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Thirnbeck CK, Espinoza ED, Beaman EA, Rozen AL, Dukes KC, Singh H, Herwaldt LA, Landrigan CP, Reisinger HS, Cifra CL. Interfacility Referral Communication for PICU Transfer. Pediatr Crit Care Med 2024; 25:499-511. [PMID: 38483193 PMCID: PMC11153023 DOI: 10.1097/pcc.0000000000003479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVES For patients requiring transfer to a higher level of care, excellent interfacility communication is essential. Our objective was to characterize verbal handoffs for urgent interfacility transfers of children to the PICU and compare these characteristics with known elements of high-quality intrahospital shift-to-shift handoffs. DESIGN Mixed methods retrospective study of audio-recorded referral calls between referring clinicians and receiving PICU physicians for urgent interfacility PICU transfers. SETTING Academic tertiary referral PICU. PATIENTS Children 0-18 years old admitted to a single PICU following interfacility transfer over a 4-month period (October 2019 to January 2020). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We reviewed interfacility referral phone calls for 49 patients. Referral calls between clinicians lasted a median of 9.7 minutes (interquartile range, 6.8-14.5 min). Most referring clinicians provided information on history (96%), physical examination (94%), test results (94%), and interventions (98%). Fewer clinicians provided assessments of illness severity (87%) or code status (19%). Seventy-seven percent of referring clinicians and 6% of receiving PICU physicians stated the working diagnosis. Only 9% of PICU physicians summarized information received. Interfacility handoffs usually involved: 1) indirect references to illness severity and diagnosis rather than explicit discussions, 2) justifications for PICU admission, 3) statements communicating and addressing uncertainty, and 4) statements indicating the referring hospital's reliance on PICU resources. Interfacility referral communication was similar to intrahospital shift-to-shift handoffs with some key differences: 1) use of contextual information for appropriate PICU triage, 2) difference in expertise between communicating clinicians, and 3) reliance of referring clinicians and PICU physicians on each other for accurate information and medical/transport guidance. CONCLUSIONS Interfacility PICU referral communication shared characteristics with intrahospital shift-to-shift handoffs; however, communication did not adhere to known elements of high-quality handovers. Structured tools specific to PICU interfacility referral communication must be developed and investigated for effectiveness in improving communication and patient outcomes.
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Affiliation(s)
- Caitlin K. Thirnbeck
- Division of Critical Care, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Elizabeth D. Espinoza
- Oregon Health and Science University School of Nursing and School of Medicine, Portland, Oregon
| | | | - Alexis L. Rozen
- University of Iowa College of Public Health, Iowa City, Iowa
| | - Kimberly C. Dukes
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Loreen A. Herwaldt
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| | - Christopher P. Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Heather Schacht Reisinger
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Institute for Clinical and Translational Science, University of Iowa, Iowa City, Iowa
| | - Christina L. Cifra
- Division of Medical Critical Care, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Critical Care, Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Tjan TE, Wong LY, Rixon A. Conflict in emergency medicine: A systematic review. Acad Emerg Med 2024; 31:538-546. [PMID: 38415363 DOI: 10.1111/acem.14874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/04/2024] [Accepted: 01/07/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND The emergency department (ED) is a demanding and time-pressured environment where doctors must navigate numerous team interactions. Conflicts between health care professionals frequently arise in these settings. We aim to synthesize the individual-, team-, and systemic-level factors that contribute to conflict between clinicians within the ED and explore strategies and opportunities for future research. METHODS Online databases PubMed and Web of Science were systematically searched for relevant peer-reviewed journal articles in English with keywords relating to "conflict" and "emergency department," yielding a total of 29 articles. RESULTS Narrative analysis showed that conflict often occurred during referrals or admissions from ED to inpatient or admitting units. Individual-level contributors to conflict include a lack of trust in ED workup and staff inexperience. Team-level contributors include perceptions of bias between groups, patient complexity, communication errors, and difference in practice. Systems-level contributors include high workload/time pressures, ambiguities around patient responsibility, power imbalances, and workplace culture. Among identified solutions to mitigate conflict are better communication training, standardizing admission guidelines, and improving interdepartmental relationships. CONCLUSIONS In emergency medicine, conflict is common and occurs at multiple levels, reflecting the complex interface of tasks and relationships within ED.
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Affiliation(s)
- Timothy Edward Tjan
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lee Yung Wong
- Emergency Department, Austin Health, Melbourne, Victoria, Australia
- School of Business, Law and Entrepreneurship, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Andrew Rixon
- Department of Business, Strategy and Innovation, Griffith Business School, Griffith University, Brisbane, Queensland, Australia
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Festekjian A, Hall JE, Zipkin R, Schiff J, Pham PK, Mesropyan L, Araradian C, Nager AL, Chang TP. A checklist intervention for pediatric emergency department transfer of care sign-outs. Am J Emerg Med 2024; 77:215-219. [PMID: 38216365 DOI: 10.1016/j.ajem.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/01/2024] [Accepted: 01/01/2024] [Indexed: 01/14/2024] Open
Affiliation(s)
- Ara Festekjian
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 113, Los Angeles, CA 90027, United States of America; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America.
| | - Jeanine E Hall
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 113, Los Angeles, CA 90027, United States of America; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America.
| | - Ronen Zipkin
- Department of Pediatrics, Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 94, Los Angeles, CA 90027, United States of America; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America.
| | - Jared Schiff
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 113, Los Angeles, CA 90027, United States of America; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America.
| | - Phung K Pham
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 113, Los Angeles, CA 90027, United States of America
| | - Levon Mesropyan
- University of California Los Angeles, Burbank Pediatrics, 2625 W. Alameda, Suite 300, Burbank, CA 9150, United States of America.
| | - Cynthia Araradian
- Oregon Health Sciences University*, 3181 S.W. Jackson Park Road, Portland, OR 97239, United States of America.
| | - Alan L Nager
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 113, Los Angeles, CA 90027, United States of America; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America.
| | - Todd P Chang
- Department of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd, Mailstop 113, Los Angeles, CA 90027, United States of America; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States of America.
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Kirk JW, Lindstroem MB, Stefánsdóttir NT, Andersen O, Powell BJ, Nilsen P, Tjørnhøj-Thomsen T. Influences of specialty identity when implementing a new emergency department in Denmark: a qualitative study. BMC Health Serv Res 2024; 24:162. [PMID: 38302985 PMCID: PMC10836004 DOI: 10.1186/s12913-024-10604-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 01/15/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND The Danish Health Authority recommended the implementation of new types of emergency departments. Organizational changes in the hospital sector challenged the role, identity, and autonomy of medical specialists. They tend to identify with their specialty, which can challenge successful implementation of change. However, investigations on specialty identity are rare in implementation science, and how the co-existence of different specialty identities influences the implementation of new emergency departments needs to be explored for the development of tailored implementation strategies. The aim of this study was to examine how medical specialty identity influences collaboration between physicians when implementing a new emergency department in Denmark. METHODS Qualitative methods in the form of participants' observations at 13 oilcloth sessions (a micro-simulation method) were conducted followed up by 53 individual semi-structured interviews with participants from the oilcloth sessions. Out of the 53 interviews, 26 were conducted with specialists. Data from their interviews are included in this study. Data were analysed deductively inspired by Social Identity Theory. RESULTS The analysis yielded three overarching themes: [1] ongoing creation and re-creation of specialty identity through boundary drawing; [2] social categorization and power relations; and [3] the patient as a boundary object. CONCLUSIONS Specialty identity is an important determinant of collaboration among physicians when implementing a new emergency department. Specialty identity involves social categorization, which entails ongoing creation and re-creation of boundary drawing and exercising of power among the physicians. In some situations, the patient became a positive boundary object, increasing the possibility for a successful collaboration and supporting successful implementation, but direct expressions of boundaries and mistrust were evident. Both were manifested through a dominating power expressed through social categorization in the form of in- and out-groups and in an "us and them" discourse, which created distance and separation among physicians from different specialties. This distancing and separation became a barrier to the implementation of the new emergency department.
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Affiliation(s)
- Jeanette Wassar Kirk
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark.
- Department of Health and Social Context, National Institute of Public Health, University of Southern Denmark, Odense, Denmark.
| | - Mette Bendtz Lindstroem
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
| | | | - Ove Andersen
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
- Emergency Department, Copenhagen University Hospital Hvidovre, 2650, Hvidovre, Denmark
- Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, 2200, Copenhagen, Denmark
| | - Byron J Powell
- Center for Mental Health Services Research, Brown School and School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Per Nilsen
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- School of Health and Welfare, Halmstad University, Halmstad, Sweden
| | - Tine Tjørnhøj-Thomsen
- Department of Health and Social Context, National Institute of Public Health, University of Southern Denmark, Odense, Denmark
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Subramonian D, Krahn G, Wlodarczak J, Lamb L, Malherbe S, Skarsgard E, Patel M. Improved patient safety with a simplified operating room to pediatric intensive care unit handover tool (PATHQS). Front Pediatr 2024; 12:1327381. [PMID: 38328344 PMCID: PMC10847360 DOI: 10.3389/fped.2024.1327381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/03/2024] [Indexed: 02/09/2024] Open
Abstract
Introduction Patient handover is a crucial transition requiring a high level of coordination and communication. In the BC Children's Hospital (BCCH) pediatric intensive care unit (PICU), 10 adverse events stemming from issues that should have been addressed at the operating room (OR) to PICU handover were reported into the patient safety learning system (PSLS) within 1 year. We aimed to undertake a quality improvement project to increase adherence to a standardized OR to PICU handover process to 100% within a 6-month time frame. In doing so, the secondary aim was to reduce adverse events by 50% within the same 6-month period. Methods The model for improvement and a Plan, Do, Study, Act method of quality improvement was used in this project. The adverse events were reviewed to identify root causes. The findings were reviewed by a multidisciplinary inter-departmental group comprised of members from surgery, anesthesia, and intensive care. Issues were batched into themes to address the most problematic parts of handover that were contributing to risk. Intervention A bedside education campaign was initiated to familiarize the team with an existing handover standard. The project team then formulated a new simplified visual handover tool with the mnemonic "PATHQS" where each letter denoted a step addressing a theme that had been noted in the pre-intervention work as contributing to adverse events. Results Adherence to standardized handover at 6 months improved from 69% to 92%. This improvement was sustained at 12 months and 3 years after the introduction of PATHQS. In addition, there were zero PSLS events relating to handover at 6 and 12 months, with only one filed by 36 months. Notably, staff self-reporting of safety concerns during handover reduced from 69% to 13% at 6 months and 0% at 3 years. The PATHQS tool created in this work also spread to six other units within the hospital as well as to one adult teaching hospital. Conclusion A simplified handover tool built collaboratively between departments can improve the quality and adherence of OR to PICU handover and improve patient safety. Simplification makes it adaptable and applicable in many different healthcare settings.
