Communication at Transitions of Care

Comparing Outcomes Between Direct and ED Admissions for Neonatal Hyperbilirubinemia

OBJECTIVES

Pediatric direct admissions (DA) have multiple benefits including reduced emergency department (ED) volumes, greater patient and provider satisfaction, and decreased costs without compromising patient safety. We sought to compare resource utilization and outcomes between patients with a primary diagnosis of neonatal hyperbilirubinemia directly admitted with those admitted from the ED.

METHODS

Single-center, retrospective study at a large, academic, free-standing children's hospital (2017-2021). Patients were between 24 hours and 14 days old with a gestational age of ≥35 weeks, admitted with a primary diagnosis of neonatal hyperbilirubinemia. Outcomes included length of stay (LOS), time to clinical care, resource utilization, NICU transfer, and 7-day readmission for phototherapy.

RESULTS

A total of 1098 patients were included, with 276 (25.1%) ED admissions and 822 (74.9%) DAs. DAs experienced a shorter median time to bilirubin level collection (1.9 vs 2.1 hours, P = .003), received less intravenous fluids (8.9% vs 51.4%, P < .001), had less bilirubin levels collected (median of 3.0 vs 4.0, P < .001), received phototherapy sooner (median of 0.8 vs 4.2 hours, P < .001), and had a shorter LOS (median of 21 vs 23 hours, P = .002). One patient who was directly admitted required transfer to the NICU. No differences were observed in the 7-day readmission rates for phototherapy.

CONCLUSIONS

Directly admitting patients for the management of neonatal hyperbilirubinemia is a preferred alternative to ED admission as our study demonstrated that DAs had a shorter time to clinical care, shorter LOS, and less unnecessary resource utilization with no difference in 7-day readmissions for phototherapy.

Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool

OBJECTIVES

The transition from the intensive care unit (ICU) to the medical ward is a high-risk period due to medical complexity, reduced patient monitoring, and diagnostic uncertainty. Standardized handoff practices reduce errors associated with transitions of care, but little work has been done to standardize the ICU to ward handoff. Further, tools that exist do not focus on preventing diagnostic error. Using Human-Centered Design methods we previously created a novel EHR-based ICU-ward handoff tool (ICU-PAUSE) that embeds a diagnostic pause at the time of transfer. This study aims to explore barriers and facilitators to implementing a diagnostic pause at the ICU-to-ward transition.

METHODS

This is a multi-center qualitative study of semi-structured interviews with intensivists from ten academic medical centers. Interviews were analyzed iteratively through a grounded theory approach. The Sittig-Singh sociotechnical model was used as a unifying conceptual framework.

RESULTS

Across the eight domains of the model, we identified major benefits and barriers to implementation. The embedded pause to address diagnostic uncertainty was recognized as a key benefit. Participants agreed that standardization of verbal and written handoff would decrease variation in communication. The main barriers fell within the domains of workflow, institutional culture, people, and assessment.

CONCLUSIONS

This study represents a novel application of the Sittig-Singh model in the assessment of a handoff tool. A unique feature of ICU-PAUSE is the explicit acknowledgement of diagnostic uncertainty, a practice that has been shown to reduce medical error and prevent premature closure. Results will be used to inform future multi-site implementation efforts.

Medication Reconciliation during Transitions of Care Across Institutions: A Quantitative Analysis of Challenges and Opportunities

OBJECTIVE

Medication discrepancies between clinical systems may pose a patient safety hazard. In this paper, we identify challenges and quantify medication discrepancies across transitions of care.

METHODS

We used structured clinical data and free-text hospital discharge summaries to compare active medications' lists at four time points: preadmission (outpatient), at-admission (inpatient), at-discharge (inpatient), and postdischarge (outpatient). Medication lists were normalized to RxNorm. RxNorm identifiers were further processed using the RxNav API to identify the ingredient. The specific drugs and ingredients from inpatient and outpatient medication lists were compared.

