Handoffs: Transitions of Care for Children in the Emergency Department

Transitions of care (ToCs), also referred to as handoffs or sign-outs, occur when the responsibility for a patient's care transfers from 1 health care provider to another. Transitions are common in the acute care setting and have been noted to be vulnerable events with opportunities for error. Health care is taking ideas from other high-risk industries, such as aerospace and nuclear power, to create models of structured transition processes. Although little literature currently exists to establish 1 model as superior, multiorganizational consensus groups agree that standardization is warranted and that additional work is needed to establish characteristics of ToCs that are associated with clinical or practice outcomes. The rationale for structuring ToCs, specifically those related to the care of children in the emergency setting, and a description of identified strategies are presented, along with resources for educating health care providers on ToCs. Recommendations for development, education, and implementation of transition models are included.

[Neonatal transport characteristics]

Neonatal transport is necessary where a neonate is transferred between two care units. It provides all the skills of a dedicated team, representing a real mobile neonatal intensive care unit. Informing and involving the families is essential during this transport, which can be a source of stress for the child and its family.

Buprenorphine Initiation and Linkage to Outpatient Buprenorphine do not Reduce Frequency of Injection Opiate Use Following Hospitalization

BACKGROUND

Buprenorphine has established effectiveness for outpatient treatment of opioid use disorder. Our previously published STOP (Suboxone Transition to Opiate Program) trial showed that buprenorphine induction, stabilization, and linkage to outpatient treatment in opioid-dependent inpatients (injection and non-injection drug users) decreased illicit opioid use over 6months. The present study was a planned subgroup analysis of injection opiate users from STOP.

OBJECTIVE

To determine if inpatient buprenorphine initiation and linkage to outpatient buprenorphine reduce injection opiate users' frequency of injection opiate use (IOU).

METHODS

Inpatient injection opiate users at a safety-net hospital were randomized to buprenorphine linkage (induction, stabilization, bridge prescription, and facilitated referral to outpatient treatment) or detoxification (5-day inpatient buprenorphine taper). Conditional fixed-effects Poisson regression was used to estimate the effects of intervention on 30-day (self-report) at 1, 3, and 6months, measured using 30-day timeline follow-back. The secondary outcome was linkage effectiveness, measured as % presenting to initial outpatient buprenorphine visits after hospital discharge.

RESULTS

Analysis was limited to persons (n=62 randomized to detoxification and n=51 to linkage) with baseline IOU. There were no significant differences in age, ethnicity, or baseline IOU frequency. At follow-up, linkage patients (70.6%) were significantly more likely (p<0.001) to present to initial buprenorphine visits than detoxification patients (9.7%). However, there was no significant between group difference in the rate of IOU at 1- (IRR=0.73, p=0.32), 3- (IRR=1.20, p=0.54), or 6-month (IRR=0.73, p=0.23) follow-ups. Using person-day analysis, participants self-reported IOU on 5.8% of follow-up days in which they used prescription buprenorphine and 37.5% of non-buprenorphine days. Using a generalized estimating equation, the estimated odds of IOU was 4.57 times higher (p<0.001) on non-buprenorphine days.

CONCLUSIONS

Despite STOP's success in linking patients who inject opiates to outpatient buprenorphine, the intervention did not significantly decrease their IOU frequency. Injection opiate users will require a more intensive protocol to sustain outpatient buprenorphine treatment and decrease injection with its attendant risks.

Experience with technology-supported transitions of care to improve medication use

OBJECTIVE

To describe an innovative community pharmacy-based pilot program using technology to support transitions of care for patients living in rural areas.

SETTING

This service occurred through a partnership between 1 independent community pharmacy organization with 5 locations in Ohio and Indiana and one 92-bed general medical and surgical county hospital during May 2014 to May 2015.

PRACTICE DESCRIPTION AND INNOVATION

Community pharmacists worked with patients immediately following discharge to reconcile their medications and make recommendations to optimize therapy. The pharmacy packaged their new medication regimen in clear, individual dose adherence packaging. Medications were delivered by a staff driver to the patient's home within 72 hours of discharge. Patients consulted with the pharmacist by videoconference using a computer tablet device. Patients received telephone follow-up shortly before their medication supply was to run out, and additionally as needed on an individual basis.

EVALUATION

Self-reported hospital readmissions were collected at 30 and 180 days after enrollment. Patient satisfaction data were also collected at 30 and 180 days using a tool modified from the 5-item Transition Measure (15-item Care Transitions Measure).