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Affiliation(s)
- D. Subramonian
- Division of Biochemical Diseases, BC Children’s Hospital, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - G. Krahn
- Division of Critical Care, BC Children’s Hospital, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - J. Wlodarczak
- Office of Virtual Health, Provincial Health Services Authority, Vancouver, BC, Canada
| | - L. Lamb
- Division of General Surgery, BC Children’s Hospital, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - S. Malherbe
- Division of Cardiac Anesthesia, BC Children’s Hospital, Department of Anesthesia, University of British Columbia, Vancouver, BC, Canada
| | - E. Skarsgard
- Division of General Surgery, BC Children’s Hospital, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - M. Patel
- Division of Critical Care, BC Children’s Hospital, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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Kunce NE, Lyon A, Carlton D, Jeyarajah T, Strayhorn CM, Lopreiato J, Wilson R. A Review of Verbal and Written Patient Handoffs Applicable to the U.S. Military's Expeditionary Care System. Mil Med 2024; 189:e76-e81. [PMID: 36617244 DOI: 10.1093/milmed/usac418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 11/22/2022] [Accepted: 12/20/2022] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Long considered a danger point in patient care, handoffs and patient care transitions contribute to medical errors and adverse events. Without standardization of patient handoffs, communication breakdowns arise and critical patient information is lost. Minimal training and informal learning have led to a lack of understanding the process involved in this vital aspect of patient care. In 2017, the U.S. Army commissioned a report to study the process of patient handoffs and identify training gaps. Our report summarizes that process and makes recommendations for implementation. MATERIALS AND METHODS Scoping literature review of 139 articles published between 1999 and 2017 using PubMed, CINAHL, Cochrane, and Medline databases. Verbal tools for handoffs were evaluated against 12 criteria including patient ID, history, current situation, contingency planning, ability to ask questions, ownership, and read back. Written tools were evaluated against a matrix of 126 casualty/treatment attributes. RESULTS Among verbal communication protocols, the highest scoring handoff mnemonics were HAND ME AN ISOBAR, IPASS the BATON, and I-SBARQ. Among written handoff tools, the highest scoring documents were the Special Operations Forces (SOF) Mechanism, Injuries, Signs, and Treatment (MIST) Casualty Treatment Card and the Department of Defense (DD) Form 1380 Tactical Combat Casualty Care (TCCC) Card. Four critical process elements for patient handoffs and transfers were identified: (1) interactive communications, (2) limited interruptions, (3) a process for verification, and (4) an opportunity to review any relevant historical data. CONCLUSIONS The findings in this review highlight the need for standardized tools and techniques for patient handoffs in the U.S. Military's expeditionary care system. Future research is needed to trial verbal and nonverbal handoffs under field conditions to gather observational data to assess effectiveness. The results of our gap analyses may provide researchers insight for determining which handoffs to study. If standardized handoffs are utilized, training programs should incorporate the four critical elements into their curricula.
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Affiliation(s)
- Nicholas E Kunce
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Arthur Lyon
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Duncan Carlton
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | | | | | - Joseph Lopreiato
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Ramey Wilson
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
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Kanjee Z, Beltran CP, Smith CC, Tibbles CD, Lewis JJ, Sullivan AM. "Two Years Later I'm Still Just as Angry": A Focus Group Study of Emergency and Internal Medicine Physicians on Disrespectful Communication. TEACHING AND LEARNING IN MEDICINE 2023:1-11. [PMID: 38041804 DOI: 10.1080/10401334.2023.2288706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 11/07/2023] [Indexed: 12/04/2023]
Abstract
Phenomenon: Disrespectful behavior between physicians across departments can contribute to burnout, poor learning environments, and adverse patient outcomes. Approach: In this focus group study, we aimed to describe the nature and context of perceived disrespectful communication between emergency and internal medicine physicians (residents and faculty) at patient handoff. We used a constructivist approach and framework method of content analysis to conduct and analyze focus group data from 24 residents and 11 faculty members from May to December 2019 at a large academic medical center. Findings: We organized focus group results into four overarching categories related to disrespectful communication: characteristics and context (including specific phrasing that members from each department interpreted as disrespectful, effects of listener engagement/disengagement, and the tendency for communication that is not in-person to result in misunderstanding and conflict); differences across training levels (with disrespectful communication more likely when participants were at different training levels); the individual correspondent's tendency toward perceived rudeness; and negative/long-term impacts of disrespectful communication on the individual and environment (including avoidance and effects on patient care). Insights: In the context of predominantly positive descriptions of interdepartmental communication, participants described episodes of perceived disrespectful behavior that often had long-lasting, negative impacts on the quality of the learning environment and clinical work. We created a conceptual model illustrating the process and outcomes of these interactions. We make several recommendations to reduce disrespectful communication that can be applied throughout the hospital to potentially improve patient care, interdepartmental collaboration, and trainee and faculty quality of life.
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Affiliation(s)
- Zahir Kanjee
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christine P Beltran
- Program for Medical Education Innovations and Research, New York University Grossman School of Medicine, New York, New York, USA
| | - C Christopher Smith
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Carrie D Tibbles
- Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jason J Lewis
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Amy M Sullivan
- Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Veverka MC, Ryus CR, Gerardo CJ, Bernstein SL, Limkakeng AJ. Fixing the leaky physician-scientist pipeline: Integrated-dedicated research period programs in emergency medicine. AEM EDUCATION AND TRAINING 2023; 7:e10919. [PMID: 38037629 PMCID: PMC10685392 DOI: 10.1002/aet2.10919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 12/02/2023]
Abstract
Emergency physicians (EPs) are well positioned to perform medical research. EPs are exposed to a wide range of disease types, medical specialties, and treatment modalities. Furthermore, emergency medicine (EM) serves as the safety net for the U.S. health care system. The diverse exposure provides a vast opportunity for EP to perform many worthwhile research projects. Yet, EM has historically had the lowest amount of funding and a lower number of National Institutes of Health-funded research projects. Many suggest the etiology is a "leaky" educational pipeline with loss of many potential physician-scientists over the training and development course. Current research training options for the EM physician-scientist includes MD-PhD, 4-year EM residency program and postresidency fellowships. While each has its advantages and disadvantages, we describe an additional educational alternative of EM physician-scientists, which we have named the integrated-dedicated research period within an EM residency. We describe the features of these programs and preliminary results from the graduates and current trainees.
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Affiliation(s)
| | | | | | - Steven L. Bernstein
- Yale University School of MedicineNew HavenConnecticutUSA
- Dartmouth School of MedicineHanoverNew HampshireUSA
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Kolikof J, Shaw D, Stenson B, Grossestreuer A, Sanchez L, Chiu D. Standardized evaluation of hand-off documentation of ICU boarders in the emergency department. J Am Coll Emerg Physicians Open 2023; 4:e13039. [PMID: 37745866 PMCID: PMC10511838 DOI: 10.1002/emp2.13039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/07/2023] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
Objective The boarding of ICU patients in the emergency department (ED) represents a considerable risk to patient safety. This study aims to describe the generation of a rubric to ensure the fidelity of vital, written hand-off between ED teams. Methods We performed a mixed methods design to develop a scoring rubric to evaluate written hand-off communication of medical ICU boarders between ED teams during the COVID-19 pandemic. The primary outcome was the quality of the written hand-off as agreed upon by the inter-user agreement. Our secondary outcome included variability in written quality as a function of the number of separate and distinct ED teams at the point of the transition of care. Results There was a moderate inter-user agreement with rubric scoring (κ = 0.70 [95% confidence interval, 0.66-0.75]). The overall trend noted that several key elements, including code status, performed interventions, and contingency planning, were infrequently documented. Conclusions We effectively created a quality assurance tool for ED ICU boarders that ensures relevant and vital information is relayed between ED teams. Our analysis demonstrated that all relevant information is only sometimes present in the hand-off.
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Affiliation(s)
- Joshua Kolikof
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Daniel Shaw
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Bryan Stenson
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Anne Grossestreuer
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Leon Sanchez
- Department of Emergency MedicineBrigham and Women's Faulkner HospitalBostonMassachusettsUSA
| | - David Chiu
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
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Amick AE, Schrepel C, Bann M, Watsjold B, Jauregui J, Ilgen JS, Lu DW, Sebok-Syer SS. From Battles to Burnout: Investigating the Role of Interphysician Conflict in Physician Burnout. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:1076-1082. [PMID: 37043749 DOI: 10.1097/acm.0000000000005226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
PURPOSE Despite the recognized importance of collaborative communication among physicians, conflict at transitions of care remains a pervasive issue. Recent work has underscored how poor communication can undermine patient safety and organizational efficiency, yet little is known about how interphysician conflict (I-PC) impacts the physicians forced to navigate these tensions. The goal of this study was to explore the social processes and interpersonal interactions surrounding I-PC and their impact, using conversations regarding admission between internal medicine (IM) and emergency medicine (EM) as a lens to explore I-PC in clinical practice. METHOD The authors used constructivist grounded theory to explore the interpersonal and social dynamics of I-PC. They used purposive sampling to recruit participants, including EM resident and attending physicians and IM attending physicians. The authors conducted hour-long, semistructured interviews between June and October 2020 using the Zoom video conferencing platform. Interviews were coded in 3 phases: initial line-by-line coding, focused coding, and recording. Constant comparative analysis was used to refine emerging codes, and the interview guide was iteratively updated. RESULTS The authors interviewed 18 residents and attending physicians about how engaging in I-PC led to both personal and professional harm. Specifically, physicians described how I-PC resulted in emotional distress, demoralization, diminished sense of professional attributes, and job dissatisfaction. Participants also described how emotional residue attached to past I-PC events primed the workplace for future conflict. CONCLUSIONS I-PC may represent a serious yet underrecognized source of harm, not only to patient safety but also to physician well-being. Participants described both the personal and professional consequences of I-PC, which align with the core tenets of burnout. Burnout is a well-established threat to the physician workforce, but unlike many other contributors to burnout, I-PC may be modifiable through improved education that equips physicians with the skills to navigate I-PC throughout their careers.
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Affiliation(s)
- Ashley E Amick
- A.E. Amick is assistant professor, Department of Emergency Medicine and Department of Internal Medicine, University of Washington, Seattle, Washington
| | - Caitlin Schrepel
- C. Schrepel is assistant professor, Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Maralyssa Bann
- M. Bann is assistant professor, Department of Medicine, University of Washington, Seattle, Washington
| | - Bjorn Watsjold
- B. Watsjold is assistant professor, Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Joshua Jauregui
- J. Jauregui is associate professor, Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Jonathan S Ilgen
- J.S. Ilgen is professor, Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Dave W Lu
- D.W. Lu is associate professor, Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Stefanie S Sebok-Syer
- S.S. Sebok-Syer is assistant professor, Department of Emergency Medicine, Stanford University, Stanford, California
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Claret PG, Bobbia X, Renia R, Stowell A, Crampagne J, Flechet J, Czeschan C, Sebbane M, Landais P, de La Coussaye JE. Prescription errors by emergency physicians for inpatients are associated with emergency department length of stay. Therapie 2023; 78:S59-S65. [PMID: 27793421 DOI: 10.2515/therapie/2015049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 07/10/2015] [Indexed: 10/15/2023]
Abstract
OBJECTIVES Adverse drug events are the sixth-leading cause of death in Western countries and are also more frequent in emergency departments (EDs). In some hospitals or on some occasions, ED physicians prescribe for patients who they have admitted. These prescriptions are then followed by the wards and can persist for several days. Our objectives were to determine the frequency of prescription errors for patients over 18years old hospitalized from ED to medical or surgical wards, and whether there exists a relationship between those prescription errors and ED LOS. METHODS This was a single center retrospective study that was conduct in the ED of a university hospital with an annual census of 65 000 patients. The population studied consisted of patients over 18years old hospitalized from ED to medical or surgical wards between January 1st, 2012 and January 21st, 2012. RESULTS Six hundred eight patients were included. One hundred fifty-four (25%) patients had prescription errors. Prescription errors were associated with increased ED length of stay (OR=2.47; 95% CIs [1.58; 3.92]) and polypharmacy (OR=1.78; 95% CIs [1.20; 2.66]). Fewer prescription errors were found when the patient was examined in the ED by a consultant (OR=0.61; 95% CIs [0.41; 0.91]) and when the medical history was known (OR=0.28; 95% CIs [0.10; 0.88]). CONCLUSION Prescription errors occurred frequently in the ED. We assume that a clear communication and cooperation between EPs and consultants may help improve prescription accuracy.
