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Caregiver Perspectives on Communication During Hospitalization at an Academic Pediatric Institution: A Qualitative Study
Provision of high-quality, high-value medical care hinges upon effective communication. During a hospitalization, critical information is communicated between patients, caregivers, and providers multiple times each day. This can cause inconsistent and misinterpreted messages, leaving ample room for error.1 The Joint Commission notes that communication failures occurring between medical providers account for ~60% of all sentinel or serious adverse events that result in death or harm to a patient.2 Communication that occurs between patients and/or their caregivers and medical providers is also critically important. The content and consistency of this communication is highly valued by patients and providers and can affect patient outcomes during hospitalizations and during transitions to home.3,4 Still, the multifactorial, complex nature of communication in the pediatric inpatient setting is not well understood.5,6
During hospitalization, communication happens continuously during both daytime and nighttime hours. It also precedes the particularly fragile period of transition from hospital to home. Studies have shown that nighttime communication between caregivers and medical providers (ie, nurses and physicians), as well as caregivers’ perceptions of interactions that occur between nurses and physicians, may be closely linked to that caregiver’s satisfaction and perceived quality of care.6,7 Communication that occurs between inpatient and outpatient providers is also subject to barriers (eg, limited availability for direct communication)8-12; studies have shown that patient and/or caregiver satisfaction has also been tied to perceptions of this communication.13,14 Moreover, a caregiver’s ability to understand diagnoses and adhere to postdischarge care plans is intimately tied to communication during the hospitalization and at discharge. Although many improvement efforts have aimed to enhance communication during these vulnerable time periods,3,15,16 there remains much work to be done.1,10,12
The many facets and routes of communication, and the multiple stakeholders involved, make improvement efforts challenging. We believe that more effective communication strategies could result from a deeper understanding of how caregivers view communication successes and challenges during a hospitalization. We see this as key to developing meaningful interventions that are directed towards improving communication and, by extension, patient satisfaction and safety. Here, we sought to extend findings from a broader qualitative study17 by developing an in-depth understanding of communication issues experienced by families during their child’s hospitalization and during the transition to home.
METHODS
Setting
The analyses presented here emerged from the Hospital to Home Outcomes Study (H2O). The first objective of H2O was to explore the caregiver perspective on hospital-to-home transitions. Here, we present the results related to caregiver perspectives of communication, while broader results of our qualitative investigation have been published elsewhere.17 This objective informed the latter 2 aims of the H2O study, which were to modify an existing nurse-led transitional home visit (THV) program and to study the effectiveness of the modified THV on reutilization and patient-specific outcomes via a randomized control trial. The specifics of the H2O protocol and design have been presented elsewhere.18
H2O was approved by the Institutional Review Board at Cincinnati Children’s Hospital Medical Center (CCHMC), a free-standing, academic children’s hospital with ~600 inpatient beds. This teaching hospital has >800 total medical students, residents, and fellows. Approximately 8000 children are hospitalized annually at CCHMC for general pediatric conditions, with ~85% of such admissions staffed by hospitalists from the Division of Hospital Medicine. The division is composed of >40 providers who devote the majority of their clinical time to the hospital medicine service; 15 additional providers work on the hospital medicine service but have primary clinical responsibilities in another division.
Family-centered rounds (FCR) are the standard of care at CCHMC, involving family members at the bedside to discuss patient care plans and diagnoses with the medical team.19 On a typical day, a team conducting FCR is composed of 1 attending, 1 fellow, 2 to 3 pediatric residents, 2 to 3 medical students, a charge nurse or bedside nurse, and a pharmacist. Other ancillary staff, such as social workers, care coordinators, nurse practitioners, or dieticians, may also participate on rounds, particularly for children with greater medical complexity.
Population
Caregivers of children discharged with acute medical conditions were eligible for recruitment if they were English-speaking (we did not have access to interpreter services during focus groups/interviews), had a child admitted to 1 of 3 services (hospital medicine, neurology, or neurosurgery), and could attend a focus group within 30 days of the child’s discharge. The majority of participants had a child admitted to hospital medicine; however, caregivers with a generally healthy child admitted to either neurology or neurosurgery were eligible to participate in the study.
Study Design
As presented elsewhere,17,20 we used focus groups and individual in-depth interviews to generate consensus themes about patient and caregiver experiences during the transition from hospital to home. Because there is evidence suggesting that focus group participants are more willing to talk openly when among others of similar backgrounds, we stratified the sample by the family’s estimated socioeconomic status.21,22 Socioeconomic status was estimated by identifying the poverty rate in the census tract in which each participant lived. Census tracts, relatively homogeneous areas of ~4000 individuals, have been previously shown to effectively detect socioeconomic gradients.23-26 Here, we separated participants into 2 socioeconomically distinct groupings (those in census tracts where <15% or ≥15% of the population lived below the federal poverty level).26 This cut point ensured an equivalent number of eligible participants within each stratum and diversity within our sample.
Data Collection
Caregivers were recruited on the inpatient unit during their child’s hospitalization. Participants then returned to CCHMC facilities for the focus group within 30 days of discharge. Though efforts were made to enhance participation by scheduling sessions at multiple sites and during various days and times of the week, 4 sessions yielded just 1 participant; thus, the format for those became an individual interview. Childcare was provided, and participants received a gift card for their participation.
An open-ended, semistructured question guide,17 developed de novo by the research team, directed the discussion for focus groups and interviews. As data collection progressed, the question guide was adapted to incorporate new issues raised by participants. Questions broadly focused on aspects of the inpatient experience, discharge processes, and healthcare system and family factors thought to be most relevant to patient- and family-centered outcomes. Communication-related questions addressed information shared with families from the medical team about discharge, diagnoses, instructions, and care plans. An experienced moderator and qualitative research methodologist (SNS) used probes to further elucidate responses and expand discussion by participants. Sessions were held in private conference rooms, lasted ~90 minutes, were audiotaped, and were transcribed verbatim. Identifiers were stripped and transcripts were reviewed for accuracy. After conducting 11 focus groups (generally composed of 5-10 participants) and 4 individual interviews, the research team determined that theoretical saturation27 was achieved, and recruitment was suspended.
Data Analysis
An inductive, thematic approach was used for analysis.27 Transcripts were independently reviewed by a multidisciplinary team of 4 researchers, including 2 pediatricians (LGS and AFB), a clinical research coordinator (SAS), and a qualitative research methodologist (SNS). The study team identified emerging concepts and themes related to the transition from hospital to home; themes related to communication during hospitalization are presented here.
During the first phase of analysis, investigators independently read transcripts and later convened to identify and define initial concepts and themes. A preliminary codebook was then designed. Investigators continued to review and code transcripts independently, meeting regularly to discuss coding decisions collaboratively, resolving differences through consensus.28 As patterns in the data became apparent, the codebook was modified iteratively, adding, subtracting, and refining codes as needed and grouping related codes. Results were reviewed with key stakeholders, including parents, inpatient and outpatient pediatricians, and home health nurses, throughout the analytic process.27,28 Coded data were maintained in an electronic database accessible only to study personnel.
RESULTS
Participants
Resulting Themes
Analyses revealed the following 3 major communication-related themes with associated subthemes: (1) experiences that affect caregiver perceptions of communication between the inpatient medical team and families, (2) communication challenges for caregivers related to a teaching hospital environment, and (3) caregiver perceptions of communication between medical providers. Each theme (and subtheme) is explored below with accompanying verbatim quotes in the narrative and the tables.
Major Theme 1: Experiences that Affect Caregiver Perceptions of Communication Between the Inpatient Medical Team and Families
In contrast, some of the negative experiences shared by participants related to feeling excluded from discussions about their child’s care. One participant said, “They tell you…as much as they want to tell you. They don’t fully inform you on things.” Additionally, concerns were voiced about insufficient time for face-to-face discussions with physicians: “I forget what I have to say and it’s something really, really important…But now, my doctor is going, you can’t get the doctor back.” Finally, participants discussed how the use of medical jargon often made it more difficult to understand things, especially for those not in the medical field.
Major Theme 2: Communication Challenges for Caregivers Related to a Teaching Hospital Environment
Major Theme 3: Caregiver Perceptions of Communication Between Medical Providers
Perceptions were not isolated to the inpatient setting. Based on their experiences, caregivers similarly described their sense of how inpatient and outpatient providers were communicating with each other. In some cases, it was clear that good communication, as perceived by the participant, had occurred in situations in which the primary care physician knew “everything” about the hospitalization when they saw the patient in follow-up. One participant described, “We didn’t even realize at the time, [the medical team] had actually called our doctor and filled them in on our situation, and we got [to the follow up visit]…He already knew the entire situation.” There were others, however, who shared their uncertainty about whether the information exchange about their child’s hospitalization had actually occurred. They, therefore, voiced apprehension around who to call for advice after discharge; would their outpatient provider have their child’s hospitalization history and be able to properly advise them?
DISCUSSION
Communication during a hospitalization and at transition from hospital to home happens in both formal and informal ways; it is a vital component of appropriate, effective patient care. When done poorly, it has the potential to negatively affect a patient’s safety, care, and key outcomes.2 During a hospitalization, the multifaceted nature of communication and multidisciplinary approach to care provision can create communication challenges and make fixing challenges difficult. In order to more comprehensively move toward mitigation, it is important to gather perspectives of key stakeholders, such as caregivers. Caregivers are an integral part of their child’s care during the hospitalization and particularly at home during their child’s recovery. They are also a valued member of the team, particularly in this era of family-centered care.19,29 The perspectives of the caregivers presented here identified both successes and challenges of their communication experiences with the medical team during their child’s hospitalization. These perspectives included experiences affecting perceptions of communication between the inpatient medical team and families; communication related to the teaching hospital environment, including confusing messages associated with large multidisciplinary teams, aspects of FCR, and confusion about medical team member roles; and caregivers’ perceptions of communication between providers in and out of the hospital, including types of communication caregivers observed or believed occurred between medical providers. We believe that these qualitative results are crucial to developing better, more targeted interventions to improve communication.
Maintaining a healthy and productive relationship with patients and their caregivers is critical to providing comprehensive and safe patient care. As supported in the literature, we found that when caregivers were included in conversations, they felt appreciated and valued; in addition, when answers were not directly shared by providers or there were lingering questions, nurses often served as “interpreters.”29,30 Indeed, nurses were seen as a critical touchpoint for many participants, individuals that could not only answer questions but also be a trusted source of information. Supporting such a relationship, and helping enhance the relationship between the family and other team members, may be particularly important considering the degree to which a hospitalization can stress a patient, caregiver, and family.31-34 Developing rapport with families and facilitating relationships with the inclusion of nursing during FCR can be particularly helpful. Though this can be challenging with the many competing priorities of medical providers and the fast-paced, acute nature of inpatient care, making an effort to include nursing staff on rounds can cut down on confusion and assist the family in understanding care plans. This, in turn, can minimize the stress associated with hospitalization and improve the patient and family experience.
While academic institutions’ resources and access to subspecialties are often thought to be advantageous, there are other challenges inherent to providing care in such complex environments. Some caregivers cited confusion related to large teams of providers with, to them, indistinguishable roles asking redundant questions. These experiences affected their perceptions of FCR, generally leading to a fixation on its overwhelming aspects. Certain caregivers highlighted that FCR caused them, and their child, to feel overwhelmed and more confused about the plan for the day. It is important to find ways to mitigate these feelings while simultaneously continuing to support the inclusion of caregivers during their child’s hospitalization and understanding of care plans. Some initiatives (in addition to including nursing on FCR as discussed above) focus on improving the ways in which providers communicate with families during rounds and throughout the day, seeking to decrease miscommunications and medical errors while also striving for better quality of care and patient/family satisfaction.35 Other initiatives seek to clarify identities and roles of the often large and confusing medical team. One such example of this is the development of a face sheet tool, which provides families with medical team members’ photos and role descriptions. Unaka et al.36 found that the use of the face sheet tool improved the ability of caregivers to correctly identify providers and their roles. Thinking beyond interventions at the bedside, it is also important to include caregivers on higher level committees within the institution, such as on family advisory boards and/or peer support groups, to inform systems-wide interventions that support the tenants of family-centered care.29 Efforts such as these are worth trialing in order to improve the patient and family experience and quality of communication.
