Improving Safety and Quality During Interhospital Transfer of Patients With Nontraumatic Intracranial Hemorrhage: A Simulation-Based Pilot Program

BACKGROUND

The presentation of critically ill patients to emergency departments often necessitates interhospital transfer (IHT) to a tertiary care center for specialized neurocritical care. Patients with nontraumatic intracranial hemorrhage represent a critically ill population subject to high rates of IHT and who is thus an important target for research and quality improvement of IHT. We describe the use of an innovative simulation methodology engaging transfer staff, clinicians, and stakeholders to refine and facilitate the adoption of a standardized IHT protocol for transferring patients with neurovascular emergencies.

METHODS

This was a qualitative study using a phenomenological approach. Participants consisted of IHT call center staff members, neurointensivists, neurosurgeons, and emergency physicians. We conducted a standardized telephone-based simulation case to prime participants for feedback on their experiences with IHT for intracranial hemorrhage patients. Facilitators conducted focus groups immediately after the simulation to identify process improvement opportunities. A structured thematic analysis identified overarching concepts from the data.

RESULTS

We achieved data saturation with 7 simulations and a total of 24 participants. Thematic analysis identified 3 IHT-specific themes: (1) challenges unique to multispecialty critical illness, (2) interdisciplinary relationships and dynamics, and (3) communication and information processing for IHT. Three quality improvement initiatives emerged from the debriefings: standardized communication checklist, early acceptance protocol, and structure for telephone-based care handoffs.

CONCLUSIONS

We demonstrate the use of telephone-based simulation technology to identify potential pitfalls and accelerate the adoption of a new IHT protocol for patients with nontraumatic intracranial hemorrhage. New quality improvement strategies can organically result through interprofessional debriefings for patients with potentially complex handoffs between hospitals.

Closing the Loop: Program Description and Qualitative Analysis of a Pediatric Posttransfer Follow-up and Feedback Program

OBJECTIVES

Follow-up and feedback foster improvement. General emergency medicine providers working in community hospitals desire follow-up and feedback on pediatric patients transferred to children's hospitals. We implemented a novel program to provide these data to our colleagues. The objective of this study was to explore stakeholder perspectives of our program.

METHODS

We provided secure, electronic reports on transfers from 7 general emergency departments (GEDs). Patient follow-up and feedback data were delivered to the GED's pediatric emergency care coordinator. Seven pediatric emergency care coordinators and 2 children's hospital liaisons participated in semistructured interviews. Five researchers coded and analyzed transcribed data using the constant comparative method of grounded theory. Codes were refined and clustered to develop themes.

RESULTS

Perceived values of the program included GED appreciation of closing the loop on transferred patients, providing education, and informing quality improvement. Participants valued the concise and timely nature of the reports and their empathetic delivery. Facilitators of program implementation included established professional relationships between the GED and the children's hospital liaisons and a GED's culture of self-inquiry. Barriers to program implementation included potential medicolegal exposure and the time burden for report generation and processing. Suggested programmatic improvements included focusing on generalizable, evidence-based learning points and analyzing care trends.

CONCLUSIONS

Stakeholders of our pediatric posttransfer follow-up and feedback program reported many benefits and provided key suggestions that may promote successful dissemination of similar programs nationwide. Examining data trends in transferred children may focus efforts to improve the care of children across all emergency care settings.

A Multimodal Intervention to Improve the Quality and Safety of Interhospital Care Transitions for Nontraumatic Intracerebral and Subarachnoid Hemorrhage

BACKGROUND

Regionalization of care has increased interhospital transfers (IHTs) of nontraumatic intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) to specialized centers yet exposes patients to the latent risks inherent to IHT. The researchers examined how a multimodal quality improvement intervention affected quality and safety measures for patients with ICH or SAH exposed to IHT.

METHODS

Pre and post analyses of timeliness, effectiveness, and communication outcome measures were performed for patients transferred to an urban, academic center with nontraumatic ICH/SAH following implementation of a multimodal intervention. Intervention components included clinical practice guideline dissemination, IHT process redesign, electronic patient arrival notification, electronic imaging exchange, and electronic health record improvements. Three months of preintervention outcomes were compared to six months of postintervention outcomes to assess impact and sustainability of the intervention; t-tests and chi-square tests were used to compare continuous and proportional outcomes, respectively.

RESULTS

The IHT study population included 106 patients (37 preintervention, 69 postintervention). Significant improvements were observed in timeliness outcomes, including emergency department (ED) time to admission order (preintervention median: 66 minutes vs. postintervention: 33 minutes, p = 0.008), ED boarding time (preintervention median: 223 minutes vs. postintervention: 93 minutes, p = 0.001), and ED length of stay (preintervention median: 300 minutes vs. postintervention: 150 minutes, p ≤ 0.0001). Verbal communication between ED and neurocritical care clinicians prior to IHT improved from 40.0% preintervention to 90.9% postintervention.

CONCLUSION

Application of scripted quality improvement interventions as part of the IHT process is feasible and effective at improving the timeliness of care and communication of critical information in patients with nontraumatic ICH/SAH.