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Affiliation(s)
- Pierre-Géraud Claret
- Pôle anesthésie réanimation douleur urgences, centre hospitalier universitaire de Nîmes, 4, rue du Professeur-Robert-Debré, 30029 Nîmes, France; EA 2415, Clinical Research University Institute, centre hospitalier universitaire de Montpellier, 34000 Montpellier, France.
| | - Xavier Bobbia
- Pôle anesthésie réanimation douleur urgences, centre hospitalier universitaire de Nîmes, 4, rue du Professeur-Robert-Debré, 30029 Nîmes, France
| | - Rhoda Renia
- Pôle anesthésie réanimation douleur urgences, centre hospitalier universitaire de Nîmes, 4, rue du Professeur-Robert-Debré, 30029 Nîmes, France
| | - Andrew Stowell
- Pôle anesthésie réanimation douleur urgences, centre hospitalier universitaire de Nîmes, 4, rue du Professeur-Robert-Debré, 30029 Nîmes, France
| | - Jacques Crampagne
- Pôle anesthésie réanimation douleur urgences, centre hospitalier universitaire de Nîmes, 4, rue du Professeur-Robert-Debré, 30029 Nîmes, France
| | - Jean Flechet
- Pôle anesthésie réanimation douleur urgences, centre hospitalier universitaire de Nîmes, 4, rue du Professeur-Robert-Debré, 30029 Nîmes, France
| | - Christian Czeschan
- Département informatique médicale, centre hospitalier universitaire de Nîmes, 30029 Nîmes, France
| | - Mustapha Sebbane
- Pôle anesthésie réanimation douleur urgences, centre hospitalier universitaire de Nîmes, 4, rue du Professeur-Robert-Debré, 30029 Nîmes, France
| | - Paul Landais
- EA 2415, Clinical Research University Institute, centre hospitalier universitaire de Montpellier, 34000 Montpellier, France; Département de biostatistique, épidémiologie, santé publique et informatique médicale, centre hospitalier universitaire de Nîmes, 30029 Nîmes, France
| | - Jean-Emmanuel de La Coussaye
- Pôle anesthésie réanimation douleur urgences, centre hospitalier universitaire de Nîmes, 4, rue du Professeur-Robert-Debré, 30029 Nîmes, France
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12
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Mamalelala TT, Schmollgruber S, Botes M, Holzemer W. Effectiveness of handover practices between emergency department and intensive care unit nurses. Afr J Emerg Med 2023; 13:72-77. [PMID: 36969481 PMCID: PMC10033719 DOI: 10.1016/j.afjem.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/16/2023] [Accepted: 03/06/2023] [Indexed: 03/29/2023] Open
Abstract
Background Nurses from the emergency department (ED) and the intensive care unit (ICU) must interact during the handover procedure. Factors such as unit boundaries, the interaction between different specialities, patient acuities, and treatment adjustments generate specific negotiating and teamwork problems during the transition of patients from ED to ICU. Objective This study aimed to describe the opinions of nurses regarding the effectiveness of handover practices between nurses in the ED and ICU in a major academic hospital in Gauteng province, South Africa. Method An analytical cross-sectional survey design was used. Data were collected using a 16-item handover evaluation tool. It comprises two sections (1) biographical details and (2) 16 statements about handover quality divided into five constructs, namely information transfer, shared understanding, working atmosphere, overall handover quality, and circumstances of handover. Data analysis was done utilising descriptive and non-parametric statistics. Results The majority (51.8%; n = 115) of the handovers occurred during the day. Out of 171 nurses, there were specialist practice emergency (19.2%; n = 33) and intensive care (28.0%; n = 48) nurses. There was statistical significance in information transfer between the ED and ICU nurses. (Me = 4.0, p < 0.05), compared to ICU nurses (Me = 3.0). Nurse specialist and non-specialist nurses' handovers differed statistically significantly on 12 of the 16 items on the rating scale, compared to 10 for non-specialist nurses' handovers. Conclusion The study showed that ED and ICU nurses have significantly different requirements and expectations for handover procedures. In addition to completed documentation, subtle interpretations of the information provided and received also impact the need. The ED and ICU nurses would need to agree on the contents of a structured handover framework because different specialities and departments have varied expectations to achieve an effective handover.
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Affiliation(s)
- Tebogo T. Mamalelala
- School of Nursing, University of Botswana, School of Nursing, Rutgers, The State University of New Jersey, NJ, United States
| | - Shelley Schmollgruber
- Department of Nursing Education, Faculty of Health Sciences, University of the Witwatersrand, Gauteng, South Africa
- Corresponding author:
| | - Meghan Botes
- Department of Nursing Education, Faculty of Health Sciences, University of the Witwatersrand, Gauteng, South Africa
| | - William Holzemer
- School of Nursing, Rutgers, The State University of New Jersey, NJ, United States
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13
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Crossman L, Ronald Funk C, Kandiah S, Hemrajani R. Disseminated Peritoneal Tuberculosis Initially Misdiagnosed as Nephrogenic Ascites. Case Rep Nephrol 2023; 2023:4240423. [PMID: 37124145 PMCID: PMC10139807 DOI: 10.1155/2023/4240423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/30/2022] [Accepted: 01/27/2023] [Indexed: 05/02/2023] Open
Abstract
A middle-aged immigrant male from a region with endemic tuberculosis who had a history of end-stage kidney disease presented to the emergency room for routine hemodialysis and abdominal swelling. He was admitted to the medicine service for suggested daily dialysis to improve his volume overload, which was attributed to nephrogenic ascites. He was found to have several findings concerning for systemic illness, including fevers, night sweats, hypercalcemia, lymphadenopathy, omental thickening, ascitic fluid with a serum ascites albumin gradient of less than 1.1 gm/dL, and exudative pleural effusions. Our suspicion for hematologic malignancy versus disseminated infection was high. During admission, there were many diagnostic challenges in obtaining histologic and bacteriologic confirmation of our leading suspected diagnosis, disseminated tuberculosis. Ultimately, tuberculosis infection was confirmed with histologic evidence of granulomatous inflammation of cervical lymph node and sputum culture positive for Mycobacterium tuberculosis. This case highlights the necessity for every patient presenting with new ascites to undergo diagnostic paracentesis. Nephrogenic ascites is a rare syndrome that is possible in volume overloaded states but is a diagnosis of exclusion that should be supported by an exudative serum ascites albumin gradient and no evidence of an alternate etiology.
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Affiliation(s)
| | | | - Sheetal Kandiah
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Reena Hemrajani
- Division of Hospital Medicine, Emory University School of Medicine, Atlanta, GA, USA
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14
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Burns B, Heilman J, Kusin S, Chess L, Tanski ME. Turn that frown upside down: implementation of a visual cue improves communication during emergency department to inpatient hand-offs. BMJ Open Qual 2022; 11:bmjoq-2022-002078. [PMID: 36543381 PMCID: PMC9772622 DOI: 10.1136/bmjoq-2022-002078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
When a patient is admitted to the hospital from the emergency department (ED), the ED clinician passes on relevant clinical information to the admitting team to transition care, a process known as patient hand-off and commonly referred to as 'calling report'. This information exchange between clinical teams is not only important for care continuity but also signifies a transition of care.However, there are unique challenges in this hand-off process given the unpredictability of the busy ED environment, ED boarding and discontinuity in physician, nursing and transportation workflows. These challenges create the potential for gaps in communication and can create patient safety concerns, particularly if a patient is transported to an inpatient bed before hand-off takes place.We set out to determine whether introducing a visual cue on the electronic health record (EHR) ED trackboard to communicate that report had been given would improve hand-off compliance. We sought to improve the utility of the visual cue and compliance of calling report prior to patient transport through a series of several Plan Do Study Act (PDSA) cycles.Baseline compliance using the 'Report Called' button prior to implementation of our visual intervention was 9.8%. With staff education alone, compliance rose to 41.3%. However, with an easily recognisable visual cue highlighted on the trackboard and an improved workflow compliance immediately rose to >97% and has been sustained for 84 months. Additionally, we have had zero reported incidents of patients being transported to a hospital bed before physician report was called since implementation.Our study demonstrates that simple visual cues and incorporation of a user-friendly process in the workflow can improve compliance with ensuring report is called prior to patient transfer from the ED. This may have a positive impact on physician communication and patient safety during the admission process.
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Affiliation(s)
- Beech Burns
- Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - James Heilman
- Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Shana Kusin
- Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Laura Chess
- Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Mary Elizabeth Tanski
- Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon, USA
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15
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Joseph MM, Mahajan P, Snow SK, Ku BC, Saidinejad M. Optimizing Pediatric Patient Safety in the Emergency Care Setting. Pediatrics 2022; 150:189658. [PMID: 36189487 DOI: 10.1542/peds.2022-059674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 02/25/2023] Open
Abstract
Patient safety is the foundation of high-quality health care and remains a critical priority for all clinicians caring for children. There are numerous aspects of pediatric care that increase the risk of patient harm, including but not limited to risk from medication errors attributable to weight-dependent dosing and need for appropriate equipment and training. Of note, the majority of children who are ill and injured are brought to community hospital emergency departments. It is, therefore, imperative that all emergency departments practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This technical report outlined the challenges and resources necessary to minimize pediatric medical errors and to provide safe medical care for children of all ages in emergency care settings.
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Affiliation(s)
- Madeline M Joseph
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine-Jacksonville, University of Florida Health Sciences Center-Jacksonville, Jacksonville, Florida
| | - Prashant Mahajan
- Departments of Pediatrics and Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Sally K Snow
- Independent Consultant in Pediatric Emergency and Trauma Nursing; Graham, Texas
| | - Brandon C Ku
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mohsen Saidinejad
- The Lundquist Institute for Biomedical Innovation at Harbor-University of California Los Angeles, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
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16
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Optimizing Pediatric Patient Safety in the Emergency Care Setting. Ann Emerg Med 2022; 80:e83-e92. [DOI: 10.1016/j.annemergmed.2022.08.456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022]
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17
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Joseph MM, Mahajan P, Snow SK, Ku BC, Saidinejad M. Optimizing Pediatric Patient Safety in the Emergency Care Setting. Pediatrics 2022; 150:189657. [PMID: 36189490 DOI: 10.1542/peds.2022-059673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 11/05/2022] Open
Abstract
This is a revision of the previous American Academy of Pediatrics policy statement titled "Patient Safety in the Emergency Care Setting," and is the first joint policy statement by the American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association to address pediatric patient safety in the emergency care setting. Caring for children in the emergency setting can be prone to medical errors because of a number of environmental and human factors. The emergency department (ED) has frequent workflow interruptions, multiple care transitions, and barriers to effective communication. In addition, the high volume of patients, high-decision density under time pressure, diagnostic uncertainty, and limited knowledge of patients' history and preexisting conditions make the safe care of critically ill and injured patients even more challenging. It is critical that all EDs, including general EDs who care for the majority of ill and injured children, understand the unique safety issues related to children. Furthermore, it is imperative that all EDs practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This policy statement outlines the recommendations necessary for EDs to minimize pediatric medical errors and to provide safe care for children of all ages.