Multiple studies have evaluated the challenges with ensuring consistent and useful handoffs across the inpatient-to-outpatient transition,8-10,12 but few have looked at it from the perspective of the caregiver.13 After leaving the hospital to care for their recovering child, caregivers often feel overwhelmed; they may want, or need, to rely on the support of others in the outpatient environment. This support can be enhanced when outpatient providers are intimately aware of what occurred during the hospitalization; trust erodes if this is not the case. Given the value caregivers place on this communication occurring and occurring well, interventions supporting this communication are critical. Furthermore, as providers, we should also inform families that communication with outpatient providers is happening. Examples of efforts that have worked to improve the quality and consistency of communication with outpatient providers include improving discharge summary documentation, ensuring timely faxing of documentation to outpatient providers, and reliably making phone calls to outpatient providers.37-39 These types of interventions seek to bridge the gap between inpatient and outpatient care and facilitate a smooth transfer of information in order to provide optimal quality of care and avoid undesired outcomes (eg, emergency department revisits, readmissions, medication errors, etc) and can be adopted by institutions to address the issue of communication between inpatient and outpatient providers.
We acknowledge limitations to our study. This was done at a single academic institution with only English-speaking participants. Thus, our results may not be reflective of caregivers of children cared for in different, more ethnically or linguistically diverse settings. The patient population at CCHMC, however, is diverse both demographically and clinically, which was reflected in the composition of our focus groups and interviews. Additionally, the inclusion of participants who received a nurse home visit after discharge may limit generalizability. However, only 4 participants had a nurse home visit; thus, the overwhelming majority of participants did not receive such an intervention. We also acknowledge that those willing to participate may have differed from nonparticipants, specifically sharing more positive experiences. We believe that our sampling strategy and use of an unbiased, nonhospital affiliated moderator minimized this possibility. Recall bias is possible, as participants were asked to reflect back on a discharge experience occurring in their past. We attempted to minimize this by holding sessions no more than 30 days from the day of discharge. Finally, we present data on caregivers’ perception of communication and not directly observed communication occurrences. Still, we expect that perception is powerful in and of itself, relevant to both outcomes and to interventions.
CONCLUSION
Communication during hospitalization influences how caregivers understand diagnoses and care plans. Communication perceived as effective fosters mutual understandings and positive relationships with the potential to result in better care and improved outcomes. Communication perceived as ineffective negatively affects experiences of patients and their caregivers and can adversely affect patient outcomes. Learning from caregivers’ experiences with communication during their child’s hospitalization can help identify modifiable factors and inform strategies to improve communication, support families through hospitalization, and facilitate a smooth reentry home.
ACKNOWLEDGMENTS
This manuscript is submitted on behalf of the H2O study group: Katherine A. Auger, MD, MSc, JoAnne Bachus, BSN, Monica L. Borell, BSN, Lenisa V. Chang, MA, PhD, Jennifer M. Gold, BSN, Judy A. Heilman, RN, Joseph A. Jabour, BS, Jane C. Khoury, PhD, Margo J. Moore, BSN, CCRP, Rita H. Pickler, PNP, PhD, Anita N. Shah, DO, Angela M. Statile, MD, MEd, Heidi J. Sucharew, PhD, Karen P. Sullivan, BSN, Heather L. Tubbs-Cooley, RN, PhD, Susan Wade-Murphy, MSN, and Christine M. White, MD, MAT.
Disclaimer
All statements in this report, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors, or Methodology Committee.
Disclosure
This work was (partially) supported through a Patient-Centered Outcomes Research Institute (PCORI) Award (HIS-1306-0081). The authors have no financial relationships relevant to this article to disclose. The authors have no conflicts of interest to disclose.
1. Riesenberg LA, Leitzsch J, Massucci JL, et al. Residents’ and Attending Physicians’ Handoffs: A Systematic Review of the Literature. Acad Med. 2009;84(12):1775-1787. PubMed
6. Comp D. Improving parent satisfaction by sharing the inpatient daily plan of care: an evidence review with implications for practice and research. Pediatr Nurs. 2011;37(5):237-242. PubMed
30. Latta LC, Dick R, Parry C, Tamura GS. Parental responses to involvement in rounds on a pediatric inpatient unit at a teaching hospital: a qualitative study. Acad Med. 2008;83(3):292-297. PubMed
Provision of high-quality, high-value medical care hinges upon effective communication. During a hospitalization, critical information is communicated between patients, caregivers, and providers multiple times each day. This can cause inconsistent and misinterpreted messages, leaving ample room for error.1 The Joint Commission notes that communication failures occurring between medical providers account for ~60% of all sentinel or serious adverse events that result in death or harm to a patient.2 Communication that occurs between patients and/or their caregivers and medical providers is also critically important. The content and consistency of this communication is highly valued by patients and providers and can affect patient outcomes during hospitalizations and during transitions to home.3,4 Still, the multifactorial, complex nature of communication in the pediatric inpatient setting is not well understood.5,6
During hospitalization, communication happens continuously during both daytime and nighttime hours. It also precedes the particularly fragile period of transition from hospital to home. Studies have shown that nighttime communication between caregivers and medical providers (ie, nurses and physicians), as well as caregivers’ perceptions of interactions that occur between nurses and physicians, may be closely linked to that caregiver’s satisfaction and perceived quality of care.6,7 Communication that occurs between inpatient and outpatient providers is also subject to barriers (eg, limited availability for direct communication)8-12; studies have shown that patient and/or caregiver satisfaction has also been tied to perceptions of this communication.13,14 Moreover, a caregiver’s ability to understand diagnoses and adhere to postdischarge care plans is intimately tied to communication during the hospitalization and at discharge. Although many improvement efforts have aimed to enhance communication during these vulnerable time periods,3,15,16 there remains much work to be done.1,10,12
The many facets and routes of communication, and the multiple stakeholders involved, make improvement efforts challenging. We believe that more effective communication strategies could result from a deeper understanding of how caregivers view communication successes and challenges during a hospitalization. We see this as key to developing meaningful interventions that are directed towards improving communication and, by extension, patient satisfaction and safety. Here, we sought to extend findings from a broader qualitative study17 by developing an in-depth understanding of communication issues experienced by families during their child’s hospitalization and during the transition to home.
METHODS
Setting
The analyses presented here emerged from the Hospital to Home Outcomes Study (H2O). The first objective of H2O was to explore the caregiver perspective on hospital-to-home transitions. Here, we present the results related to caregiver perspectives of communication, while broader results of our qualitative investigation have been published elsewhere.17 This objective informed the latter 2 aims of the H2O study, which were to modify an existing nurse-led transitional home visit (THV) program and to study the effectiveness of the modified THV on reutilization and patient-specific outcomes via a randomized control trial. The specifics of the H2O protocol and design have been presented elsewhere.18
H2O was approved by the Institutional Review Board at Cincinnati Children’s Hospital Medical Center (CCHMC), a free-standing, academic children’s hospital with ~600 inpatient beds. This teaching hospital has >800 total medical students, residents, and fellows. Approximately 8000 children are hospitalized annually at CCHMC for general pediatric conditions, with ~85% of such admissions staffed by hospitalists from the Division of Hospital Medicine. The division is composed of >40 providers who devote the majority of their clinical time to the hospital medicine service; 15 additional providers work on the hospital medicine service but have primary clinical responsibilities in another division.
Family-centered rounds (FCR) are the standard of care at CCHMC, involving family members at the bedside to discuss patient care plans and diagnoses with the medical team.19 On a typical day, a team conducting FCR is composed of 1 attending, 1 fellow, 2 to 3 pediatric residents, 2 to 3 medical students, a charge nurse or bedside nurse, and a pharmacist. Other ancillary staff, such as social workers, care coordinators, nurse practitioners, or dieticians, may also participate on rounds, particularly for children with greater medical complexity.
Population
Caregivers of children discharged with acute medical conditions were eligible for recruitment if they were English-speaking (we did not have access to interpreter services during focus groups/interviews), had a child admitted to 1 of 3 services (hospital medicine, neurology, or neurosurgery), and could attend a focus group within 30 days of the child’s discharge. The majority of participants had a child admitted to hospital medicine; however, caregivers with a generally healthy child admitted to either neurology or neurosurgery were eligible to participate in the study.
Study Design
As presented elsewhere,17,20 we used focus groups and individual in-depth interviews to generate consensus themes about patient and caregiver experiences during the transition from hospital to home. Because there is evidence suggesting that focus group participants are more willing to talk openly when among others of similar backgrounds, we stratified the sample by the family’s estimated socioeconomic status.21,22 Socioeconomic status was estimated by identifying the poverty rate in the census tract in which each participant lived. Census tracts, relatively homogeneous areas of ~4000 individuals, have been previously shown to effectively detect socioeconomic gradients.23-26 Here, we separated participants into 2 socioeconomically distinct groupings (those in census tracts where <15% or ≥15% of the population lived below the federal poverty level).26 This cut point ensured an equivalent number of eligible participants within each stratum and diversity within our sample.
Data Collection
Caregivers were recruited on the inpatient unit during their child’s hospitalization. Participants then returned to CCHMC facilities for the focus group within 30 days of discharge. Though efforts were made to enhance participation by scheduling sessions at multiple sites and during various days and times of the week, 4 sessions yielded just 1 participant; thus, the format for those became an individual interview. Childcare was provided, and participants received a gift card for their participation.
An open-ended, semistructured question guide,17 developed de novo by the research team, directed the discussion for focus groups and interviews. As data collection progressed, the question guide was adapted to incorporate new issues raised by participants. Questions broadly focused on aspects of the inpatient experience, discharge processes, and healthcare system and family factors thought to be most relevant to patient- and family-centered outcomes. Communication-related questions addressed information shared with families from the medical team about discharge, diagnoses, instructions, and care plans. An experienced moderator and qualitative research methodologist (SNS) used probes to further elucidate responses and expand discussion by participants. Sessions were held in private conference rooms, lasted ~90 minutes, were audiotaped, and were transcribed verbatim. Identifiers were stripped and transcripts were reviewed for accuracy. After conducting 11 focus groups (generally composed of 5-10 participants) and 4 individual interviews, the research team determined that theoretical saturation27 was achieved, and recruitment was suspended.
Data Analysis
An inductive, thematic approach was used for analysis.27 Transcripts were independently reviewed by a multidisciplinary team of 4 researchers, including 2 pediatricians (LGS and AFB), a clinical research coordinator (SAS), and a qualitative research methodologist (SNS). The study team identified emerging concepts and themes related to the transition from hospital to home; themes related to communication during hospitalization are presented here.
During the first phase of analysis, investigators independently read transcripts and later convened to identify and define initial concepts and themes. A preliminary codebook was then designed. Investigators continued to review and code transcripts independently, meeting regularly to discuss coding decisions collaboratively, resolving differences through consensus.28 As patterns in the data became apparent, the codebook was modified iteratively, adding, subtracting, and refining codes as needed and grouping related codes. Results were reviewed with key stakeholders, including parents, inpatient and outpatient pediatricians, and home health nurses, throughout the analytic process.27,28 Coded data were maintained in an electronic database accessible only to study personnel.
RESULTS
Participants
Resulting Themes
Analyses revealed the following 3 major communication-related themes with associated subthemes: (1) experiences that affect caregiver perceptions of communication between the inpatient medical team and families, (2) communication challenges for caregivers related to a teaching hospital environment, and (3) caregiver perceptions of communication between medical providers. Each theme (and subtheme) is explored below with accompanying verbatim quotes in the narrative and the tables.
