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Nguyen KT, Lee TM, Mueller SK. Multi-Institution Survey of Accepting Physicians' Perception of Appropriate Reasons for Interhospital Transfer: A Mixed-Methods Evaluation. J Patient Saf 2024; 20:216-221. [PMID: 38345409 DOI: 10.1097/pts.0000000000001203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Abstract
OBJECTIVES There is a lack of evidence-based guidelines to direct best practices in interhospital transfers (IHTs). We aimed to identify frontline physicians' current and ideal reasons for accepting IHT patients to inform future IHT research and guidelines. METHODS We conducted a cross-sectional survey of hospitalist physicians across 11 geographically diverse hospitals. The survey asked respondents how frequently they currently consider and should consider various factors when triaging IHT requests. Responses were dichotomized into "highly considered" and "less considered" factors. Frequencies of the "highly considered" factors (current and ideal) were analyzed. Write-in responses were coded into themes within a priori domains in a qualitative analysis. RESULTS Of the 666 hospitalists surveyed, 238 (36%) responded. Respondents most frequently identified the need for specialty procedural and nonprocedural care and bed capacity as factors that should be considered when triaging IHT patients in current and ideal practice, whereas the least frequently considered factors were COVID-related care, insurance/financial considerations, and patient/family preference. More experienced respondents considered patient/family preference more frequently in current and ideal practice compared with less experienced respondents (33% versus 11% [ P = 0.0001] and 26% versus 9% [ P = 0.01], respectively). Qualitative analysis identified several themes in the domains of Criteria for Acceptance, Threshold for Acceptance, and Indications for Physician-to-Physician Communication. CONCLUSIONS This geographically diverse sample of hospitalist physicians responsible for accepting IHT patients showed general agreement between primary factors that are currently and that should be considered for IHT acceptance, with greatest weight placed on patients' need for specialty care.
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Affiliation(s)
- Khanh T Nguyen
- From the Section of Hospital Medicine, University of Chicago, Chicago, Illinois
| | - Tiffany M Lee
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California
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Gardner C, Rubinfeld I, Gupta AH, Johnson JL. Inter-Hospital Transfer Is an Independent Risk Factor for Hospital-Associated Infection. Surg Infect (Larchmt) 2024; 25:125-132. [PMID: 38117608 DOI: 10.1089/sur.2023.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
Background: Regionalization of surgical care shifts higher acuity patients to larger centers. Hospital-associated infections (HAIs) are important quality measures with financial implications. In our ongoing efforts to eliminate HAIs, we examined the potential role for inter-hospital transfer in our cases of HAI across a multihospital system. Hypothesis: Surgical patients transferred to a regional multihospital system have a higher risk of National Healthcare Safety Network (NHSN)-labeled HAIs. Patients and Methods: The analysis cohort of adult surgical inpatients was filtered from a five-hospital health system administration registry containing encounters from 2014 to 2021. The dataset contained demographics, health characteristics, and acuity variables, along with the NHSN defined HAIs of central line-associated blood stream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and Clostridioides difficile infection (CDI). Univariable and multivariable statistics were performed. Results: The surgical cohort identified 92,832 patients of whom 3,232 (3.5%) were transfers. The overall HAI rate was 0.6% (528): 86 (0.09%) CLABSI, 133 (0.14%) CAUTI, and 325 (0.35%) CDI. Across the three HAIs, the rate was higher in transfer patients compared with non-transfer patients (CLABSI: n = 18 (1.3%); odds ratio [OR], 4.79; CAUTI: n = 25 (1.8%); OR, 4.20; CDI: n = 37 (1.1%); OR, 3.59); p < 0.001 for all. Multivariable analysis found transfer patients had an increased rate of HAIs (OR, 1.56; p < 0.001). Conclusions: There is an increased risk-adjusted rate of HAIs in transferred surgical patients as reflected in the NHSN metrics. This phenomenon places a burden on regional centers that accept high-risk surgical transfers, in part because of the downstream effects of healthcare reimbursement programs.
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Affiliation(s)
- Camden Gardner
- Henry Ford Hospital, Detroit, Michigan, USA
- Henry Ford Health, Detroit, Michigan, USA
| | - Ilan Rubinfeld
- Henry Ford Hospital, Detroit, Michigan, USA
- Henry Ford Health, Detroit, Michigan, USA
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3
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Yu A, Chopra V, Mueller SK, Wray CM, Jones CD. Engineering safe care journeys: Reenvisioning interhospital transfers. J Hosp Med 2024. [PMID: 38193639 DOI: 10.1002/jhm.13266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/08/2023] [Accepted: 12/14/2023] [Indexed: 01/10/2024]
Affiliation(s)
- Amy Yu
- Department of Medicine, Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Vineet Chopra
- Department of Medicine, Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Stephanie K Mueller
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Charlie M Wray
- Department of Medicine, University of California, San Francisco, California, USA
- Section of Hospital Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Christine D Jones
- Department of Medicine, Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Medicine, Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Veterans Health Administration, Eastern Colorado Health Care System, Denver-Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Aurora, Colorado, USA
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Mueller S, Murray M, Goralnick E, Kelly C, Fiskio JM, Yoon C, Schnipper JL. Implementation of a standardised accept note to improve communication during inter-hospital transfer: a prospective cohort study. BMJ Open Qual 2023; 12:e002518. [PMID: 37899076 PMCID: PMC10619021 DOI: 10.1136/bmjoq-2023-002518] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/09/2023] [Indexed: 10/31/2023] Open
Abstract
IMPORTANCE The transfer of patients between hospitals (interhospital transfer, IHT), exposes patients to communication errors and gaps in information exchange. OBJECTIVE To design and implement a standardised accept note to improve communication during medical service transfers, and evaluate its impact on patient outcomes. DESIGN Prospective interventional cohort study. SETTING A 792-bed tertiary care hospital. PARTICIPANTS All patient transfers from any acute care hospital to the general medicine, cardiology, oncology and intensive care unit (ICU) services between August 2020 and June 2022. INTERVENTIONS A standardised accept note template was developed over a 9-month period with key stakeholder input and embedded in the electronic health record, completed by nurses within the hospital's Access Centre. MAIN OUTCOMES AND MEASURES Primary outcome was clinician-reported medical errors collected via surveys of admitting clinicians within 72 hours after IHT patient admission. Secondary outcomes included clinician-reported failures in communication; presence and 'timeliness' of accept note documentation; patient length of stay (LOS) after transfer; rapid response or ICU transfer within 24 hours and in-hospital mortality. All outcomes were analysed postintervention versus preintervention, adjusting for patient demographics, diagnosis, comorbidity, illness severity, admitting service, time of year, hospital COVID census and census of admitting service and admitting team on date of admission. RESULTS Of the 1004 and 654 IHT patients during preintervention and postintervention periods, surveys were collected on 735 (73.2%) and 462 (70.6%), respectively. Baseline characteristics were similar among patients in each time period and between survey responders and non-responders. Adjusted analyses demonstrated a 27% reduction in clinician-reported medical error rates postimplementation versus preimplementation (11.5 vs 15.8, adjusted OR (aOR) 0.73, 95% CI 0.53 to 0.99). Secondary outcomes demonstrated lower adjusted odds of clinician-reported failures in communication (aOR 0.88; 0.78 to 0.98) and rapid response/ICU transfer (aOR 0.57; 0.34 to 0.97), and improved presence (aOR 2.30; 1.75 to 3.02) and timeliness (-21.4 hours vs -8.7 hours, p<0.001) of accept note documentation. There were no significant differences in LOS or mortality. CONCLUSIONS AND RELEVANCE Among 1658 medical patient transfers, implementing a standardised accept note was associated with improved presence and timeliness of accept note documentation, clinician-reported medical errors, failures in communication and clinical decline following transfer, suggesting that improving communication during IHT can improve patient outcomes.
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Affiliation(s)
- Stephanie Mueller
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Maria Murray
- Patient Transfer and Access Center, MassGeneral Brigham Healthcare System, Boston, MA, USA
| | - Eric Goralnick
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Caitlin Kelly
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Julie M Fiskio
- MassGeneral Brigham HealthCare System Inc, Boston, Massachusetts, USA
| | - Cathy Yoon
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey L Schnipper
- Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Lee T, Lukac PJ, Vangala S, Kowsari K, Vu V, Fogelman S, Pfeffer MA, Bell DS. Evaluating the predictive ability of natural language processing in identifying tertiary/quaternary cases in prioritization workflows for interhospital transfer. JAMIA Open 2023; 6:ooad069. [PMID: 37600073 PMCID: PMC10435371 DOI: 10.1093/jamiaopen/ooad069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/26/2023] [Accepted: 08/06/2023] [Indexed: 08/22/2023] Open
Abstract
Objectives Tertiary and quaternary (TQ) care refers to complex cases requiring highly specialized health services. Our study aimed to compare the ability of a natural language processing (NLP) model to an existing human workflow in predictively identifying TQ cases for transfer requests to an academic health center. Materials and methods Data on interhospital transfers were queried from the electronic health record for the 6-month period from July 1, 2020 to December 31, 2020. The NLP model was allowed to generate predictions on the same cases as the human predictive workflow during the study period. These predictions were then retrospectively compared to the true TQ outcomes. Results There were 1895 transfer cases labeled by both the human predictive workflow and the NLP model, all of which had retrospective confirmation of the true TQ label. The NLP model receiver operating characteristic curve had an area under the curve of 0.91. Using a model probability threshold of ≥0.3 to be considered TQ positive, accuracy was 81.5% for the NLP model versus 80.3% for the human predictions (P = .198) while sensitivity was 83.6% versus 67.7% (P<.001). Discussion The NLP model was as accurate as the human workflow but significantly more sensitive. This translated to 15.9% more TQ cases identified by the NLP model. Conclusion Integrating an NLP model into existing workflows as automated decision support could translate to more TQ cases identified at the onset of the transfer process.