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Affiliation(s)
- Madeline M Joseph
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, University of Florida Health Sciences Center, Jacksonville, Jacksonville, Florida
| | - Prashant Mahajan
- Departments of Pediatrics and Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Sally K Snow
- Independent Consultant in Pediatric Emergency and Trauma Nursing
| | - Brandon C Ku
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mohsen Saidinejad
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA, David Geffen School of Medicine at UCLA, Los Angeles, California
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18
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A Multiple Baseline Trial of an Electronic ICU Discharge Summary Tool for Improving Quality of Care. Crit Care Med 2022; 50:1566-1576. [PMID: 35972243 DOI: 10.1097/ccm.0000000000005638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Effective communication between clinicians is essential for seamless discharge of patients between care settings. Yet, discharge summaries are commonly not available and incomplete. We implemented and evaluated a structured electronic health record-embedded electronic discharge (eDischarge) summary tool for patients discharged from the ICU to a hospital ward. DESIGN Multiple baseline trial with randomized and staggered implementation. SETTING Adult medical-surgical ICUs at four acute care hospitals serving a single Canadian city. PATIENTS Health records of patients 18 years old or older, in the ICU 24 hours or longer, and discharged from the ICU to an in-hospital patient ward between February 12, 2018, and June 30, 2019. INTERVENTION A structured electronic note (ICU eDischarge tool) with predefined fields (e.g., diagnosis) embedded in the hospital-wide electronic health information system. MEASUREMENTS AND MAIN RESULTS We compared the percent of timely (available at discharge) and complete (included goals of care designation, diagnosis, list of active issues, active medications) discharge summaries pre and post implementation using mixed effects logistic regression models. After implementing the ICU eDischarge tool, there was an immediate and sustained increase in the proportion of patients discharged from ICU with timely and complete discharge summaries from 10.8% (preimplementation period) to 71.1% (postimplementation period) (adjusted odds ratio, 32.43; 95% CI, 18.22-57.73). No significant changes were observed in rapid response activation, cardiopulmonary arrest, death in hospital, ICU readmission, and hospital length of stay following ICU discharge. Preventable (60.1 vs 5.7 per 1,000 d; p = 0.023), but not nonpreventable (27.3 vs 40.2 per 1,000d; p = 0.54), adverse events decreased post implementation. Clinicians perceived the eDischarge tool to produce a higher quality discharge process. CONCLUSIONS Implementation of an electronic tool was associated with more timely and complete discharge summaries for patients discharged from the ICU to a hospital ward.
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19
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Joseph MM, Mahajan P, Snow SK, Ku BC, Saidinejad M. Optimizing Pediatric Patient Safety in the Emergency Care Setting. J Emerg Nurs 2022; 48:652-665. [DOI: 10.1016/j.jen.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 08/28/2022] [Indexed: 11/05/2022]
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Zhang W, Wong LY, Liu J, Sarkar S. MONitoring Knockbacks in EmergencY (MONKEY) – An Audit of Disposition Outcomes in Emergency Patients with Rejected Admission Requests. OPEN ACCESS EMERGENCY MEDICINE 2022; 14:481-490. [PMID: 36081749 PMCID: PMC9448349 DOI: 10.2147/oaem.s376419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 08/23/2022] [Indexed: 11/23/2022] Open
Abstract
Background Emergency Department (ED) clinicians commonly experience difficulties in referring patients to inpatient teams for hospital admission. There is limited literature reporting on patient outcomes following these complicated referrals, where ED requests for inpatient admission are rejected – which study investigators termed a “knockback”. Purpose To identify disposition outcomes and referral accuracy in ED patients whose admission referral was initially rejected. Secondary objectives were to identify additional patient, clinician and systemic factors associated with knockbacks. Selection and Methodology Emergency clinicians prospectively nominated a convenience sample of patients identified as having knockbacks over two time periods (Jan–Feb 2020 and Aug 2020 to Jan 2021) at a tertiary Australian ED. Data were analyzed with a mixed-methods approach and subsequent descriptive and thematic analyses were performed. Results A total of 109 patients were identified as knockbacks. The referrals were warranted, with 89.0% of cases (n = 97) ultimately requiring a hospital admission. In 60.6% (n = 66) of the admissions, patients were admitted under the inpatient team initially referred to by the ED, suggesting referrals were generally accurate. The number of in-hospital units involved in the admission process and ED length of stay were positively correlated (0.409, p < 0.001). Patient factors associated with knockbacks include pre-existing chronic medical conditions and presenting acutely unwell. Analysis of clinicians’ perspectives yielded recurring themes of disagreements over admission destination and diagnostic uncertainty. Conclusion In this patient sample, emergency referrals for admission were mostly warranted and accurate. Knockbacks increase ED length of stay and may adversely affect patient care. Further focused discussion and clearer referral guidelines between ED clinicians and their inpatient colleagues are required.
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Affiliation(s)
- Wendell Zhang
- University of Melbourne Clinical School, Austin Health, Heidelberg, VIC, Australia
| | - Lee Yung Wong
- Emergency Department, Austin Hospital, Heidelberg, VIC, Australia
- Correspondence: Lee Yung Wong, Austin Hospital Emergency Department, 145 Studley Road, Heidelberg, 3084, VIC, Australia, Tel +613 9496 5000, Fax +613 9496 3572, Email
| | - Jasmine Liu
- Emergency Department, Austin Hospital, Heidelberg, VIC, Australia
| | - Soham Sarkar
- Emergency Department, Austin Hospital, Heidelberg, VIC, Australia
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21
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Comparison of 2 Methods of Debriefing for Learning of Interprofessional Handoff Skills. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2022. [DOI: 10.1097/jat.0000000000000200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Development of An Interprofessional Handoff Assessment for Doctor of Physical Therapy Students. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2022. [DOI: 10.1097/jat.0000000000000196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Schrepel C, Amick AE, Bann M, Watsjold B, Jauregui J, Ilgen JS, Sebok-Syer SS. Who's on your team? Specialty identity and inter-physician conflict during admissions. MEDICAL EDUCATION 2022; 56:625-633. [PMID: 34942027 DOI: 10.1111/medu.14715] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 12/01/2021] [Accepted: 12/11/2021] [Indexed: 06/14/2023]
Abstract
PURPOSE Despite the implementation of professionalism curricula and standardised communication tools, inter-physician conflict persists. In particular, the interface between emergency medicine (EM) and internal medicine (IM) has long been recognised as a source of conflict. The social nuances of this conflict remain underexplored, limiting educators' ability to comprehensively address these issues in the clinical learning environment. Thus, the authors explored EM and IM physicians' experiences with negotiating hospital admissions to better understand the social dynamics that contribute to inter-physician conflict and provide foundational guidance for communication best practices. METHODS Using a constructivist grounded theory (CGT) approach, the authors conducted 18 semi-structured interviews between June and October 2020 with EM and IM physicians involved in conversations regarding admissions (CRAs). They asked participants to describe the social exchanges that influenced these conversations and to reflect on their experiences with inter-physician conflict. Data collection and analysis occurred iteratively. The relationships between the codes were discussed by the research team with the goal of developing conceptual connections between the emergent themes. RESULTS Participants described how their approaches to CRAs were shaped by their specialty identity, and how allegiance to members of their group contributed to interpersonal conflict. This conflict was further promoted by a mutual sense of disempowerment within the organisation, misaligned expectations, and a desire to promote their group's prerogatives. Conflict was mitigated when patient care experiences fostered cross-specialty team formation and collaboration that dissolved traditional group boundaries. CONCLUSIONS Conflict between EM and IM physicians during CRAs was primed by participants' specialty identities, their power struggles within the broader organisation, and their sense of duty to their own specialty. However, formation of collaborative inter-specialty physician teams and expansion of identity to include colleagues from other specialties can mitigate inter-physician conflict.
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Affiliation(s)
- Caitlin Schrepel
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
| | - Ashley E Amick
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Maralyssa Bann
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Bjorn Watsjold
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
| | - Joshua Jauregui
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
| | - Jonathan S Ilgen
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
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Alshyyab MA, Albsoul RA, Kinnear FB, Saadeh RA, Alkhaldi SM, Borkoles E, Fitzgerald G. Assessment of patient safety culture in two emergency departments in Australia: a cross sectional study. TQM JOURNAL 2022. [DOI: 10.1108/tqm-01-2022-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposePatient safety culture is a vital element to create patient safety in healthcare organisations. Emergency department (ED) professionals operate in unstable conditions that may pose risk to patient safety on day-to-day basis. The aim of this study was to assess the status of patient safety culture and to quantify the dimensions of safety culture in the ED setting.Design/methodology/approachThis was a descriptive cross sectional study that used a validated questionnaire distributed to the staff working in the nominated EDs . Perceptions on various dimensions of safety culture were reported and the frequency of positive responses for each dimension was calculated.Findings“Teamwork” is the only dimension that rated positive by over 70% of participants. Other dimensions rated below 50%, except for “Organisational learning–continuous improvement” which rated 51.2%. Areas that rated the lowest were “Handover and transitions”, “Staffing”, “Non-punitive response to error” and “Frequency of event reporting” with average positive response rate of 15.4%, 26%, 26.8% and 27.6%, respectively.Originality/valueThis study displayed a concerning perceptions held by participants about the deficiency of patient safety culture in their EDs. Moreover, it provided a baseline finding giving a clearer vision of the areas of patient safety culture that need improvement.
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Effect of a Multispecialty Faculty Handoff Initiative on Safety Culture and Handoff Quality. Pediatr Qual Saf 2022; 7:e539. [PMID: 35369417 PMCID: PMC8970093 DOI: 10.1097/pq9.0000000000000539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 12/11/2021] [Indexed: 11/26/2022] Open
Abstract
Structured handoffs at transitions of care are vital components of patient safety. A safety culture survey showed that “handoffs and transitions” were among the lowest scoring dimensions at our hospital. We sought to improve physician handoffs and safety culture scores by implementing standardized handoff communication across multiple divisions of an academic pediatric department.
