Summary
While up to 80% of medical errors may result from poor communication at clinical transitions of care, there has been relatively little study of the effect of standardized communication tools on clinical quality measures. We prospectively examined the effect of a standardized handoff checklist on clinical outcomes for patients dismissed from the neurointensive care unit. We found that the checklist resulted in significant reductions in patients transferred with inaccurate medication reconciliation and unnecessary urinary catheters. Participating physicians were surveyed and generally viewed the handoff checklist favorably. Standardized communication tools such as checklists may play a useful role in reducing medical errors related to communication between patient care teams.
Improving transfers of care between clinical providers is an increasing priority of patients, policymakers, and regulatory agencies,1 yet much of the systematic study of clinical handoffs has emphasized communication at the same level of care, such as during shift changes.2,3 Comparatively few studies have examined handoffs between the intensive care unit (ICU) and hospital floor services,4 and most studies have relied on practitioner interviews or surveys rather than on clinical measures or outcomes.5,6
Up to 80% of medical errors involve ineffective communication at clinical transfers of care7,8 and standardizing handoffs can reduce potential errors.3,9 The purpose of our study was to measure the effect of a standardized transfer documentation checklist on clinical measures and on provider satisfaction. We hypothesized that incorporating a standardized checklist into existing transfer documentation would increase the rate of inaccurate medication reconciliation by transferring physicians and would reduce unnecessary urinary catheter use, ICU readmission, length of stay, and adverse events. We postulated that the standardized documentation would be valued by transferring and accepting physicians alike.
METHODS
Creation of the transfer checklist
A team of neurology physicians, including 4 authors (E.A.C., N.M.K., R.R.F., S.A.M.), created a transfer checklist to address issues considered important at transfer and to supplement the transfer note and verbal physician-to-physician report in use at our academic medical institution. A revised version containing the elements pertinent to this study is included in figure 1 and the original version used during the study is provided as figure e-1 at Neurology.org/cp. The checklist prompted transferring resident physicians to explain their affirmative responses to yes/no questions in text boxes that appeared for select questions. All resident physicians transferring patients from the neurosciences ICU during the study period were instructed on its use and its insertion into the existing electronic medical record transfer note.
The transfer checklist is divided into 6 categories with Yes/No response options or a text box for answers, as applicable. Certain responses prompt a follow-up question or allow a written response. DNI = do not intubate; DNR = do not resuscitate; DVT = deep vein thrombosis; ICU = intensive care unit; SC = subcutaneous; SCDs = sequential compression devices; TEDs = thromboembolic-deterrent stockings.
Data collection
We prospectively studied all consecutive patient transfers at Saint Marys Hospital, Rochester, Minnesota, from the neurosciences ICU to hospital floor services that occurred between October 1, 2011, and April 28, 2012. The transfer checklist was implemented on January 28, 2012, and used for the last 3 months of the study period, until April 28, 2012. Information from the electronic medical record and the ordering system was recorded, including patient birth date, age at admission, sex, diagnosis, palliative/comfort care status (defined as comfort as the primary goal), admission and discharge dates, and time of transfer order from the neurosciences ICU. Diagnoses were categorized according to cause (vascular, seizure, neoplastic, neuromuscular, or other) and were not exclusive.
Data associated with transfer-related issues were collected, including urinary catheter use, including time of order for urinary catheter insertion and removal. When urinary catheters were placed prior to ICU admission, the time was recorded as 00:00 on the admission date. When there was no electronic order for discontinuation of the urinary catheter, the time used for removal was the final hour charted of indwelling catheter use on the intake and outtake nursing record. Patients were considered to have had the urinary catheter removed prior to transfer if the discontinue catheter order was placed by an ICU physician within 90 minutes from the time of the transfer order (in all cases, this reflected the time the patient was still in the ICU, as based on ICU vital signs charting). Medication reconciliation of IV antihypertensives and vasopressors was considered to have not been performed if patients had active orders for either IV antihypertensives or vasopressors at transfer. Neither IV antihypertensives nor vasopressors can be administered on non-ICU neurology hospital floors, which is why this was used as a marker for completion of medication reconciliation. Neurosciences ICU readmission rates, rapid response team alerts, and catheter-associated urinary tract infections (CAUTI) were recorded as adverse events.