Major Theme 1: Experiences that Affect Caregiver Perceptions of Communication Between the Inpatient Medical Team and Families
In contrast, some of the negative experiences shared by participants related to feeling excluded from discussions about their child’s care. One participant said, “They tell you…as much as they want to tell you. They don’t fully inform you on things.” Additionally, concerns were voiced about insufficient time for face-to-face discussions with physicians: “I forget what I have to say and it’s something really, really important…But now, my doctor is going, you can’t get the doctor back.” Finally, participants discussed how the use of medical jargon often made it more difficult to understand things, especially for those not in the medical field.
Major Theme 2: Communication Challenges for Caregivers Related to a Teaching Hospital Environment
Major Theme 3: Caregiver Perceptions of Communication Between Medical Providers
Perceptions were not isolated to the inpatient setting. Based on their experiences, caregivers similarly described their sense of how inpatient and outpatient providers were communicating with each other. In some cases, it was clear that good communication, as perceived by the participant, had occurred in situations in which the primary care physician knew “everything” about the hospitalization when they saw the patient in follow-up. One participant described, “We didn’t even realize at the time, [the medical team] had actually called our doctor and filled them in on our situation, and we got [to the follow up visit]…He already knew the entire situation.” There were others, however, who shared their uncertainty about whether the information exchange about their child’s hospitalization had actually occurred. They, therefore, voiced apprehension around who to call for advice after discharge; would their outpatient provider have their child’s hospitalization history and be able to properly advise them?
DISCUSSION
Communication during a hospitalization and at transition from hospital to home happens in both formal and informal ways; it is a vital component of appropriate, effective patient care. When done poorly, it has the potential to negatively affect a patient’s safety, care, and key outcomes.2 During a hospitalization, the multifaceted nature of communication and multidisciplinary approach to care provision can create communication challenges and make fixing challenges difficult. In order to more comprehensively move toward mitigation, it is important to gather perspectives of key stakeholders, such as caregivers. Caregivers are an integral part of their child’s care during the hospitalization and particularly at home during their child’s recovery. They are also a valued member of the team, particularly in this era of family-centered care.19,29 The perspectives of the caregivers presented here identified both successes and challenges of their communication experiences with the medical team during their child’s hospitalization. These perspectives included experiences affecting perceptions of communication between the inpatient medical team and families; communication related to the teaching hospital environment, including confusing messages associated with large multidisciplinary teams, aspects of FCR, and confusion about medical team member roles; and caregivers’ perceptions of communication between providers in and out of the hospital, including types of communication caregivers observed or believed occurred between medical providers. We believe that these qualitative results are crucial to developing better, more targeted interventions to improve communication.
Maintaining a healthy and productive relationship with patients and their caregivers is critical to providing comprehensive and safe patient care. As supported in the literature, we found that when caregivers were included in conversations, they felt appreciated and valued; in addition, when answers were not directly shared by providers or there were lingering questions, nurses often served as “interpreters.”29,30 Indeed, nurses were seen as a critical touchpoint for many participants, individuals that could not only answer questions but also be a trusted source of information. Supporting such a relationship, and helping enhance the relationship between the family and other team members, may be particularly important considering the degree to which a hospitalization can stress a patient, caregiver, and family.31-34 Developing rapport with families and facilitating relationships with the inclusion of nursing during FCR can be particularly helpful. Though this can be challenging with the many competing priorities of medical providers and the fast-paced, acute nature of inpatient care, making an effort to include nursing staff on rounds can cut down on confusion and assist the family in understanding care plans. This, in turn, can minimize the stress associated with hospitalization and improve the patient and family experience.
While academic institutions’ resources and access to subspecialties are often thought to be advantageous, there are other challenges inherent to providing care in such complex environments. Some caregivers cited confusion related to large teams of providers with, to them, indistinguishable roles asking redundant questions. These experiences affected their perceptions of FCR, generally leading to a fixation on its overwhelming aspects. Certain caregivers highlighted that FCR caused them, and their child, to feel overwhelmed and more confused about the plan for the day. It is important to find ways to mitigate these feelings while simultaneously continuing to support the inclusion of caregivers during their child’s hospitalization and understanding of care plans. Some initiatives (in addition to including nursing on FCR as discussed above) focus on improving the ways in which providers communicate with families during rounds and throughout the day, seeking to decrease miscommunications and medical errors while also striving for better quality of care and patient/family satisfaction.35 Other initiatives seek to clarify identities and roles of the often large and confusing medical team. One such example of this is the development of a face sheet tool, which provides families with medical team members’ photos and role descriptions. Unaka et al.36 found that the use of the face sheet tool improved the ability of caregivers to correctly identify providers and their roles. Thinking beyond interventions at the bedside, it is also important to include caregivers on higher level committees within the institution, such as on family advisory boards and/or peer support groups, to inform systems-wide interventions that support the tenants of family-centered care.29 Efforts such as these are worth trialing in order to improve the patient and family experience and quality of communication.
Multiple studies have evaluated the challenges with ensuring consistent and useful handoffs across the inpatient-to-outpatient transition,8-10,12 but few have looked at it from the perspective of the caregiver.13 After leaving the hospital to care for their recovering child, caregivers often feel overwhelmed; they may want, or need, to rely on the support of others in the outpatient environment. This support can be enhanced when outpatient providers are intimately aware of what occurred during the hospitalization; trust erodes if this is not the case. Given the value caregivers place on this communication occurring and occurring well, interventions supporting this communication are critical. Furthermore, as providers, we should also inform families that communication with outpatient providers is happening. Examples of efforts that have worked to improve the quality and consistency of communication with outpatient providers include improving discharge summary documentation, ensuring timely faxing of documentation to outpatient providers, and reliably making phone calls to outpatient providers.37-39 These types of interventions seek to bridge the gap between inpatient and outpatient care and facilitate a smooth transfer of information in order to provide optimal quality of care and avoid undesired outcomes (eg, emergency department revisits, readmissions, medication errors, etc) and can be adopted by institutions to address the issue of communication between inpatient and outpatient providers.
We acknowledge limitations to our study. This was done at a single academic institution with only English-speaking participants. Thus, our results may not be reflective of caregivers of children cared for in different, more ethnically or linguistically diverse settings. The patient population at CCHMC, however, is diverse both demographically and clinically, which was reflected in the composition of our focus groups and interviews. Additionally, the inclusion of participants who received a nurse home visit after discharge may limit generalizability. However, only 4 participants had a nurse home visit; thus, the overwhelming majority of participants did not receive such an intervention. We also acknowledge that those willing to participate may have differed from nonparticipants, specifically sharing more positive experiences. We believe that our sampling strategy and use of an unbiased, nonhospital affiliated moderator minimized this possibility. Recall bias is possible, as participants were asked to reflect back on a discharge experience occurring in their past. We attempted to minimize this by holding sessions no more than 30 days from the day of discharge. Finally, we present data on caregivers’ perception of communication and not directly observed communication occurrences. Still, we expect that perception is powerful in and of itself, relevant to both outcomes and to interventions.
CONCLUSION
Communication during hospitalization influences how caregivers understand diagnoses and care plans. Communication perceived as effective fosters mutual understandings and positive relationships with the potential to result in better care and improved outcomes. Communication perceived as ineffective negatively affects experiences of patients and their caregivers and can adversely affect patient outcomes. Learning from caregivers’ experiences with communication during their child’s hospitalization can help identify modifiable factors and inform strategies to improve communication, support families through hospitalization, and facilitate a smooth reentry home.
ACKNOWLEDGMENTS
This manuscript is submitted on behalf of the H2O study group: Katherine A. Auger, MD, MSc, JoAnne Bachus, BSN, Monica L. Borell, BSN, Lenisa V. Chang, MA, PhD, Jennifer M. Gold, BSN, Judy A. Heilman, RN, Joseph A. Jabour, BS, Jane C. Khoury, PhD, Margo J. Moore, BSN, CCRP, Rita H. Pickler, PNP, PhD, Anita N. Shah, DO, Angela M. Statile, MD, MEd, Heidi J. Sucharew, PhD, Karen P. Sullivan, BSN, Heather L. Tubbs-Cooley, RN, PhD, Susan Wade-Murphy, MSN, and Christine M. White, MD, MAT.
Disclaimer
All statements in this report, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors, or Methodology Committee.
Disclosure
This work was (partially) supported through a Patient-Centered Outcomes Research Institute (PCORI) Award (HIS-1306-0081). The authors have no financial relationships relevant to this article to disclose. The authors have no conflicts of interest to disclose.
Provision of high-quality, high-value medical care hinges upon effective communication. During a hospitalization, critical information is communicated between patients, caregivers, and providers multiple times each day. This can cause inconsistent and misinterpreted messages, leaving ample room for error.1 The Joint Commission notes that communication failures occurring between medical providers account for ~60% of all sentinel or serious adverse events that result in death or harm to a patient.2 Communication that occurs between patients and/or their caregivers and medical providers is also critically important. The content and consistency of this communication is highly valued by patients and providers and can affect patient outcomes during hospitalizations and during transitions to home.3,4 Still, the multifactorial, complex nature of communication in the pediatric inpatient setting is not well understood.5,6
During hospitalization, communication happens continuously during both daytime and nighttime hours. It also precedes the particularly fragile period of transition from hospital to home. Studies have shown that nighttime communication between caregivers and medical providers (ie, nurses and physicians), as well as caregivers’ perceptions of interactions that occur between nurses and physicians, may be closely linked to that caregiver’s satisfaction and perceived quality of care.6,7 Communication that occurs between inpatient and outpatient providers is also subject to barriers (eg, limited availability for direct communication)8-12; studies have shown that patient and/or caregiver satisfaction has also been tied to perceptions of this communication.13,14 Moreover, a caregiver’s ability to understand diagnoses and adhere to postdischarge care plans is intimately tied to communication during the hospitalization and at discharge. Although many improvement efforts have aimed to enhance communication during these vulnerable time periods,3,15,16 there remains much work to be done.1,10,12
The many facets and routes of communication, and the multiple stakeholders involved, make improvement efforts challenging. We believe that more effective communication strategies could result from a deeper understanding of how caregivers view communication successes and challenges during a hospitalization. We see this as key to developing meaningful interventions that are directed towards improving communication and, by extension, patient satisfaction and safety. Here, we sought to extend findings from a broader qualitative study17 by developing an in-depth understanding of communication issues experienced by families during their child’s hospitalization and during the transition to home.
METHODS
Setting
The analyses presented here emerged from the Hospital to Home Outcomes Study (H2O). The first objective of H2O was to explore the caregiver perspective on hospital-to-home transitions. Here, we present the results related to caregiver perspectives of communication, while broader results of our qualitative investigation have been published elsewhere.17 This objective informed the latter 2 aims of the H2O study, which were to modify an existing nurse-led transitional home visit (THV) program and to study the effectiveness of the modified THV on reutilization and patient-specific outcomes via a randomized control trial. The specifics of the H2O protocol and design have been presented elsewhere.18
H2O was approved by the Institutional Review Board at Cincinnati Children’s Hospital Medical Center (CCHMC), a free-standing, academic children’s hospital with ~600 inpatient beds. This teaching hospital has >800 total medical students, residents, and fellows. Approximately 8000 children are hospitalized annually at CCHMC for general pediatric conditions, with ~85% of such admissions staffed by hospitalists from the Division of Hospital Medicine. The division is composed of >40 providers who devote the majority of their clinical time to the hospital medicine service; 15 additional providers work on the hospital medicine service but have primary clinical responsibilities in another division.
Family-centered rounds (FCR) are the standard of care at CCHMC, involving family members at the bedside to discuss patient care plans and diagnoses with the medical team.19 On a typical day, a team conducting FCR is composed of 1 attending, 1 fellow, 2 to 3 pediatric residents, 2 to 3 medical students, a charge nurse or bedside nurse, and a pharmacist. Other ancillary staff, such as social workers, care coordinators, nurse practitioners, or dieticians, may also participate on rounds, particularly for children with greater medical complexity.