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Affiliation(s)
- Timothy Lee
- Altamed Health Services, Commerce, CA, United States
| | - Paul J Lukac
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA, United States
- Office of Health Informatics and Analytics, University of California, Los Angeles, Los Angeles, CA, United States
| | - Sitaram Vangala
- Department of Medicine Statistics Core, University of California, Los Angeles, Los Angeles, CA, United States
| | - Kamran Kowsari
- Office of Health Informatics and Analytics, University of California, Los Angeles, Los Angeles, CA, United States
| | - Vu Vu
- Office of Health Informatics and Analytics, University of California, Los Angeles, Los Angeles, CA, United States
| | | | - Michael A Pfeffer
- Department of Medicine, Stanford University, Palo Alto, CA, United States
| | - Douglas S Bell
- Department of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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Abstract
Relational event models expand the analytical possibilities of existing statistical models for interorganizational networks by: (i) making efficient use of information contained in the sequential ordering of observed events connecting sending and receiving units; (ii) accounting for the intensity of the relation between exchange partners, and (iii) distinguishing between short- and long-term network effects. We introduce a recently developed relational event model (REM) for the analysis of continuously observed interorganizational exchange relations. The combination of efficient sampling algorithms and sender-based stratification makes the models that we present particularly useful for the analysis of very large samples of relational event data generated by interaction among heterogeneous actors. We demonstrate the empirical value of event-oriented network models in two different settings for interorganizational exchange relations-that is, high-frequency overnight transactions among European banks and patient-sharing relations within a community of Italian hospitals. We focus on patterns of direct and generalized reciprocity while accounting for more complex forms of dependence present in the data. Empirical results suggest that distinguishing between degree- and intensity-based network effects, and between short- and long-term effects is crucial to our understanding of the dynamics of interorganizational dependence and exchange relations. We discuss the general implications of these results for the analysis of social interaction data routinely collected in organizational research to examine the evolutionary dynamics of social networks within and between organizations.
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HSUAN CHARLEEN, CARR BRENDANG, VANNESS DAVID, WANG YINAN, LESLIE DOUGLASL, DUNHAM ELEANOR, ROGOWSKI JEANNETTEA. A Conceptual Framework for Optimizing the Equity of Hospital-Based Emergency Care: The Structure of Hospital Transfer Networks. Milbank Q 2023; 101:74-125. [PMID: 36919402 PMCID: PMC10037699 DOI: 10.1111/1468-0009.12609] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Policy Points Current pay-for-performance and other payment policies ignore hospital transfers for emergency conditions, which may exacerbate disparities. No conceptual framework currently exists that offers a patient-centered, population-based perspective for the structure of hospital transfer networks. The hospital transfer network equity-quality framework highlights the external and internal factors that determine the structure of hospital transfer networks, including structural inequity and racism. CONTEXT Emergency care includes two key components: initial stabilization and transfer to a higher level of care. Significant work has focused on ensuring that local facilities can stabilize patients. However, less is understood about transfers for definitive care. To better understand how transfer network structure impacts population health and equity in emergency care, we proposea conceptual framework, the hospital transfer network equity-quality model (NET-EQUITY). NET-EQUITY can help optimize population outcomes, decrease disparities, and enhance planning by supporting a framework for understanding emergency department transfers. METHODS To develop the NET-EQUITY framework, we synthesized work on health systems and quality of health care (Donabedian, the Institute of Medicine, Ferlie, and Shortell) and the research framework of the National Institute on Minority Health and Health Disparities with legal and empirical research. FINDINGS The central thesis of our framework is that the structure of hospital transfer networks influences patient outcomes, as defined by the Institute of Medicine, which includes equity. The structure of hospital transfer networks is shaped by internal and external factors. The four main external factors are the regulatory, economic environment, provider, and sociocultural and physical/built environment. These environments all implicate issues of equity that are important to understand to foster an equitable population-based system of emergency care. The framework highlights external and internal factors that determine the structure of hospital transfer networks, including structural racism and inequity. CONCLUSIONS The NET-EQUITY framework provides a patient-centered, equity-focused framework for understanding the health of populations and how the structure of hospital transfer networks can influence the quality of care that patients receive.
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Saucke MC, Alagoz E, Arroyo N, Gutierrez-Meza DE, Fernandes-Taylor S, Ingraham AM. The invisible work of transfer centre nurses: A qualitative study of strategies to overcome communication challenges. J Adv Nurs 2023. [PMID: 36843245 DOI: 10.1111/jan.15603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 01/12/2023] [Accepted: 02/05/2023] [Indexed: 02/28/2023]
Abstract
AIMS To explore the role of transfer centre nurses and how they facilitate communication between referring and accepting providers during calls about interhospital transfers, including their strategies to overcome communication challenges. DESIGN A qualitative interview study. METHODS We conducted semi-structured interviews with 17 transfer centre nurses at one tertiary medical centre from March to August 2019, asking participants to describe their work. We performed content analysis, applying codes based on the Relational Coordination Framework and generating emergent codes, then organized codes in higher-order concepts. We followed the COREQ checklist. RESULTS Transfer centre nurses employed multiple strategies to mitigate communication challenges. When referring providers had misconceptions about the transfer centre nurse's role and the accepting hospital's processes, the nurses informed referring providers why sharing information with them was necessary. If providers expressed frustrations or lacked understanding about their counterpart's caseload, the nurses managed providers' emotions by letting them "vent," explaining the other provider's situational context and describing the hospital's capabilities. Some nurses also mediated conflict and sought to break the tension if providers debated about the best course of action. When providers struggled to share complete and accurate information, the nurses hunted down details and 'filled in the blanks'. CONCLUSION Transfer centre nurses perform invisible work throughout the lifespan of interhospital transfers. Nurses' expert knowledge of the transfer process and hospitals' capabilities can enhance provider communication. Meanwhile, providers' lack of knowledge of the nurse's role can impede respectful and efficient transfer conversations. Interventions to support and optimize the transfer centre nurses' critical work are needed. IMPACT This study describes how transfer centre nurses facilitate communication and overcome challenges during calls about interhospital transfers. An intervention that supports this critical work has the potential to benefit nurses, providers and patients by ensuring accurate and complete information exchange in an effective, efficient manner that respects all parties. PATIENT OR PUBLIC CONTRIBUTION This study was designed to capture the perspectives and experiences of transfer centre nurses themselves through interviews. Therefore, it was not conducted using input or suggestions from the public or the patient population served by the organization.
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Affiliation(s)
- Megan C Saucke
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Esra Alagoz
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Natalia Arroyo
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | | | | | - Angela M Ingraham
- Department of Surgery, University of Wisconsin, Madison, Wisconsin, USA
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French WJ, Gunderson M, Travis D, Bieniarz M, Zegre‐Hemsey J, Goyal A, Jacobs AK. Emergency Interhospital Transfer of Patients With ST‐Segment–Elevation Myocardial Infarction: Call 9‐1‐1—The American Heart Association Mission: Lifeline Program. J Am Heart Assoc 2022; 11:e026700. [DOI: 10.1161/jaha.122.026700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
ABSTRACT: The American Heart Association Mission: Lifeline program objectives are to improve the quality of care and outcomes for patients with ST‐segment–elevation myocardial infarction. Every minute of delay in treatment adversely affects 1‐year mortality. Transfer of patients safely and timely to hospitals with primary percutaneous coronary intervention capability is needed to improve outcomes. But treatment times continue to show delays, especially during interhospital transfers. A simple 3‐step process of an interhospital “Call 9‐1‐1” protocol may expedite this process. This STAT TRANSFER process uses a systems approach that considers diverse ways in which patients access care, how EMS responds and determines destinations, how referring hospital transfers are performed, urban and rural differences, and how receiving hospitals prepare for an incoming patient with ST‐segment–elevation myocardial infarction. This initiative suggests a strategy to reduce variability in interhospital transfer times using a STAT TRANSFER and a Call 9‐1‐1 process in a system of care that involves all stakeholders.
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Affiliation(s)
- William J. French
- Geffen School of Medicine at UCLA, Cardiac Catheterization Laboratory, Harbor‐UCLA Medical Center Torrance CA
| | - Mic Gunderson
- Center for Systems Improvement, Cambridge Consulting Group; Emergency Health Services University of Maryland Baltimore County MD
| | - David Travis
- EMS Programs Hillsborough Community College Tampa FL
| | - Mark Bieniarz
- New Mexico Heart Institute Lovelace Medical Center Albuquerque NM
| | - Jessica Zegre‐Hemsey
- School of Nursing; Department of Emergency Medicine The University of North Carolina at Chapel Hill NC
| | - Abhinav Goyal
- Emory Heart and Vascular Center, Emory Healthcare; Medicine (Cardiology) Emory School of Medicine; Emory Rollins School of Public Health Atlanta GA
| | - Alice K. Jacobs
- Department of Medicine Boston University School of Medicine and Boston Medical Center Boston MA
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Alagoz E, Saucke M, Arroyo N, Ingraham A. Communication During Interhospital Transfers of Emergency General Surgery Patients: A Qualitative Study of Challenges and Opportunities. J Patient Saf 2022; 18:711-716. [PMID: 36170588 PMCID: PMC9523144 DOI: 10.1097/pts.0000000000000979] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Transferred emergency general surgery (EGS) patients experience worse outcomes than directly admitted patients. Improving communication during transfers may improve patient care. We sought to understand the nature of and challenges to communication between referring (RP) and accepting (AP) providers transferring EGS patients from the transfer center nurse's (TCN) perspective. METHODS Guided by the Relational Coordination Framework, we interviewed 17 TCNs at an academic medical center regarding (in)efficient and (in)effective communication between RPs and APs. In-person interviews were recorded, transcribed, and managed in NVivo. Four researchers developed a codebook, cocoded transcripts, and met regularly to build consensus and discuss emergent themes. We used data matrices to perform constant comparisons and arrive at higher-level concepts. RESULTS Challenges to ideal communication centered on the appropriateness and completeness of information, efficiency of the conversation, and degree of consensus. Transfer center nurses described that RPs provided incomplete information because of a lack of necessary infrastructure, personnel, or technical knowledge; competing clinical demands; or a fear of the transfer request being rejected. Inefficient communication resulted from RPs being unfamiliar with the information APs expected and the lack of a structured process to share information. Communication also failed when providers disagreed about the necessity of the transfer. Accepting providers diffused tension and facilitated communication by embracing the role of a "coach," negotiating "wait-and-see" agreements, and providing explanations of why transfers were unnecessary. CONCLUSIONS Transfer center nurses described numerous challenges to provider communication. Opportunities for improvement include sharing appropriate and complete information, ensuring efficient communication, and reaching consensus about the course of action.