RESULTS

Eighteen patients participated in the evaluation of the pilot. Three patients were readmitted within 30 days (17%), and 2 additional patients were readmitted within 180 days (11%). Patient satisfaction results were positive overall. Lessons learned relate to establishing partnerships, logistics, and patient engagement. These lessons will assist future community pharmacies in implementing a transition of care service.

CONCLUSION

This pharmacist care model may offer a solution to increase access to pharmacy services for patients in rural areas during a critical transition in care.

Improvement in Patient Transfer Process From the Operating Room to the PICU Using a Lean and Six Sigma-Based Quality Improvement Project

BACKGROUND AND OBJECTIVES

Ineffective and inefficient patient transfer processes can increase the chance of medical errors. Improvements in such processes are high-priority local institutional and national patient safety goals. At our institution, nonintubated postoperative pediatric patients are first admitted to the postanesthesia care unit before transfer to the PICU. This quality improvement project was designed to improve the patient transfer process from the operating room (OR) to the PICU.

METHODS

After direct observation of the baseline process, we introduced a structured, direct OR-PICU transfer process for orthopedic spinal fusion patients. We performed value stream mapping of the process to determine error-prone and inefficient areas. We evaluated primary outcome measures of handoff error reduction and the overall efficiency of patient transfer process time. Staff satisfaction was evaluated as a counterbalance measure.

RESULTS

With the introduction of the new direct OR-PICU patient transfer process, the handoff communication error rate improved from 1.9 to 0.3 errors per patient handoff (P = .002). Inefficiency (patient wait time and non-value-creating activity) was reduced from 90 to 32 minutes. Handoff content was improved with fewer information omissions (P < .001). Staff satisfaction significantly improved among nearly all PICU providers.

CONCLUSIONS

By using quality improvement methodology to design and implement a new direct OR-PICU transfer process with a structured multidisciplinary verbal handoff, we achieved sustained improvements in patient safety and efficiency. Handoff communication was enhanced, with fewer errors and content omissions. The new process improved efficiency, with high staff satisfaction.

Cognitive aid use improves transition of care by graduating medical students during a simulated crisis

BACKGROUND

Residents are expected to have transition of care (ToC) skills upon entering graduate medical education. It is unclear whether experience and training during medical school is adequate.

OBJECTIVE

The aim of the project was to assess: 1) graduating medical students' ability to perform ToC in a crisis situation, and 2) whether using a cognitive aid improves the ToC quality.

METHODS

The authors developed simulation scenarios for rapid response teams and a cognitive aid to assist in the ToC during crisis situations. Graduating medical students were enrolled and randomly divided into teams of three students, randomly assigned into one of two groups: teams using a cognitive aid for ToC (CA), or not using a cognitive aid (nCA). In the scenario, teams respond to a deteriorating patient and then transfer care to the next provider after stabilization. Three faculty reviewed the recording to assess completeness of the ToC and the overall quality. A completeness score was expressed as a fraction of the maximum score. Statistical analysis was performed using a t-test and Mann-Whitney U test.

RESULTS

A total of 112 senior medical students participated: CA n=19, nCA n=17. The completeness score of the ToC and overall quality improved when using the cognitive aid (completeness score: CA 0.80±0.06 vs. nCA 0.52±0.07, p<0.01; ToC quality: CA 3.16±0.65 vs. nCA 1.92±0.56, p<0.01). Participants' rating of knowledge and comfort with the ToC process increased after the simulation.

CONCLUSION

The completeness of information transfer during the ToC process by graduating medical students improved by using a cognitive aid in a simulated patient crisis.

Individual and contextual-level factors associated with continuity of care for adults with schizophrenia

This retrospective cohort study examined rates of conformance to continuity of care treatment guidelines and factors associated with conformance for persons with schizophrenia. Subjects were 8,621 adult Ohio Medicaid recipients, aged 18-64, treated for schizophrenia in 2004. Information on individual-level (demographic and clinical characteristics) and contextual-level variables (county socio-demographic, economic, and health care resources) were abstracted from Medicaid claim files and the Area Resource File. Outcome measures captured four dimensions of continuity of care: (1) regularity of care; (2) transitions; (3) care coordination, and (4) treatment engagement. Multilevel modeling was used to assess the association between individual and contextual-level variables and the four continuity of care measures. The results indicated that conformance rates for continuity of care for adults with schizophrenia are below recommended guidelines and that variations in continuity of care are associated with both individual and contextual-level factors. Efforts to improve continuity of care should target high risk patient groups (racial/ethnic minorities, the dually diagnosed, and younger adults with early onset psychosis), as well as community-level risk factors (provider supply and geographic barriers of rural counties) that impede access to care.