RESULTS

Using RxNorm drugs, the median percentage intersection when comparing active medication lists within the same electronic health record system ranged between 94.1 and 100% indicating substantial overlap. Similarly, when using RxNorm ingredients the median percentage intersection was 94.1 to 100%. In contrast, the median percentage intersection when comparing active medication lists across EHR systems was significantly lower (RxNorm drugs: 6.1-7.1%; RxNorm ingredients: 29.4-35.0%) indicating that the active medication lists were significantly less similar (p < 0.05).Medication lists in the same EHR system are more similar to each other (fewer discrepancies) than medication lists in different EHR systems when comparing specific RxNorm drug and the more general RxNorm ingredients at transitions of care. Transitions of care that require interoperability between two EHR systems are associated with more discrepancies than transitions where medication changes are expected (e.g., at-admission vs. at-discharge). Challenges included lack of access to structured, standardized medication data across systems, and difficulty distinguishing medications from orderable supplies such as lancets and diabetic test strips.

CONCLUSION

Despite the challenges to medication normalization, there are opportunities to identify and assist with medication reconciliation across transitions of care between institutions.

Development of the Pediatric Hospitalization Admission Survey of Experience (PHASE) Measure

BACKGROUND

Although significant research is devoted to transitions of care at discharge, few measures assess the quality of transitions into the hospital. Our objective was to develop a caregiver-reported quality measure to evaluate the pediatric hospital admission experience.

METHODS

Measure development included: (1) adapting items from existing instruments; (2) an expert-consensus process to prioritize survey items; (3) cognitive pretesting with caregivers (n = 16); and (4) pilot testing revised items (n = 27). Subsequently, the survey was administered to caregivers at 2 children's hospitals and 1 general hospital from February 2020 through November 2021. Item reduction statistics and exploratory factor analysis were performed followed by confirmatory factor analysis. Domain scores were calculated using a top-box approach. Known-group validity and indices of model fit were evaluated.

RESULTS

The initial survey included 25 items completed by 910 caregivers. Following item reduction and the exploratory factor analysis, 14 items were mapped to 4 domains: (1) Patient and Family Engagement, (2) Information Sharing, (3) Effectiveness of Care Delivery, and (4) Timeliness of Care. The confirmatory factor analysis and validity testing supported the factor structure. Domain scores ranged from 49% (95% confidence interval, 46-53) for Timelines of Care to 81% (95% confidence interval, 65-84) for Patient and Family Engagement, with significant differences between general and children's hospitals in Information Sharing and Effectiveness of Care Delivery.

CONCLUSIONS

A 4-domain caregiver-reported hospital admission experience measure demonstrated acceptable validity and psychometric properties across children's and general hospitals. This measure can be used to evaluate the quality of transitions into the hospital and to focus quality improvement efforts.

Safe handoff practices and improvement of communication in different paediatric settings

Inadequate information management, especially during patient handoff, contributes to a large part of health care-related adverse events. The Committee for Quality of Care and Patient Safety of the Asociación Española de Pediatría has developed this document to provide an overview of handover practices in different paediatric care settings (emergency, inpatient, intensive care, neonatal and primary care). It describes resources to achieve safe and effective communication in all these settings, such as standardised handoff tools. It also proposes recommendations for the prevention of medication errors during the handover process, to improve safety in interhospital and intrahospital patient transfer, and to optimise communication and continuity of care in chronically ill and medically complex children.

Improving Handoffs in the Perioperative Environment: A Conceptual Framework of Key Theories, System Factors, Methods, and Core Interventions to Ensure Success

BACKGROUND

Patient handoffs involve the transition of information and responsibility for care from one health care provider to another. They occur frequently during a patient's perioperative care continuum, potentially introducing communication errors that could result in harmful, even fatal consequences. The perioperative environment poses distinct challenges to team communication and patient safety, which in turn leaves the surgical patient uniquely vulnerable to adverse events.

