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Applying a Process-based Framework to examine Interunit Patient Transfers

Applying a Process-based Framework to examine Interunit Patient Transfers. Joanna Abraham, PhD Co-authors : Shirley Burton and Imade Ihianle S80: Patient Centered C are and Care Transitions AMIA 2017 11/7/2017. Disclosures.

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Applying a Process-based Framework to examine Interunit Patient Transfers

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  1. Applying a Process-based Framework to examine Interunit Patient Transfers Joanna Abraham, PhD Co-authors: Shirley Burton and ImadeIhianle S80: Patient Centered Care and Care Transitions AMIA 2017 11/7/2017

  2. Disclosures • I have no relationships with commercial interests that have the potential to bias this presentation

  3. Learning Objectives • To map the ED-MICU patient transfer process and its phases • To investigate barriers to ED-MICU patient transfers and their root contributors • To examine strategies to address the ED-MICU transfer process challenges

  4. Interunit Patient Transfers • In-hospital interunit transfers refer to the transfer of patients between two clinical units • They involve a transfer of information, responsibility and control between clinicians from the sending and receiving units • In the US, approximately 29 million patients are transferred from the ED to inpatient clinical units annually for specialized care management

  5. Significance: Interunit Patient Transfer Failures • Interunit patient transfers are complex and prone to bottlenecks in the process (Horwitz et al, 2009, Hilligoss & Cohen, 2013) • Interunit patient transfers are particularly vulnerable to handoff problems (Abraham et al., 2010; Kitch et al., 2008) Kitch et al., 2008

  6. Barriers to Interunit Patient Transfer • Communication gaps (Stephens et al., 2011) • Negotiation failures (Hilligoss & Cohen, 2013; Apkeret al., 2007) • Care coordination breakdowns (Abraham & Reddy, 2008; Abraham & Reddy, 2010) • Interunit transfer challenges have shown to result in: • Patient non-co-localization and inappropriate use of resources (Abraham & Reddy, 2010) • Increased length of hospital stay (Apker, et al, 2007) • Confusion and stress on patients and their families (Hendrich et al, 2005) • Delays in care (Howitz, 2009) • Inadequate access to transfer equipment and supplies (Gillman et al, 2006) • Patient boarding (Chalfin et al, 2007) • Duplicate tests and procedures (Colvin, 2016)

  7. Proposed/ Implemented Strategies • Standardized transfer procedures and verbal communication protocols (Beach, 2015) • Staff training on negotiation skills (Hilligoss & Cohen, 2013; Hendrichet al, 2005) • Interpersonal relationship building and use of hospital champions to support care coordination (Abraham et al., 2012) However, interunit patient transfer barriers still pose a threat to patient safety

  8. Limitations of Proposed Solutions • Standardized transfer tools are rarely used (Kessler, 2014) • Training of residents is uncommon (Kessler, 2014) • Variations in patient transfer process across institutions (Beach, 2015) • Lack of validated tools to assess the effectiveness of a care transition process • Use of workarounds that allow for process deviations (Abraham et al., 2010) These can be attributed to the lack of understanding of the interunit transfer workflow

  9. Study Goal • To gain a holistic understanding of the interunit patient transfer workflow, with specific emphasis on: • Barriers and its root contributors • Strategies used to address the barriers and root causes • Use of a Process-based framework (Kannampallil et al., 2017; Arora et al., 2006) • Provides a holistic approach to trace the current process, its challenges, areas for improvement, and strategies adopted during process • Elucidates contributing sequence and order of activities within a process at a granular level • Maps how an individual clinician interacts with the system and others “If people do not see the process, they cannot improve it” (W.E. Deming)

  10. Study Sites • Multi-site study of interunit patient transfer process between ED and MICU • Reasons for selecting ED and MICU • ~25% of ED patients are transferred to MICU • ED and MICU use discipline-specific terminologies and taxonomies • ED and MICU have different clinical workflows including care goals, priorities and care team roles and responsibilities Site 1: UIH Site 2: JBVAMC

  11. Study Settings

  12. UIH: CERNER Study Artifacts: Patient Transfer Tools • EHR systems • ED Summary Note • Problem-based format • Integrated into EHR JBVAMC: CPRS-VISTA