Surgery in the Air — Evacuating Finnish Tsunami Victims from Thailand

In connection with the Asian tsunami disaster on December 26, 2004, a specially equipped Finnair B-757 airplane capable of evacuating badly injured patients was remodeled into an ambulance airplane. The vehicle could take up to 22 severely injured or ill patients and intensive care and limited surgical procedures could be provided to the patients. The plane was manned with a civilian medical team of 37 physicians and nurses. The plane left for Thailand to evacuate the most severely injured Finnish citizens within 10 hours of the evacuation decision. A total of 14 patients including 4 critically ill (two on ventilator) were transferred to Helsinki within 32 hours of takeoff. The medical team included a general, an orthopedic and a plastic surgeon. Soft tissue wounds, some of them severely infected, were the most common injuries, followed by extremity fractures and head injuries. The surgical procedures that were performed midair included wound surgery, to remove necrotic tissue, and external fixation and fasciotomy for a lower extremity fracture. The facilities under these circumstances would allow performing life-saving procedures to maintain airway and breathing, and surgical procedures of the soft tissues, extremity and pelvic fractures. Cavitary surgery would require additional equipment and resources.

[Potential for intervention of private health insurers in discharge management using the example of stroke patients]

The study reveals that stroke patients today can still experience gaps in the provision of healthcare and fragmented therapy. This is often the case on transferral from the inpatient to outpatient sector, causing complications that could be avoided by means of good discharge management across all sectors. Private health insurance can actively support and positively influence the treatment process in the form of case management. Individual contact with stroke patients and their relatives allows for early planning and organisation of the next steps, and offers patients the support they need during a difficult phase of life.

Pharmacy led medicine reconciliation at hospital: A systematic review of effects and costs

BACKGROUND

Transition of patients care between settings presents an increased opportunity for errors and preventable morbidity. A number of studies outlined that pharmacy-led medicine reconciliation (MR) might facilitate safer information transfer and medication use. MR practice is not well standardized and often delivered in combination with other health care activities. The question regarding the effects and costs of pharmacy-led MR and the optimum MR practice is warranted of value.

OBJECTIVES

To review the evidence for the effects and costs/cost-effectiveness of complete pharmacy-led MR in hospital settings.

METHODS

A systematic review searching the following database was conducted up to the 13th December 2015; EMBASE & MEDLINE Ovid, CINAHL and the Cochrane library. Studies evaluating pharmacy-led MR performed fully from admission till discharges were included. Studies evaluated non-pharmacy-led MR at only one end of patient care or transfer was not included. Articles were screened and extracted independently by two investigators. Studies were divided into those in which: MR was the primary element of the intervention and labeled as "primarily MR" studies, or MR combined with non-MR care activities and labeled as "supplemented MR" studies. Quality assessment of studies was performed by independent reviewers using a pre-defined and validated tool.

RESULTS

The literature search identified 4065 citations, of which 13 implemented complete MR. The lack of evidence precluded addressing the effects and costs of MR.

CONCLUSIONS

The composite of optimum MR practice is not widely standardized and requires discussion among health professions and key organizations. Research focused on evaluating cost-effectiveness of pharmacy-led MR is lacking.

Using Sandelowski and Barroso's Meta-Synthesis Method in Advancing Qualitative Evidence

The purpose of this article was to iteratively account for and discuss the handling of methodological challenges in two qualitative research syntheses concerning patients' experiences of hospital transition. We applied Sandelowski and Barroso's guidelines for synthesizing qualitative research, and to our knowledge, this is the first time researchers discuss their methodological steps. In the process, we identified a need for prolonged discussions to determine mutual understandings of the methodology. We discussed how to identify the appropriate qualitative research literature and how to best conduct exhaustive literature searches on our target phenomena. Another finding concerned our status as third-order interpreters of participants' experiences and what this meant for synthesizing the primary findings. Finally, we discussed whether our studies could be classified as metasummaries or metasyntheses. Although we have some concerns regarding the applicability of the methodology, we conclude that following Sandelowski and Barroso's guidelines contributed to valid syntheses of our studies.