CONCEPTUAL FRAMEWORK

The best way to achieve safe, coordinated handoffs throughout the perioperative continuum has yet to be established. However, a variety of theoretical principles, methods, and interventions have been used successfully in operative and nonoperative contexts among multiple disciplines. Informed by a literature review, the authors describe a conceptual framework for the development, implementation, and sustainment of a multimodal perioperative handoff improvement bundle. The conceptual framework presented here begins with overarching objectives for patient-centered handoff improvement efforts. The article outlines theoretical principles that could be used to guide and inform future multimodal interventions, as well as health care system factors to consider. Further, the authors propose employing data-driven quality improvement and research methodologies to conduct, measure, achieve, and sustain long-term success. Finally, this report describes essential evidence-based interventional components to employ.

IMPLICATIONS

Future efforts to improve handoff safety in the perioperative environment will require a comprehensive evidence-based approach. The authors believe the conceptual framework presented here outlines essential components for success. It integrates proven theoretical frameworks, consideration of system factors, data-driven iterative methods, and synergistic patient-centered interventions.

Implementation of ED I-PASS as a Standardized Handoff Tool in the Pediatric Emergency Department

INTRODUCTION

Communication, failures during patient handoffs are a significant cause of medical error. There is a paucity of data on standardized handoff tools for intershift transitions of care in pediatric emergency medicine (PEM). The purpose of this quality improvement (QI) initiative was to improve handoffs between PEM attending physicians (i.e., supervising physicians ultimately responsible for patient care) through the implementation of a modified I-PASS tool (ED I-PASS). Our aims were to: (1) increase the proportion of physicians using ED I-PASS by two-thirds and (2) decrease the proportion reporting information loss during shift change by one-third, over a 6-month period.

METHODS

After literature and stakeholder review, Expected Disposition, Illness Severity, Patient Summary, Action List, Situational Awareness, Synthesis by Receiver (ED I-PASS) was implemented using iterative Plan-Do-Study-Act cycles, incorporating: trained "super-users"; print and electronic cognitive support tools; direct observation; and general and targeted feedback. Implementation occurred from September to April of 2021, during the height of the COVID-19 pandemic, when patient volumes were significantly lower than prepandemic levels. Data from observed handoffs were collected for process outcomes. Surveys regarding handoff practices were distributed before and after ED I-PASS implementation.

RESULTS

82.8% of participants completed follow-up surveys, and 69.6% of PEM physicians were observed performing a handoff. Use of ED I-PASS increased from 7.1% to 87.5% ( p < .001) and the reported perceived loss of important patient information during transitions of care decreased 50%, from 75.0% to 37.5% ( p = .02). Most (76.0%) participants reported satisfaction with ED I-PASS, despite half citing a perceived increase in handoff length. 54.2% reported a concurrent increase in written handoff documentation during the intervention.

CONCLUSION

ED I-PASS can be successfully implemented among attending physicians in the pediatric emergency department setting. Its use resulted in significant decreases in reported perceived loss of patient information during intershift handoffs.

Family Safety Reporting in Hospitalized Children With Medical Complexity

BACKGROUND AND OBJECTIVES

Hospitalized children with medical complexity (CMC) are at high risk of medical errors. Their families are an underutilized source of hospital safety data. We evaluated safety concerns from families of hospitalized CMC and patient/parent characteristics associated with family safety concerns.

METHODS

We conducted a 12-month prospective cohort study of English- and Spanish-speaking parents/staff of hospitalized CMC on 5 units caring for complex care patients at a tertiary care children's hospital. Parents completed safety and experience surveys predischarge. Staff completed surveys during meetings and shifts. Mixed-effects logistic regression with random intercepts controlling for clustering and other patient/parent factors evaluated associations between family safety concerns and patient/parent characteristics.

