Abstract
Critically ill patients may be exposed to unique safety threats as a result of the complexity of interhospital and intrahospital transitions involving the emergency department (ED). Real-time surveys were administered to clinicians in the ED and neuroscience intensive care unit of a tertiary health care system to assess perceptions of handoff safety and quality in transitions involving critically ill neurologic patients. In all, 115 clinical surveys were conducted among 26 patient transfers. Among all clinician types, 1 in 5 respondents felt the handoff process was inadequate. Risks to patient safety during the transfer process were reported by 1 in 3 of respondents. Perceived risks were reported more frequently by nurses (44%) than physicians/advanced practice providers (28%). Real-time survey methodology appears to be a feasible and valuable, albeit resource intensive, tool to identify safety risks, expose barriers to communication, and reveal challenges not captured by traditional approaches to inform multidisciplinary quality improvement efforts.
A large body of evidence exists linking time-sensitive processes to quality and safety outcomes for critical illnesses.1-4 The regionalization of acute hospital care has encouraged the interhospital transfer (IHT) of critically ill patients to tertiary care institutions, promoting timely access to more specialized services and resulting in improved outcomes.5,6 Accordingly, IHT pathways are common for critical care illnesses, including neurologic emergencies.7,8 However, limitations in available inpatient critical care resources in conjunction with the increasingly multidisciplinary management of acute critical illness frequently necessitates transfer via the receiving hospital’s emergency department (ED). As a result, the ED has become the acute care transition hub and primary portal for hospitalization of transferred critically ill patients.9,10 Paradoxically, the effort to promote expedited specialized care delivery exposes patients to a unique set of safety threats as a result of the complexity of interhospital and intrahospital transitions that involve numerous providers, handoffs, and process variability. 11
Previous work examining safety threats unique to hospital transitions has focused largely on either intrahospital or interhospital handoffs.12-17 This siloed approach may oversimplify a more complex process, comprising both formal and informal care transitions, that carries latent risk. 18 Prior work has conceptualized interhospital care transitions as isolated events between 2 hospitals rather than acknowledging the multiple subcycle handoffs and care processes, both synchronous and asynchronous, that occur across a panoply of providers and hospital settings. To date, the characterization of clinician perceptions regarding the safety of IHT has been limited, with wide variability in study depth and rigor.
Quality and safety interventions have often relied on the use of structured chart audits or electronic health record–based data dashboards to identify gaps in care. Unfortunately, errors in communication that may expose patients to the unique risks of IHT often are not captured by structured data. As such, qualitative approaches such as focus groups, semistructured interviews, or root cause analyses have been used to assess these care transitions. Though effective in establishing powerful narratives to inform problem identification, 19 these strategies often solicit feedback from clinicians based on aggregate reflections formed after multiple exposures or from select patients with unexpectedly poor outcomes, and thus may be subject to a number of well-defined memory biases. 20
Real-time surveys, an interactive form of direct observation, have been utilized successfully to minimize these biases and provide a more accurate description of safety risks in complex clinical situations. 21 Accordingly, the study team sought to pilot a real-time survey methodology to solicit clinicians’ perceptions of safety threats and quality of handoffs during 2 important care transitions for critically ill neurologic patients: (1) transfer from an outside hospital ED to a tertiary care ED and (2) admission from the tertiary care ED to the tertiary care inpatient unit. This study was conducted as part of a larger multimodal quality improvement project to improve transitions into the ED and hospital with a focus on acute neurologic emergencies, given that these patients frequently require both transfer to tertiary care hospitals and to multiple subspecialties during acute care transitions.
Methods
Design
Real-time surveys were administered to clinicians in the ED and neuroscience intensive care unit (NICU) of a tertiary health care system.
Subjects
A convenience sample of providers caring for patients who met the following inclusion criteria were selected for the study: (1) acute neurological or neurosurgical condition, (2) transfer via the IHT service at an urban tertiary care hospital, and (3) age ≥18 years.