Population
Caregivers of children discharged with acute medical conditions were eligible for recruitment if they were English-speaking (we did not have access to interpreter services during focus groups/interviews), had a child admitted to 1 of 3 services (hospital medicine, neurology, or neurosurgery), and could attend a focus group within 30 days of the child’s discharge. The majority of participants had a child admitted to hospital medicine; however, caregivers with a generally healthy child admitted to either neurology or neurosurgery were eligible to participate in the study.
Study Design
As presented elsewhere,17,20 we used focus groups and individual in-depth interviews to generate consensus themes about patient and caregiver experiences during the transition from hospital to home. Because there is evidence suggesting that focus group participants are more willing to talk openly when among others of similar backgrounds, we stratified the sample by the family’s estimated socioeconomic status.21,22 Socioeconomic status was estimated by identifying the poverty rate in the census tract in which each participant lived. Census tracts, relatively homogeneous areas of ~4000 individuals, have been previously shown to effectively detect socioeconomic gradients.23-26 Here, we separated participants into 2 socioeconomically distinct groupings (those in census tracts where <15% or ≥15% of the population lived below the federal poverty level).26 This cut point ensured an equivalent number of eligible participants within each stratum and diversity within our sample.
Data Collection
Caregivers were recruited on the inpatient unit during their child’s hospitalization. Participants then returned to CCHMC facilities for the focus group within 30 days of discharge. Though efforts were made to enhance participation by scheduling sessions at multiple sites and during various days and times of the week, 4 sessions yielded just 1 participant; thus, the format for those became an individual interview. Childcare was provided, and participants received a gift card for their participation.
An open-ended, semistructured question guide,17 developed de novo by the research team, directed the discussion for focus groups and interviews. As data collection progressed, the question guide was adapted to incorporate new issues raised by participants. Questions broadly focused on aspects of the inpatient experience, discharge processes, and healthcare system and family factors thought to be most relevant to patient- and family-centered outcomes. Communication-related questions addressed information shared with families from the medical team about discharge, diagnoses, instructions, and care plans. An experienced moderator and qualitative research methodologist (SNS) used probes to further elucidate responses and expand discussion by participants. Sessions were held in private conference rooms, lasted ~90 minutes, were audiotaped, and were transcribed verbatim. Identifiers were stripped and transcripts were reviewed for accuracy. After conducting 11 focus groups (generally composed of 5-10 participants) and 4 individual interviews, the research team determined that theoretical saturation27 was achieved, and recruitment was suspended.
Data Analysis
An inductive, thematic approach was used for analysis.27 Transcripts were independently reviewed by a multidisciplinary team of 4 researchers, including 2 pediatricians (LGS and AFB), a clinical research coordinator (SAS), and a qualitative research methodologist (SNS). The study team identified emerging concepts and themes related to the transition from hospital to home; themes related to communication during hospitalization are presented here.
During the first phase of analysis, investigators independently read transcripts and later convened to identify and define initial concepts and themes. A preliminary codebook was then designed. Investigators continued to review and code transcripts independently, meeting regularly to discuss coding decisions collaboratively, resolving differences through consensus.28 As patterns in the data became apparent, the codebook was modified iteratively, adding, subtracting, and refining codes as needed and grouping related codes. Results were reviewed with key stakeholders, including parents, inpatient and outpatient pediatricians, and home health nurses, throughout the analytic process.27,28 Coded data were maintained in an electronic database accessible only to study personnel.
RESULTS
Participants
Resulting Themes
Analyses revealed the following 3 major communication-related themes with associated subthemes: (1) experiences that affect caregiver perceptions of communication between the inpatient medical team and families, (2) communication challenges for caregivers related to a teaching hospital environment, and (3) caregiver perceptions of communication between medical providers. Each theme (and subtheme) is explored below with accompanying verbatim quotes in the narrative and the tables.
Major Theme 1: Experiences that Affect Caregiver Perceptions of Communication Between the Inpatient Medical Team and Families
In contrast, some of the negative experiences shared by participants related to feeling excluded from discussions about their child’s care. One participant said, “They tell you…as much as they want to tell you. They don’t fully inform you on things.” Additionally, concerns were voiced about insufficient time for face-to-face discussions with physicians: “I forget what I have to say and it’s something really, really important…But now, my doctor is going, you can’t get the doctor back.” Finally, participants discussed how the use of medical jargon often made it more difficult to understand things, especially for those not in the medical field.
Major Theme 2: Communication Challenges for Caregivers Related to a Teaching Hospital Environment
Major Theme 3: Caregiver Perceptions of Communication Between Medical Providers
Perceptions were not isolated to the inpatient setting. Based on their experiences, caregivers similarly described their sense of how inpatient and outpatient providers were communicating with each other. In some cases, it was clear that good communication, as perceived by the participant, had occurred in situations in which the primary care physician knew “everything” about the hospitalization when they saw the patient in follow-up. One participant described, “We didn’t even realize at the time, [the medical team] had actually called our doctor and filled them in on our situation, and we got [to the follow up visit]…He already knew the entire situation.” There were others, however, who shared their uncertainty about whether the information exchange about their child’s hospitalization had actually occurred. They, therefore, voiced apprehension around who to call for advice after discharge; would their outpatient provider have their child’s hospitalization history and be able to properly advise them?
DISCUSSION
Communication during a hospitalization and at transition from hospital to home happens in both formal and informal ways; it is a vital component of appropriate, effective patient care. When done poorly, it has the potential to negatively affect a patient’s safety, care, and key outcomes.2 During a hospitalization, the multifaceted nature of communication and multidisciplinary approach to care provision can create communication challenges and make fixing challenges difficult. In order to more comprehensively move toward mitigation, it is important to gather perspectives of key stakeholders, such as caregivers. Caregivers are an integral part of their child’s care during the hospitalization and particularly at home during their child’s recovery. They are also a valued member of the team, particularly in this era of family-centered care.19,29 The perspectives of the caregivers presented here identified both successes and challenges of their communication experiences with the medical team during their child’s hospitalization. These perspectives included experiences affecting perceptions of communication between the inpatient medical team and families; communication related to the teaching hospital environment, including confusing messages associated with large multidisciplinary teams, aspects of FCR, and confusion about medical team member roles; and caregivers’ perceptions of communication between providers in and out of the hospital, including types of communication caregivers observed or believed occurred between medical providers. We believe that these qualitative results are crucial to developing better, more targeted interventions to improve communication.
Maintaining a healthy and productive relationship with patients and their caregivers is critical to providing comprehensive and safe patient care. As supported in the literature, we found that when caregivers were included in conversations, they felt appreciated and valued; in addition, when answers were not directly shared by providers or there were lingering questions, nurses often served as “interpreters.”29,30 Indeed, nurses were seen as a critical touchpoint for many participants, individuals that could not only answer questions but also be a trusted source of information. Supporting such a relationship, and helping enhance the relationship between the family and other team members, may be particularly important considering the degree to which a hospitalization can stress a patient, caregiver, and family.31-34 Developing rapport with families and facilitating relationships with the inclusion of nursing during FCR can be particularly helpful. Though this can be challenging with the many competing priorities of medical providers and the fast-paced, acute nature of inpatient care, making an effort to include nursing staff on rounds can cut down on confusion and assist the family in understanding care plans. This, in turn, can minimize the stress associated with hospitalization and improve the patient and family experience.
While academic institutions’ resources and access to subspecialties are often thought to be advantageous, there are other challenges inherent to providing care in such complex environments. Some caregivers cited confusion related to large teams of providers with, to them, indistinguishable roles asking redundant questions. These experiences affected their perceptions of FCR, generally leading to a fixation on its overwhelming aspects. Certain caregivers highlighted that FCR caused them, and their child, to feel overwhelmed and more confused about the plan for the day. It is important to find ways to mitigate these feelings while simultaneously continuing to support the inclusion of caregivers during their child’s hospitalization and understanding of care plans. Some initiatives (in addition to including nursing on FCR as discussed above) focus on improving the ways in which providers communicate with families during rounds and throughout the day, seeking to decrease miscommunications and medical errors while also striving for better quality of care and patient/family satisfaction.35 Other initiatives seek to clarify identities and roles of the often large and confusing medical team. One such example of this is the development of a face sheet tool, which provides families with medical team members’ photos and role descriptions. Unaka et al.36 found that the use of the face sheet tool improved the ability of caregivers to correctly identify providers and their roles. Thinking beyond interventions at the bedside, it is also important to include caregivers on higher level committees within the institution, such as on family advisory boards and/or peer support groups, to inform systems-wide interventions that support the tenants of family-centered care.29 Efforts such as these are worth trialing in order to improve the patient and family experience and quality of communication.
Multiple studies have evaluated the challenges with ensuring consistent and useful handoffs across the inpatient-to-outpatient transition,8-10,12 but few have looked at it from the perspective of the caregiver.13 After leaving the hospital to care for their recovering child, caregivers often feel overwhelmed; they may want, or need, to rely on the support of others in the outpatient environment. This support can be enhanced when outpatient providers are intimately aware of what occurred during the hospitalization; trust erodes if this is not the case. Given the value caregivers place on this communication occurring and occurring well, interventions supporting this communication are critical. Furthermore, as providers, we should also inform families that communication with outpatient providers is happening. Examples of efforts that have worked to improve the quality and consistency of communication with outpatient providers include improving discharge summary documentation, ensuring timely faxing of documentation to outpatient providers, and reliably making phone calls to outpatient providers.37-39 These types of interventions seek to bridge the gap between inpatient and outpatient care and facilitate a smooth transfer of information in order to provide optimal quality of care and avoid undesired outcomes (eg, emergency department revisits, readmissions, medication errors, etc) and can be adopted by institutions to address the issue of communication between inpatient and outpatient providers.
We acknowledge limitations to our study. This was done at a single academic institution with only English-speaking participants. Thus, our results may not be reflective of caregivers of children cared for in different, more ethnically or linguistically diverse settings. The patient population at CCHMC, however, is diverse both demographically and clinically, which was reflected in the composition of our focus groups and interviews. Additionally, the inclusion of participants who received a nurse home visit after discharge may limit generalizability. However, only 4 participants had a nurse home visit; thus, the overwhelming majority of participants did not receive such an intervention. We also acknowledge that those willing to participate may have differed from nonparticipants, specifically sharing more positive experiences. We believe that our sampling strategy and use of an unbiased, nonhospital affiliated moderator minimized this possibility. Recall bias is possible, as participants were asked to reflect back on a discharge experience occurring in their past. We attempted to minimize this by holding sessions no more than 30 days from the day of discharge. Finally, we present data on caregivers’ perception of communication and not directly observed communication occurrences. Still, we expect that perception is powerful in and of itself, relevant to both outcomes and to interventions.
CONCLUSION
Communication during hospitalization influences how caregivers understand diagnoses and care plans. Communication perceived as effective fosters mutual understandings and positive relationships with the potential to result in better care and improved outcomes. Communication perceived as ineffective negatively affects experiences of patients and their caregivers and can adversely affect patient outcomes. Learning from caregivers’ experiences with communication during their child’s hospitalization can help identify modifiable factors and inform strategies to improve communication, support families through hospitalization, and facilitate a smooth reentry home.
ACKNOWLEDGMENTS
This manuscript is submitted on behalf of the H2O study group: Katherine A. Auger, MD, MSc, JoAnne Bachus, BSN, Monica L. Borell, BSN, Lenisa V. Chang, MA, PhD, Jennifer M. Gold, BSN, Judy A. Heilman, RN, Joseph A. Jabour, BS, Jane C. Khoury, PhD, Margo J. Moore, BSN, CCRP, Rita H. Pickler, PNP, PhD, Anita N. Shah, DO, Angela M. Statile, MD, MEd, Heidi J. Sucharew, PhD, Karen P. Sullivan, BSN, Heather L. Tubbs-Cooley, RN, PhD, Susan Wade-Murphy, MSN, and Christine M. White, MD, MAT.
