patients should be offered these services.1

Use of integrative medicine (eg, acupuncture, massage, mind-body therapies) along with conventional medicine is becoming more common in the United States. In the outpatient setting, patients access these services as independent consumers. In the inpatient setting, however, access to such services is largely clinician controlled and little is known about the interaction between referral processes, clinician attitude, and patient use. Therefore, researchers conducted this study to better understand the flow of referrals for integrative medicine for hospitalized patients.

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For this study, a referral is defined as an order placed in the patient's electronic health record (EHR). The researchers reviewed referrals for integrative therapies of all inpatients 18 years and older between July 2012 and December 2014 at Abbott Northwestern Hospital, a 630-bed tertiary care hospital with a well-established integrative medicine program. In addition, they interviewed 15 physicians, 15 nurses, and 7 administrators to assess their perspectives on referring patients for these services.

The greatest number of referrals was made for patients hospitalized for 3 days or less (5801 of 50,782 patients).1 Although a larger proportion of patients with hospital stays of 10 days or longer was referred for IM services, the absolute number of these patients was smaller (2942 of 7466 patients).1

Interview responses followed 3 general themes: criteria used to make referrals, factors influencing the referral process, and concerns and challenges related to having an IM program in the hospital.

Criteria used to consider a referral to IM included length of hospital stay and presence of chronic conditions. Significance of patient symptoms, particularly pain, anxiety, stress, or difficulty coping, also prompted referrals to IM services. Some referrals were made as a last resort; after ruling out contraindications, a referral to IM services would be considered if the patient is not responding to conventional treatments. Lastly, some referrals were initiated via patient request, particularly if the patient had had experience with the practice or is seeking a nonpharmacologic approach to symptom management.

Referrals were often generated through standing orders for all patients, who could opt out if they did not want the service. However, physicians and administrators described referrals to IM services as primarily nurse-driven. Survey responses indicated an acknowledgment that because nurses spent the greater amount of time with patients, they were better able to assess a need for IM services, initiate discussion about them, and consequently order them for patients. Physicians tended to support nurses' judgment on who would benefit from a referral and to which services.

Challenges to using IM services were often related to the time from request/placement of the order and when the services were actually rendered. Nurses reported that if a patient was going home the next day, they would not order the service because it would not be provided before the patient was discharged. Patient expectation that IM services would be rendered more quickly than experienced was also reported. Greater familiarity with the IM services offered at the facility, more often mentioned by physicians than nurses, was another challenge clinicians reported.

A significant challenge to integrative medicine is the pace of the approach. Integrative medicine has a slow pace to it. Although physicians, nurses, and administrators saw the benefits of providing care that brings a sense of calm to the hectic pace of medical care, they also saw the conflict with the demand to follow a rushed modern medicine model.

The most significant findings of this study were that, when IM services are available, physicians and nurses will refer patients to them; referrals are driven largely by length of stay and severity of patient symptoms; and IM referrals are often generated by nurses, whose decisions get a great deal of support from physicians.

Reference

1. Griffin KH, Nate KC, Rivard RL, Christianson JB, Dusek JA. Referrals to integrative medicine in a tertiary hospital: findings from electronic health record data and qualitative interviews. BMJ Open. 2016;6:e012006. doi: 10.1136/mbjopen-2016-012006.

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