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Affiliation(s)
- Esra Alagoz
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin-Madison, Wisconsin, USA
| | - Megan Saucke
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin-Madison, Wisconsin, USA
| | - Natalia Arroyo
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin-Madison, Wisconsin, USA
| | - Angela Ingraham
- Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin-Madison, Wisconsin, USA
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11
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Franklin BJ, Mueller SK, Bates DW, Gandhi TK, Morris CA, Goralnick E. Use of Hospital Capacity Command Centers to Improve Patient Flow and Safety: A Scoping Review. J Patient Saf 2022; 18:e912-e921. [PMID: 35435429 DOI: 10.1097/pts.0000000000000976] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Delayed emergency department (ED) and hospital patient throughput is recognized as a critical threat to patient safety. Increasingly, hospitals are investing significantly in deploying command centers, long used in airlines and the military, to proactively manage hospital-wide patient flow. This scoping review characterizes the evidence related to hospital capacity command centers (CCCs) and synthesizes current data regarding their implementation. METHODS As no consensus definition exists for CCCs, we characterized them as units (i) involving interdisciplinary, permanently colocated teams, (ii) using real-time data, and (iii) managing 2 or more patient flow functions (e.g., bed management, transfers, discharge planning, etc.), to distinguish CCCs from transfer centers. We undertook a scoping review of the medical and gray literature published through April 2019 related to CCCs meeting these criteria. RESULTS We identified 8 eligible articles (including 4 peer-reviewed studies) describing 7 CCCs of varying designs. The most common CCC outcome measures related to transfer volume (n = 5) and ED boarding (n = 4). Several CCCs also monitored patient-level clinical parameters. Although all articles reported performance improvements, heterogeneity in CCC design and evidence quality currently restricts generalizability of findings. CONCLUSIONS Numerous anecdotal accounts suggest that CCCs are being widely deployed in an effort to improve hospital patient flow and safety, yet peer-reviewed evidence regarding their design and effectiveness is in its earliest stages. The costs, objectives, and growing deployment of CCCs merit an investment in rigorous research to better measure their processes and outcomes. We propose a standard definition, conceptual framework, research priorities, and reporting standards to guide future investigation of CCCs.
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Ching HL, Lau MS, Azmy IA, Hopper AD, Keuchel M, Gyökeres T, Kuvaev R, Macken EJ, Bhandari P, Thoufeeq M, Leclercq P, Rutter MD, Veitch AM, Bisschops R, Sanders DS. Performance measures for the SACRED team-centered approach to advanced gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2022; 54:712-722. [PMID: 35636453 DOI: 10.1055/a-1832-4232] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
The European Society of Gastrointestinal Endoscopy and United European Gastroenterology have defined performance measures for upper and lower gastrointestinal, pancreaticobiliary, and small-bowel endoscopy. Quality indicators to guide endoscopists in the growing field of advanced endoscopy are also underway. We propose that equal attention is given to developing the entire advanced endoscopy team and not the individual endoscopist alone.We suggest that the practice of teams intending to deliver high quality advanced endoscopy is underpinned by six crucial principles concerning: selection, acceptance, complications, reconnaissance, envelopment, and documentation (SACRED).
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Affiliation(s)
- Hey-Long Ching
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Michelle S Lau
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Iman A Azmy
- Department of Breast Surgery, Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield, UK
| | - Andrew D Hopper
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Martin Keuchel
- Clinic for Internal Medicine, Bethesda Krankenhaus Bergedorf, Hamburg, Germany
| | - Tibor Gyökeres
- Department of Gastroenterology, Medical Center Hungarian Defence Forces, Budapest, Hungary
| | - Roman Kuvaev
- Endoscopy Department, Yaroslavl Regional Cancer Hospital, Yaroslavl, Russian Federation.,Gastroenterology Department, Faculty of Additional Professional Education, Pirogov Russian National Research Medical University, Moscow, Russian Federation
| | - Elisabeth J Macken
- Division of Gastroenterology and Hepatology, Antwerp University Hospital, Antwerp, Belgium
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | - Mo Thoufeeq
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| | | | - Matthew D Rutter
- North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK.,Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - Andrew M Veitch
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, KU Leuven, Belgium
| | - David S Sanders
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
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Usher MG, Tignanelli CJ, Hilliard B, Kaltenborn ZP, Lupei MI, Simon G, Shah S, Kirsch JD, Melton GB, Ingraham NE, Olson AP, Baum KD. Responding to COVID-19 Through Interhospital Resource Coordination: A Mixed-Methods Evaluation. J Patient Saf 2022; 18:287-294. [PMID: 34569998 PMCID: PMC8940726 DOI: 10.1097/pts.0000000000000916] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The COVID-19 pandemic stressed hospital operations, requiring rapid innovations to address rise in demand and specialized COVID-19 services while maintaining access to hospital-based care and facilitating expertise. We aimed to describe a novel hospital system approach to managing the COVID-19 pandemic, including multihospital coordination capability and transfer of COVID-19 patients to a single, dedicated hospital. METHODS We included patients who tested positive for SARS-CoV-2 by polymerase chain reaction admitted to a 12-hospital network including a dedicated COVID-19 hospital. Our primary outcome was adherence to local guidelines, including admission risk stratification, anticoagulation, and dexamethasone treatment assessed by differences-in-differences analysis after guideline dissemination. We evaluated outcomes and health care worker satisfaction. Finally, we assessed barriers to safe transfer including transfer across different electronic health record systems. RESULTS During the study, the system admitted a total of 1209 patients. Of these, 56.3% underwent transfer, supported by a physician-led System Operations Center. Patients who were transferred were older (P = 0.001) and had similar risk-adjusted mortality rates. Guideline adherence after dissemination was higher among patients who underwent transfer: admission risk stratification (P < 0.001), anticoagulation (P < 0.001), and dexamethasone administration (P = 0.003). Transfer across electronic health record systems was a perceived barrier to safety and reduced quality. Providers positively viewed our transfer approach. CONCLUSIONS With standardized communication, interhospital transfers can be a safe and effective method of cohorting COVID-19 patients, are well received by health care providers, and have the potential to improve care quality.
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Affiliation(s)
- Michael G. Usher
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| | - Christopher J. Tignanelli
- Department of Surgery, University of Minnesota Medical School
- Institute for Health Informatics, University of Minnesota
| | - Brian Hilliard
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| | - Zachary P. Kaltenborn
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| | | | - Gyorgy Simon
- Institute for Health Informatics, University of Minnesota
| | - Surbhi Shah
- Division of Hematology and Oncology, Department of Medicine
| | - Jonathan D. Kirsch
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| | - Genevieve B. Melton
- Department of Surgery, University of Minnesota Medical School
- Institute for Health Informatics, University of Minnesota
| | - Nicholas E. Ingraham
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Andrew P.J. Olson
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
| | - Karyn D. Baum
- From the Section of Hospital Medicine, Division of General Internal Medicine, Department of Medicine
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Yu A, Jordan SR, Gilmartin H, Mueller SK, Holliman BD, Jones CD. "Our Hands Are Tied Until Your Doctor Gets Here": Nursing Perspectives on Inter-hospital Transfers. J Gen Intern Med 2022; 37:1729-1736. [PMID: 34993869 PMCID: PMC8735724 DOI: 10.1007/s11606-021-07276-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 11/10/2021] [Indexed: 12/02/2022]
Abstract
BACKGROUND The transfer of patients between hospitals (inter-hospital transfer, or IHT) is a common occurrence for patients, but guidelines to ensure safe and effective IHTs are lacking. Poor IHTs result in higher rates of mortality, longer lengths of stay, and higher hospitalization costs compared to admissions from the emergency department. Nurses are often the first point of contact for IHT patients and can provide valuable insights on key challenges to IHT processes. OBJECTIVE To characterize the experiences of inpatient floor-level bedside nurses caring for IHT patients and identify care coordination challenges and solutions. DESIGN/PARTICIPANTS/APPROACH Qualitative study using semi-structured focus groups and interviews conducted from October 2019 to July 2020 with 21 inpatient floor-level nurses caring for adult medicine patients at an academic hospital. Nurses were recruited using a purposive convenience sampling approach. A combined inductive and deductive coding approach guided by thematic analysis was used for data analysis. KEY RESULTS Results from this study are mapped to the Agency for Healthcare Research and Quality Care Coordination Measurement Framework domains of communication, assessing needs and goals, and negotiating accountability. The following key themes characterize nurses' experiences with IHT related to these domains: (1) challenges with information exchange and team communication during IHT, (2) environmental and information preparation needed to anticipate transfers, and (3) determining responsibility and care plans after the IHT patient has arrived at the accepting facility. CONCLUSIONS Nurses described the absence of standardized processes to coordinate care before or at the time of patient arrival. Challenges to communication and coordination during IHTs negatively impacted patient care and nursing professional satisfaction. To streamline care for IHT patients and reduce nursing stress, future IHT interventions should include standardized handoff reports, timely identification and easy access to admitting clinicians, and timely clinician evaluation and orders.
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Affiliation(s)
- Amy Yu
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, 12401 E. 17th Avenue Mailstop F-782, Aurora, CO, 80045, USA.
| | - Sarah R Jordan
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Heather Gilmartin
- Veterans Health Administration, Eastern Colorado Health Care System, Denver-Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Aurora, CO, USA
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Stephanie K Mueller
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Brooke Dorsey Holliman
- Department of Family Medicine, University of Colorado Denver School of Medicine, Aurora, CO, USA
| | - Christine D Jones
- Division of Hospital Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, 12401 E. 17th Avenue Mailstop F-782, Aurora, CO, 80045, USA
- Veterans Health Administration, Eastern Colorado Health Care System, Denver-Seattle Center of Innovation for Veteran-Centered and Value Driven Care, Aurora, CO, USA
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Young E, Kopunic HS, Trochsler MI, Maddern GJ. Predictors of interhospital transfer delays in acute surgical patient deaths in Australia: a retrospective study. ANZ J Surg 2022; 92:1322-1331. [PMID: 35373494 DOI: 10.1111/ans.17669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Interhospital transfers in Australia facilitate access to acute surgical services, however transfer delays can occur. The aims of this study were to examine Australian mortality audit data on acute surgical patients who were transferred after presenting with a surgical emergency, and to identify modifiable predictors of transfer delay. METHODS Surgical admissions between 1 January 2001 and 18 August 2020 were retrospectively extracted from the Australian and New Zealand Audit of Surgical Mortality database. Relevant factors and themes of interest were collated. Results were presented as odds ratios (OR) and 95% confidence intervals (CI), with statistical significance defined as P <0.05. RESULTS After exclusion, a final 8270 cases were analysed. Non-modifiable predictors identified were female gender (OR 1.34, 95% CI 1.05-1.70, P = 0.0184), comorbidities (OR 1.50, 95% CI 1.40-161, P <0.0001) and major non-trauma non-vascular specialty (OR 1.54 to 7.77, depending on specialty, P < 0.05). Modifiable predictors were inadequate clinical assessment (OR 49.48, 95% CI 32.91-74.38, P <0.0001), poor communication (OR 6.62, 95% CI 3.70-11.85, P <0.0001) and multiple transfers (OR 6.30, OR 95% 4.31-9.21, P <0.0001). Age, lack of bed and after-hours transfer did not predict transfer delays. Metropolitan transfers was protective against transfer delays (OR 0.64, 95% CI 0.47-0.86, P = 0.0035). CONCLUSION In the view of the receiving surgeon or assessor, all transfer delays potentially contributed to patient deaths, and may have been preventable. Strategies directed at modifiable factors could minimize delays. Increased surgical services in non-metropolitan regions could reduce need for transfer. Prospective data is required to examine if the same predictors are observed in surgical patients who survive.