Disclaimer
All statements in this report, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors, or Methodology Committee.
Disclosure
This work was (partially) supported through a Patient-Centered Outcomes Research Institute (PCORI) Award (HIS-1306-0081). The authors have no financial relationships relevant to this article to disclose. The authors have no conflicts of interest to disclose.
1. Riesenberg LA, Leitzsch J, Massucci JL, et al. Residents’ and Attending Physicians’ Handoffs: A Systematic Review of the Literature. Acad Med. 2009;84(12):1775-1787. PubMed
6. Comp D. Improving parent satisfaction by sharing the inpatient daily plan of care: an evidence review with implications for practice and research. Pediatr Nurs. 2011;37(5):237-242. PubMed
30. Latta LC, Dick R, Parry C, Tamura GS. Parental responses to involvement in rounds on a pediatric inpatient unit at a teaching hospital: a qualitative study. Acad Med. 2008;83(3):292-297. PubMed
1. Riesenberg LA, Leitzsch J, Massucci JL, et al. Residents’ and Attending Physicians’ Handoffs: A Systematic Review of the Literature. Acad Med. 2009;84(12):1775-1787. PubMed
6. Comp D. Improving parent satisfaction by sharing the inpatient daily plan of care: an evidence review with implications for practice and research. Pediatr Nurs. 2011;37(5):237-242. PubMed
30. Latta LC, Dick R, Parry C, Tamura GS. Parental responses to involvement in rounds on a pediatric inpatient unit at a teaching hospital: a qualitative study. Acad Med. 2008;83(3):292-297. PubMed
© 2018 Society of Hospital Medicine
Monitor Alarms in a Children's Hospital
Physiologic monitor alarms are an inescapable part of the soundtrack for hospitals. Data from primarily adult hospitals have shown that alarms occur at high rates, and most alarms are not actionable.[1] Small studies have suggested that high alarm rates can lead to alarm fatigue.[2, 3] To prioritize alarm types to target in future intervention studies, in this study we aimed to investigate the alarm rates on all inpatient units and the most common causes of alarms at a children's hospital.
METHODS
This was a cross‐sectional study of audible physiologic monitor alarms at Cincinnati Children's Hospital Medical Center (CCHMC) over 7 consecutive days during August 2014. CCHMC is a 522‐bed free‐standing children's hospital. Inpatient beds are equipped with GE Healthcare (Little Chalfont, United Kingdom) bedside monitors (models Dash 3000, 4000, and 5000, and Solar 8000). Age‐specific vital sign parameters were employed for monitors on all units.
We obtained date, time, and type of alarm from bedside physiologic monitors using Connexall middleware (GlobeStar Systems, Toronto, Ontario, Canada).
We determined unit census using the electronic health records for the time period concurrent with the alarm data collection. Given previously described variation in hospital census over the day,[4] we used 4 daily census measurements (6:00 am, 12:00 pm, 6:00 pm, and 11:00 pm) rather than 1 single measurement to more accurately reflect the hospital census.
The CCHMC Institutional Review Board determined this work to be not human subjects research.
Statistical Analysis
For each unit and each census time interval, we generated a rate based on the number of occupied beds (alarms per patient‐day) resulting in a total of 28 rates (4 census measurement periods per/day 7 days) for each unit over the study period. We used descriptive statistics to summarize alarms per patient‐day by unit. Analysis of variance was used to compare alarm rates between units. For significant main effects, we used Tukey's multiple comparisons tests for all pairwise comparisons to control the type I experiment‐wise error rate. Alarms were then classified by alarm cause (eg, high heart rate). We summarized the cause for all alarms using counts and percentages.
RESULTS
There were a total of 220,813 audible alarms over 1 week. Median alarm rate per patient‐day by unit ranged from 30.4 to 228.5; the highest alarm rates occurred in the cardiac intensive care unit, with a median of 228.5 (interquartile range [IQR], 193275) followed by the pediatric intensive care unit (172.4; IQR, 141188) (Figure 1). The average alarm rate was significantly different among the units (P < 0.01).
Technical alarms (eg, alarms for artifact, lead failure), comprised 33% of the total number of alarms. The remaining 67% of alarms were for clinical conditions, the most common of which was low oxygen saturation (30% of clinical alarms) (Figure 2).
DISCUSSION
We described alarm rates and causes over multiple units at a large children's hospital. To our knowledge, this is the first description of alarm rates across multiple pediatric inpatient units. Alarm counts were high even for the general units, indicating that a nurse taking care of 4 monitored patients would need to process a physiologic monitor alarm every 4 minutes on average, in addition to other sources of alarms such as infusion pumps.
Alarm rates were highest in the intensive care unit areas, which may be attributable to both higher rates of monitoring and sicker patients. Importantly, however, alarms were quite high and variable on the acute care units. This suggests that factors other than patient acuity may have substantial influence on alarm rates.
Technical alarms, alarms that do not indicate a change in patient condition, accounted for the largest percentage of alarms during the study period. This is consistent with prior literature that has suggested that regular electrode replacement, which decreases technical alarms, can be effective in reducing alarm rates.[5, 6] The most common vital sign change to cause alarms was low oxygen saturation, followed by elevated heart rate and elevated respiratory rate. Whereas in most healthy patients, certain low oxygen levels would prompt initiation of supplemental oxygen, there are many conditions in which elevated heart rate and respiratory rate may not require titration of any particular therapy. These may be potential intervention targets for hospitals trying to improve alarm rates.
Limitations
There are several limitations to our study. First, our results are not necessarily generalizable to other types of hospitals or those utilizing monitors from other vendors. Second, we were unable to include other sources of alarms such as infusion pumps and ventilators. However, given the high alarm rates from physiologic monitors alone, these data add urgency to the need for further investigation in the pediatric setting.
CONCLUSION
Alarm rates at a single children's hospital varied depending on the unit. Strategies targeted at reducing technical alarms and reducing nonactionable clinical alarms for low oxygen saturation, high heart rate, and high respiratory rate may offer the greatest opportunity to reduce alarm rates.
Acknowledgements
The authors acknowledge Melinda Egan for her assistance in obtaining data for this study and Ting Sa for her assistance with data management.
Disclosures: Dr. Bonafide is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K23HL116427. Dr. Bonafide also holds a Young Investigator Award grant from the Academic Pediatric Association evaluating the impact of a data‐driven monitor alarm reduction strategy implemented in safety huddles. Dr. Brady is supported by the Agency for Healthcare Research and Quality under award number K08HS23827. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Agency for Healthcare Research and Quality. This study was funded by the Arnold W. Strauss Fellow Grant, Cincinnati Children's Hospital Medical Center. The authors have no conflicts of interest to disclose.
- , , , et al. Systematic review of physiologic monitor alarm characteristics and pragmatic interventions to reduce alarm frequency. J Hosp Med. 2016;11(2):136–144.
- , , , et al. Association between exposure to nonactionable physiologic monitor alarms and response time in a children's hospital. J Hosp Med. 2015;10(6):345–351.
- , , , et al. Pulse oximetry desaturation alarms on a general postoperative adult unit: a prospective observational study of nurse response time. Int J Nurs Stud. 2013;50(10):1351–1358.
- , , , , . Traditional measures of hospital utilization may not accurately reflect dynamic patient demand: findings from a children's hospital. Hosp Pediatr. 2012;2(1):10–18.
- , , , et al. A team‐based approach to reducing cardiac monitor alarms. Pediatrics. 2014;134(6):e1686–e1694.
- , , , . Daily electrode change and effect on cardiac monitor alarms: an evidence‐based practice approach. J Nurs Care Qual. 2013;28(3):265–271.
Physiologic monitor alarms are an inescapable part of the soundtrack for hospitals. Data from primarily adult hospitals have shown that alarms occur at high rates, and most alarms are not actionable.[1] Small studies have suggested that high alarm rates can lead to alarm fatigue.[2, 3] To prioritize alarm types to target in future intervention studies, in this study we aimed to investigate the alarm rates on all inpatient units and the most common causes of alarms at a children's hospital.
METHODS
This was a cross‐sectional study of audible physiologic monitor alarms at Cincinnati Children's Hospital Medical Center (CCHMC) over 7 consecutive days during August 2014. CCHMC is a 522‐bed free‐standing children's hospital. Inpatient beds are equipped with GE Healthcare (Little Chalfont, United Kingdom) bedside monitors (models Dash 3000, 4000, and 5000, and Solar 8000). Age‐specific vital sign parameters were employed for monitors on all units.
We obtained date, time, and type of alarm from bedside physiologic monitors using Connexall middleware (GlobeStar Systems, Toronto, Ontario, Canada).
We determined unit census using the electronic health records for the time period concurrent with the alarm data collection. Given previously described variation in hospital census over the day,[4] we used 4 daily census measurements (6:00 am, 12:00 pm, 6:00 pm, and 11:00 pm) rather than 1 single measurement to more accurately reflect the hospital census.
The CCHMC Institutional Review Board determined this work to be not human subjects research.
Statistical Analysis
For each unit and each census time interval, we generated a rate based on the number of occupied beds (alarms per patient‐day) resulting in a total of 28 rates (4 census measurement periods per/day 7 days) for each unit over the study period. We used descriptive statistics to summarize alarms per patient‐day by unit. Analysis of variance was used to compare alarm rates between units. For significant main effects, we used Tukey's multiple comparisons tests for all pairwise comparisons to control the type I experiment‐wise error rate. Alarms were then classified by alarm cause (eg, high heart rate). We summarized the cause for all alarms using counts and percentages.
RESULTS
There were a total of 220,813 audible alarms over 1 week. Median alarm rate per patient‐day by unit ranged from 30.4 to 228.5; the highest alarm rates occurred in the cardiac intensive care unit, with a median of 228.5 (interquartile range [IQR], 193275) followed by the pediatric intensive care unit (172.4; IQR, 141188) (Figure 1). The average alarm rate was significantly different among the units (P < 0.01).
Technical alarms (eg, alarms for artifact, lead failure), comprised 33% of the total number of alarms. The remaining 67% of alarms were for clinical conditions, the most common of which was low oxygen saturation (30% of clinical alarms) (Figure 2).
DISCUSSION
We described alarm rates and causes over multiple units at a large children's hospital. To our knowledge, this is the first description of alarm rates across multiple pediatric inpatient units. Alarm counts were high even for the general units, indicating that a nurse taking care of 4 monitored patients would need to process a physiologic monitor alarm every 4 minutes on average, in addition to other sources of alarms such as infusion pumps.
Alarm rates were highest in the intensive care unit areas, which may be attributable to both higher rates of monitoring and sicker patients. Importantly, however, alarms were quite high and variable on the acute care units. This suggests that factors other than patient acuity may have substantial influence on alarm rates.
Technical alarms, alarms that do not indicate a change in patient condition, accounted for the largest percentage of alarms during the study period. This is consistent with prior literature that has suggested that regular electrode replacement, which decreases technical alarms, can be effective in reducing alarm rates.[5, 6] The most common vital sign change to cause alarms was low oxygen saturation, followed by elevated heart rate and elevated respiratory rate. Whereas in most healthy patients, certain low oxygen levels would prompt initiation of supplemental oxygen, there are many conditions in which elevated heart rate and respiratory rate may not require titration of any particular therapy. These may be potential intervention targets for hospitals trying to improve alarm rates.
Limitations
There are several limitations to our study. First, our results are not necessarily generalizable to other types of hospitals or those utilizing monitors from other vendors. Second, we were unable to include other sources of alarms such as infusion pumps and ventilators. However, given the high alarm rates from physiologic monitors alone, these data add urgency to the need for further investigation in the pediatric setting.