Survey Development
A pilot survey was developed with input from ED physicians and administered over a 2-week period to a variety of providers to assess face validity and improve question wording. The survey was modified twice during this period. The final survey instrument consisted of 9 individual survey data collection tools. Each survey included 6 to 14 survey questions constructed to query handoff and patient safety concepts and framed in a manner relevant to distinct care roles. The 9 survey tools were tailored for: ED ambulance triage nurse, ED nurse, ED resident/advanced practice provider (APP), ED attending, consulting neurology resident, consulting neurosurgery resident, NICU resident/APP, NICU nurse, and NICU attending. The survey was designed to take less than 5 minutes to complete. Each survey included up to 2 closed-ended questions, up to 4 five-point Likert-type scale questions with responses ranging from strongly disagree to strongly agree (handoff prepared me to care for this patient; care plan was communicated clearly; risks to patient safety occurred during transition; and, for ED providers, safe handoff was provided to receiving unit), up to 4 binary yes–no questions (care plan communicated; ED team care same as consulting team’s; signed out to receiving unit; and, for consulting residents, will continue to care for patient on unit), and up to 4 open-ended questions. The survey instrument is presented in supplementary Appendix 1, which is available with the article online.
Survey Administration
All surveys were conducted in person between June and September 2016. Surveys were administered contemporaneously with clinical care to capture each handoff and transition of care at 3 time points: (1) after a patient’s arrival in the ED, (2) upon placement of the hospital admission order, and (3) upon patient arrival in the NICU. Surveys were administered by nursing students trained as research assistants (RAs). Each RA was trained by the study project manager (EBF) and investigators (AKV, JS, VP).
Outcomes
The primary outcomes were the proportion of respondents who (1) reported risks to patient safety and (2) reported a lack of effective handoff. Dichotomized Likert-type scale responses were utilized to improve the interpretability of findings. As the pilot survey was not based on a validated scale, and because the intent was to identify any inadequacy in handoff communication or safety risk, a dichotomous outcome was considered suitable for analysis and interpretation. Risks to patient safety were defined as responses of strongly agree or somewhat agree to the statement, “At some point during the transition of care for this patient, there were risks to patient safety.” Lack of effective handoff was defined as responses of strongly disagree or somewhat disagree to the statement, “I felt prepared to care for this patient, based on the handoff I received.” For a sensitivity analysis, risks to patient safety and lack of an effective handoff were defined by including the midpoint neutral response to assess the sensitivity of the findings to a looser definition.
Analysis
The primary analysis reports descriptive statistics. In addition, responses were assessed between provider types (nurses vs physicians/APPs) and between services lines (ED vs NICU). All analyses were conducted using R version 3.4 (R Foundation for Statistical Computing, Vienna, Austria). Open-ended survey questions also were analyzed for content and summarized.
Results
A total of 115 clinician surveys were conducted during 26 patient transfers. An average of 4.46 clinicians were surveyed per patient, with at least 1 nurse and 1 physician/APP response in 92.3% of transfers and 1 ED and 1 NICU clinician in 73.1% of patient transfers. Table 1 describes the patient characteristics for the 26 transfers.
Characteristics of the Patient Population.
Abbreviations: ED, emergency department; IQR, interquartile range; NICU, neuroscience intensive care unit; SD, standard deviation.
Overall, 33% of respondents perceived that there were risks to patient safety during the transfer process. Perceptions were similar between ED (32%) and NICU (34%) providers. The perceived risks to safety were more frequently reported in the nurse population (44%) than in the physician/APP group (28%). Regarding the handoff of care, 19% of all respondents felt this process was inadequate. The perception of an inadequate handoff was similar among NICU and ED respondents and among nurse and physician/APP respondents (Table 2). Surveys for only 3 patients (12%) revealed multiple respondents reporting no risks to patient safety and an effective handoff. The sensitivity analysis showed consistent findings using the looser definition of safety risk and effective handoff (supplementary Appendix 2, available with the article online). Responses to open-ended questions provide further insight into the nature of the perception of safety risk and handoff risks and are displayed in Table 3.