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Guo P, Pinto C, Edwards B, Pask S, Firth A, O'Brien S, Murtagh FE. Experiences of transitioning between settings of care from the perspectives of patients with advanced illness receiving specialist palliative care and their family caregivers: A qualitative interview study. Palliat Med 2022; 36:124-134. [PMID: 34477022 PMCID: PMC8793309 DOI: 10.1177/02692163211043371] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Transitions between care settings (hospice, hospital and community) can be challenging for patients and family caregivers and are often an under-researched area of health care, including palliative care. AIM To explore the experience of transitions between care settings for those receiving specialist palliative care. DESIGN Qualitative study using thematic analysis. SETTING/PARTICIPANTS Semi-structured interviews were conducted with adult patients (n = 15) and family caregivers (n = 11) receiving specialist palliative care, who had undergone at least two transitions. RESULTS Four themes were identified. (1) Uncertainty about the new care setting. Most participants reported that lack of information about the new setting of care, and difficulties with access and availability of care in the new setting, added to feelings of uncertainty. (2) Biographical disruption. The transition to the new setting often resulted in changes to sense of independence and identity, and maintaining normality was a way to cope with this. (3) Importance of continuity of care. Continuity of care had an impact on feelings of safety in the new setting and influenced decisions about the transition. (4) Need for emotional and practical support. Most participants expressed a greater need for emotional and practical support, when transitioning to a new setting. CONCLUSIONS Findings provide insights into how clinicians might better negotiate transitions for these patients and family caregivers, as well as improve patient outcomes. The complexity and diversity of transition experiences, particularly among patients and families from different ethnicities and cultural backgrounds, need to be further explored in future research.
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Affiliation(s)
- Ping Guo
- School of Nursing, Institute of Clinical Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Cathryn Pinto
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Beth Edwards
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Sophie Pask
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.,Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Alice Firth
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Suzanne O'Brien
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Fliss Em Murtagh
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.,Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Hoonakker PLT, Hose BZ, Carayon P, Eithun BL, Rusy DA, Ross JC, Kohler JE, Dean SM, Brazelton TB, Kelly MM. Scenario-Based Evaluation of Team Health Information Technology to Support Pediatric Trauma Care Transitions. Appl Clin Inform 2022; 13:218-229. [PMID: 35139563 PMCID: PMC8828456 DOI: 10.1055/s-0042-1742368] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 12/21/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Clinicians need health information technology (IT) that better supports their work. Currently, most health IT is designed to support individuals; however, more and more often, clinicians work in cross-functional teams. Trauma is one of the leading preventable causes of children's death. Trauma care by its very nature is team based but due to the emergent nature of trauma, critical clinical information is often missed in the transition of these patients from one service or unit to another. Teamwork transition technology can help support these transitions and minimize information loss while enhancing information gathering and storage. In this study, we created a large screen technology to support shared situational awareness across multiple clinical roles and departments. OBJECTIVES This study aimed to examine if the Teamwork Transition Technology (T3) supports teams and team cognition. METHODS We used a scenario-based mock-up methodology with 36 clinicians and staff from the different units and departments who are involved in pediatric trauma to examine T3. RESULTS Results of the evaluation show that most participants agreed that the technology helps achieve the goals set out in the design phase. Respondents thought that T3 organizes and presents information in a different way that was helpful to them. CONCLUSION In this study, we examined a health IT (T3) that was designed to support teams and team cognition. The results of our evaluation show that participants agreed that T3 does support them in their work and increases their situation awareness.
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Affiliation(s)
- Peter L. T. Hoonakker
- Wisconsin Institute for Health Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, United States
| | - Bat-Zion Hose
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, United States
| | - Pascale Carayon
- Wisconsin Institute for Health Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, United States
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, United States
| | - Ben L. Eithun
- American Family Children's Hospital, Madison, Wisconsin, United States
| | - Deborah A. Rusy
- Department of Anesthesiology, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, United States
| | - Joshua C. Ross
- Department of Emergency Medicine, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, United States
| | - Jonathan E. Kohler
- Department of Surgery, UC Davis Children's Hospital, Sacramento, California, United States
| | - Shannon M. Dean
- Department of Pediatrics, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, United States
| | - Tom B. Brazelton
- Department of Pediatrics, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, United States
| | - Michelle M. Kelly
- Department of Pediatrics, University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin, United States
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Carter K, Podczerwinski J, Love L, Twiss M, Blanchard A, Arora VM, Martin SK. Utilizing Telesimulation for Advanced Skills Training in Consultation and Handoff Communication: A Post-COVID-19 GME Bootcamp Experience. J Hosp Med 2021; 16:730-734. [PMID: 34797994 DOI: 10.12788/jhm.3733] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/03/2021] [Indexed: 11/20/2022]
Abstract
COVID-19 forced the switch to virtual for many educational strategies, including simulation. Virtual formats have the potential to broaden access to simulation training, especially in resource-heavy "bootcamp"-type settings. We converted our in-person communication skills bootcamp to telesimulation and compared effectiveness and satisfaction between formats. During June 2020 orientation, 130 entering interns at one institution participated, using Zoom® to perform one mock consultation and three mock handoffs. Faculty rated performance with checklists and gave feedback. Post-bootcamp surveys assessed participant satisfaction and practice preparedness. Telesimulation performance was comparable to in-person for consultations and slightly inferior for handoffs. Survey response rate was 100%. Compared to in-person, there was higher satisfaction with telesimulation, and interns felt more prepared for practice (95% vs 78%, P < .01); 99% recommended the experience. Fifty percent fewer faculty were required for implementation. Telesimulation was well-received and comparable to in-person bootcamp, representing a feasible, scalable training strategy for communication skills essential in hospital medicine.
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Affiliation(s)
- Keme Carter
- University of Chicago Pritzker School of Medicine, Department of Medicine, Chicago, Illinois
| | - Jeremy Podczerwinski
- University of Chicago Medicine, Office of Graduate Medical Education, Chicago, Illinois
| | - Latassa Love
- University of Chicago Medicine, Office of Graduate Medical Education, Chicago, Illinois
| | - Megham Twiss
- University of Chicago Medicine, Office of Graduate Medical Education, Chicago, Illinois
| | - Anita Blanchard
- University of Chicago Pritzker School of Medicine, Department of Obstetrics and Gynecology, Chicago, Illinois
| | - Vineet M Arora
- University of Chicago Pritzker School of Medicine, Department of Medicine, Chicago, Illinois
| | - Shannon K Martin
- University of Chicago Pritzker School of Medicine, Department of Medicine, Chicago, Illinois
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29
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Gill S, Mills PD, Watts BV, Paull DE, Tomolo A. A Review of Adverse Event Reports From Emergency Departments in the Veterans Health Administration. J Patient Saf 2021; 17:e898-e903. [PMID: 32084094 DOI: 10.1097/pts.0000000000000636] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous work assessing the frequency of adverse events in emergency medicine has been limited. The emergency department (ED) provides an initial point of care for millions of patients. Given the volume of patient encounters and the complexity of medical conditions treated in the ED, it is necessary to determine the system-based issues and associated contributing factors impacting patient safety. OBJECTIVES The aim of this retrospective study were to use root cause analysis reports of adverse events occurring in Veterans Health Administration EDs to understand the range of events that were happening and to determine the primary causes of these events as well as actions to prevent them. METHODS Retrospective safety reports from EDs from Veterans Health Administration medical centers across the nation for a 2-year period (2015-2016) were coded by event type, root cause, and recommended actions. RESULTS One hundred forty-four cases were included for analysis. The most common adverse events were as follows: delays in care (n = 38, 26.4%), elopements (n = 21, 14.6%), suicide attempts and deaths by suicide (n = 15, 10.4%), inappropriate discharges (n = 15, 10.4%), and errors in following procedures (n = 14, 9.7%). Overall, the most common root cause categories leading to adverse events were knowledge/educational deficits (11.4%), policies/procedures needing improvement (11.1%), and lack of standardized policies/procedures (9.4%). DISCUSSION Root cause analysis reports are a useful tool to determine the primary systems-based factors of common adverse events in the ED. Recommendations made in this article for addressing these root causes and potentially ameliorating these events will be useful to EDs and related health systems.
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Affiliation(s)
| | - Peter D Mills
- Veterans Affairs National Center for Patient Safety Field Office, VA Medical Center, White River Junction, Vermont
| | | | | | - Anne Tomolo
- Atlanta VA Healthcare System, Decatur, Georgia
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Kanjee Z, Beltran CP, Smith CC, Lewis J, Hall MM, Tibbles CD, Sullivan AM. "Friction by Definition": Conflict at Patient Handover Between Emergency and Internal Medicine Physicians at an Academic Medical Center. West J Emerg Med 2021; 22:1227-1239. [PMID: 34787545 PMCID: PMC8597691 DOI: 10.5811/westjem.2021.7.52762] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/23/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Patient handoffs from emergency physicians (EP) to internal medicine (IM) physicians may be complicated by conflict with the potential for adverse outcomes. The objective of this study was to identify the specific types of, and contributors to, conflict between EPs and IM physicians in this context. METHODS We performed a qualitative focus group study using a constructivist grounded theory approach involving emergency medicine (EM) and IM residents and faculty at a large academic medical center. Focus groups assessed perspectives and experiences of EP/IM physician interactions related to patient handoffs. We interpreted data with the matrix analytic method. RESULTS From May to December 2019, 24 residents (IM = 11, EM = 13) and 11 faculty (IM = 6, EM = 5) from the two departments participated in eight focus groups and two interviews. Two key themes emerged: 1) disagreements about disposition (ie, whether a patient needed to be admitted, should go to an intensive care unit, or required additional testing before transfer to the floor); and 2) contextual factors (ie, the request to discuss an admission being a primer for conflict; lack of knowledge of the other person and their workflow; high clinical workload and volume; and different interdepartmental perspectives on the benefits of a rapid emergency department workflow). CONCLUSIONS Causes of conflict at patient handover between EPs and IM physicians are related primarily to disposition concerns and contextual factors. Using theoretical models of task, process, and relationship conflict, we suggest recommendations to improve the EM/IM interaction to potentially reduce conflict and advance patient care.
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Affiliation(s)
- Zahir Kanjee
- Beth Israel Deaconess Medical Center, Hospital Medicine Program, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Christine P Beltran
- Beth Israel Deaconess Medical Center, Carl J. Shapiro Institute for Education and Research, Boston, Massachusetts
| | - C Christopher Smith
- Beth Israel Deaconess Medical Center, Hospital Medicine Program, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Internal Medicine Residency Program, Boston, Massachusetts
| | - Jason Lewis
- Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Matthew M Hall
- Providence Regional Medical Center, Department of Emergency Medicine, Everett, Washington.,Washington State University, Pullman, Washington
| | - Carrie D Tibbles
- Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Carl J. Shapiro Institute for Education and Research, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Emergency Medicine Residency Program, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Office of Graduate Medical Education, Boston, Massachusetts
| | - Amy M Sullivan
- Harvard Medical School, Boston, Massachusetts.,Beth Israel Deaconess Medical Center, Carl J. Shapiro Institute for Education and Research, Boston, Massachusetts
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Engel M, van der Padt-Pruijsten A, Huijben AMT, Kuijper TM, Leys MBL, Talsma A, van der Heide A. Quality of hospital discharge letters for patients at the end of life: A retrospective medical record review. Eur J Cancer Care (Engl) 2021; 31:e13524. [PMID: 34697850 PMCID: PMC9285046 DOI: 10.1111/ecc.13524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 06/29/2021] [Accepted: 09/24/2021] [Indexed: 11/28/2022]
Abstract
Objective For patients who are discharged to go home after a hospitalisation, timely and adequately informing their general practitioner is important for continuity of care, especially at the end of life. We studied the quality of the hospital discharge letter for patients who were hospitalised in their last year of life. Methods A retrospective medical record review was performed. Included patients had been admitted to the hospital during the period 1 January to 1 July 2017 and had died within a year after discharge. Results Data were collected from records of 108 patients with cancer or other diseases. For 57 patients (53%), the discharge letter included information that related to their limited life expectancy (e.g., agreements about treatment limitations), whereas the patient's limited life expectancy was addressed in the medical record in 76 cases (70%). We found related information in discharge letters for 36 patients (66%) who died <3 months compared to 21 patients (40%) who died 3–12 months after hospitalisation (p < 0.01). Conclusion For patients with a limited life expectancy going home after a hospitalisation, one out of two hospital discharge letters lacked any information addressing their limited life expectancy. Specific guidelines for medical information exchange between care settings are needed.