CONCLUSION
Alarm rates at a single children's hospital varied depending on the unit. Strategies targeted at reducing technical alarms and reducing nonactionable clinical alarms for low oxygen saturation, high heart rate, and high respiratory rate may offer the greatest opportunity to reduce alarm rates.
Acknowledgements
The authors acknowledge Melinda Egan for her assistance in obtaining data for this study and Ting Sa for her assistance with data management.
Disclosures: Dr. Bonafide is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K23HL116427. Dr. Bonafide also holds a Young Investigator Award grant from the Academic Pediatric Association evaluating the impact of a data‐driven monitor alarm reduction strategy implemented in safety huddles. Dr. Brady is supported by the Agency for Healthcare Research and Quality under award number K08HS23827. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Agency for Healthcare Research and Quality. This study was funded by the Arnold W. Strauss Fellow Grant, Cincinnati Children's Hospital Medical Center. The authors have no conflicts of interest to disclose.
Physiologic monitor alarms are an inescapable part of the soundtrack for hospitals. Data from primarily adult hospitals have shown that alarms occur at high rates, and most alarms are not actionable.[1] Small studies have suggested that high alarm rates can lead to alarm fatigue.[2, 3] To prioritize alarm types to target in future intervention studies, in this study we aimed to investigate the alarm rates on all inpatient units and the most common causes of alarms at a children's hospital.
METHODS
This was a cross‐sectional study of audible physiologic monitor alarms at Cincinnati Children's Hospital Medical Center (CCHMC) over 7 consecutive days during August 2014. CCHMC is a 522‐bed free‐standing children's hospital. Inpatient beds are equipped with GE Healthcare (Little Chalfont, United Kingdom) bedside monitors (models Dash 3000, 4000, and 5000, and Solar 8000). Age‐specific vital sign parameters were employed for monitors on all units.
We obtained date, time, and type of alarm from bedside physiologic monitors using Connexall middleware (GlobeStar Systems, Toronto, Ontario, Canada).
We determined unit census using the electronic health records for the time period concurrent with the alarm data collection. Given previously described variation in hospital census over the day,[4] we used 4 daily census measurements (6:00 am, 12:00 pm, 6:00 pm, and 11:00 pm) rather than 1 single measurement to more accurately reflect the hospital census.
The CCHMC Institutional Review Board determined this work to be not human subjects research.
Statistical Analysis
For each unit and each census time interval, we generated a rate based on the number of occupied beds (alarms per patient‐day) resulting in a total of 28 rates (4 census measurement periods per/day 7 days) for each unit over the study period. We used descriptive statistics to summarize alarms per patient‐day by unit. Analysis of variance was used to compare alarm rates between units. For significant main effects, we used Tukey's multiple comparisons tests for all pairwise comparisons to control the type I experiment‐wise error rate. Alarms were then classified by alarm cause (eg, high heart rate). We summarized the cause for all alarms using counts and percentages.
RESULTS
There were a total of 220,813 audible alarms over 1 week. Median alarm rate per patient‐day by unit ranged from 30.4 to 228.5; the highest alarm rates occurred in the cardiac intensive care unit, with a median of 228.5 (interquartile range [IQR], 193275) followed by the pediatric intensive care unit (172.4; IQR, 141188) (Figure 1). The average alarm rate was significantly different among the units (P < 0.01).
Technical alarms (eg, alarms for artifact, lead failure), comprised 33% of the total number of alarms. The remaining 67% of alarms were for clinical conditions, the most common of which was low oxygen saturation (30% of clinical alarms) (Figure 2).
DISCUSSION
We described alarm rates and causes over multiple units at a large children's hospital. To our knowledge, this is the first description of alarm rates across multiple pediatric inpatient units. Alarm counts were high even for the general units, indicating that a nurse taking care of 4 monitored patients would need to process a physiologic monitor alarm every 4 minutes on average, in addition to other sources of alarms such as infusion pumps.
Alarm rates were highest in the intensive care unit areas, which may be attributable to both higher rates of monitoring and sicker patients. Importantly, however, alarms were quite high and variable on the acute care units. This suggests that factors other than patient acuity may have substantial influence on alarm rates.
Technical alarms, alarms that do not indicate a change in patient condition, accounted for the largest percentage of alarms during the study period. This is consistent with prior literature that has suggested that regular electrode replacement, which decreases technical alarms, can be effective in reducing alarm rates.[5, 6] The most common vital sign change to cause alarms was low oxygen saturation, followed by elevated heart rate and elevated respiratory rate. Whereas in most healthy patients, certain low oxygen levels would prompt initiation of supplemental oxygen, there are many conditions in which elevated heart rate and respiratory rate may not require titration of any particular therapy. These may be potential intervention targets for hospitals trying to improve alarm rates.
Limitations
There are several limitations to our study. First, our results are not necessarily generalizable to other types of hospitals or those utilizing monitors from other vendors. Second, we were unable to include other sources of alarms such as infusion pumps and ventilators. However, given the high alarm rates from physiologic monitors alone, these data add urgency to the need for further investigation in the pediatric setting.
CONCLUSION
Alarm rates at a single children's hospital varied depending on the unit. Strategies targeted at reducing technical alarms and reducing nonactionable clinical alarms for low oxygen saturation, high heart rate, and high respiratory rate may offer the greatest opportunity to reduce alarm rates.
Acknowledgements
The authors acknowledge Melinda Egan for her assistance in obtaining data for this study and Ting Sa for her assistance with data management.
Disclosures: Dr. Bonafide is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K23HL116427. Dr. Bonafide also holds a Young Investigator Award grant from the Academic Pediatric Association evaluating the impact of a data‐driven monitor alarm reduction strategy implemented in safety huddles. Dr. Brady is supported by the Agency for Healthcare Research and Quality under award number K08HS23827. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Agency for Healthcare Research and Quality. This study was funded by the Arnold W. Strauss Fellow Grant, Cincinnati Children's Hospital Medical Center. The authors have no conflicts of interest to disclose.
- , , , et al. Systematic review of physiologic monitor alarm characteristics and pragmatic interventions to reduce alarm frequency. J Hosp Med. 2016;11(2):136–144.
- , , , et al. Association between exposure to nonactionable physiologic monitor alarms and response time in a children's hospital. J Hosp Med. 2015;10(6):345–351.
- , , , et al. Pulse oximetry desaturation alarms on a general postoperative adult unit: a prospective observational study of nurse response time. Int J Nurs Stud. 2013;50(10):1351–1358.
- , , , , . Traditional measures of hospital utilization may not accurately reflect dynamic patient demand: findings from a children's hospital. Hosp Pediatr. 2012;2(1):10–18.
- , , , et al. A team‐based approach to reducing cardiac monitor alarms. Pediatrics. 2014;134(6):e1686–e1694.
- , , , . Daily electrode change and effect on cardiac monitor alarms: an evidence‐based practice approach. J Nurs Care Qual. 2013;28(3):265–271.
- , , , et al. Systematic review of physiologic monitor alarm characteristics and pragmatic interventions to reduce alarm frequency. J Hosp Med. 2016;11(2):136–144.
- , , , et al. Association between exposure to nonactionable physiologic monitor alarms and response time in a children's hospital. J Hosp Med. 2015;10(6):345–351.
- , , , et al. Pulse oximetry desaturation alarms on a general postoperative adult unit: a prospective observational study of nurse response time. Int J Nurs Stud. 2013;50(10):1351–1358.
- , , , , . Traditional measures of hospital utilization may not accurately reflect dynamic patient demand: findings from a children's hospital. Hosp Pediatr. 2012;2(1):10–18.
- , , , et al. A team‐based approach to reducing cardiac monitor alarms. Pediatrics. 2014;134(6):e1686–e1694.
- , , , . Daily electrode change and effect on cardiac monitor alarms: an evidence‐based practice approach. J Nurs Care Qual. 2013;28(3):265–271.
Parent and Stakeholder Engagement
We believe that patients, families, and other stakeholders can provide meaningful contributions throughout the research process. Involvement of a diverse group of stakeholders is also encouraged by the Patient Centered Outcomes Research Institute (PCORI), which emphasizes research focused on patient‐ and family‐centered outcomes.[1] Patient and family engagement in healthcare, however, has generally focused on children and adults with chronic conditions.[1, 2] Engagement of families of children with serious acute illnesses is infrequent, and no studies have documented the feasibility or acceptability of different methods of family engagement.[3] Furthermore, stakeholders, such as nurses, may participate in study execution but rarely receive opportunities to inform the research process. In this Perspective, we describe our experiences with family engagement using a novel approach of serial, focused, short‐term engagement of stakeholders.
PRESTUDY WORK
In 2012, our institution introduced a nurse‐led transitional home‐visit program, an approach associated with reduced healthcare utilization in adults.[4] Patients hospitalized for acute illness received a 1‐time transitional home visit 24 to 72 hours after hospital discharge. We formed a multidisciplinary team, consisting of physicians, nurse scientists, home healthcare (HHC) nursing staff, patient families, and research staff to design a mixed‐methods study of the transitional home visit, which was funded by PCORI in 2014. This study, the Hospital‐to‐Home Outcomes (H2O) study, has 3 aims: (1) identify barriers to successful transitions home and outcomes of such transitions that are meaningful to families, (2) optimize the transitional home visits to address family‐identified barriers and outcomes, and (3) determine the efficacy of transitional home visits through a randomized control trial.
Two parents joined the study team during study development. Both had children hospitalized for acute illnesses, received a transitional home visit, and participated in a pilot focus group to provide insight into barriers families encounter during care transitions. These parents made valuable contributions, including recommending strategies for patient enrollment and retention. They also committed to participating in regularly scheduled study meetings and ad hoc discussions. However, feedback from the pilot focus group also highlighted a potential research engagement challenge; specifically, once the acute illness resolved, many families were primarily focused on the return to their normal routine and may not be easily engaged in research.
Based on family input, we included several mechanisms to engage caregivers of children with acute illness in the study design of H2O. Each design element allowed families and other stakeholders to contribute via short‐term focused approaches (eg, focus groups, phone surveys). These short‐term interactions drove iterative changes in study processes and approaches, including how to measure outcomes important to families. Rather than a small group of stakeholders making a series of recommendations over a long period of time, we had dozens of individual stakeholders make a few recommendations apiece that were quickly implemented and subsequently tested via feedback from the next few stakeholders (Figure 1).
PATIENT AND STAKEHOLDER ENGAGEMENT IN THE H2O STUDY
Having the short‐term, focused engagement strategy built into the study proved beneficial, when the 2 parents who were part of the initial design team and had planned to participate longitudinally were no longer able to participate. Over time, their circumstances changed. One parent moved out of the area to pursue a professional opportunity, and the second parent became increasingly difficult to reach and unable to join planned study meetings, a situation anticipated by the pilot focus group participants. These 2 instances illustrate challenges with long‐term engagement of families in research when the potential primary driver of their engagement, their child's acute illness, has resolved.
Short‐Term Focused Engagement Via Focus Groups With Parents/Caregivers
The first aim of the H2O study used 15 focus groups and semistructured interviews with parents/caregivers of recently discharged patients to identify barriers to and metrics of successful transitions of care from the hospital to home. The focus group question guide was developed by the research team and adapted as the focus groups progressed to incorporate new issues raised by participants. Analysis of focus group data revealed opportunities to improve the transitional home visit and identified outcomes important to families, including the need for emotional reassurance in the immediate period after discharge and the impact on family finances.
Short‐Term Focused Engagement Via Phone Calls With Parents/Caregivers
To continuously improve study processes and the transitional home visit during the second aim of H2O, we relied on short‐term focused engagement from 2 stakeholder groups, families and field nurses. We completed 107 phone calls with families who received a transitional home visit during the visit optimization period. These calls, completed 3 to 7 days after the visit, assessed parental perceptions of the effect of recent visit modifications through a standardized survey documented in an electronic database. These data were utilized in plan‐do‐study‐act cycles,[5] every 1 to 2 weeks, to determine if additional modifications to the visits were necessary. A cycle ended when the calls no longer provided new information. The questions asked on the calls also changed over time as different interventions were tested.