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Affiliation(s)
- Edward Young
- The University of Adelaide, Faculty of Health and Medical Sciences, Adelaide, South Australia, Australia
| | - Helena S Kopunic
- Australian and New Zealand Audit of Surgical Mortality (ANZASM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia
| | - Markus I Trochsler
- The University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Guy J Maddern
- Australian and New Zealand Audit of Surgical Mortality (ANZASM), Royal Australasian College of Surgeons, Adelaide, South Australia, Australia.,The University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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Ray JM, Wong AH, Finn EB, Sheth KN, Matouk CC, Sudikoff SN, Auerbach MA, Sather JE, Venkatesh AK. Improving Safety and Quality During Interhospital Transfer of Patients With Nontraumatic Intracranial Hemorrhage: A Simulation-Based Pilot Program. J Patient Saf 2022; 18:77-87. [PMID: 33852541 DOI: 10.1097/pts.0000000000000808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The presentation of critically ill patients to emergency departments often necessitates interhospital transfer (IHT) to a tertiary care center for specialized neurocritical care. Patients with nontraumatic intracranial hemorrhage represent a critically ill population subject to high rates of IHT and who is thus an important target for research and quality improvement of IHT. We describe the use of an innovative simulation methodology engaging transfer staff, clinicians, and stakeholders to refine and facilitate the adoption of a standardized IHT protocol for transferring patients with neurovascular emergencies. METHODS This was a qualitative study using a phenomenological approach. Participants consisted of IHT call center staff members, neurointensivists, neurosurgeons, and emergency physicians. We conducted a standardized telephone-based simulation case to prime participants for feedback on their experiences with IHT for intracranial hemorrhage patients. Facilitators conducted focus groups immediately after the simulation to identify process improvement opportunities. A structured thematic analysis identified overarching concepts from the data. RESULTS We achieved data saturation with 7 simulations and a total of 24 participants. Thematic analysis identified 3 IHT-specific themes: (1) challenges unique to multispecialty critical illness, (2) interdisciplinary relationships and dynamics, and (3) communication and information processing for IHT. Three quality improvement initiatives emerged from the debriefings: standardized communication checklist, early acceptance protocol, and structure for telephone-based care handoffs. CONCLUSIONS We demonstrate the use of telephone-based simulation technology to identify potential pitfalls and accelerate the adoption of a new IHT protocol for patients with nontraumatic intracranial hemorrhage. New quality improvement strategies can organically result through interprofessional debriefings for patients with potentially complex handoffs between hospitals.
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Abstract
OBJECTIVES Although existing data suggest marked variability in interhospital transfer (IHT), little is known about specific factors that may impact the quality and safety of this care transition. We aimed to explore transferred patients' and involved physicians' experience with IHT to better understand the components of the transfer continuum and identify potential targets for improvement. METHODS We performed a qualitative study using individual interviews of adult patients recently transferred to cardiology, general medicine, and oncology services at a tertiary care academic medical center, as well as their transferring physician, accepting attending physician, and accepting/admitting resident physician. We conducted a thematic analysis, using an inductive approach and an a priori framework from pre-established domains. RESULTS Participants included 10 hospitalized adults (6 cardiology, 2 general medicine, and 2 oncology), 9 accepting attending physicians, 12 accepting and/or admitting resident physicians, and 5 transferring physicians (N = 36). Emergent themes demonstrated that participants held a shared understanding of the reason for transfer (most commonly access to more specialized care), and relayed a general dissatisfaction regarding the timing and lack of advanced notification of transfer. We also found distinct differences in IHT experience by stakeholder group: physician participants relayed discontent with intrahospital chains of communication and interhospital information exchange, and patient participants focused more readily on the physical aspects of IHT. CONCLUSIONS This study offers insight into IHT from the perspective of those most affected by this process, thereby identifying potential targets in addressing the quality and safety of this transition.
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Affiliation(s)
| | - Evan Shannon
- From the Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
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Parzen-Johnson S, Kronforst KD, Shah RM, Whitmer GR, Scardina T, Chandarraju M, Patel SJ. Use of the Electronic Health Record to Optimize Antimicrobial Prescribing. Clin Ther 2021; 43:1681-1688. [PMID: 34645574 DOI: 10.1016/j.clinthera.2021.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE This review summarizes how interventions in the electronic health record (EHR) can optimize antimicrobial stewardship across the continuum of antimicrobial decision making, from diagnosis of infection to discontinuation of therapy. In addition, opportunities to optimize provider communication and patient education are identified. METHODS A narrative review was conducted to identify how interventions in the EHR can influence antimicrobial prescribing behavior. Examples from pediatrics were specifically identified. Interventions were then categorized into high-impact/low-effort, high-impact/high-effort, and low-impact/low-effort groupings based on historical experience. FINDINGS EHR-based interventions can be used for stratifying patients at risk for infection and are useful in identifying patients with new-onset infections. Additional tools include automatically updated antibiograms tailored to specific patient populations, timely authorization of restricted antimicrobials, and more accurate allergy labeling. Medical errors can be reduced and communication between providers can be improved by standardized data fields. Clinical decision support tools can guide appropriate selection of therapy, and visual prompts can reduce unnecessarily prolonged therapy. Benchmarking of antimicrobial use, tailored patient education, and improved communication during transitions of care are enhanced through EHR-based interventions. IMPLICATIONS Prescribing behavior can be modified through a range of interventions in the EHR, including tailored education, alerts, prompts, and restrictions on provider behavior. Further studies are needed to compare the effectiveness of various strategies.
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Affiliation(s)
| | - Kenny D Kronforst
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Grant R Whitmer
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tonya Scardina
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Meg Chandarraju
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Sameer J Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Abstract
INTRODUCTION Interhospital transfers (IHT) are important yet high-risk transitions in care. Variable IHT processes and a lack of clarity around best practice may contribute to risk. To define the best practice principles for IHTs and identify improvement opportunities in the transfer process to our hospital's Cardiology services. METHODS Through literature review, interviews with experts and key stakeholders, a survey of health care professionals at our institution, and a failure modes effect analysis, we identified themes in IHT best practices and improvement opportunities. RESULTS We identified six critical elements of IHT: (1) initiation of transfer request; (2) the management of transfer request and information exchange; (3) updates between transfer acceptance and patient transport; (4) transport; (5) patient admission and information availability; and (6) measurement, evaluation, and feedback. Improvement opportunities were found in all elements. CONCLUSIONS The standardization of these six critical elements may improve the safety of IHTs.
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20
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Baig SH, Gorth DJ, Yoo EJ. Critical Care Utilization and Outcomes of Interhospital Medical Transfers at Lower Risk of Death. J Intensive Care Med 2021; 37:679-685. [PMID: 34080443 DOI: 10.1177/08850666211022613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To evaluate utilization and mortality outcomes of interhospital transferred critically-ill medical patients with lower predicted risk of hospital mortality. MATERIALS & METHODS Multisite retrospective cohort analysis of patients with Acute Physiology and Chronic Health Evaluation (APACHE) IV-a predicted mortality of ≤20% from 335 ICUs in 208 hospitals in the Philips eICU database between 2014-2015. Differences in length-of-stay (LOS) and mortality between transferred and local patients were evaluated using negative binomial logistic regression and logistic regression, respectively. Stratified analyses were conducted for subgroups of predicted mortality: 0%-5%, 6%-10%, 11%-15%, and 16%-20%. RESULTS Transfers had a higher risk of longer ICU and hospital LOS across all risk strata (IRR 1.12; 95% CI 1.09-1.16, P < 0.001 and IRR 1.11; 95% CI 1.07-1.14, P < 0.001 respectively). Mortality was higher among transfers, largely driven by the 6%-10% mortality risk strata (OR 1.30; 95% CI 1.09-1.54, P = 0.003). CONCLUSIONS Interhospital transfer of critically-ill medical patients with lower illness severity is associated with higher ICU and hospital utilization and increased mortality. Better understanding of factors driving patient selection for and characteristics of interhospital transfer for this population will have an impact on ICU resource utilization, care efficiency, and hospital quality.
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Affiliation(s)
- Saqib H Baig
- Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, PA, USA
| | - Deborah J Gorth
- Sidney Kimmel Medical College, Thomas Jefferson University, PA, USA
| | - Erika J Yoo
- Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, PA, USA
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Pagali S, Kocher JP, Coons T, King K, Hansel S, Van Brunt N, Smith C, Williams A, Newman J. Quality Performance of a Transfer Center Reduces Interhospital Transfer and Direct Admission-Related ED Evaluations. Am J Med Qual 2021. [PMID: 33990473 DOI: 10.1097/01.JMQ.0000735520.04870.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Transfer centers play a vital role in the efficient triage of hospital admission requests that generate outside the emergency department (ED) of the given facility. This cohort study includes all the calls processed through the transfer center requesting an admission to Mayo Clinic, Rochester, from January 2016 to December 2018. More than 116,000 transfer request calls were processed. Of these, about 65% (75,000) were accepted for ED evaluation or direct admission. Of the 75,000 patients, >50% were accepted as direct admits. Among patients accepted for direct admission, a trend toward reduced utilization of ED reevaluation at the receiving facility was noted from 2016 to 2018. A temporal trend of overall reduced ED utilization reflects the adeptness of the transfer center. An effective transfer center promotes value-based care, optimizes the workflow in a hospital, and augments hospital administrative decisions to allocate resources.