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Affiliation(s)
- Marijanne Engel
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | - Auke M T Huijben
- Department of Internal Medicine, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Maria B L Leys
- Department of Internal Medicine, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Kukielka E. Safety Events Impacting Hospitalized Patients Following Motor Vehicle Crashes: A Qualitative Study of Reports From Pennsylvania Hospitals. PATIENT SAFETY 2021. [DOI: 10.33940/data/2021.9.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Motor vehicle crashes (MVCs) are a significant cause of morbidity and mortality in the
United States and around the world. When a patient who has experienced trauma in an
MVC presents to the emergency department, they may be unable to participate in their
own care due to numerous factors, such as being unconscious, physically incapacitated, or suffering from confusion. To better characterize challenges with care of these patients, we analyzed reports of patient safety events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) related to MVCs, and we identified 282 reports for analysis that occurred from 2018–2020. Patients were more often male (58.9%; 166 of 282) than female (41.1%; 116 of 282), and they ranged in age from 1 to 93 years. A total of 13.1% (37 of 282) of reports were classified as serious events (i.e., events that resulted in patient harm), compared with 2.9% in the full acute care PA-PSRS database. Problems with monitoring or treatment were most common (43.3%; 122 of 282), followed by problems with evaluation (18.4%; 52 of 282), falls (11.7%; 33 of 282), problems with documentation (7.4%; 21 of 282), medication errors (7.4%; 21 of 282), and problems with transfers (6.4%; 18 of 282). Some potential contributing factors included communication breakdowns, lack of policies or protocols or unawareness about existing policies or protocols for treating certain patient populations, and prioritization of conditions related to an MVC over underlying health conditions.
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Jaulin F, Lopes T, Martin F. Standardised handover process with checklist improves quality and safety of care in the postanaesthesia care unit: the Postanaesthesia Team Handover trial. Br J Anaesth 2021; 127:962-970. [PMID: 34364652 DOI: 10.1016/j.bja.2021.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 06/19/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Miscommunication is a leading cause of preventable incidents in healthcare. A number of checklists have been created in an attempt to improve patient outcomes with only a small impact. However, the 2009 WHO Surgical Safety Checklist demonstrated benefits in terms of reduced morbidity and mortality. Our aim was to determine whether use of a Postanaesthesia Team Handover (PATH) checklist would reduce hypoxaemic events in the postanaesthesia care unit (PACU). METHODS This single-centre, prospective, pre-/post-implementation study was conducted between February 2019 and July 2020 in the PACU of Versailles Private Hospital, Paris, France. Pre-PATH implementation data were collected for 294 consecutive adult patients (≥18 yr old) admitted to the PACU and post-PATH implementation data were collected for 293 consecutive patients. The primary outcome was the rate of hypoxaemic events post-surgery during PACU stay. RESULTS The rates of hypoxaemic events were 4.1% (11/267 [95% confidence interval {CI}: 2.3-7.2%]) before the PATH checklist was introduced and 0.8% (2/266 [95% CI: 0.2-2.7%]) after. Patients in the PATH group were 5.6 times (odds ratio [OR] [95% CI: 1.3-33.6], P=0.041) less likely to have a hypoxaemic event than those in the control group. The handover process in the PATH checklist group also had significantly less interruptions (38.6% control vs 20.7% PATH; OR=2.5 [95% CI: 1.7-3.7]; P<0.0001). CONCLUSIONS Implementation of the PATH checklist in adult patients post-surgery was associated with a reduction in the rate of hypoxaemic events in the PACU. These findings support standardisation of the handover process with checklists following anaesthesia and surgery. CLINICAL TRIAL REGISTRATION NCT03972423.
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Affiliation(s)
- François Jaulin
- Patient Safety Database, SafeTeam Academy, Facteurs Humains en Santé Association, Paris, France
| | - Thomas Lopes
- Versailles Private Hospital, Ramsay Santé, Paris, France
| | - Frederic Martin
- Patient Safety Database, SafeTeam Academy, Facteurs Humains en Santé Association, Paris, France; Versailles Private Hospital, Ramsay Santé, Paris, France.
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Zaheer S, Ginsburg L, Wong HJ, Thomson K, Bain L, Wulffhart Z. Acute care nurses' perceptions of leadership, teamwork, turnover intention and patient safety - a mixed methods study. BMC Nurs 2021; 20:134. [PMID: 34330272 PMCID: PMC8323271 DOI: 10.1186/s12912-021-00652-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 07/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study contributes to a small but growing body of literature on how context influences perceptions of patient safety in healthcare settings. We examine the impact of senior leadership support for safety, supervisory leadership support for safety, teamwork, and turnover intention on overall patient safety grade. Interaction effects of predictors on perceptions of patient safety are also examined. METHODS In this mixed methods study, cross-sectional survey data (N = 185) were collected from nurses and non-physician healthcare professionals. Semi-structured interview data (N = 15) were collected from nurses. The study participants worked in intensive care, general medicine, mental health, or the emergency department of a large community hospital in Southern Ontario. RESULTS Hierarchical regression analyses showed that staff perceptions of senior leadership (p < 0.001), teamwork (p < 0.01), and turnover intention (p < 0.01) were significantly associated with overall patient safety grade. The interactive effect of teamwork and turnover intention on overall patient safety grade was also found to be significant (p < 0.05). The qualitative findings corroborated the survey results but also helped expand the characteristics of the study's key concepts (e.g., teamwork within and across professional boundaries) and why certain statistical relationships were found to be non-significant (e.g., nurse interviewees perceived the safety specific responsibilities of frontline supervisors much more broadly compared to the narrower conceptualization of the construct in the survey). CONCLUSIONS The results of the current study suggest that senior leadership, teamwork, and turnover intention significantly impact nursing staff perceptions of patient safety. Leadership is a modifiable contextual factor and resources should be dedicated to strengthen relational competencies of healthcare leaders. Healthcare organizations must also proactively foster inter and intra-professional collaboration by providing teamwork educational workshops or other on-site learning opportunities (e.g., simulation training). Healthcare organizations would benefit by considering the interactive effect of contextual factors as another lever for patient safety improvement, e.g., lowering staff turnover intentions would maximize the positive impact of teamwork improvement initiatives on patient safety.
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Affiliation(s)
- Shahram Zaheer
- School of Health Policy and Management, York University, Toronto, Canada. .,Daphne Cockwell School of Nursing, Ryerson University, Toronto, Canada. .,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.
| | - Liane Ginsburg
- School of Health Policy and Management, York University, Toronto, Canada
| | - Hannah J Wong
- School of Health Policy and Management, York University, Toronto, Canada
| | - Kelly Thomson
- School of Administrative Studies, York University, Toronto, Canada
| | - Lorna Bain
- Interprofessional Collaboration and Education, Southlake Regional Health Centre, Newmarket, Canada.,University of Toronto, Toronto, Canada
| | - Zaev Wulffhart
- University of Toronto, Toronto, Canada.,Regional Cardiac Care Program, Southlake Regional Health Centre, Newmarket, Canada
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Chladek MS, Doughty C, Patel B, Alade K, Rus M, Shook J, LIttle-Weinert K. The Standardisation of handoffs in a large academic paediatric emergency department using I-PASS. BMJ Open Qual 2021; 10:e001254. [PMID: 34244172 PMCID: PMC8273485 DOI: 10.1136/bmjoq-2020-001254] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 06/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite the American College of Emergency Physicians and American Academy of Pediatrics recommendations for standardised handoffs in the emergency department (ED), few EDs have an established tool. Our aim was to improve the quality of handoffs in the ED by establishing compliance with the I-PASS handoff tool. METHODS This is a quality improvement (QI) initiative to standardise handoffs in a large academic paediatric ED. Following review of the literature and focus groups with key stakeholders, I-PASS was selected and modified to fit departmental needs. Implementation throughPlan-Do-Study-Act cycles included the development of educational materials, reminders and real-time feedback. Required use of I-PASS during designated team sign-out began in June 2016. Compliance with the handoff tool and handoff deficiencies was measured through observations by faculty trained in I-PASS. As a balancing measure, time to complete handoff was monitored and compared with preintervention data. RESULTS Compliance with I-PASS reached 80% within 6 months, 100% within 7 months and sustained at 100% during the remainder of the study period. The average percent of omissions of crucial information per handoff declined to 8.3%, which was a 53% decrease. Average percentage of tangential information and miscommunications per handoff did not show a decline. The average handoff took 20 min, which did not differ from the preintervention time. Survey results demonstrated a perceived improvement in patient safety through closed-loop communication, clear action lists and contingency planning and proper patient acuity identification. CONCLUSIONS I-PASS is applicable in the ED and can be successfully implemented through QI methodology contributing to an overall culture of safety.
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Affiliation(s)
| | - Cara Doughty
- Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Binita Patel
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Kyetta Alade
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Marideth Rus
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Joan Shook
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Kim LIttle-Weinert
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
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Midega TD, Leite Filho NCV, Nassar AP, Alencar RM, Capone Neto A, Ferraz LJR, Corrêa TD. Impact of intensive care unit admission during handover on mortality: propensity matched cohort study. EINSTEIN-SAO PAULO 2021; 19:eAO5748. [PMID: 34161436 PMCID: PMC8225264 DOI: 10.31744/einstein_journal/2021ao5748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 12/06/2020] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To investigate the impact of intensive care unit admission during medical handover on mortality. METHODS Post-hoc analysis of data extracted from a prior study aimed at addressing the impacts of intensive care unit readmission on clinical outcomes. This retrospective, single-center, propensity-matched cohort study was conducted in a 41-bed general open-model intensive care unit. Patients were assigned to one of two cohorts according to time of intensive care unit admission: Handover Group (intensive care unit admission between 6:30 am and 7:30 am or 6:30 pm and 7:30 pm) or Control Group (intensive care unit admission between 7:31 am and 6:29 pm or 7:31 pm and 6:29 am). Patients in the Handover Group were propensity-matched to patients in the Control Group at a 1:2 ratio. RESULTS A total of 6,650 adult patients were admitted to the intensive care unit between June 1st 2013 and May 31st 2015. Following exclusion of non-eligible participants, 5,779 patients (389; 6.7% and 5,390; 93.3%, Handover and Control Group) were deemed eligible for propensity score matching. Of these, 1,166 were successfully matched (389; 33.4% and 777; 66.6%, Handover and Control Group). Following propensity-score matching, intensive care unit admission during handover was not associated with increased risk of intensive care unit (OR: 1.40; 95%CI: 0.92-2.11; p=0.113) or in-hospital (OR: 1.23; 95%CI: 0.85-1.75; p=0.265) mortality. CONCLUSION Intensive care unit admission during medical handover did not affect in-hospital mortality in this propensity-matched, single-center cohort study.
