Developing an Interfacility Transfer Handoff Intervention: Applying the Person-Based Approach Method

Interfacility Referral Communication for PICU Transfer

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.

Implementation of an Interdisciplinary Transfer Huddle Intervention for Prolonged Wait Times During Inter-ICU Transfer

BACKGROUND

ICU transfers from a regional to a tertiary-level hospital are initiated typically for a higher level of care. Extended transfer wait times can negatively affect survival, length of stay (LOS), and cost.

METHODS

In this prospective single-center study, the subjects were adult ICU patients admitted to regional hospitals between January and October 2022, for whom a request was made to transfer to a tertiary-level medical ICU. The authors developed and implemented an interdisciplinary transfer huddle intervention (THI) with the goal of reducing wait times by providing a consistent channel of communication between key stakeholders. The primary outcome was the number of hours elapsed between transfer request and the time of transfer to the tertiary hospital. Secondary outcomes included in-hospital mortality, discharge to home, ICU LOS, and hospital LOS. Data were abstracted from electronic health records and periods before (January to June 2022) and after (June to October 2022) the intervention were compared. Data were analyzed using logistic regression or negative binomial regression, adjusting for patient demographic and clinical characteristics. ICU fellows also completed a daily survey about barriers they perceived to the THI application.

RESULTS

During the study period, 76 patients were transferred. The THI was completed 75.0% of the time. There were no statistically significant differences in the primary and secondary outcomes before and after the intervention. The top perceived barriers to transfer were lack of physical beds (50.0%) and staffing limitations (37.5%).

CONCLUSION

The authors successfully developed and implemented a transfer huddle to ensure consistent interdisciplinary communication for patients being transferred between ICUs and identified barriers to such transfer. However, transfer times and patient outcomes were not significantly different after the change. Future studies should consider staffing challenges, hospital capacity, and the role of dedicated transfer teams in in decreasing inter-ICU transfer wait times.

Development and Evaluation of I-PASS-to-PICU: A Standard Electronic Template to Improve Referral Communication for Interfacility Transfers to the Pediatric ICU

BACKGROUND

Miscommunication during interfacility handoffs to a higher level of care can harm critically ill children. Adapting evidence-based handoff interventions to interfacility referral communication may prevent adverse events. The objective of this project was to develop and evaluate a standard electronic referral template (I-PASS-to-PICU) to improve communication for interfacility pediatric ICU (PICU) transfers.

METHODS

I-PASS-to-PICU was iteratively developed in a single PICU. A core PICU stakeholder group collaboratively designed an electronic health record (EHR)-supported clinical note template by adapting elements from I-PASS, an evidence-based handoff program, to support information exchange between referring clinicians and receiving PICU physicians. I-PASS-to-PICU is a receiver-driven tool used by PICU physicians to guide verbal communication and electronic documentation during PICU transfer calls. The template underwent three cycles of iterative evaluation and redesign informed by individual and group interviews of multidisciplinary PICU staff, usability testing using simulated and actual referral calls, and debriefing with PICU physicians.

RESULTS

Individual and group interviews with 21 PICU staff members revealed that relevant, accurate, and concise information was needed for adequate admission preparedness. Time constraints and secondhand information transmission were identified as barriers. Usability testing with six receiving PICU physicians using simulated and actual calls revealed good usability on the validated System Usability Scale (SUS), with a mean score of 77.5 (standard deviation 10.9). Fellows indicated that most fields were relevant and that the template was feasible to use.

CONCLUSION

I-PASS-to-PICU was technically feasible, usable, and relevant. The authors plan to further evaluate its effectiveness in improving information exchange during real-time PICU practice.

Development of an Approach to Assessing Pediatric Fellows' Transport Medical Control Skills

BACKGROUND AND OBJECTIVE

Pediatric interfacility transport teams facilitate access to subspecialty care, and physicians often guide management remotely as transport medical control (TMC). Pediatric subspecialty fellows frequently perform TMC duties, but tools assessing competency are lacking. Our objective was to develop content validity for the items required to assess pediatric subspecialty fellows' TMC skills.