RESULTS

A total of 155 parents and 214 staff completed surveys (>89% response rates). 43% (n = 66) had ≥1 hospital safety concerns, totaling 115 concerns (1-6 concerns each). On physician review, 69% of concerns were medical errors and 22% nonsafety-related quality issues. Most parents (68%) reported concerns to staff, particularly bedside nurses. Only 32% of parents recalled being told how to report safety concerns. Higher education (adjusted odds ratio 2.94, 95% confidence interval [1.21-7.14], P = .02) and longer length of stay (3.08 [1.29-7.38], P = .01) were associated with family safety concerns.

CONCLUSIONS

Although parents of CMC were infrequently advised about how to report safety concerns, they frequently identified medical errors during hospitalization. Hospitals should provide clear mechanisms for families, particularly of CMC and those from disadvantaged backgrounds, to share safety concerns. Actively engaging patients/families in reporting will allow hospitals to develop a more comprehensive, patient-centered view of safety.

Communication Disparities between Nursing Home Team Members

Optimal care in nursing home (NH) settings requires effective team communication. Certified nursing assistants (CNAs) interact with nursing home residents frequently, but the extent to which CNAs feel their input is valued by other team members is not known. We conducted a cross-sectional study in which we administered a communication survey within 20 Utah nursing home facilities to 650 team members, including 124 nurses and 264 CNAs. Respondents used a 4-point scale to indicate the extent to which their input is valued by other team members when reporting their concerns about nursing home residents. We used a one-way ANOVA with a Bonferroni correction. When compared to nurses, CNAs felt less valued (CNA mean = 2.14, nurse mean = 3.24; p < 0.001) when reporting to physicians, and less valued (CNA mean = 1.66, nurse mean = 2.71; p < 0.001) when reporting to pharmacists. CNAs did not feel less valued than nurses (CNA mean = 3.43, nurse mean = 3.37; p = 0.25) when reporting to other nurses. Our findings demonstrate that CNAs feel their input is not valued outside of nursing, which could impact resident care. Additional research is needed to understand the reasons for this perception and to design educational interventions to improve the culture of communication in nursing home settings.

Frequency and Nature of Communication and Handoff Failures in Medical Malpractice Claims

BACKGROUND

The Joint Commission has identified miscommunication as a leading cause of sentinel events, the most serious adverse events, but it is unclear what role miscommunications play in malpractice claims. We sought to determine the proportion of medical malpractice claims involving communication failure and describe their nature, including providers involved, locations, miscommunications types, costs, and the potential for handoff tools to avert risk and associated costs.

METHODS

We retrospectively reviewed a random sample of malpractice claims from 2001 to 2011, collected in CRICO Strategies' Comparative Benchmarking System, a national claims database. Two researchers reviewed cases to determine if a claim involved communication failure, its type, and potential preventability using a communication tool. Interrater reliability was assessed by dual review of 50 cases (81% agreement, κ = 0.62 for evidence of miscommunication). Claimant demographics, case characteristics, and financial data were analyzed.

RESULTS

Communication failures were identified in 49% of claims. Claims with communication failures were significantly less likely to be dropped, denied, or dismissed than claims without (54% versus 67%, P = 0.015). Fifty-three percent of claims with communication failures involved provider-patient miscommunication, and 47% involved provider-provider miscommunication. The information types most frequently miscommunicated were contingency plans, diagnosis, and illness severity. Forty percent of communication failures involved a failed handoff; the majority could potentially have been averted by using a handoff tool (77%). Mean total costs for cases involving communication failures were higher ($237,600 versus $154,100, P = 0.005).

CONCLUSIONS

Communication failures are a significant contributing cause of malpractice claims and impose a substantial financial burden on the healthcare system. Interventions to improve transmission of critical patient information have the potential to substantially reduce malpractice expenditures.

Quality Improvement of Primary Care Provider Communication on Hospital Discharge

BACKGROUND AND OBJECTIVES

Effective communication between inpatient and primary care providers (PCPs) is important for safe transition of care for hospitalized patients. In 2017, communication with PCPs was prioritized for the pediatric hospital medicine division. Our primary aim was to improve documented attempted communication with PCPs within 72 hours of discharge from 41% to at least 60% by January 1, 2018, and maintain this performance through 2019.