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Affiliation(s)
| | | | | | - Roger Monteiro Alencar
- Hospital Municipal Dr. Moysés Deutsch; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Kanjee Z, Bilello L. Leadership & Professional Development: Specialty Silos in Medicine. J Hosp Med 2021; 16:357. [PMID: 34129488 DOI: 10.12788/jhm.3647] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 05/10/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Zahir Kanjee
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Leslie Bilello
- Harvard Medical School, Boston, Massachusetts
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Abstract
OBJECTIVES To examine adverse events and associated factors and outcomes during transition from ICU to hospital ward (after ICU discharge). DESIGN Multicenter cohort study. SETTING Ten adult medical-surgical Canadian ICUs. PATIENTS Patients were those admitted to one of the 10 ICUs from July 2014 to January 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two ICU physicians independently reviewed progress and consultation notes documented in the medical record within 7 days of patient's ICU discharge date to identify and classify adverse events. The adverse event data were linked to patient characteristics and ICU and ward physician surveys collected during the larger prospective cohort study. Analyses were conducted using multivariable logistic regression. Of the 451 patients included in the study, 84 (19%) experienced an adverse event, the majority (62%) within 3 days of transfer from ICU to hospital ward. Most adverse events resulted only in symptoms (77%) and 36% were judged to be preventable. Patients with adverse events were more likely to be readmitted to the ICU (odds ratio, 5.5; 95% CI, 2.4-13.0), have a longer hospital stay (mean difference, 16.1 d; 95% CI, 8.4-23.7) or die in hospital (odds ratio, 4.6; 95% CI, 1.8-11.8) than those without an adverse event. ICU and ward physician predictions at the time of ICU discharge had low sensitivity and specificity for predicting adverse events, ICU readmissions, and hospital death. CONCLUSIONS Adverse events are common after ICU discharge to hospital ward and are associated with ICU readmission, increased hospital length of stay and death and are not predicted by ICU or ward physicians.
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Sauro K, Maini A, Machan M, Lorenzetti D, Chandarana S, Dort J. Are there opportunities to improve care as patients transition through the cancer care continuum? A scoping review protocol. BMJ Open 2021; 11:e043374. [PMID: 33495258 PMCID: PMC7839915 DOI: 10.1136/bmjopen-2020-043374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Transitions in Care (TiC) are vulnerable periods in care delivery associated with adverse events, increased cost and decreased patient satisfaction. Patients with cancer encounter many transitions during their care journey due to improved survival rates and the complexity of treatment. Collectively, improving TiC is particularly important among patients with cancer. The objective of this scoping review is to synthesise and map the existing literature regarding TiC among patients with cancer in order to explore opportunities to improve TiC among patients with cancer. METHODS AND ANALYSIS This scoping review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review Extension and the Joanna Briggs Institute methodology. The PubMed cancer filter and underlying search strategy will be tailored to each database (Embase, Cochrane, CINAHL and PsycINFO) and combined with search terms for TiC. Grey literature and references of included studies will be searched. The search will include studies published from database inception until 9 February 2020. Quantitative and qualitative studies will be included if they describe transitions between any type of healthcare provider or institution among patients with cancer. Descriptive statistics will summarise study characteristics and quantitative data of included studies. Qualitative data will be synthesised using thematic analysis. ETHICS AND DISSEMINATION Our objective is to synthesise and map the existing evidence; therefore, ethical approval is not required. Evidence gaps around TiC will inform a programme of research aimed to improve high-risk transitions among patients with cancer. The findings of this scoping review will be published in a peer-reviewed journal and widely presented at academic conferences. More importantly, decision makers and patients will be provided a summary of the findings, along with data from a companion study, to prioritise TiC in need of interventions to improve continuity of care for patients with cancer.
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Affiliation(s)
- Khara Sauro
- Department of Community Health Sciences & O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology & Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Arjun Maini
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matthew Machan
- Department of Community Health Sciences & O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Diane Lorenzetti
- Department of Community Health Sciences & O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shamir Chandarana
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Joseph Dort
- Department of Community Health Sciences & O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology & Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Abstract
Previous transitional care research has focused on transitions occurring between community and hospital settings. Little is known regarding intrahospital transitions and how they affect care quality. A systematic review was therefore conducted to synthesize the literature regarding clinical outcomes associated with intrahospital transitions. Literature published between January 2003 and December 2018 and indexed in Medline/PubMed, CINAHL, and PsychINFO were reviewed using PRISMA guidelines. Articles were limited to English language and peer-reviewed. Articles were excluded if they focused on transitions occurring from or to the hospital, discharge/discharge planning, or postdischarge follow-up. Data abstraction included study characteristics, sample characteristics, and reported clinical outcomes. Fourteen studies met inclusion criteria, primarily using cross-sectional, cohort, or retrospective chart review quantitative designs. Data were analyzed and synthesized based on outcomes reported. Major outcomes emerging from the articles included delirium, hospital length of stay, mortality, and adverse events. Delirium, hospital length of stay, and morbidity and mortality rates were associated with delayed transfers and transfers to inappropriate units. In addition, increased fall risk and infection rates were associated with higher rates of transfer. Intrahospital transitions represent critical periods of time where the quality of care being provided may be diminished, negatively affecting patient safety and outcomes.
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Parsons Leigh J, Brundin-Mather R, Whalen-Browne L, Kashyap D, Sauro K, Soo A, Petersen J, Taljaard M, Stelfox HT. Effectiveness of an Electronic Communication Tool on Transitions in Care From the Intensive Care Unit: Protocol for a Cluster-Specific Pre-Post Trial. JMIR Res Protoc 2021; 10:e18675. [PMID: 33416509 PMCID: PMC7822720 DOI: 10.2196/18675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Transitions in care are vulnerable periods in health care that can expose patients to preventable errors due to incomplete or delayed communication between health care providers. Transitioning critically ill patients from intensive care units (ICUs) to other patient care units (PCUs) is particularly risky, due to the high acuity of the patients and the diversity of health care providers involved in their care. Instituting structured documentation to standardize written communication between health care providers during transitions has been identified as a promising means to reduce communication breakdowns. We developed an evidence-informed, computer-enabled, ICU-specific structured tool-an electronic transfer (e-transfer) tool-to facilitate and standardize the composition of written transfer summaries in the ICUs of one Canadian city. The tool consisted of 10 primary sections with a user interface combination of structured, automated, and free-text fields. OBJECTIVE Our overarching goal is to evaluate whether implementation of our e-transfer tool will improve the completeness and timeliness of transfer summaries and streamline communications between health care providers during high-risk transitions. METHODS This study is a cluster-specific pre-post trial, with randomized and staggered implementation of the e-transfer tool in four hospitals in Calgary, Alberta. Hospitals (ie, clusters) were allocated randomly to cross over every 2 months from control (ie, dictation only) to intervention (ie, e-transfer tool). Implementation at each site was facilitated with user education, point-of-care support, and audit and feedback. We will compare transfer summaries randomly sampled over 6 months postimplementation to summaries randomly sampled over 6 months preimplementation. The primary outcome will be a binary composite measure of the timeliness and completeness of transfer summaries. Secondary measures will include overall completeness, timeliness, and provider ratings of transfer summaries; hospital and ICU lengths of stay; and post-ICU patient outcomes, including ICU readmission, adverse events, cardiac arrest, rapid response team activation, and mortality. We will use descriptive statistics (ie, medians and means) to describe demographic characteristics. The primary outcome will be compared within each hospital pre- and postimplementation using separate logistic regression models for each hospital, with adjustment for patient characteristics. RESULTS Participating hospitals were cluster randomized to the intervention between July 2018 and January 2019. Preliminary extraction of ICU patient admission lists was completed in September 2019. We anticipate that evaluation data collection will be completed by early 2021, with first results ready for publication in spring or summer 2021. CONCLUSIONS This study will report the impact of implementing an evidence-informed, computer-enabled, ICU-specific structured transfer tool on communication and preventable medical errors among patients transferred from the ICU to other hospital care units. TRIAL REGISTRATION ClinicalTrials.gov NCT03590002; https://www.clinicaltrials.gov/ct2/show/NCT03590002. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/18675.
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Affiliation(s)
- Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada.,Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Rebecca Brundin-Mather
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Liam Whalen-Browne
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Devika Kashyap
- Critical Care Medicine, Alberta Health Services, Calgary, AB, Canada
| | - Khara Sauro
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada.,Arnie Charbonneau Cancer Institute, Health Research Innovation Centre, University of Calgary, Calgary, AB, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Critical Care Medicine, Alberta Health Services, Calgary, AB, Canada
| | - Jennie Petersen
- Faculty of Applied Health Sciences, Brock University, St Catharines, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Critical Care Medicine, Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Sarver WL, Seabold K, Kline M. Shadowing to Improve Teamwork and Communication:. NURSE LEADER 2020; 18:597-603. [PMID: 32837350 PMCID: PMC7369004 DOI: 10.1016/j.mnl.2020.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/29/2020] [Accepted: 05/12/2020] [Indexed: 11/12/2022]
Abstract
Teamwork and communication are paramount to patient safety. Poor communication during handoff is implicated in near misses and adverse events. Exposing nurses to other units’ workflow early in their orientation may also aid in surge staffing. This study showed improvements in teamwork and communication, and a deeper understanding of another units’ workflow.
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Hermanson S, Osborn S, Gordanier C, Coates E, Williams B, Blackmore C. Reduction of early inpatient transfers and rapid response team calls after implementation of an emergency department intake huddle process. BMJ Open Qual 2020; 9:bmjoq-2019-000862. [PMID: 32217533 PMCID: PMC7170542 DOI: 10.1136/bmjoq-2019-000862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 11/06/2022] Open
Abstract
Patients admitted to the hospital and requiring a subsequent transfer to a higher level of care have increased morbidity, mortality and length of stay compared with patients who do not require a transfer during their hospital stay. We identified that a high number of patients admitted to our intermediate care (IMC) unit required a rapid response team (RRT) call and an early (<24 hours) transfer to the intensive care unit (ICU). A quality improvement project was initiated with the goal to reduce subsequent early transfers to the ICU and RRT calls. We started by focusing on IMC patients, implementing acuity-based nursing assignments and standardised daily nursing rounds in the IMC aiming to reduce early patient transfers to the ICU. Then, we expanded to all patients admitted to a hospital medical unit from the emergency department (ED), targeting patients with gastrointestinal (GI) bleed and sepsis who were at a higher risk for early transfer to the ICU. We then created an ED intake huddle process that over time was refined to target patients with SIRS criteria with an elevated serum lactic acid level greater than 2.0 mmol/L or a GI bleed with a haematocrit value less than 24%. These interventions resulted in an 10.8 percentage points (31.7% (225/710) to 20.9% (369/1764)) decrease in the early transfers to the ICU for all hospital medicine patients admitted to the hospital from the ED. Mean RRT calls/day decreased by 17%, from 3.0 mean calls/day preintervention to 2.5 mean calls/day postintervention. These quality improvement initiatives have sustained successful outcomes for over 6 years due to integrating enhanced team communication as organisational cultural norm that has become the standard.