Compliance with checklist use was recorded using the electronic medical record. All resident physicians accepting care of patients from the neurosciences ICU during the study period were anonymously queried via an electronic survey during the last week of each month from October 1, 2011, to April 28, 2012. After checklist initiation, transferring physicians were surveyed at the end of each month from February to April 28, 2012. Overall satisfaction was assessed on a 5-point Likert scale ([1] completely unsatisfied; [2] somewhat unsatisfied; [3] neutral; [4] somewhat satisfied; [5] completely satisfied). The checklist used during the study period was revised on the basis of survey responses and results of our review of the electronic medical record.
Statistical analysis
Statistical analyses were performed using JMP software (version 9.0.1; SAS Institute, Cary, NC). Data were visually inspected for normality. Categorical data were analyzed with the χ2 or Fisher exact test (2-sided), and continuous variables were analyzed with the Student t test. Group differences were considered significant at p < 0.05.
Standard protocol approvals, registrations, and patient consents
This study was approved by the Mayo Clinic Institutional Review Board.
RESULTS
There were 130 and 131 patient transfers from the neurosciences ICU during the preimplementation and postimplementation phases, respectively. The checklist compliance rate was 93% (122/131). Transition to palliative care and transfer to a non-neurologic hospital service were the most common factors in noncompliance. The survey results and the electronic medical record results led us to revise the checklist to keep only those features identified as helpful by transferring and accepting physicians. The revised checklist (figure 1) has been added as a permanent section of the established transfer document.
Demographic information for the preimplementation and postimplementation groups is summarized in table 1. No significant difference existed between groups in average age, sex, or number of patients transitioned to palliative care. Diagnoses were similar, except that more patients in the preimplementation group were admitted with seizure (p = 0.002). There was no difference in the length of inpatient stay after dismissal from the ICU in either group (table 2).
Characteristics of ICU patients before and after implementation of a standardized ICU transfer documentation checklista
Outcomes of ICU patients before and after implementation of a standardized ICU transfer documentation checklist
The number of patients with a urinary catheter prior to transfer was similar between the groups. After checklist implementation, the mean duration of urinary catheter use per patient decreased by 26 hours (from 120 hours to 94 hours) (p = 0.03). After transfer checklist implementation, fewer patients were transferred with a urinary catheter in place (71% [62/87] compared with 56% [47/84]) (p = 0.07). This difference was significant when palliative care patients were excluded from the analysis (urinary catheter use is a comfort measure in some palliative care patients) (p = 0.001). Implementation of the checklist increased the number of patients transferred with reconciled IV antihypertensives and vasopressors as indicated by the decrease in transferred patients on such medications from 36% (47/130) to 10% (13/131) (p < 0.001). There were no CAUTIs during the study period, and there were no changes in the rates of ICU readmissions or rapid response team calls.
Of accepting physicians, 38% (19/50) returned surveys preimplementation and 63% (19/30) returned surveys postimplementation, whereas 67% (8/12) of transferring physicians returned surveys (table 3). Initiation of the checklist did not change the overall satisfaction of accepting physicians with the transfer process, from 3.89 preimplementation to 3.68 postimplementation (p = 0.34). Accepting physicians reported a decrease in the number of patients transferred to them with a urinary catheter from 1.74 to 0.79 (p = 0.04), but not in the number of times that they themselves thought that medication reconciliation had not been completed, from 1.84 to 1.26 (p = 0.20). Most (74% [14/19]) accepting physicians indicated that the checklist facilitated documentation; 95% (18/19) indicated that it saved time for them in the transfer process. One-half (4/8 [50%]) of the transferring physicians reported that the checklist took 2–5 minutes to complete, whereas one-fourth each (25% [2/8]) reported that the checklist required less than 2 minutes or 5–10 minutes. Most transferring physicians (88% [7/8]) reported that the checklist reminded them to address an issue prior to patient transfer, yet just over half (62% [5/8]) indicated that the checklist should continue to be used. The most useful aspects of the checklist reported by both the transferring and the accepting physicians were medication reconciliation (38% [3/8] and 68% [13/19]), urinary catheter use (25% [2/8] and 16% [3/19]), and deep vein thrombosis prophylaxis (12% [1/8] and 11% [2/19]). The category of pain/agitation on the checklist was considered most useful by 5% (1/19) of the accepting physicians. Just over one-third (38% [3/8]) of the transferring physicians indicated that the checklist had no useful components.