As an example, in aim 1, families highlighted the lack of clarity of discharge instructions, particularly regarding when and why to return for medical care. Thus, we developed condition‐specific red flag reminder cards to be shared at transitional home visits to help families remember and recognize concerning signs and symptoms and understand when additional evaluation may be warranted (Figure 2). Families in postvisit calls endorsed the concept of red flags, but sometimes preferred electronic rather than paper versions of the red flag cards to facilitate sharing with family members. Thus, we tested and refined texting the red flag information to families. Subsequent calls strongly supported this practice, so we will continue to use it during the third aim, the randomized trial of the transitional home visit.
The remaining calls (N=72) were completed 14 days after the visit to mirror the time frame for follow‐up calls in the planned randomized trial. These calls allowed us to test measurement of family‐identified outcomes and determine their usability in the trial. We used family feedback to shorten the survey and reorder questions. We also used feedback from these calls to develop an optimal call‐back strategy to maximize family contacts.
Short‐Term Focused Engagement Via Discussions With Nurses
We also incorporated feedback from HHC nurses on 60 visits to ensure that the visit modifications were feasible to implement. HHC nurse feedback, which aligned with aim 1 data from families, highlighted the potential benefits of standardizing the transitional home visit to be more condition specific. The nurses also provided ongoing ad hoc feedback on other changes to the transitional home visit, which indicated both when tests were successful and when they were challenging to implement. The study team wanted to ensure that the nurses performing the visits were involved in the modification process.
ONGOING H2O WORK AND CONCLUSION
The third aim, with ongoing patient enrollment, involves a randomized trial to determine the efficacy of the revised transitional home visit compared with standard of care as measured by subsequent healthcare utilization and outcomes suggested in aim 1 and refined during aim 2, such as parental coping, stress, and confidence in care. We have engaged 1 parent to provide longitudinal feedback during regularly scheduled meetings.
We believe that our short‐term, focused engagement strategies have allowed integration of the invaluable perspective of families and other stakeholders into our research questions, intervention design, outcome measurement, and study execution. Our approach combined short‐term engagement from many stakeholders, blending qualitative techniques with rapid‐cycle implementation methods to quickly react to stakeholder input. Given the challenge of sustaining longitudinal engagement of families in research focused on acute care questions, and the tendency for many families interested in such engagement to be well versed in the care system due to chronic conditions, we propose this short‐term focused approach to include the unique viewpoints of families and patients whose care experience is confined to an acute period. Similarly, we propose that such an approach can efficiently include and rapidly react to input from other hard‐to‐engage key stakeholders such as field nurses.
Disclosures
This work was supported by the Patient Centered Outcomes Research Institute(HIS‐1306‐0081, SSS). The Patient Centered Outcomes Research Institute had no role in the design, preparation, review, or approval of the manuscript or in the decision to submit the manuscript for publication. The authors have no financial relationships relevant to this article to disclose. The authors report no potential conflicts of interest. The H2O study team members include the following: Katherine A. Auger, MD, MSc, JoAnne Bachus, BSN, Andrew F. Beck, MD, MPH, Monica L. Borell, BSN, Stephanie A. Brunswick, BS, Lenisa Chang, MA, PhD, Jennifer M. Gold, BSN, Judy A. Heilman, RN, Joseph A. Jabour, BS, Jane C. Khoury, PhD, Margo J. Moore, BSN, CCRP, Rita H. Pickler, PNP, PhD, Susan N. Sherman, DPA, Lauren G. Solan, MD, MEd, Angela M. Statile, MD, MEd, Heidi J. Sucharew, PhD, Karen P. Sullivan, BSN, Heather L. Tubbs‐Cooley, RN, PhD, Susan Wade‐Murphy, MSN, and Christine M. White, MD, MAT.
- , , , et al. Conceptual and practical foundations of patient engagement in research at the patient‐centered outcomes research institute. Qual Life Res. 2015;24(5):1033–1041.
- , . A review of parent participation engagement in child and family mental health treatment. Clin Child Fam Psychol Rev. 2015;18(2):133–150.
- , , , et al. Patient engagement in research: a systematic review. BMC Health Serv Res. 2014;14:89.
- , , , . Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review. J Hosp Med. 2014;9:251–260.
- , , , , , . The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey‐Bass; 2009.
We believe that patients, families, and other stakeholders can provide meaningful contributions throughout the research process. Involvement of a diverse group of stakeholders is also encouraged by the Patient Centered Outcomes Research Institute (PCORI), which emphasizes research focused on patient‐ and family‐centered outcomes.[1] Patient and family engagement in healthcare, however, has generally focused on children and adults with chronic conditions.[1, 2] Engagement of families of children with serious acute illnesses is infrequent, and no studies have documented the feasibility or acceptability of different methods of family engagement.[3] Furthermore, stakeholders, such as nurses, may participate in study execution but rarely receive opportunities to inform the research process. In this Perspective, we describe our experiences with family engagement using a novel approach of serial, focused, short‐term engagement of stakeholders.
PRESTUDY WORK
In 2012, our institution introduced a nurse‐led transitional home‐visit program, an approach associated with reduced healthcare utilization in adults.[4] Patients hospitalized for acute illness received a 1‐time transitional home visit 24 to 72 hours after hospital discharge. We formed a multidisciplinary team, consisting of physicians, nurse scientists, home healthcare (HHC) nursing staff, patient families, and research staff to design a mixed‐methods study of the transitional home visit, which was funded by PCORI in 2014. This study, the Hospital‐to‐Home Outcomes (H2O) study, has 3 aims: (1) identify barriers to successful transitions home and outcomes of such transitions that are meaningful to families, (2) optimize the transitional home visits to address family‐identified barriers and outcomes, and (3) determine the efficacy of transitional home visits through a randomized control trial.
Two parents joined the study team during study development. Both had children hospitalized for acute illnesses, received a transitional home visit, and participated in a pilot focus group to provide insight into barriers families encounter during care transitions. These parents made valuable contributions, including recommending strategies for patient enrollment and retention. They also committed to participating in regularly scheduled study meetings and ad hoc discussions. However, feedback from the pilot focus group also highlighted a potential research engagement challenge; specifically, once the acute illness resolved, many families were primarily focused on the return to their normal routine and may not be easily engaged in research.
Based on family input, we included several mechanisms to engage caregivers of children with acute illness in the study design of H2O. Each design element allowed families and other stakeholders to contribute via short‐term focused approaches (eg, focus groups, phone surveys). These short‐term interactions drove iterative changes in study processes and approaches, including how to measure outcomes important to families. Rather than a small group of stakeholders making a series of recommendations over a long period of time, we had dozens of individual stakeholders make a few recommendations apiece that were quickly implemented and subsequently tested via feedback from the next few stakeholders (Figure 1).
PATIENT AND STAKEHOLDER ENGAGEMENT IN THE H2O STUDY
Having the short‐term, focused engagement strategy built into the study proved beneficial, when the 2 parents who were part of the initial design team and had planned to participate longitudinally were no longer able to participate. Over time, their circumstances changed. One parent moved out of the area to pursue a professional opportunity, and the second parent became increasingly difficult to reach and unable to join planned study meetings, a situation anticipated by the pilot focus group participants. These 2 instances illustrate challenges with long‐term engagement of families in research when the potential primary driver of their engagement, their child's acute illness, has resolved.
Short‐Term Focused Engagement Via Focus Groups With Parents/Caregivers
The first aim of the H2O study used 15 focus groups and semistructured interviews with parents/caregivers of recently discharged patients to identify barriers to and metrics of successful transitions of care from the hospital to home. The focus group question guide was developed by the research team and adapted as the focus groups progressed to incorporate new issues raised by participants. Analysis of focus group data revealed opportunities to improve the transitional home visit and identified outcomes important to families, including the need for emotional reassurance in the immediate period after discharge and the impact on family finances.
Short‐Term Focused Engagement Via Phone Calls With Parents/Caregivers
To continuously improve study processes and the transitional home visit during the second aim of H2O, we relied on short‐term focused engagement from 2 stakeholder groups, families and field nurses. We completed 107 phone calls with families who received a transitional home visit during the visit optimization period. These calls, completed 3 to 7 days after the visit, assessed parental perceptions of the effect of recent visit modifications through a standardized survey documented in an electronic database. These data were utilized in plan‐do‐study‐act cycles,[5] every 1 to 2 weeks, to determine if additional modifications to the visits were necessary. A cycle ended when the calls no longer provided new information. The questions asked on the calls also changed over time as different interventions were tested.
As an example, in aim 1, families highlighted the lack of clarity of discharge instructions, particularly regarding when and why to return for medical care. Thus, we developed condition‐specific red flag reminder cards to be shared at transitional home visits to help families remember and recognize concerning signs and symptoms and understand when additional evaluation may be warranted (Figure 2). Families in postvisit calls endorsed the concept of red flags, but sometimes preferred electronic rather than paper versions of the red flag cards to facilitate sharing with family members. Thus, we tested and refined texting the red flag information to families. Subsequent calls strongly supported this practice, so we will continue to use it during the third aim, the randomized trial of the transitional home visit.
The remaining calls (N=72) were completed 14 days after the visit to mirror the time frame for follow‐up calls in the planned randomized trial. These calls allowed us to test measurement of family‐identified outcomes and determine their usability in the trial. We used family feedback to shorten the survey and reorder questions. We also used feedback from these calls to develop an optimal call‐back strategy to maximize family contacts.
Short‐Term Focused Engagement Via Discussions With Nurses
We also incorporated feedback from HHC nurses on 60 visits to ensure that the visit modifications were feasible to implement. HHC nurse feedback, which aligned with aim 1 data from families, highlighted the potential benefits of standardizing the transitional home visit to be more condition specific. The nurses also provided ongoing ad hoc feedback on other changes to the transitional home visit, which indicated both when tests were successful and when they were challenging to implement. The study team wanted to ensure that the nurses performing the visits were involved in the modification process.
ONGOING H2O WORK AND CONCLUSION
The third aim, with ongoing patient enrollment, involves a randomized trial to determine the efficacy of the revised transitional home visit compared with standard of care as measured by subsequent healthcare utilization and outcomes suggested in aim 1 and refined during aim 2, such as parental coping, stress, and confidence in care. We have engaged 1 parent to provide longitudinal feedback during regularly scheduled meetings.
We believe that our short‐term, focused engagement strategies have allowed integration of the invaluable perspective of families and other stakeholders into our research questions, intervention design, outcome measurement, and study execution. Our approach combined short‐term engagement from many stakeholders, blending qualitative techniques with rapid‐cycle implementation methods to quickly react to stakeholder input. Given the challenge of sustaining longitudinal engagement of families in research focused on acute care questions, and the tendency for many families interested in such engagement to be well versed in the care system due to chronic conditions, we propose this short‐term focused approach to include the unique viewpoints of families and patients whose care experience is confined to an acute period. Similarly, we propose that such an approach can efficiently include and rapidly react to input from other hard‐to‐engage key stakeholders such as field nurses.
Disclosures
This work was supported by the Patient Centered Outcomes Research Institute(HIS‐1306‐0081, SSS). The Patient Centered Outcomes Research Institute had no role in the design, preparation, review, or approval of the manuscript or in the decision to submit the manuscript for publication. The authors have no financial relationships relevant to this article to disclose. The authors report no potential conflicts of interest. The H2O study team members include the following: Katherine A. Auger, MD, MSc, JoAnne Bachus, BSN, Andrew F. Beck, MD, MPH, Monica L. Borell, BSN, Stephanie A. Brunswick, BS, Lenisa Chang, MA, PhD, Jennifer M. Gold, BSN, Judy A. Heilman, RN, Joseph A. Jabour, BS, Jane C. Khoury, PhD, Margo J. Moore, BSN, CCRP, Rita H. Pickler, PNP, PhD, Susan N. Sherman, DPA, Lauren G. Solan, MD, MEd, Angela M. Statile, MD, MEd, Heidi J. Sucharew, PhD, Karen P. Sullivan, BSN, Heather L. Tubbs‐Cooley, RN, PhD, Susan Wade‐Murphy, MSN, and Christine M. White, MD, MAT.