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22
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Chilakamarri P, Finn EB, Sather J, Sheth KN, Matouk C, Parwani V, Ulrich A, Davis M, Pham L, Chaudhry SI, Venkatesh AK. Failure Mode and Effect Analysis: Engineering Safer Neurocritical Care Transitions. Neurocrit Care 2021; 35:232-240. [PMID: 33403581 DOI: 10.1007/s12028-020-01160-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 11/18/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND/OBJECTIVE Inter-hospital patient transfers for neurocritical care are increasingly common due to increased regionalization for acute care, including stroke and intracerebral hemorrhage. This process of transfer is uniquely vulnerable to errors and risk given numerous handoffs involving multiple providers, from several disciplines, located at different institutions. We present failure mode and effect analysis (FMEA) as a systems engineering methodology that can be applied to neurocritical care transitions to reduce failures in communication and improve patient safety. Specifically, we describe our local implementation of FMEA to improve the safety of inter-hospital transfer for patients with intracerebral and subarachnoid hemorrhage as evidence of success. METHODS We describe the conceptual basis for and specific use-case example for each formal step of the FMEA process. We assembled a multi-disciplinary team, developed a process map of all components required for successful transfer, and identified "failure modes" or errors that hinder completion of each subprocess. A risk or hazard analysis was conducted for each failure mode, and ones of highest impact on patient safety and outcomes were identified and prioritized for implementation. Interventions were then developed and implemented into an action plan to redesign the process. Importantly, a comprehensive evaluation method was established to monitor outcomes and reimplement interventions to provide for continual improvement. RESULTS This intervention was associated with significant reductions in emergency department (ED) throughput (ED length of stay from 300 to 149 min, (p < .01), and improvements in inter-disciplinary communication (increase from pre-intervention (10%) to post- (64%) of inter-hospital transfers where the neurological intensive care unit and ED attendings discussed care for the patient prior to their arrival). CONCLUSIONS Application of the FMEA approach yielded meaningful and sustained process change for patients with neurocritical care needs. Utilization of FMEA as a change instrument for quality improvement is a powerful tool for programs looking to improve timely communication, resource utilization, and ultimately patient safety.
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Affiliation(s)
- Priyanka Chilakamarri
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Veteran Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Emily B Finn
- Yale Center for Healthcare Innovation, Redesign and Learning, New Haven, CT, USA
| | - John Sather
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave. Suite 260, New Haven, CT, 06519, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Vivek Parwani
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave. Suite 260, New Haven, CT, 06519, USA
| | - Andrew Ulrich
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave. Suite 260, New Haven, CT, 06519, USA
| | - Melissa Davis
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Laura Pham
- Yale New Haven Hospital Patient and Physician Access, New Haven, CT, USA
| | - Sarwat I Chaudhry
- Yale New Haven Hospital, Center for Outcomes Research and Evaluation, New Haven, CT, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave. Suite 260, New Haven, CT, 06519, USA.
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Fernandes-Taylor S, Yang DY, Schumacher J, Ljumani F, Fertel BS, Ingraham A. Factors associated with Interhospital transfers of emergency general surgery patients from emergency departments. Am J Emerg Med 2020; 40:83-88. [PMID: 33360394 DOI: 10.1016/j.ajem.2020.12.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/30/2020] [Accepted: 12/07/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Emergency general surgery (EGS) conditions account for over 3 million or 7.1% of hospitalizations per year in the US. Patients are increasingly transferred from community emergency departments (EDs) to larger centers for care, and a growing demand for treating EGS conditions mandates a better understanding of how ED clinicians transfer patients. We identify patient, clinical, and organizational characteristics associated with interhospital transfers of EGS patients originating from EDs in the United States. METHOD We analyze data from the Agency for Healthcare Research and Quality Nationwide Emergency Department Sample (NEDS) for the years 2010-2014. Patient-level sociodemographic characteristics, clinical factors, and hospital-level factors were examined as predictors of transfer from the ED to another acute care hospital. Multivariable logistic regression analysis includes patient and hospital characteristics as predictors of transfer from an ED to another acute care hospital. RESULTS Of 47,442,892 ED encounters (weighted) between 2008 and 2014, 1.9% resulted in a transfer. Multivariable analysis indicates that men (Odds ratio (OR) 1.18 95% Confidence Interval (95% CI) 1.16-1.21) and older patients (OR 1.02 (95% CI 1.02-1.02)) were more likely to be transferred. Relative to patients with private health insurance, patients covered by Medicare (OR 1.09 (95% CI 1.03-1.15) or other insurance (OR 1.34 (95% CI 1.07-1.66)) had a higher odds of transfer. Odds of transfer increased with a greater number of comorbid conditions compared to patients with an EGS diagnosis alone. EGS diagnoses predicting transfer included resuscitation (OR 36.72 (95% CI 30.48-44.22)), cardiothoracic conditions (OR 8.47 (95% CI 7.44-9.63)), intestinal obstruction (OR 4.49 (95% CI 4.00-5.04)), and conditions of the upper gastrointestinal tract (OR 2.82 (95% CI 2.53-3.15)). Relative to Level I or II trauma centers, hospitals with a trauma designation III or IV had a 1.81 greater odds of transfer. Transfers were most likely to originate at rural hospitals (OR 1.69 (95% CI 1.43-2.00)) relative to urban non-teaching hospitals. CONCLUSION Medically complex and older patients who present at small, rural hospitals are more likely to be transferred. Future research on the unique needs of rural hospitals and timely transfer of EGS patients who require specialty surgical care have the potential to significantly improve outcomes and reduce costs.
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Affiliation(s)
- Sara Fernandes-Taylor
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America.
| | - Dou-Yan Yang
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Jessica Schumacher
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Fiona Ljumani
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Baruch S Fertel
- Emergency Services Institute & Enterprise Quality and Safety Cleveland Clinic, Cleveland OH, United States of America
| | - Angela Ingraham
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, United States of America
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Everson J, Adler-Milstein JR, Hollingsworth JM, Lee SD. Dispersion in the hospital network of shared patients is associated with less efficient care. Health Care Manage Rev 2020. [PMID: 33298805 DOI: 10.1097/HMR.0000000000000295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is growing recognition that health care providers are embedded in networks formed by the movement of patients between providers. However, the structure of such networks and its impact on health care are poorly understood. PURPOSE We examined the level of dispersion of patient-sharing networks across U.S. hospitals and its association with three measures of care delivered by hospitals that were likely to relate to coordination. METHODOLOGY/APPROACH We used data derived from 2016 Medicare Fee-for-Service claims to measure the volume of patients that hospitals treated in common. We then calculated a measure of dispersion for each hospital based on how those patients were concentrated in outside hospitals. Using this measure, we created multivariate regression models to estimate the relationship between network dispersion, Medicare spending per beneficiary, readmission rates, and emergency department (ED) throughput rates. RESULTS In multivariate analysis, we found that hospitals with more dispersed networks (those with many low-volume patient-sharing relationships) had higher spending but not greater readmission rates or slower ED throughput. Among hospitals with fewer resources, greater dispersion related to greater readmission rates and slower ED throughput. Holding an individual hospital's dispersion constant, the level of dispersion of other hospitals in the hospital's network was also related to these outcomes. CONCLUSION Dispersed interhospital networks pose a challenge to coordination for patients who are treated at multiple hospitals. These findings indicate that the patient-sharing network structure may be an overlooked factor that shapes how health care organizations deliver care. PRACTICE IMPLICATIONS Hospital leaders and hospital-based clinicians should consider how the structure of relationships with other hospitals influences the coordination of patient care. Effective management of this broad network may lead to important strategic partnerships.
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Tran QK, Famuyiwa O, Haase DJ, Holland K, Lawner B, Matta S, McGuin L, Menaker J, Menne A, Ngono EE, Niles E, O'Connor J, Scalea T, Galvagno S. Care Intensity During Transport to the Critical Care Resuscitation Unit: Transport Clinician's Role. Air Med J 2020; 39:473-478. [PMID: 33228897 DOI: 10.1016/j.amj.2020.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 08/02/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Patients are often transferred between hospitals for a higher level of care. Critically ill patients require high-intensity care after transfer, but their care intensity during transport is unknown. We studied transport clinicians' management for patients who had time-sensitive or critical illnesses and were transferred to a critical care resuscitation unit (CCRU) at a quaternary academic center. METHODS We prospectively surveyed transport clinicians who brought interhospital transport patients to the CCRU between March 1, 2019, and January 8, 2020. The primary outcome was care intensity during transport, which was defined as new interventions rendered by transport clinicians. RESULTS We analyzed 852 surveys. Seventy-four percent of transports occurred by ground, and 54% originated from emergency departments. Up to 19% of patients received 2 or more interventions, whereas 29% received at least 1 intervention during transport. Ventilator management occurred in 25% of cases. When adjusting for known confounders, respiratory failure or acute respiratory distress syndrome, air transport, and contacting the CCRU attending physicians en route were associated with a higher likelihood of an intervention during transport. CONCLUSION Transport clinicians provided new interventions in 48% of patients being transferred to the CCRU. Patients with respiratory failure or acute respiratory distress syndrome and those transported by helicopter emergency medical services were more likely to receive interventions en route.
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Affiliation(s)
- Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD; Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD; Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD.
| | - Olufisola Famuyiwa
- Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel J Haase
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD; Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Kaitlynn Holland
- The Critical Care Resuscitation Unit, University of Maryland Medical Center, Baltimore, MD
| | - Benjamin Lawner
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD; Maryland ExpressCare Critical Care Transport, University of Maryland Medical Center, Baltimore, MD
| | - Samuel Matta
- John Hopkins Lifeline, John Hopkins Medical Institution, Baltimore, MD
| | - Leigha McGuin
- Maryland ExpressCare Critical Care Transport, University of Maryland Medical Center, Baltimore, MD
| | - Jay Menaker
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Ashley Menne
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD; Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
| | - Edgard E Ngono
- Research Associate Program, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Erin Niles
- The Critical Care Resuscitation Unit, University of Maryland Medical Center, Baltimore, MD
| | - James O'Connor
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Thomas Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Samuel Galvagno
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD
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Emry ME, Settelmeyer DR, McMann LP, Hopkinson SG. Improving the Efficiency of a Military Treatment Facility Transfer Center Process. Mil Med 2020; 185:e995-e1001. [DOI: 10.1093/milmed/usaa097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 03/24/2020] [Accepted: 04/20/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
A performance improvement project was initiated at Tripler Army Medical Center (TAMC) to decrease the amount of inpatient stays by military beneficiaries at civilian hospitals. Before the start of the project, the transfer process from external emergency rooms was completed by patient administration personnel and residents. This process had a median time to disposition decision of 40 minutes and led to missed opportunities for TAMC to care for military beneficiaries. The goals for the project were to have the median transfer process at less than 30 minutes from first call to time of disposition, to minimize unnecessary transfer denials, and to improve the perception of TAMC transfer process.