METHODS

This study included all inpatient encounters discharged by a pediatric hospital medicine provider from March 2017 to April 2020. An electronic health record phrase debuted March 2017. Successful documentation was defined as any attempt to contact the PCP, regardless of whether actual communication occurred. Group and individual audit and feedback occurred in July 2017 to April 2020. Provider communication was financially incentivized in July 2018 to June 2019. An annotated P-chart for the proportion of encounters with documented PCP communication occurring within 72 hours was established. Special-cause variation was determined by using Shewhart rules.

RESULTS

The mean proportion of encounters with documented PCP communication increased from 41% at baseline (March 2017 through July 2017) to 60% in August 2017 and 66% in December 2017. After the financial incentive was removed in July 2019, documentation decreased to 54%. Phone calls with clinic staff were the most common communication method (40% to 71%). Direct conversations with the PCP occurred rarely (0% to 3%).

CONCLUSIONS

Even when coupled with audit and feedback with EHR interventions, our work suggests that shifting to external financial motivation may hinder sustainability of behavior change to improve attempted documented PCP communication.

Trends in and Documentation of Refusal of Common Routine Newborn Interventions: 2013-2019

BACKGROUND

Refusals of intramuscular (IM) vitamin K, ocular prophylaxis, and hepatitis B vaccine (HBV) during the birth hospitalization continue to occur. Refusal of IM vitamin K increases the risk of life-threatening vitamin K deficiency bleeding. Trends in refusal rates and how well clinicians document IM vitamin K refusal is unknown.

METHODS

We reviewed charts of livebirths admitted to 5 well newborn units from 2013 to 2019. We report trends in rates of refusal and documentation of no IM vitamin K by clinicians during the birth hospitalization and within the first 6 months of life at emergency department (ED) visits.

RESULTS

Of 67 750 live births, 283 (0.4%) did not receive IM vitamin K, and 1645 (2.4%) did not receive ocular prophylaxis. Rates of IM vitamin K refusal increased slightly over time (P < .05). For HBV, 7551 (11.1%) did not receive the birth dose, but refusal rates decreased from 16.1% to 8.7% (P < .0001). Of 283 newborns who did not receive IM vitamin K, refusal was documented in 49.8% of discharge summaries, 17 (6%) had an invasive procedure without documentation of IM vitamin K administration, and 30 (10.6%) infants <6 months old had ED visits. A total of 4 infants were evaluated for potential bleeding, and there was no documentation about IM vitamin K prophylaxis.

CONCLUSION

Refusal rates of IM vitamin K and ocular prophylaxis remained low, and uptake of HBV increased over time. Documentation of IM vitamin K refusal by clinicians during the birth hospitalization, before invasive procedures, and in ED visits can be improved.

I-PSI: Short- and Long-Term Efficacy of a Comprehensive Initiative to Promote Patient Safety Event Reporting by Trainees

Despite benefits of safety event reporting, few are trainee initiated. A comprehensive intervention was created to increase trainee reporting, partnering a trainee safety council with high-level faculty. Data were collected for 12 months pre intervention and 30 months post intervention, including short-term (1-12 mo) and long-term (13-30 mo) follow-up. A total of 2337 trainee events were submitted over the study period, primarily communication-related (40%) and on the medicine service (39%). Monthly submissions increased from 29.3 pre intervention to 66.2, 77.7, and 58.6 events/mo at post intervention, short-term follow-up, and long-term follow-up, respectively (P < 0.001). Proportion of hospital events submitted by trainees increased from 2.3% pre intervention to 4.1%, 4.9%, and 3.6% at post intervention, short-term, and long-term follow-up, respectively (P < 0.001). Trainee monthly submissions (P = 0.015) and proportion of hospital events (P < 0.001) declined from short- to long-term follow-up. Low- and intermediate-level harm events significantly increased post intervention (P < 0.001) while high-level events did not (P = 0.15-1.0). Our comprehensive intervention increased trainee event submissions at long-term follow-up.