Using Arden Syntax for the Generation of Intelligent Intensive Care Discharge Letters

Discharge letters are an important means of communication between physicians and nurses from intensive care units and their colleagues from normal wards. The patient data management system (PDMS) used at our local intensive care units provides an export tool to create discharge letters by inserting data items from electronic medical records into predefined templates. Local intensivists criticized the limitations of this tool regarding the identification and the further processing of clinically relevant data items for a flexible creation of discharge letters. As our PDMS supports Arden Syntax, and the demanded functionalities are well within the scope of this standard, we set out to investigate the suitability of Arden Syntax for the generation of discharge letters. To provide an easy-to-understand facility for integrating data items into document templates, we created an Arden Syntax interface function which replaces the names of previously defined variables with their content in a way that permits arbitrary custom formatting by clinical users. Our approach facilitates the creation of flexible text sections by conditional statements, as well as the integration of arbitrary HTML code and dynamically generated graphs. The resulting prototype enables clinical users to apply the full set of Arden Syntax language constructs to identify and process relevant data items in a way that far exceeds the capabilities of the PDMS export tool. The generation of discharge letters is an uncommon area of application for Arden Syntax, considerably differing from its original purpose. However, we found our prototype well suited for this task and plan to evaluate it in clinical production after the next major release change of our PDMS.

[Making a safe transition home after a meningioma resection: The impact of nursing care]

INTRODUCTION

This study originated from patients' demands that they be better informed and that their meningioma diagnosis be considered serious. Meningioma are brain tumours that represent about 30% of all primary brain tumours. In 90% of the cases, they are non-cancerous. The objective was to identify whether educational intervention by nurses would have a positive impact on transition.

METHOD

The study lasted 12 months and included two groups: intervention and control. Intervention involved the verbal and written delivery of answers to frequently asked questions, as well as patient follow-up for six weeks post-surgery. Nurses were available during the preparation for discharge, as well as the follow-up call 48-72 hours later.

RESULTS

Educational nursing care had no demonstrable effect.

DISCUSSION

Differences between the groups might have influenced the effect of educational intervention. Our results suggest certain lines of thought as to the doses of information that should be given based on stages of care and individual particularities.

Information Challenges in Patient Transition

The aim of this workshop is to address challenges in access to accurate and relevant information for both patients and their clinicians during patient transitions. Successful exchange of information across transitions relies on clinicians' use of the electronic health record, information systems that support workflow and communication and access to actionable information to facilitate information exchange. In this workshop the speakers will illustrate the above mentioned challenges. The chairman will initially make a short statement of the purpose and the organization of the workshops.

Attributes common to programs that successfully treat high-need, high-cost individuals

Using literature review and interviews, we have identified 8 attributes of programs, such as accountable care organizations, readmission initiatives, special needs plans, care transition programs, and patient-centered medical homes, that successfully treat high-need, high-cost patients. These 8 attributes--illustrated here with specific examples--are specific ways to target these types of individuals, promote leadership at various levels, emphasize interaction with the care coordinator, use data strategically to refine the program, update the program periodically, allow physicians to spend more time with patients, and promote interaction among clinicians and high-need, high cost patients and their families.

The Institutional Costs and Resource Profile of Transfer Patients Into an Arthroplasty Service

The decision point with inter-hospital arthroplasty patient transfers and its financial implications have not been well studied. Factors outside of complexity of medical and surgical care are believed to drive the transfer of orthopaedic patients to tertiary care centers. We compared our institutional cost and resource utilization between transfer and elective patients in need of arthroplasty care. We hypothesized that transfer patients will incur a higher direct cost and resource utilization compared to elective patients, and that socioeconomic factors will play a role in the decision of transfer. After analysis of key metrics, transfer patients at our institution did not have any significant differences in insurance types. However, they did incur a longer length of stay (p<0.0001) and incurred greater direct costs (p<0.0001) to the hospital. After analysis of key parameters, transfer patients were more complex and costly to care for compared to our in-system patients.

Addressing Needs of Long-Term Care Facility Residents During Acute Hospitalization

Patients who reside in long-term care facilities for extended periods of time offer many health care challenges. Recognition of early signs of illness, care transitions, and underutilization of community resources are common concerns.

Successes and Challenges in Patient Care Transition Programming: One Hospital's Journey

The 2013 addition of the Care Transition Measures to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey; enactment of the Patient Protection and Affordable Care Act (2010); and a greater focus on population health have brought a heightened awareness and need for action with patient transitions. Data are emerging from the additional Care Transition Measures and benchmarks have been developed. This article briefly describes the context of care transition. We describe the journey of Indiana University Health North Hospital to overcome patient care transition obstacles, ultimately achieving designation as a top performer. We will discuss our efforts to personalize patient outcomes and transition through activation and improve transitions for vulnerable populations, specifically in the bariatric and orthopedic patient populations. The article concludes with discussion of overcoming obstacles and future directions with continued focus on collaboration and improvement.