  13. Data Collection • General observations • Transfer-related activities, participant tasks • 500 hours • Semi-structured interviews • Perceptions on transfer sequence of steps, barriers and recommendations for improvement • Interview lasted approximately 6-8 minutes

  14. Data Analysis • Observational data • Grounded theory approach (Glaser & Strauss, 1967) • Interview data • Thematic coding approach Theoretical Concepts [Decision to transfer patient to MICU] Selective coding [Presentation of assessment and care plan to ED care team] Axial coding [Formulation of care plan based on evaluation] Open coding [ED patient evaluation]

  15. ED-MICU Transfer Process Transfer phase Pre-transfer phase Post-transfer phase

  16. Management of Interdependencies • Interdependencies across phases were well-managed when the following interunit transfer aspects were ensured: • Transfer of information • Exchange of verbal and written/printed documentation of patient care-related and transfer-related information between clinicians (Horwitz et al, 2008) • Transfer of responsibility • Exchange of obligation in the form of pending/ongoing patient care tasks between clinicians (Schlenker et al, 1994) • Transfer of control • Exchange of clinical decision making authority between clinicians (Lerner et al, 1999)

  17. Impact on Transfer of Information

  18. Impact on Transfer of Responsibility

  19. Impact on Transfer of Control

  20. Discussion • Using a process-based framework, we mapped three phases in the interunit patient transfer process and their interdependencies • Coordination of care plan and transfer initiate in the pre-transfer phase • Transfer of information, responsibility and control between the ED and MICU residents occur in the transfer phase • Critical care delivery and management of transferred patient occur in the post-transfer phase • We highlighted cross-boundary barriers and related factors that result in ineffective management of interdependencies in the process

  21. Strategies for Effective Transfer of Information

  22. Strategies for Effective Transfer of Responsibility

  23. Strategies for Effective Transfer of Control

  24. Study Limitations and Future Directions • Limitations • Focused on resident perspectives of patient transfer process • Future Directions • Communication content analysis and its impact on patient transfer effectiveness and efficiency

  25. Acknowledgments • Study Participants • University of Illinois Hospital • JB VA Medical Center • Study Funding • NSF CISE CRII (1463990)

  26. References 1. Abraham, J., & Reddy, M. C. (2010). Challenges to inter-departmental coordination of patient transfers: a workflow perspective. International journal of medical informatics, 79(2), 112-122. 2. Hilligoss, B., & Cohen, M. D. (2013). The unappreciated challenges of between-unit handoffs: negotiating and coordinating across boundaries. Annals of emergency medicine, 61(2), 155-160. 3. Horwitz, L. I., Meredith, T., Schuur, J. D., Shah, N. R., Kulkarni, R. G., & Jenq, G. Y. (2009). Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Annals of emergency medicine, 53(6), 701-710. 4. Apker, J., Mallak, L. A., & Gibson, S. C. (2007). Communicating in the “gray zone”: perceptions about emergency physician–hospitalist handoffs and patient safety. Academic Emergency Medicine, 14(10), 884-894. 5. Hendrich, A. L., & Nelson, L. (2005). Intra-unit patient transports: time, motion, and cost impact on hospital efficiency. Nursing Economics, 23(4), 157. 6. Apker, J., Mallak, L. A., Applegate, E. B., Gibson, S. C., Ham, J. J., Johnson, N. A., & Street, R. L. (2010). Exploring emergency physician–hospitalist handoff interactions: development of the handoff communication assessment. Annals of emergency medicine, 55(2), 161-170.

  27. References 7. Stephens, R., Cudnik, M., & Patterson, E. (2011, September). Barriers and facilitators to timely admission and transfer of patients from an emergency department to an intensive care unit. In Proceedings of the Human Factors and Ergonomics Society Annual Meeting (Vol. 55, No. 1, pp. 763-767). Sage CA: Los Angeles, CA: SAGE Publications. 8. Abraham, J., & Reddy, M. C. (2008, November). Moving patients around: a field study of coordination between clinical and non-clinical staff in hospitals. In Proceedings of the 2008 ACM conference on Computer supported cooperative work (pp. 225-228). ACM. 9. Starmer, A. J., O’Toole, J. K., Rosenbluth, G., Calaman, S., Balmer, D., West, D. C., ... & Srivastava, R. (2014). Development, implementation, and dissemination of the I-PASS handoff curriculum: a multisite educational intervention to improve patient handoffs. Academic Medicine, 89(6), 876-884. 10. Beach, C. (2015). Crawling Before Walking: Beginning to Understand How Clinicians Communicate and Behave During Interunit Handoffs. Joint Commission journal on quality and patient safety, 41(3), 132-133. 11. Glaser, B., & Strauss, A. (1967). Discovering grounded theory. Chicago, IL. 12. Schlenker, B. R., Britt, T. W., Pennington, J., Murphy, R., & Doherty, K. (1994). The triangle model of responsibility. Psychological review, 101(4), 632-651.