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Affiliation(s)
- Sarah Hermanson
- Center for Health Care Improvement Science, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Scott Osborn
- Emergency Medicine, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Christin Gordanier
- Hospital Nursing, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Evan Coates
- Hospital Medicine, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Barbara Williams
- Center for Health Care Improvement Science, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Craig Blackmore
- Center for Health Care Improvement Science, Virginia Mason Medical Center, Seattle, Washington, USA
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Dalal PG, Cios TJ, DeMartini TKM, Prasad AA, Whitley MC, Clark JB, Lin L, Mujsce DJ, Cilley RE. A Model for a Standardized and Sustainable Pediatric Anesthesia-Intensive Care Unit Hand-Off Process. CHILDREN-BASEL 2020; 7:children7090123. [PMID: 32899207 PMCID: PMC7552720 DOI: 10.3390/children7090123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/29/2020] [Accepted: 09/01/2020] [Indexed: 11/16/2022]
Abstract
Background and Objectives: The hand-off process between pediatric anesthesia and intensive care unit (ICU) teams involves the exchange of patient health information and plays a major role in reducing errors and increasing staff satisfaction. Our objectives were to (1) standardize the hand-off process in children’s ICUs, and (2) evaluate the provider satisfaction, efficiency and sustainability of the improved hand-off process. Methods: Following multidisciplinary discussions, the hand-off process was standardized for transfers of care between anesthesia-ICU teams. A pre-implementation and two post-implementation (6 months, >2 years) staff satisfaction surveys and audits were conducted to evaluate the success, quality and sustainability of the hand-off process. Results: There was no difference in the time spent during the sign out process following standardization—median 5 min for pre-implementation versus 5 and 6 min for post-implementation at six months and >2 years, respectively. There was a significant decrease in the number of missed items (airway/ventilation, venous access, medications, and laboratory values pertinent events) post-implementation compared to pre-implementation (p ≤ 0.001). In the >2 years follow-up survey, 49.2% of providers felt that the hand-off could be improved versus 78.4% in pre-implementation and 54.2% in the six-month survey (p < 0.001). Conclusion: A standardized interactive hand-off improves the efficiency and staff satisfaction, with a decreased rate of missed information at the cost of no additional time.
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Affiliation(s)
- Priti G. Dalal
- Departments of Anesthesiology and Peri-Operative Medicine, Penn State Health Milton S Hershey Medical Center, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (T.J.C.); (A.A.P.); (M.C.W.)
- Correspondence:
| | - Theodore J. Cios
- Departments of Anesthesiology and Peri-Operative Medicine, Penn State Health Milton S Hershey Medical Center, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (T.J.C.); (A.A.P.); (M.C.W.)
| | - Theodore K. M. DeMartini
- Division of Pediatric Critical Care, Department of Pediatrics, Penn State Health Children’s Hospital, Hershey, PA 17033, USA;
| | - Amit A. Prasad
- Departments of Anesthesiology and Peri-Operative Medicine, Penn State Health Milton S Hershey Medical Center, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (T.J.C.); (A.A.P.); (M.C.W.)
| | - Meghan C. Whitley
- Departments of Anesthesiology and Peri-Operative Medicine, Penn State Health Milton S Hershey Medical Center, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (T.J.C.); (A.A.P.); (M.C.W.)
| | - Joseph B. Clark
- Division of Pediatric Cardiac Surgery, Department of Pediatrics, Penn State Health Children’s Hospital, Hershey, PA 17033, USA;
| | - Leon Lin
- Department of Emergency Medicine, Ohio State Universirty, Columbus, OH 43210, USA;
| | - Dennis J. Mujsce
- Division of Newborn Medicine, Department of Pediatrics, Penn State Health Children’s Hospital, Hershey, PA 17033, USA;
| | - Robert E. Cilley
- Division of Pediatric Surgery, Department of Surgey, Penn State Health Children’s Hospital, Hershey, PA 17033, USA;
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Abstract
Information management in the emergency department (ED) is a challenge for all providers. The volume of information required to care for each patient and to keep the ED functioning is immense. It must be managed through varying means of communication and in connection with ED information systems. Management of information in the ED is imperfect; different modes and methods of identification, interpretation, action, and communication can be beneficial or harmful to providers, patients, and departmental flow. This article reviews the state of information management in the ED and proposes recommendations to improve the management of information in the future.
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Affiliation(s)
- Evan L Leventhal
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 1 Deaconess Road, Boston, MA 02215, USA.
| | - Kraftin E Schreyer
- Department of Emergency Medicine, Temple University Hospital, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA
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Boiko O, Edwards M, Zschaler S, Miles S, Rafferty AM. Interprofessional barriers in patient flow management: an interview study of the views of emergency department staff involved in patient admissions. J Interprof Care 2020; 35:334-342. [PMID: 32506989 DOI: 10.1080/13561820.2020.1760223] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Patient flow in emergency departments (EDs) is notoriously difficult to manage efficiently. While much of the attention has focused on the procedures, protocols and pathways in which patients receive their first hours of care, less attention has been paid to the relational factors that make it happen. Our study is the first, to our knowledge, to consider the role of interprofessional barriers, defined as suboptimal ways of working, as perceived by ED staff in patient flow management. Drawing on 19 interviews with hospital staff in an acute tertiary trauma center hospital in England, we established three flow-related types of interprofessional barriers: ED teamwork barriers, performance-driven coordination barriers, and referral-related collaborative barriers. Knotworking was recognized as a form of interactions and asset to teamworking, coordination, and collaboration. Identifying processes such as chasing, escalating, and advocating enabled our investigation to highlight a very complex set of interprofessional interactions, and signpost what the suboptimal practices of flow management are. Our analysis holds promise for hospitals beyond the National Health Service in England.
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Affiliation(s)
- Olga Boiko
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew Edwards
- Academic Research Fellow, King's College Hospital Emergency Department, London, UK
| | - Steffen Zschaler
- Department of Informatics, Faculty of Natural and Mathematical Sciences, King's College London, London, UK
| | - Simon Miles
- Department of Informatics, Faculty of Natural and Mathematical Sciences, King's College London, London, UK
| | - Anne Marie Rafferty
- Florence Nightingale Faculty of Nursing and Midwifery and Palliative Care, Department of Adult Nursing, Kings' College London and Royal College of Nursing, London, UK
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Fekieta R, Rosenberg A, Hodshon B, Feder S, Chaudhry SI, Emerson BL. Organisational factors underpinning intra-hospital transfers: a guide for evaluating context in quality improvement. Health Syst (Basingstoke) 2020; 10:239-248. [PMID: 34745587 DOI: 10.1080/20476965.2020.1768807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
During intra-hospital transfers, multiple clinicians perform coordinated tasks that leave patients vulnerable to undesirable outcomes. Communication has been established as a challenge to care transitions, but less is known about the organisational complexities within which transfers take place. We performed a qualitative assessment that included various professions to capture a multi-faceted understanding of intra-hospital transfers. Ethnographic observations and semi-structured interviews were conducted with clinicians and staff from the Medical Intensive Care Unit, Emergency Department, and general medicine units at a large, urban, academic, tertiary medical centre. Results highlight the organisational factors that stakeholders view as important for successful transfers: the development, dissemination, and application of protocols; robustness of technology; degree of teamwork; hospital capacity; and the ways in which competing hospital priorities are managed. These factors broaden our understanding of the organisational context of intra-hospital transfers and informed the development of a practical guide that can be used prior to embarking on quality improvement efforts around transitions of care.
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Affiliation(s)
- Renee Fekieta
- Center for Healthcare Innovation, Redesign & Learning, Yale University School of Medicine, New Haven, CT, USA
| | | | - Beth Hodshon
- Center for Healthcare Innovation, Redesign & Learning, Yale University School of Medicine, New Haven, CT, USA
| | - Shelli Feder
- Yale University School of Nursing, New Haven, CT, USA
| | - Sarwat I Chaudhry
- Center for Healthcare Innovation, Redesign & Learning, Yale University School of Medicine, New Haven, CT, USA
| | - Beth L Emerson
- Center for Healthcare Innovation, Redesign & Learning, Yale University School of Medicine, New Haven, CT, USA
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Improving transitions in care from intensive care units: Development and pilot testing of an electronic communication tool for healthcare providers. J Crit Care 2020; 56:265-272. [DOI: 10.1016/j.jcrc.2020.01.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/08/2019] [Accepted: 01/16/2020] [Indexed: 11/23/2022]
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Kannampallil T, Abraham J. Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study. JAMIA Open 2020; 3:ooz069. [PMID: 32142114 PMCID: PMC7309249 DOI: 10.1093/jamiaopen/ooz069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 11/09/2019] [Accepted: 12/18/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To characterize interactivity during resident and nurse handoffs by investigating listening and question-asking behaviors during conversations. MATERIALS AND METHODS Resident (n = 149) and nurse (n = 126) handoffs in an inpatient medicine unit were audio-recorded. Handoffs were coded based on listening behaviors (active and passive), question types (patient status, coordination of care, clinical reasoning, and framing and alignment), and question responses. Comparisons between residents and nurses for listening and question-asking behaviors were performed using the Wilcoxon rank-sum tests. A Poisson regression model was used to investigate differences in the question-asking behaviors between residents and nurses, and the association between listening and question-asking behaviors. RESULTS There were no significant differences between residents and nurses in their active (18% resident vs 39% nurse handoffs) or passive (88% resident vs 81% nurse handoffs) listening behaviors. Question-asking was common in resident and nurse handoffs (87% vs 98%) and focused primarily on patient status, co-ordination, and framing and alignment. Nurses asked significantly more questions than residents (Mresident = 2.06 and Mnurse = 5.52) by a factor of 1.76 (P < 0.001). Unit increase in listening behaviors was associated with an increase in the number of questions during resident and nurse handoffs by 7% and 12%, respectively. DISCUSSION AND CONCLUSION As suggested by the Joint Commission, question-asking behaviors were common across resident and nurse handoffs, playing a critical role in supporting resilience in communication and collaborative cross-checks during conversations. The role of listening in initiating question-asking behaviors is discussed.
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Affiliation(s)
- Thomas Kannampallil
- Department of Anesthesiology & Institute for Informatics, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Joanna Abraham
- Department of Anesthesiology & Institute for Informatics, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
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50
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Germack HD, Fekieta R, Campbell Britton M, Feder SL, Rosenberg A, Chaudhry SI. Cooperation and conflict in intra-hospital transfers: A qualitative analysis. Nurs Open 2020; 7:634-641. [PMID: 32089862 PMCID: PMC7024622 DOI: 10.1002/nop2.434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 11/15/2019] [Accepted: 11/27/2019] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Hayley D. Germack
- National Clinician Scholars ProgramYale University School of MedicineNew HavenCTUSA
- Present address:
School of Nursing Department of Acute and Tertiary CareUniversity of PittsburghPittsburghPAUSA
| | - Renee Fekieta
- Department of Population HealthYale University School of MedicineNew HavenCTUSA
| | | | | | | | - Sarwat I. Chaudhry
- Department of Internal MedicineYale University School of MedicineNew HavenCTUSA
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