A Qualitative Study of Risks Related to Interhospital Transfer of Patients with Nontraumatic Intracranial Hemorrhage.

GOAL: Interhospital transfer (IHT) facilitates access to specialized neurocritical care but may also introduce unique risk. Our goal was to describe providers' perceptions of safety threats during IHT for patients with nontraumatic intracranial hemorrhage. MATERIALS AND METHODS: We employed qualitative, semi-structured interviews at an academic medical center receiving critically-ill neurologic transfers, and 5 referring hospitals. Interviewees included physicians, nurses, and allied health professionals with experience caring for patients transferred between hospitals for nontraumatic intracranial hemorrhage. Interviews continued until data saturation was reached. Coding occurred concurrently with interviews. Analysis was inductive, using the constant comparative method. FINDINGS: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. Insufficient communication highlights the unique communication challenges specific to IHT, which overlay and compound known intrahospital communication barriers. Gaps in clinical practice revolve primarily around the provision of neurocritical care for this patient population, often subject to resource availability, by receiving hospital emergency medicine providers. Lack of structure outlines providers' questions that emerge when institutions fail to identify process channels, expectations, and accountability during complex neurocritical care transitions. CONCLUSIONS: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. These themes serve as fundamental targets for quality improvement initiatives. To our knowledge, this is the first description of challenges to quality and safety in high-risk neurocritical care transitions through clinicians' voices.

A taxonomy and cultural analysis of intra-hospital patient transfers.

Existing research on intra-hospital patient transitions focuses chiefly on handoffs, or exchanges of information, between clinicians. Less is known about patient transfers within hospitals, which include but extend beyond the exchange of information. Using participant observations and interviews at a 1,541-bed, academic, tertiary medical center, we explored the ways in which staff define and understand patient transfers between units. We conducted observations of staff (n = 16) working in four hospital departments and interviewed staff (n = 29) involved in transfers to general medicine floors from either the Emergency Department or the Medical Intensive Care Unit between February and September 2015. The collected data allowed us to understand transfers in the context of several hospital cultural microsystems. Decisions were made through the lens of the specific unit identity to which staff felt they belonged; staff actively strategized to manage workload; and empty beds were treated as a scarce commodity. Staff concepts informed the development of a taxonomy of intra-hospital transfers that includes five categories of activity: disposition, or determining the right floor and bed for the patient; notification to sending and receiving staff of patient assignment, departure and arrival; preparation to send and receive the patient; communication between sending and receiving units; and coordination to ensure that transfer components occur in a timely and seamless manner. This taxonomy widens the study of intra-hospital patient transfers from a communication activity to a complex cultural phenomenon with several categories of activity and views them as part of multidimensional hospital culture, as constructed and understood by staff.

Towards Reducing Health Information Inequities in the Caribbean: The Eastern Caribbean Health Outcomes Research Network Data Sharing Platform Usability Study.

There is a dearth of health research among Caribbean populations. Underrepresented individuals are affected by structural and data inequities that limit the usefulness, availability, and accessibility to health information systems and research-generated data. To overcome this limitation, a data sharing platform was created for the Eastern Caribbean Health Outcomes Research Network Cohort Study. This study aimed to evaluate the usability of the platform. Usability testing was conducted remotely, via video conferencing, using a cognitive walkthrough and think-aloud protocol. Participants completed a self-administered web-based survey which included an adapted version of the System Usability Scale (SUS). The results showed (N=16) overall average SUS score was 73.1 (SD±21.0), translating to a 'good' usability rating. Most recommendations for improvement focused on navigation and error prevention. Participatory data sharing platforms have the potential to reduce health information inequities in the Caribbean, however, usability testing should be conducted to improve user satisfaction and increase engagement.

Mapping the care transition from hospital to skilled nursing facility.

PURPOSE: Care transitions between hospitals and skilled nursing facilities (SNFs) are often associated with breakdowns in communication that may place patients at risk for adverse events. Less is known about how to address these issues in the context of busy patient care settings. We used process mapping to examine hospital discharge and SNF admission processes to identify opportunities for improvement. METHODS: A quality improvement (QI) team worked with frontline staff to create a process map illustrating the sequence of events involved with hospital discharge and SNF admission. The project was completed at an academic medical centre and two local SNFs in the north-eastern United States. Participants represented the care management, medicine, nursing, admissions, and physical therapy services. The data informed hospital QI interventions seeking to improve the quality and safety of hospital-SNF transfers and reduce unplanned hospital readmissions. RESULTS: The final process map highlighted numerous activities that need to be coordinated between care teams, including the time-sensitive exchange of clinical and administrative information. Participants shared insights about how care teams reach critical decisions about patient disposition and post-acute care utilization. CONCLUSIONS: Process mapping highlighted specific opportunities for improving communication between care teams. Participants advocated for earlier assessments of patients' functional status and support systems, including reliable at-home services. They also reasoned that improved communication would help patients and providers reach decisions together, coordinate work efforts, and better prepare for hospital discharge and SNF admission. This information can be used to improve patient care transitions between hospitals and SNFs.

Cooperation and conflict in intra-hospital transfers: A qualitative analysis.

Aim: The purpose of this study was to explore the latent conditions of cooperation and conflict in intra-hospital patient transfers (i.e. transfers of patients between units in a hospital). Design: Secondary qualitative analysis of 28 interviews conducted with 29 hospital staff, including physicians (N = 13), nurses (N = 10) and support staff (N = 6) from a single, large academic tertiary hospital in the Northeastern United States. Methods: A two-member multidisciplinary team applied a directed content analysis approach to data collected from semi-structured interviews. Results: Three recurrent themes were generated: (a) patient flow policies created imbalances of power; (b) relationships were helpful to facilitate safe transfers; and (c) method of admission order communication was a source of disagreement. Hospital quality improvement efforts could benefit from a teaming approach to minimize unintentional power imbalances and optimize communicative relationships between units.

Implementing a Warm Handoff Between Hospital and Skilled Nursing Facility Clinicians.

OBJECTIVES: Care transitions between hospitals and skilled nursing facilities (SNFs) are associated with disruptions in patient care and high risk for adverse events. Communication between hospital-based and SNF-based clinicians is often suboptimal; there have been calls to foster direct, real-time communication between sending and receiving clinicians to enhance patient safety. This article described the implementation of a warm handoff between hospital and SNF physicians and advanced practice providers at the time of hospital discharge. METHODS: Before patient transfer, hospital clinicians called SNF clinicians to provide information relevant to the continuation of safe patient care and offer SNF clinicians the opportunity to ask clarifying questions. The calls were documented in the hospital discharge summary. RESULTS: A total of 2417 patient discharges were eligible for inclusion. Warm handoffs were documented at an increasing rate throughout implementation of the intervention, beginning with 15.78% (n = 3) in stage 1, then 20.27% (n = 75) in stage 2, and finally 46.89% (n = 951) in stage 3. The overall average rate of documentation was 42.57%. Participant feedback indicated that clinicians were most concerned about understanding the purpose of the warm handoff, managing their workload, and improving the efficiency of the process. CONCLUSIONS: Use of a warm handoff showed promise in improving communication during hospital-SNF patient transfers. However, the implementation also highlighted specific barriers to the handoff related to organizational structures and clinician workload. Addressing these underlying issues will be critical in ensuring continued participation and support for efforts that foster direct communication among clinicians from different healthcare institutions.