Materials and Methods
The team implemented multiple countermeasures as a performance improvement project to improve the transfer process. These included enhancing technological capabilities, providing clinically trained personnel to answer initial telephone calls, establishing rapid attending physician contact for acceptance, and standardizing data collection. Descriptive data were used to describe the progress toward project goals to include median time to disposition, number of monthly calls, and reasons for denials of patient transfers.
Results
The project met all proposed goals. The median time to disposition decision was reduced to 22 minutes. The primary reasons for denials included that the transfer was considered medically unnecessary (40.6%), no beds were available (18.9%), and the patient was unstable for transport (14.9%). As a reflection of improved customer service, there was an overall increase in transfer requests and positive feedback from the referring physicians at the local civilian hospitals.
Conclusion
The improved transfer process at TAMC resulted in a decreased median time of transfer request process, increased total transfer requests, and improved relationships with local civilian hospitals. While we acknowledge that each MTF has facility and regional characteristics (such as capability, capacity, military staffing, and degree of availability of civilian healthcare resources) that may contribute to variation from TAMC, the concepts and changes made in the transfer process may be considered a best practice to be adopted by other military facilities to promote the recapture of beneficiaries into the Defense Health Agency system.
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Affiliation(s)
- Marvin E Emry
- Army Recruiting Station, 112 S Del Guzzi Dr suite 1a, Port Angeles, WA 98362
| | | | - Leah P McMann
- Tripler Army Medical Center, 1 Jarrett White Rd, Honolulu, HI 96859
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Jones JM, Vikram HR, Lauzardo M, Hill A, Jones J, Haley C, Seaworth B, Oldham S, Brown M, Gutierrez F, Basavaraju SV. Tuberculosis transmission across three states: The story of a solid organ donor born in an endemic country, 2018. Transpl Infect Dis 2020; 22:e13357. [PMID: 32510808 DOI: 10.1111/tid.13357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 05/11/2020] [Accepted: 05/24/2020] [Indexed: 11/30/2022]
Abstract
Transmission of tuberculosis (TB) from a deceased solid organ donor to recipients can result in severe morbidity and mortality. In 2018, four solid organ transplant recipients residing in three states but sharing a common organ donor were diagnosed with TB disease. Two recipients were hospitalized and none died. The organ donor was born in a country with a high incidence of TB and experienced 8 weeks of headache and fever prior to death, but was not tested for TB during multiple hospitalizations or prior to organ procurement. TB isolates of two organ recipients and a close contact of the donor had identical TB genotypes and closely related whole-genome sequencing results. Donors with risk factors for TB, in particular birth or residence in countries with a higher TB incidence, should be carefully evaluated for TB.
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Affiliation(s)
- Jefferson M Jones
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Michael Lauzardo
- Southeastern National Tuberculosis Center, University of Florida, Gainesville, Florida, USA
| | - Amy Hill
- Oklahoma State Department of Health, Oklahoma City, Oklahoma, USA
| | - Jeffrey Jones
- San Antonio Infectious Diseases Consultants, San Antonio, Texas, USA
| | - Clinton Haley
- North Texas Infectious Diseases Consultants, Dallas, Texas, USA
| | - Barbara Seaworth
- Heartland National Tuberculosis Center, San Antonio, Texas, USA.,University of Texas Health Science Center, Tyler, Texas, USA
| | - Sara Oldham
- St. Mary's Regional Medical Center, Enid, Oklahoma, USA
| | - Marcus Brown
- St. Mary's Regional Medical Center, Enid, Oklahoma, USA
| | - Felipe Gutierrez
- Maricopa County Department of Public Health, Phoenix VA Health Care System, University of Arizona College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Sridhar V Basavaraju
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Mueller S, Murray M, Schnipper J, Goralnick E. An initiative to improve advanced notification of inter-hospital transfers. Healthc (Amst) 2020; 8:100423. [PMID: 32199862 PMCID: PMC11094626 DOI: 10.1016/j.hjdsi.2020.100423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 02/14/2020] [Accepted: 03/05/2020] [Indexed: 11/28/2022]
Abstract
Poor communication during inter-hospital transfer (IHT, the transfer of patients between acute care hospitals) is common. Clinicians often report feeling unprepared to care for IHT patients due to inadequate advance notification. The aim of this project was to improve advance notification of general medicine service patient transfers to a tertiary care referral hospital. We used quality improvement principles to design and implement two interventions: (1) Use of a checklist; (2) Redesign role/responsibilities within the Access Center and Bed Control Department. Data on frequency of advance notification was collected over 9 months and plotted on a statistical process control chart with evaluation for special cause variation. We also evaluated barriers/facilitators to implementation and surveyed clinicians on information received with the advance notification. 103 patients underwent IHT during the study. Frequency of advance notification increased from a baseline of 63.6%-85.4% post-intervention. Several contributors to successful implementation were identified, including ensuring key stakeholder input and leveraging existing systems structure, among others. Survey results highlighted potential targets for future IHT improvements such as improved clinical information available to admitting clinicians in advance of patient transfer. In conclusion, we successfully improved advance notification of IHT, an essential step to improve communication. Next steps include sustainment and automation of these efforts and ongoing targeted process improvement efforts with an ultimate goal of improving patient outcomes during IHT.
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Affiliation(s)
- Stephanie Mueller
- Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | | | - Jeffrey Schnipper
- Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Eric Goralnick
- Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Heincelman M, Gebregziabher M, Kirkland E, Schumann SO, Schreiner A, Warr P, Zhang J, Mauldin PD, Moran WP, Rockey DC. Impact of Patient-Level Characteristics on In-hospital Mortality After Interhospital Transfer to Medicine Services: an Observational Study. J Gen Intern Med 2020; 35:1127-1134. [PMID: 31965521 PMCID: PMC7174524 DOI: 10.1007/s11606-020-05659-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 12/30/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND National administrative datasets have demonstrated increased risk-adjusted mortality among patients undergoing interhospital transfer (IHT) compared to patients admitted through the emergency department (ED). OBJECTIVE To investigate the impact of patient-level data not available in larger administrative datasets on the association between IHT status and in-hospital mortality. DESIGN Retrospective cohort study with logistic regression analyses to examine the association between IHT status and in-hospital mortality, controlling for covariates that were potential confounders. Model 1: IHT status, admit service. Model 2: model 1 and patient demographics. Model 3: model 2 and disease-specific conditions. Model 4: model 3 and vital signs and laboratory data. PARTICIPANTS Nine thousand three hundred twenty-eight adults admitted to Medicine services. MAIN MEASURES Interhospital transfer status, coded as an unordered categorical variable (IHT vs ED vs clinic), was the independent variable. The primary outcome was in-hospital mortality. Secondary outcomes included unadjusted length of stay and total cost. KEY RESULTS IHT patients accounted for 180 out of 484 (37%) in-hospital deaths, despite accounting for only 17% of total admissions. Unadjusted mean length of stay was 8.4 days vs 5.6 days (p < 0.0001) and mean total cost was $22,647 vs $12,968 (p < 0.0001) for patients admitted via IHT vs ED respectively. The odds ratios (OR) for in-hospital mortality for patients admitted via IHT compared to the ED were as follows: model 1 OR, 2.06 (95% CI 1.66-2.56, p < 0.0001); model 2 OR, 2.07 (95% CI 1.66-2.58, p < 0.0001); model 3 OR, 2.07 (95% CI 1.63-2.61, p < 0.0001); model 4 OR, 1.70 (95% CI 1.31-2.19, p < 0.0001). The AUCs of the models were as follows: model 1, 0.74; model 2, 0.76; model 3, 0.83; model 4, 0.88, consistent with a good prediction model. CONCLUSIONS Patient-level characteristics affect the association between IHT and in-hospital mortality. After adjusting for patient-level clinical characteristics, IHT status remains associated with in-hospital mortality.
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Affiliation(s)
- Marc Heincelman
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA.
| | - Mulugeta Gebregziabher
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Elizabeth Kirkland
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Samuel O Schumann
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Andrew Schreiner
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Phillip Warr
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Jingwen Zhang
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Patrick D Mauldin
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - William P Moran
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
| | - Don C Rockey
- Department of Medicine, Medical University of South Carolina, 135 Rutledge Avenue, Rm 1240, Charleston, SC, 29425, USA
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Knight SW, Trinkle J, Tschannen D. Hospital-to-Homecare Videoconference Handoff: Improved Communication, Coordination of Care, and Patient/Family Engagement. Home Healthc Now 2019; 37:198-207. [PMID: 31274582 DOI: 10.1097/NHH.0000000000000755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Transitions of care between settings and clinicians are a time of vulnerability for patients, and can result in fragmented care, medication errors, avoidable readmissions, and patient/nurse dissatisfaction. Through the use of technology and a structured face-to-face handoff, the patient and family can be engaged in the transition across settings. The purpose of this project was to determine the feasibility and effectiveness of videoconference handoffs between inpatient, case management, and home care nurses, and the patients/families during transitions of care from hospital to home care. Videoconferences were conducted for 2 months with patients transitioning from two pediatric inpatient units to the hospital-based home care agency. The nurses and patient/family connected through a secure cloud-based videoconferencing platform. Participants discussed the patient's status, safety concerns, ongoing plan of care, what the patient/family could expect at home, and the coordination of equipment/supply needs and postdischarge visits. Videoconference handoffs (n = 10) were found to be feasible and address gaps in communication, coordination of care, and patient/family engagement during transitions from hospital to home care. Postpilot, nurses agreed the videoconference handoffs should continue with minimal modifications.
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Raeisi A, Rarani MA, Soltani F. Challenges of patient handover process in healthcare services: A systematic review. J Educ Health Promot 2019; 8:173. [PMID: 31867358 PMCID: PMC6796291 DOI: 10.4103/jehp.jehp_460_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 03/20/2019] [Indexed: 06/02/2023]
Abstract
BACKGROUND The patient handover process is in fact a valuable and essential part of the care processes in the hospitals. This can be a factor in increasing the quality and effectiveness of medical care. Incorrect and incomplete handover can increase the percentage of errors and cause serious problems for patients. The aim of this study was to identify the handover challenges concerning safety and quality of health services. MATERIALS AND METHODS A systematic review was conducted according to the Preferred Reporting Item for Systematic Reviews and Meta-analyses guideline. The key words "challenges of patient handover" or "challenges of patient handoff" were used in combination with the Boolean operators OR and AND. The ProQuest, Ovid, Doaj, Magiran, SID, Scopus, Science Direct, PubMed, and ISI were searched. RESULTS A total of 263 articles were extracted, and 20 articles were selected for final review. The results of selected articles indicated that there are various challenges such as communication, noncoordination, nonuse of checklist, poor management, time management, and other things. These studies reported that communication was the main challenge of handover process. CONCLUSIONS Hospitals try to provide a lot of services to the patients and other customers in a safe and healthy environment. Lack of communication among the incoming and outgoing nurses in handover process is one of the main causes of reduced safety and quality of services and patient dissatisfaction.