  28. References 13. Lerner, J. S., & Tetlock, P. E. (1999). Accounting for the effects of accountability. Psychological bulletin, 125(2), 255. 14. Cheung, D. S., Kelly, J. J., Beach, C., Berkeley, R. P., Bitterman, R. A., Broida, R. I., ... & Klauer, K. M. (2010). Improving handoffs in the emergency department. Annals of emergency medicine, 55(2), 171-180. 15. Brannen, M. L., Cameron, K. A., Adler, M., Goodman, D., & Holl, J. L. (2009). Admission handoff communications: clinician's shared understanding of patient severity of illness and problems. Journal of patient safety, 5(4), 237-242. 16. Kessler, C., Scott, N. L., Siedsma, M., Jordan, J., Beach, C., & Coletti, C. M. (2014). Interunit handoffs of patients and transfers of information: a survey of current practices. Annals of emergency medicine, 64(4), 343-349. 17. Cohen, R. I., Kennedy, H., Amitrano, B., Dillon, M., Guigui, S., & Kanner, A. (2015). A quality improvement project to decrease emergency department and medical intensive care unit transfer times. Journal of critical care, 30(6), 1331-1337. 18. Manser, T., Foster, S., Flin, R., & Patey, R. (2013). Team communication during patient handover from the operating room: more than facts and figures. Human factors, 55(1), 138-156.

  29. References 19. Smith, C. J., Britigan, D. H., Lyden, E., Anderson, N., Welniak, T. J., & Wadman, M. C. (2015). Interunit handoffs from emergency department to inpatient care: A cross‐sectional survey of physicians at a university medical center. Journal of hospital medicine, 10(11), 711-717. 20. Chalfin, D. B., Trzeciak, S., Likourezos, A., Baumann, B. M., Dellinger, R. P., & DELAY-ED study group. (2007). Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Critical care medicine, 35(6), 1477-1483. 21. Gillman, L., Leslie, G., Williams, T., Fawcett, K., Bell, R., & McGibbon, V. (2006). Adverse events experienced while transferring the critically ill patient from the emergency department to the intensive care unit. Emergency medicine journal, 23(11), 858-861. 22. Arora, V., & Johnson, J. (2006). A model for building a standardized hand-off protocol. The Joint Commission Journal on Quality and Patient Safety, 32(11), 646-655. 23. Kannampallil, T. G., Abraham, J., & Patel, V. L. (2016). Methodological framework for evaluating clinical processes: a cognitive informatics perspective. Journal of biomedical informatics, 64, 342-351. 24. Murphy, A. R., & Reddy, M. C. (2017, February). Ambiguous Accountability: The Challenges of Identifying and Managing Patient-Related Information Problems in Collaborative Patient-Care Teams. In Proceedings of the 2017 ACM Conference on Computer Supported Cooperative Work and Social Computing (pp. 1646-1660). ACM.

  30. References 25. Toccafondi, G., Albolino, S., Tartaglia, R., Guidi, S., Molisso, A., Venneri, F., ... & Morelli, M. (2012). The collaborative communication model for patient handover at the interface between high-acuity and low-acuity care. BMJ QualSaf, 21(Suppl 1), i58-i66. 26. Abraham, J., Riesenberg, L.A., Patterson, E., Wears, R. (2016). Handoffs: The Good, the Bad, and the Ugly, 2016 International Symposium on Human Factors and Ergonomics in Health Care: Shaping the Future, San Diego, CA. 27. Abraham, J., & Reddy, M. C. (2013, February). Re-coordinating activities: an investigation of articulation work in patient transfers. In Proceedings of the 2013 conference on Computer supported cooperative work (pp. 67-78). ACM.

  31. My contact: abrahamj@uic.edu

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