Clinician Perceptions by Provider Type and Location.
Abbreviations: APP, advanced practice provider; ED, emergency department; NICU, neuroscience intensive care unit.
Categorization of Safety Risks Based on Open-Ended Question Responses (N = 37).
Abbreviations: ED, emergency department; EMS, emergency medical services.
Discussion
This study found that clinicians perceived exposure to harm associated with the interhospital and intrahospital transfer process in 1 in 3 care transitions of critically ill neurologic patients. Furthermore, handoff communication was perceived to be inadequate in nearly 1 in 5 of these transitions. These findings have particular relevance to quality and safety initiatives pertaining to IHTs for neurological conditions, which commonly require multidisciplinary subspecialty management and time-sensitive diagnostic and management strategies. These findings augment prior work utilizing medical record review or administrative claims to suggest that the IHT process harbors latent safety threats related to inadequate communication and handoffs, particularly in critical care populations. 7
This study was part of a larger project that used a multimodal approach employing both quantitative and qualitative methods to understand the complex transitions into the study health system for patients with acute neurologic emergencies. In the study team’s experience, the incorporation of survey data and narratives derived from this approach, rather than reliance solely on quantitative data, played a critical role in understanding the complex clinical processes involved in IHT of critically ill neurologic patients. Evidence suggests that quality improvement interventions employing such narratives may in fact engender a stronger response than those based solely on quantitative data.22-24 In the team’s experience, these findings were concerning to both nursing and medical directors given previous efforts to improve interhospital and intrahospital communication through the electronic health record. As such, these findings motivated clinical leaders to commit to the subsequent launch of a multimodal care transition program for patients with neurologic emergencies, including the use of structured communication tools and checklists.
To the study team’s knowledge, this is the first time that the safety and quality of complex transitions have been examined in real time utilizing surveys conducted at or near the time of care provision. Traditionally, qualitative data have been obtained through semistructured interviews or focus groups. 25 These methods offer the ability to capture unique insights outside of the busy realm of clinical activity; however, they are subject to information and group dynamic biases, respectively. In the team’s experience, the real-time methodology not only captured data missed by these more commonly employed qualitative methods but also provided some structured assessment of respondent perceptions. Specifically, the perception of risk associated with these transitions revealed during real-time survey data collection appears to be higher in the nurse population than in the physician/APP population. The study team postulates that these findings are related to the resource-intensive nature of the nursing care provided in the proximate phases of neuro–critical care delivery. This insight did not emerge with such clarity in the semistructured interviews and established an area of focus for the intervention phase of this project. Similarly, the adequacy of handoff was noted to be suboptimal in a significant proportion of neuro–critical care real-time survey respondents. This “end-user” phenomenon likely reflects the degradation of information that occurs through the serial handoffs across the panoply of care settings as critically ill patients are transferred from an outside hospital through an ED to a final destination. The real-time survey findings suggest that neuro–critical care providers perceive a safety gap in this care transition process and may be vested in changes to improve care transitions for patients with acute neurologic emergencies.
This study was initiated to identify areas for improvement in the safety, quality, and timeliness of interhospital transitions of patients with acute neurologic emergencies into the study institution. The impetus for this focus was an increase in the volume of these patients cared for in the study ED that followed the development of an enhanced patient transfer service in 2010. This increase in volume occurred simultaneous to an intensification of ED boarding, consistent with national trends, as limitations in inpatient resources at the study institution necessitated that the ED play a greater role in the care provision chain. Peer review of a series of neurologic cases presenting during this time period identified a concerning trend in quality gaps and prompted an institutional commitment to perform a multidisciplinary process analysis and quality improvement initiative. In the study team’s experience, the testing of real-time survey methodology and the associated results of this study were compelling and essential to engendering support across multiple service lines to enact the intervention phase of the project.