Patient Safety Through Nursing Documentation: Barriers Identified by Healthcare Professionals and Students

Background: Although access to accurate patient documentation is recognized as a prerequisite for delivering of safe and continuous municipal elderly care, healthcare professionals often fail to provide comprehensive clinical information in an accurate and timely manner. The aim of this study was to understand the perceptions of healthcare professionals and healthcare students regarding existing barriers to patient safety through the performance of documentation practices.

Methods: Using a qualitative, exploratory design, this study conducted six focus group interviews with nurses and social educators (n = 12) involved in primary care practice and nursing and social educator bachelor’s degree students from a University College (n = 11). Data were analyzed using qualitative content analysis.

Results: Four themes emerged from the analysis, which described barriers to patient safety and quality in documentation practices: “Individual factors,” “Social factors,” “Organizational factors,” and “Technological factors.” Each theme also included several sub-themes.

Conclusion: According to the findings, several barriers negatively influenced documentation practices and information exchange, which may place primary care patients in a vulnerable and exposed situation. To achieve successful documentation, increased awareness and efforts by the individual professional are necessary. However, primary care services must facilitate the achievement of these goals by providing adequate resources, clear mission statements, and understandable policies.

Handoff Communication between Remote Healthcare Facilities

Introduction:

Handoffs and transitions of care are common weak points in healthcare provider communication as patients move between sites. With no consistent pattern of communication between St. Jude Children’s Research Hospital (St. Jude) and its affiliated clinics, the Affiliate Program Office at St. Jude developed and implemented a standardized communication tool to facilitate patient transitions between different healthcare sites.

Methods:

Each team of providers created flow diagrams to define the current state of communication when patients were transitioning between remote sites. Fishbone diagrams identified the common barriers to effective communication as a lack of consistent communication and ownership. We developed a communication tool to address these barriers, which was disseminated by secure email. We measured the percent usage of the completed hand-off tool before a patient transitioned, staff experience, and the number of errors.

Results:

The time to send or receive the communication bundle was <10 minutes. Within 3 months of implementing the SMART bundle at 3 pilot sites, the bundle was used completely in 6 of 8 patient transitions and was associated with somewhat improved staff satisfaction. We identified no adverse events related to the communication bundle.

Conclusions:

In this small pilot study, we accomplished closed-loop communication between geographically remote healthcare sites by using an electronically transmitted standardized communication bundle.

Using the Health Literacy Questionnaire (HLQ) with Providers in the Early Intervention Setting: A Qualitative Validity Testing Study

More than one in four parents in the United States of America (USA) have low health literacy, which is associated with reduced health equity and negatively impacts child health outcomes. Early intervention (EI) programs are optimally placed to build the health literacy capacity of caregivers, which could improve health equity. The health literacy of interdisciplinary EI providers has not previously been measured. This study used the Health Literacy Questionnaire (HLQ) with EI providers (n = 10) to investigate evidence based on response (cognitive) processes. Narratives from cognitive interviews gave reasons for HLQ score choices, and concordance and discordance between HLQ item intent descriptions and narrative data were assessed using thematic analysis. Results found scales with highest concordance for Scales 3, 6, and 9 (each 96%, n = 24). Concordance was lowest on Scale 5 (88%, n = 22), although still strong with only 12% discordance. Three themes reflecting discordance were identified: (1) Differences between Australian and USA culture/health systems; (2) Healthcare provider perspective; and (3) Participants with no health problems to manage. Results show strong concordance between EI providers’ narrative responses and item intents. Study results contribute validity evidence for the use of HLQ data to inform interventions that build health literacy capacity of EI providers to then empower and build the health literacy of EI parents.