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Affiliation(s)
- Ahmadreza Raeisi
- Department of Health Services Management, School of Management and Medical Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mostafa Amini Rarani
- Department of Health Services Management, School of Management and Medical Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemeh Soltani
- Department of Health Services Management, School of Management and Medical Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
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Nadig NR, Sterba KR, Johnson EE, Goodwin AJ, Ford DW. Inter-ICU transfer of patients with ventilator dependent respiratory failure: Qualitative analysis of family and physician perspectives. Patient Educ Couns 2019; 102:1703-1710. [PMID: 30979579 DOI: 10.1016/j.pec.2019.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 04/01/2019] [Accepted: 04/04/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Ventilator dependent respiratory failure (VDRF) patients are seriously ill and often transferred between ICUs. Our objective was to obtain multi-stakeholder insights into the experiences of families during inter-ICU transfer. METHODS We conducted a qualitative study using semi-structured interviews with family members of VDRF patients as well as clinicians that have received or transferred VDRF patients to our hospital. Interviews were transcribed and template analysis was used to identify themes within/across stakeholder groups. RESULTS Patient, family, clinician and systems-level factors were identified as key themes during inter-ICU transfer. The main findings highlight that family members were rarely engaged in the decision to transfer as well as a lack of standardized communication between clinicians during care transitions. Family members were reassured with the care after transfer in spite of practical and financial challenges. Clinicians acknowledged the lack of a systematic approach for meeting the needs of families and suggested various resources. CONCLUSIONS This is one of the first qualitative studies to gather a multi-stakeholder perspective and identify problems faced by families during inter-ICU transfer of VDRF patients. PRACTICE IMPLICATIONS Our results provide a starting point for the development of family-centered support interventions which will need to be tested in future studies.
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Affiliation(s)
- Nandita R Nadig
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, 96 Jonathan Lucas Dr., Suite 816 CSB, Charleston, SC, 29425, USA.
| | - Katherine R Sterba
- Department of Public Health Sciences, Medical University of South Carolina, 135 Cannon Street, Suite 303 MSC 835, Charleston, SC, 29425, USA.
| | - Emily E Johnson
- College of Nursing, Medical University of South Carolina, 99 Jonathan Lucas Street, Charleston, SC, 29425, USA.
| | - Andrew J Goodwin
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, 96 Jonathan Lucas Dr., Suite 816 CSB, Charleston, SC, 29425, USA.
| | - Dee W Ford
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, 96 Jonathan Lucas Dr., Suite 816 CSB, Charleston, SC, 29425, USA.
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Bertrand J, Fehlmann C, Grosgurin O, Sarasin F, Kherad O. Inappropriateness of Repeated Laboratory and Radiological Tests for Transferred Emergency Department Patients. J Clin Med 2019; 8:E1342. [PMID: 31470615 DOI: 10.3390/jcm8091342] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/22/2019] [Accepted: 08/27/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Laboratory and radiographic tests are often repeated during inter-hospital transfers from secondary to tertiary emergency departments (ED), despite available data from the sending structure. The aim of this study was to identify the proportion of repeated tests in patients transferred to a tertiary care ED, and to estimate their inappropriateness and their costs. Methods: A retrospective chart review of all adult patients transferred from one secondary care ED to a tertiary care ED during the year 2016 was carried out. The primary outcome was the redundancy (proportion of procedure repeated in the 8 h following the transfer, despite the availability of the previous results). Factors predicting the repetition of procedures were identified through a logistic regression analysis. Two authors independently assessed inappropriateness. Results: In 2016, 432 patients were transferred from the secondary to the tertiary ED, and 251 procedures were repeated: 179 patients (77.2%) had a repeated laboratory test, 34 (14.7%) a repeated radiological procedure and 19 (8.2%) both. Repeated procedures were judged as inappropriate for 197 (99.5%) laboratory tests and for 39 (73.6%) radiological procedures. Conclusion: Over half of the patients transferred from another emergency department had a repeated procedure. In most cases, these repeated procedures were considered inappropriate.
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Hall JA, Khan SH, Shaver C, Pye K, Salejee I, Delmas T, Giri B, White HD, Mirkes C. Sepsis as the primary admitting diagnosis of transferred patients who died within 48 hours of arrival at a Central Texas hospital. Proc (Bayl Univ Med Cent) 2019; 32:481-484. [PMID: 31656401 DOI: 10.1080/08998280.2019.1642062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/04/2019] [Accepted: 07/08/2019] [Indexed: 10/26/2022] Open
Abstract
Interhospital transfers are independently associated with inpatient mortality, and transferred patients have worse outcomes. The aim of this study was to retrospectively assess the 48-hour mortality rate in interhospital transfer cohorts of all transfers to a Central Texas teaching hospital and to identify a primary admitting diagnosis for potential intervention. A total of 15,435 patients with 19,161 transfers over the course of the study were retrospectively reviewed and placed in 18 different categories based upon the primary admitting diagnosis. There were about 5000 transfer patients yearly with ∼1.4% deaths within 48 hours of arrival. The three leading categories for transferred patients were cardiovascular, neurologic, and psychiatric. In this group, 268 of 19,161 transfers died within 48 hours of arrival. Despite being the 10th leading category for transfer, sepsis was the leading primary admitting diagnosis of patients who died within 48 hours of arrival, accounting for nearly 22% of those patients. Given the significant association found between sepsis and 48-hour mortality after transfer, we devised a novel interhospital transfer checklist based upon the Surviving Sepsis guidelines in an attempt to decrease mortality associated with these transfers.
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Affiliation(s)
- James A Hall
- Department of Internal Medicine, Baylor Scott & White Medical Center and Texas A&M Health Science Center College of MedicineTempleTexas
| | - Shamyal H Khan
- Department of Internal Medicine, Baylor Scott & White Medical Center and Texas A&M Health Science Center College of MedicineTempleTexas
| | - Courtney Shaver
- Internal Medicine, Section of Pulmonary, Critical Care, Sleep and Environmental Medicine, Baylor Scott & White Research InstituteTempleTexas
| | - Kendall Pye
- Internal Medicine, Section of Pulmonary, Critical Care, Sleep and Environmental Medicine, Baylor Scott & White Research InstituteTempleTexas
| | - Ismail Salejee
- Department of Internal Medicine, Baylor Scott & White Medical Center and Texas A&M Health Science Center College of MedicineTempleTexas
| | - Thomas Delmas
- Department of Pulmonology and Critical Care Medicine, Baylor Scott & White Medical Center and Texas A&M Health Science Center College of MedicineTempleTexas
| | - Badri Giri
- Virginia Tech Carilion School of Medicine, Roanoke Memorial HospitalRoanokeVirginia
| | - Heath D White
- Department of Pulmonology and Critical Care Medicine, Baylor Scott & White Medical Center and Texas A&M Health Science Center College of MedicineTempleTexas
| | - Curtis Mirkes
- Department of Internal Medicine, Baylor Scott & White Medical Center and Texas A&M Health Science Center College of MedicineTempleTexas
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Son YJ, Lee SK, Nam S, Shim JL. Exploring Research Topics and Trends in Nursing-related Communication in Intensive Care Units Using Social Network Analysis. Comput Inform Nurs 2018; 36:383-392. [PMID: 29742551 DOI: 10.1097/cin.0000000000000444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study used social network analysis to identify the main research topics and trends in nursing-related communication in intensive care units. Keywords from January 1967 to June 2016 were extracted from PubMed using Medical Subject Headings terms. Social network analysis was performed using Gephi software. Research publications and newly emerging topics in nursing-related communication in intensive care units were classified into five chronological phases. After the weighting was adjusted, the top five keyword searches were "conflict," "length of stay," "nursing continuing education," "family," and "nurses." During the most recent phase, research topics included "critical care nursing," "patient handoff," and "quality improvement." The keywords of the top three groups among the 10 groups identified were related to "neonatal nursing and practice guideline," "infant or pediatric and terminal care," and "family, aged, and nurse-patient relations," respectively. This study can promote a systematic understanding of communication in intensive care units by identifying topic networks. Future studies are needed to conduct large prospective cohort studies and randomized controlled trials to verify the effects of patient-centered communication in intensive care units on patient outcomes, such as length of hospital stay and mortality.
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Affiliation(s)
- Youn-Jung Son
- Author Affiliations: Red Cross College of Nursing, Chung-Ang University (Dr Son), Seoul; College of Nursing, Keimyung University (Dr Lee), Daegu; National Center of Excellence in Software, Chungnam National University (Dr Nam), Daejeon; and Department of Nursing, College of Medicine, Dongguk University (Dr Shim), Gyeongju-si, Gyeongsangbuk-do, Republic of Korea
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Usher M, Sahni N, Herrigel D, Simon G, Melton GB, Joseph A, Olson A. Diagnostic Discordance, Health Information Exchange, and Inter-Hospital Transfer Outcomes: a Population Study. J Gen Intern Med 2018; 33:1447-1453. [PMID: 29845466 PMCID: PMC6109004 DOI: 10.1007/s11606-018-4491-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 12/01/2017] [Accepted: 04/27/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Studying diagnostic error at the population level requires an understanding of how diagnoses change over time. OBJECTIVE To use inter-hospital transfers to examine the frequency and impact of changes in diagnosis on patient risk, and whether health information exchange can improve patient safety by enhancing diagnostic accuracy. DESIGN Diagnosis coding before and after hospital transfer was merged with responses from the American Hospital Association Annual Survey for a cohort of patients transferred between hospitals to identify predictors of mortality. PARTICIPANTS Patients (180,337) 18 years or older transferred between 473 acute care hospitals from NY, FL, IA, UT, and VT from 2011 to 2013. MAIN MEASURES We identified discordant Elixhauser comorbidities before and after transfer to determine the frequency and developed a weighted score of diagnostic discordance to predict mortality. This was included in a multivariate model with inpatient mortality as the dependent variable. We investigated whether health information exchange (HIE) functionality adoption as reported by hospitals improved diagnostic discordance and inpatient mortality. KEY RESULTS Discordance in diagnoses occurred in 85.5% of all patients. Seventy-three percent of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11 95% CI 1.10-1.11, p < 0.001) and allowed for improved mortality prediction. Bilateral hospital HIE participation was associated with reduced diagnostic discordance index (3.69 vs. 1.87%, p < 0.001) and decreased inpatient mortality (OR 0.88, 95% CI 0.89-0.99, p < 0.001). CONCLUSIONS Diagnostic discordance commonly occurred during inter-hospital transfers and was associated with increased inpatient mortality. Health information exchange adoption was associated with decreased discordance and improved patient outcomes.