Several limitations warrant mention. First, the conceptual approach of employing real-time surveys was based on the tracer methodology introduced by The Joint Commission and was a hybrid of both the individual and the systems tracer models. 26 However, the spontaneous and unpredictable nature of the IHT process for acute neurologic critical care posed a challenge with respect to scheduling staff to perform real-time direct observations of transitions and handoffs. As a result, a convenience sample was utilized that better approximates actual quality improvement capabilities but may be subject to selection bias. Second, the approach did not capture provider perceptions from referring hospitals. IHTs are complex and require 2-way communication, often across distinct health care systems. By examining this process only from the perspective of ED and NICU clinicians at the study institution, and excluding the clinicians involved in the proximate phase of the transfer, valuable insight regarding perception of harm and inadequate communication may have been missed.
Conclusions
During IHTs, critically ill patients are uniquely vulnerable to safety risks and handoff communication errors, with almost a third of hospital clinicians reporting perceived increased patient exposure to harm related to inadequate communication. This pilot real-time survey methodology appears to be a feasible and valuable tool with which to identify these risks to safety, expose barriers to communication, and inform areas for improvement missed by more traditional quantitative and qualitative approaches.
Supplemental Material
Rothenberg_et_al_Appendix_1_Final_survey_instrument – Supplemental material for Real-Time Surveys Reveal Important Safety Risks During Interhospital Care Transitions for Neurologic Emergencies
Supplemental material, Rothenberg_et_al_Appendix_1_Final_survey_instrument for Real-Time Surveys Reveal Important Safety Risks During Interhospital Care Transitions for Neurologic Emergencies by John Sather, Craig Rothenberg, Emily B. Finn, Kevin N. Sheth, Charles Matouk, Laura Pham, Vivek Parwani, Andrew Ulrich and Arjun K. Venkatesh in American Journal of Medical Quality
Supplemental Material
Rothenberg_et_al_Appendix_2 – Supplemental material for Real-Time Surveys Reveal Important Safety Risks During Interhospital Care Transitions for Neurologic Emergencies
Supplemental material, Rothenberg_et_al_Appendix_2 for Real-Time Surveys Reveal Important Safety Risks During Interhospital Care Transitions for Neurologic Emergencies by John Sather, Craig Rothenberg, Emily B. Finn, Kevin N. Sheth, Charles Matouk, Laura Pham, Vivek Parwani, Andrew Ulrich and Arjun K. Venkatesh in American Journal of Medical Quality
Footnotes
Acknowledgements
We thank real-time survey research assistants Julie Edwards, MSN, APRN, Kyle J. Humphrey, MSN, Allison Comick, MSN, MPH, APRN, and Julia A. Bancroft, MSN, APRN. Those acknowledged have given permission to be included. Readers may infer their endorsement of the data and conclusions. Study data were collected and managed using REDCap electronic data capture tools hosted at Yale University. 27 REDCap (Research Electronic Data Capture) is a secure, web-based application designed to support data capture for research studies, providing (1) an intuitive interface for validated data entry; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for importing data from external sources. This work was conducted at the Yale Program on Aging/Claude D. Pepper Older Americans Independence Center (P30AG21342).
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was made possible by funding received from the Agency for Healthcare Research and Quality (P30HS023554) to support the Center for Healthcare Innovation, Redesign and Learning at the Yale School of Medicine. The study also was supported by Yale New Haven Hospital and the Claude D. Pepper Older Americans Independence Center at Yale School of Medicine (#P30AG021342 NIH/NIA). Dr Venkatesh also reports support from the Emergency Medicine Foundation Health Policy Scholar Award and the Yale Center for Clinical Investigation KL2 TR000140 from the National Center for Advancing Translational Science, a component of the National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of these organizations.
References
Supplementary Material
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