METHODS

We conducted a modified Delphi process among transport and fellow education experts in pediatric critical care medicine, pediatric emergency medicine, neonatal-perinatal medicine, and pediatric hospital medicine. The study team generated an initial list of items on the basis of a literature review and personal experience. A modified Delphi panel of transport experts was recruited to participate in 3 rounds of anonymous, online voting on the importance of the items using a 3-point Likert scale (marginal, important, essential). We defined consensus for inclusion as ≥80% agreement that an item was important/essential and consensus for exclusion as ≥80% agreement that an item was marginal.

RESULTS

The study team of 20 faculty drafted an initial list of items. Ten additional experts in each subspecialty served on the modified Delphi panel. Thirty-six items met the criteria for inclusion, with widespread agreement across subspecialties. Only 1 item, "discussed bed availability," met the criteria for inclusion among some subspecialties but not others. The study team consolidated the final list into 26 items for ease of use.

CONCLUSIONS

Through a consensus-based process among transport experts, we generated content validity for the items required to assess pediatric subspecialty fellows' TMC skills.

When Duty Calls, Resident Physicians Answer: Learning to Take Transfer Calls

BACKGROUND AND OBJECTIVE

Transitions of care are error-prone. Standardized handoffs at transitions improve safety. There are limited published curricula teaching residents to perform interfacility transfer calls or providing a framework for performance evaluation. The objective of this study was to measure the impact of a workshop utilizing a standardized handoff tool on resident-reported confidence in taking transfer calls and observed behavioral change in a simulated environment.

METHODS

A pre- and posteducational intervention trial was performed at a large children's hospital in March 2021. A 1-hour session highlighting the importance of phone communication, outlining an evidence-based handoff tool, and reviewing cases was delivered to 44 of 75 residents who attended scheduled didactics. The workshop's effectiveness was measured by rating behavioral change in a simulated environment. Calls were scored by using a 0 to 24 summative score checklist created from the handoff tool. A paired t test was used to analyze the differences in pre- and postintervention scores. Resident confidence, knowledge of the call process, and perceived importance of skill were measured with an internally developed retrospective pre- and postsurvey. The survey results were analyzed with a Wilcoxon rank test and Kruskal-Wallis test.

RESULTS

Behaviors in a simulated environment, measured by an average score on the grading checklist, had a mean score increase of 6.52 points (P <.0001). Of the participants, 95% completed the survey, which revealed that reported confidence, knowledge of the transfer call process, and importance of transfer call skills increased significantly (P <.0001).

CONCLUSIONS

This workshop improved resident behaviors in a simulated environment, confidence, and knowledge of the transfer call process, demonstrating the utility of providing a standardized tool and education to improve transitions of care.

Short-term Focused Feedback: A Model to Enhance Patient Engagement in Research and Intervention Delivery

BACKGROUND

Our grant from the Patient-Centered Outcomes Research Institute (PCORI) focused on the use of nurse home visits postdischarge for primarily pediatric hospital medicine patients. While our team recognized the importance of engaging parents and other stakeholders in our study, our project was one of the first funded to address transitions of care issues in patients without chronic illness; little evidence existed about how to engage acute stakeholders longitudinally.

OBJECTIVE

This manuscript describes how we used both a short-term focused feedback model and longitudinal engagement methods to solicit input from parents, home care nurses, and other stakeholders throughout our 3-year study.

RESULTS

Short-term focused feedback allowed the study team to collect feedback from hundreds of stakeholders. Initially, we conducted focus groups with parents with children recently discharged from the hospital. We used this feedback to modify our nurse home visit intervention, then used quality improvement methods with continued short-term focus feedback from families and nurses delivering the visits to adjust the visit processes and content. We also used their feedback to modify the outcome collection. Finally, during the randomized controlled trial, we added a parent to the study team to provide longitudinal input, as well as continued to solicit short-term focused feedback to increase recruitment and retention rates.

CONCLUSION

Research studies can benefit from soliciting short-term focused feedback from many stakeholders; having this variety of perspectives allows for many voices to be heard, without placing an undue burden on a few stakeholders.