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Affiliation(s)
- Michael Usher
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Nishant Sahni
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Dana Herrigel
- Department of Hospital Internal Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Gyorgy Simon
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
- Institute for Health Informatics, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Genevieve B Melton
- Institute for Health Informatics, University of Minnesota Medical School, Minneapolis, MN, USA
- Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Anne Joseph
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Andrew Olson
- Division of General Internal Medicine, Department of Medicine, and Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA
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Wee CE, Goodman LM, Varella L, Rybicki LA, Montero AJ, Estfan BN, Best CH, Stevenson JP. Analysis of Origins of Admission for Solid Tumor Oncology Inpatients: Disease Severity and Outcomes. J Oncol Pract 2017. [PMID: 28636421 DOI: 10.1200/jop.2016.016543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Hospital transfers may affect clinical outcomes. Evaluation of admission by source of transfer, time of admission, and provider type may identify opportunities to improve inpatient outcomes. METHODS We reviewed charts of patients admitted to the solid tumor oncology service between July and December 2014 from the Cleveland Clinic Foundation (CCF) Main Campus emergency department (ED), CCF Regional EDs, outside hospital (OSH) ED, OSH inpatient services, and CCF outpatient clinics. Data collected included time of admission, mortality and severity risk scores, and provider type. Risk factors were assessed for clinical outcomes, including activations of the Adult Medical Emergency Team, intensive care unit transfers, in-hospital mortality, and length of stay (LOS). RESULTS Five hundred admissions were included. OSH inpatient transfers had significantly higher disease severity compared with all other origins of admission. OSH inpatient transfers demonstrated significantly longer LOS compared with all other origins of admission, and higher mortality rates compared with the outpatient direct admits and CCF Main Campus ED admits. After adjusting for disease severity and risk of mortality, OSH ED patients remained at higher risk for Adult Medical Emergency Team activation, OSH inpatient transfers had the longest LOS, and CCF Main Campus ED patients had the lowest risk of mortality. Time of admission and provider type were not associated with any of the outcomes. CONCLUSION Oncology inpatients transferred from an outside health care facility are at higher risk for adverse outcomes. The magnitude of difference is lessened, but still significant, after adjustment for disease severity and risk of mortality.
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Abstract
IMPORTANCE Interhospital transfer (IHT) remains a largely unstudied process of care. OBJECTIVE To determine the nationwide frequency of, patient and hospital-level predictors of, and hospital variability in IHT. DESIGN Cross-sectional study. SETTING Centers for Medicare and Medicaid 2013 100% Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data. PATIENTS Beneficiaries ≥65 years and older enrolled in Medicare A and B, with an acute care hospitalization claim in 2013. EXPOSURES Patient and hospital characteristics of transferred and nontransferred patients. MEASUREMENTS Frequency of interhospital transfers (IHT); adjusted odds of transfer of each patient and each hospital characteristic; and variability in hospital transfer rates. RESULTS Of 6.6 million eligible beneficiaries with an acute care hospitalization, 101,507 (1.5%) underwent IHT. Selected characteristics associated with greater adjusted odds of transfer included: patient age 74-85 years (odds ratio [OR], 2.38 compared with 65-74 years; 95% confidence intervals [CI], 2.33-2.43); nonblack race (OR, 1.17; 95% CI, 1.13-1.20); higher comorbidity (OR, 1.37; 95% CI, 1.36-1.37); lower diagnosis-related group-weight (OR, 2.02; 95% CI, 1.95-2.09); fewer recent hospitalizations (OR, 1.87; 95% CI, 1.79-1.95); and hospitalization in the Northeast (OR, 1.40; 95% CI, 1.27-1.55). Higher case mix index of the hospital was associated with a lower adjusted odds of transfer (OR, 0.36; 95% CI, 0.30-0.45). Variability in hospital transfer rates remained significant after adjustment for patient and hospital characteristics (variance 0.28, P = 0.01). CONCLUSIONS In this nationally representative evaluation, we found that a sizable number of patients undergo IHT. We identified both expected and unexpected patient and hospital-level predictors of IHT, as well as unexplained variability in hospital transfer rates, suggesting lack of standardization of this complex care transition. Our study highlights further investigative avenues to help guide best practices in IHT. Journal of Hospital Medicine 2017;12:435-442.
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Affiliation(s)
- Stephanie K. Mueller
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jie Zheng
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - E. John Orav
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jeffrey L. Schnipper
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Abstract
BACKGROUND Poor communication causes fragmented care. Studies of transitions of care within a hospital and on discharge suggest significant communication deficits. Communication during transfers between hospitals has not been well studied. We assessed the written communication provided during interhospital transfers of emergency general surgery patients. We hypothesized that patients are transferred with incomplete documentation from referring facilities. METHODS We performed a retrospective review of written communication provided during interhospital transfers to our emergency department (ED) from referring EDs for emergency general surgical evaluation between January 1, 2014 and January 1, 2016. Elements of written communication were abstracted from referring facility documents scanned into the medical record using a standardized abstraction protocol. Descriptive statistics summarized the information communicated. RESULTS A total of 129 patients met inclusion criteria. 87.6% (n = 113) of charts contained referring hospital documents. 42.5% (n = 48) were missing history and physicals. Diagnoses were missing in 9.7% (n = 11). Ninety-one computed tomography scans were performed; among 70 with reads, final reads were absent for 70.0% (n = 49). 45 ultrasounds and x-rays were performed; among 27 with reads, final reads were missing for 80.0% (n = 36). Reasons for transfer were missing in 18.6% (n = 21). Referring hospital physicians outside the ED were consulted in 32.7% (n = 37); consultants' notes were absent in 89.2% (n = 33). In 12.4% (n = 14), referring documents arrived after the patient's ED arrival and were not part of the original documentation provided. CONCLUSIONS This study documents that information important to patient care is often missing in the written communication provided during interhospital transfers. This gap affords a foundation for standardizing provider communication during interhospital transfers.
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Affiliation(s)
- Felicity N R Harl
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Megan C Saucke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Caprice C Greenberg
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Angela M Ingraham
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
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Abstract
BACKGROUND Interhospital transfer is frequent, and transferred patients experience delays in the provision of care and higher mortality rates when compared to patients directly admitted. The interhospital handover is a key opportunity to improve care but has not been evaluated. OBJECTIVE To determine the effect of a universal handover tool on timeliness of care, length of stay (LOS), and mortality among interhospital transfer patients. DESIGN, SETTING, AND PATIENTS Retrospective cohort of patients transferred to an academic medical center between July 1, 2009 and December 31, 2010 with interrupted time-series design. INTERVENTION One-page handover tool containing information critical for immediate patient care instituted hospital-wide on July 1, 2010. The handover tool was completed by the transferring physician and available for review before patient arrival. MEASUREMENTS Time-to-admission order entry, LOS after transfer, in-hospital mortality. RESULTS There was no significant change in the time-to-admission order entry after implementation (47 minutes vs. 45 minutes, adjusted P = 0.94). There was a nonstatistically significant reduction in LOS after implementation (6.5 days vs. 5.8 days, adjusted P = 0.06). In-hospital mortality for transfer patients declined significantly in the postintervention period from 12.0% to 8.9% (adjusted odds ratio, 0.68; 95% confidence interval, 0.47 - 0.99, P = 0.04). There was no change in mortality for the concurrent control group. CONCLUSION Implementation of a standardized handover tool for interhospital transfer was feasible and may be associated with significant reductions in length of stay and mortality. Widespread adoption of similar tools may improve outcomes in this high-risk population. Journal of Hospital Medicine 2017;12:23-28.
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Affiliation(s)
- Cecelia N Theobald
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Neesha N Choma
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jesse M Ehrenfeld
- Departments of Anesthesiology, Surgery, Biomedical Informatics, and Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephan Russ
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sunil Kripalani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, TN, USA
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Usher MG, Fanning C, Wu D, Muglia C, Balonze K, Kim D, Parikh A, Herrigel D. Information handoff and outcomes of critically ill patients transferred between hospitals. J Crit Care 2016; 36:240-245. [PMID: 27591388 DOI: 10.1016/j.jcrc.2016.08.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 08/02/2016] [Accepted: 08/05/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE Patients transferred between hospitals are at high risk of adverse events and mortality. This study aims to identify which components of the transfer handoff process are important predictors of adverse events and mortality. MATERIALS AND METHODS We conducted a retrospective, observational study of 335 consecutive patient transfers to 3 intensive care units at an academic tertiary referral center. We assessed the relationship between handoff documentation completeness and patient outcomes. The primary outcome was in-hospital mortality. Secondary outcomes included adverse events, duplication of labor, disposition error, and length of stay. RESULTS Transfer documentation was frequently absent with overall completeness of 58.3%. Adverse events occurred in 42% of patients within 24 hours of arrival, with an overall in-hospital mortality of 17.3%. Higher documentation completeness was associated with reduced in-hospital mortality (odds ratio [OR], 0.07; 95% confidence interval [CI], 0.02 to 0.38; P = .002), reduced adverse events (coefficient, -2.08; 95% CI, -2.76 to -1.390; P < .001), and reduced duplication of labor (OR, 0.19; 95% CI, 0.04 to 0.88; P = .033) when controlling for severity of illness. CONCLUSIONS Documentation completeness is associated with improved outcomes and resource utilization in patients transferred between hospitals.
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Affiliation(s)
- Michael G Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota Medical School, Minneapolis, MN 55455.
| | - Christine Fanning
- Department of Medicine, Division of General Internal Medicine, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ 08901
| | - Di Wu
- Department of Medicine, Division of General Internal Medicine, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ 08901
| | - Christine Muglia
- Department of Medicine, Division of General Internal Medicine, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ 08901
| | - Karen Balonze
- Department of Medicine, Division of General Internal Medicine, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ 08901
| | - Deborah Kim
- Department of Medicine, Division of Pulmonary and Critical Care, Boston University School of Medicine, Boston, MA 02118
| | - Amay Parikh
- Department of Medicine, Divisions of Nephrology and Critical Care, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ 08901
| | - Dana Herrigel
- Department of Medicine, Division of General Internal Medicine, Rutgers, Robert Wood Johnson Medical School, New Brunswick, NJ 08901
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