Survey results from transferring and accepting physicians
DISCUSSION
These findings demonstrate that standardized transfer documentation can improve transition of care by increasing rates of IV medication reconciliation and by decreasing unnecessary urinary catheter use. Accurate medication reconciliation at the time of ICU transfer is critical to avoid medication-related medical errors.10,11 Other authors have described nurse-led crosschecks of transfer reports from the ICU made by physicians, thereby reducing the rate of transition-related errors.4 In contrast, our protocol integrated the checklist into existing workflows and thus improved reconciliation of IV antihypertensives and vasopressors without increasing demands on other health care workers. However, we did not include medication reconciliation for all medication classes because the most common medication reconciliation issues identified in this clinical setting in our hospital were related to IV antihypertensives and vasopressors.
In addition to medication reconciliation, urinary catheterization status was considered important by both the transferring and the accepting physicians. This is in contrast to prior studies that have reported that many physicians are often unaware of unnecessary urinary catheterization.12 This change may be a reflection of increased attention to the use of urinary catheters and CAUTIs. The Centers for Medicare and Medicaid Services has targeted CAUTI as a quality measure, with implications for patient care and financial reimbursement.13 The critical care setting is of particular importance with its high frequency and duration of urinary catheter use, both of which predispose patients to CAUTI.14,15 A standardized transfer checklist is a simple, inexpensive approach that could decrease the risk of CAUTI.
Given the increased workload involved in performing quality improvement projects such as this one, it is important to consider provider satisfaction and its possible effect on long-term compliance and overall project success. Providers in our study had a generally favorable response to the checklist intervention, and most indicated that its use should continue. One critique of the checklist was that it was too lengthy to complete, which prompted a revision that incorporated only those areas considered useful by physicians and those areas that objectively improved patient care. This version of the checklist has been incorporated into our existing transfer documentation, used in conjunction with verbal physician report. The standardization of physician handoff is complementary to the nursing transfer handoff, which utilizes a standardized checklist during verbal nurse-to-nurse report.
This study has a number of limitations. A low overall adverse event rate precluded the detection of differences in adverse events between the preimplementation and postimplementation groups. Use of the transfer checklist was high but did not reach 100%. This may have been due to the comprehensive nature of the checklist, which was lengthy and required additional effort on the part of transferring physicians. The provider satisfaction survey response rate was low, possibly limiting the validity of our observations concerning physician satisfaction.
Despite the limitations, these findings demonstrate how a standardized handoff instrument can improve performance on clinical measures and be favorably received by users. Further study of standardized handoffs in other clinical transition settings is warranted.
STUDY FUNDING
No targeted funding reported.
DISCLOSURES
E.A. Coon, N.M. Kramer, R. Fabris, D. Burkholder, J. Klaas, J. Graff-Radford, and S. Arthur Moore report no disclosures. E.F.M. Wijdicks served as Editor-in-Chief of Neurocritical Care and receives publishing royalties from books published by Oxford University Press. J. Britton has received research support from Mr. and Mrs. David Hawk (charitable gift for epilepsy research). L.K. Jones Jr. reports no disclosures. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.
Footnotes
Funding information and disclosures are provided at the end of the article. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.
Supplemental data at Neurology.org/cp
- © 2015 American Academy of Neurology
REFERENCES
The Nerve!: Rapid online correspondence
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