We believe that patients, families, and other stakeholders can provide meaningful contributions throughout the research process. Involvement of a diverse group of stakeholders is also encouraged by the Patient Centered Outcomes Research Institute (PCORI), which emphasizes research focused on patient‐ and family‐centered outcomes.[1] Patient and family engagement in healthcare, however, has generally focused on children and adults with chronic conditions.[1, 2] Engagement of families of children with serious acute illnesses is infrequent, and no studies have documented the feasibility or acceptability of different methods of family engagement.[3] Furthermore, stakeholders, such as nurses, may participate in study execution but rarely receive opportunities to inform the research process. In this Perspective, we describe our experiences with family engagement using a novel approach of serial, focused, short‐term engagement of stakeholders.
PRESTUDY WORK
In 2012, our institution introduced a nurse‐led transitional home‐visit program, an approach associated with reduced healthcare utilization in adults.[4] Patients hospitalized for acute illness received a 1‐time transitional home visit 24 to 72 hours after hospital discharge. We formed a multidisciplinary team, consisting of physicians, nurse scientists, home healthcare (HHC) nursing staff, patient families, and research staff to design a mixed‐methods study of the transitional home visit, which was funded by PCORI in 2014. This study, the Hospital‐to‐Home Outcomes (H2O) study, has 3 aims: (1) identify barriers to successful transitions home and outcomes of such transitions that are meaningful to families, (2) optimize the transitional home visits to address family‐identified barriers and outcomes, and (3) determine the efficacy of transitional home visits through a randomized control trial.
Two parents joined the study team during study development. Both had children hospitalized for acute illnesses, received a transitional home visit, and participated in a pilot focus group to provide insight into barriers families encounter during care transitions. These parents made valuable contributions, including recommending strategies for patient enrollment and retention. They also committed to participating in regularly scheduled study meetings and ad hoc discussions. However, feedback from the pilot focus group also highlighted a potential research engagement challenge; specifically, once the acute illness resolved, many families were primarily focused on the return to their normal routine and may not be easily engaged in research.
Based on family input, we included several mechanisms to engage caregivers of children with acute illness in the study design of H2O. Each design element allowed families and other stakeholders to contribute via short‐term focused approaches (eg, focus groups, phone surveys). These short‐term interactions drove iterative changes in study processes and approaches, including how to measure outcomes important to families. Rather than a small group of stakeholders making a series of recommendations over a long period of time, we had dozens of individual stakeholders make a few recommendations apiece that were quickly implemented and subsequently tested via feedback from the next few stakeholders (Figure 1).
PATIENT AND STAKEHOLDER ENGAGEMENT IN THE H2O STUDY
Having the short‐term, focused engagement strategy built into the study proved beneficial, when the 2 parents who were part of the initial design team and had planned to participate longitudinally were no longer able to participate. Over time, their circumstances changed. One parent moved out of the area to pursue a professional opportunity, and the second parent became increasingly difficult to reach and unable to join planned study meetings, a situation anticipated by the pilot focus group participants. These 2 instances illustrate challenges with long‐term engagement of families in research when the potential primary driver of their engagement, their child's acute illness, has resolved.
Short‐Term Focused Engagement Via Focus Groups With Parents/Caregivers
The first aim of the H2O study used 15 focus groups and semistructured interviews with parents/caregivers of recently discharged patients to identify barriers to and metrics of successful transitions of care from the hospital to home. The focus group question guide was developed by the research team and adapted as the focus groups progressed to incorporate new issues raised by participants. Analysis of focus group data revealed opportunities to improve the transitional home visit and identified outcomes important to families, including the need for emotional reassurance in the immediate period after discharge and the impact on family finances.
Short‐Term Focused Engagement Via Phone Calls With Parents/Caregivers
To continuously improve study processes and the transitional home visit during the second aim of H2O, we relied on short‐term focused engagement from 2 stakeholder groups, families and field nurses. We completed 107 phone calls with families who received a transitional home visit during the visit optimization period. These calls, completed 3 to 7 days after the visit, assessed parental perceptions of the effect of recent visit modifications through a standardized survey documented in an electronic database. These data were utilized in plan‐do‐study‐act cycles,[5] every 1 to 2 weeks, to determine if additional modifications to the visits were necessary. A cycle ended when the calls no longer provided new information. The questions asked on the calls also changed over time as different interventions were tested.
As an example, in aim 1, families highlighted the lack of clarity of discharge instructions, particularly regarding when and why to return for medical care. Thus, we developed condition‐specific red flag reminder cards to be shared at transitional home visits to help families remember and recognize concerning signs and symptoms and understand when additional evaluation may be warranted (Figure 2). Families in postvisit calls endorsed the concept of red flags, but sometimes preferred electronic rather than paper versions of the red flag cards to facilitate sharing with family members. Thus, we tested and refined texting the red flag information to families. Subsequent calls strongly supported this practice, so we will continue to use it during the third aim, the randomized trial of the transitional home visit.
The remaining calls (N=72) were completed 14 days after the visit to mirror the time frame for follow‐up calls in the planned randomized trial. These calls allowed us to test measurement of family‐identified outcomes and determine their usability in the trial. We used family feedback to shorten the survey and reorder questions. We also used feedback from these calls to develop an optimal call‐back strategy to maximize family contacts.
Short‐Term Focused Engagement Via Discussions With Nurses
We also incorporated feedback from HHC nurses on 60 visits to ensure that the visit modifications were feasible to implement. HHC nurse feedback, which aligned with aim 1 data from families, highlighted the potential benefits of standardizing the transitional home visit to be more condition specific. The nurses also provided ongoing ad hoc feedback on other changes to the transitional home visit, which indicated both when tests were successful and when they were challenging to implement. The study team wanted to ensure that the nurses performing the visits were involved in the modification process.
ONGOING H2O WORK AND CONCLUSION
The third aim, with ongoing patient enrollment, involves a randomized trial to determine the efficacy of the revised transitional home visit compared with standard of care as measured by subsequent healthcare utilization and outcomes suggested in aim 1 and refined during aim 2, such as parental coping, stress, and confidence in care. We have engaged 1 parent to provide longitudinal feedback during regularly scheduled meetings.
We believe that our short‐term, focused engagement strategies have allowed integration of the invaluable perspective of families and other stakeholders into our research questions, intervention design, outcome measurement, and study execution. Our approach combined short‐term engagement from many stakeholders, blending qualitative techniques with rapid‐cycle implementation methods to quickly react to stakeholder input. Given the challenge of sustaining longitudinal engagement of families in research focused on acute care questions, and the tendency for many families interested in such engagement to be well versed in the care system due to chronic conditions, we propose this short‐term focused approach to include the unique viewpoints of families and patients whose care experience is confined to an acute period. Similarly, we propose that such an approach can efficiently include and rapidly react to input from other hard‐to‐engage key stakeholders such as field nurses.
Disclosures
This work was supported by the Patient Centered Outcomes Research Institute(HIS‐1306‐0081, SSS). The Patient Centered Outcomes Research Institute had no role in the design, preparation, review, or approval of the manuscript or in the decision to submit the manuscript for publication. The authors have no financial relationships relevant to this article to disclose. The authors report no potential conflicts of interest. The H2O study team members include the following: Katherine A. Auger, MD, MSc, JoAnne Bachus, BSN, Andrew F. Beck, MD, MPH, Monica L. Borell, BSN, Stephanie A. Brunswick, BS, Lenisa Chang, MA, PhD, Jennifer M. Gold, BSN, Judy A. Heilman, RN, Joseph A. Jabour, BS, Jane C. Khoury, PhD, Margo J. Moore, BSN, CCRP, Rita H. Pickler, PNP, PhD, Susan N. Sherman, DPA, Lauren G. Solan, MD, MEd, Angela M. Statile, MD, MEd, Heidi J. Sucharew, PhD, Karen P. Sullivan, BSN, Heather L. Tubbs‐Cooley, RN, PhD, Susan Wade‐Murphy, MSN, and Christine M. White, MD, MAT.
- , , , et al. Conceptual and practical foundations of patient engagement in research at the patient‐centered outcomes research institute. Qual Life Res. 2015;24(5):1033–1041.
- , . A review of parent participation engagement in child and family mental health treatment. Clin Child Fam Psychol Rev. 2015;18(2):133–150.
- , , , et al. Patient engagement in research: a systematic review. BMC Health Serv Res. 2014;14:89.
- , , , . Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review. J Hosp Med. 2014;9:251–260.
- , , , , , . The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey‐Bass; 2009.
- , , , et al. Conceptual and practical foundations of patient engagement in research at the patient‐centered outcomes research institute. Qual Life Res. 2015;24(5):1033–1041.
- , . A review of parent participation engagement in child and family mental health treatment. Clin Child Fam Psychol Rev. 2015;18(2):133–150.
- , , , et al. Patient engagement in research: a systematic review. BMC Health Serv Res. 2014;14:89.
- , , , . Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review. J Hosp Med. 2014;9:251–260.
- , , , , , . The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. San Francisco, CA: Jossey‐Bass; 2009.
Verbal Communication at Discharge
Timely and reliable communication of important data between hospital‐based physicians and primary care physicians is critical for prevention of medical adverse events.[1, 2] Extrapolation from high‐performance organizations outside of medicine suggests that verbal communication is an important component of patient handoffs.[3, 4] Though the Joint Commission does not mandate verbal communication during handoffs per se, stipulating instead that handoff participants have an opportunity to ask and respond to questions,[5] there is some evidence that primary care providers prefer verbal handoffs at least for certain patients such as those with medical complexity.[6] Verbal communication offers the receiver the opportunity to ask questions, but in practice, 2‐way verbal communication is often difficult to achieve at hospital discharge.
At our institution, hospital medicine (HM) physicians serve as the primary inpatient providers for nearly 90% of all general pediatric admissions. When the HM service was established, primary care physicians (PCPs) and HM physicians together agreed upon an expectation for verbal, physician‐to‐physician communication at the time of discharge. Discharge communication is provided by either residents or attendings depending on the facility. A telephone operator service called Physician Priority Link (PPL) was made available to facilitate this communication. The PPL service is staffed 24/7 by operators whose only responsibilities are to connect providers inside and outside the institution. By utilizing this service, PCPs could respond in a nonemergent fashion to discharge phone calls.
Over the last several years, PCPs have observed high variation in the reliability of discharge communication phone calls. A review of PPL phone records in 2009 showed that only 52% of HM discharges had a record of a call initiated to the PCP on the day of discharge. The overall goal of this improvement project was to improve the completion of verbal handoffs from HM physicians (residents or attendings) to PCPs. The specific aim of the project was to increase the proportion of completed verbal handoffs from on‐call residents or attendings to PCPs within 24 hours of discharge to more than 90% within 18 months.
METHODS
Human Subjects Protection
Our project was undertaken in accordance with institutional review board (IRB) policy on systems improvement work and did not require formal IRB review.
Setting
This study included all patients admitted to the HM service at an academic children's hospital and its satellite campus.
Planning the Intervention
The project was championed by physicians on the HM service and supported by a chief resident, PPL administrators, and 2 information technology analysts.
At the onset of the project, the team mapped the process for completing a discharge call to the PCPs, conducted a modified failure mode and effects analysis,[7, 8] and examined the key drivers used to prioritize interventions (Figure 1). Through the modified failure modes effect analysis, the team was able to identify system issues that led to unsuccessful communication: failure of call initiation, absence of an identified PCP, long wait times on hold, failure of PCP to call back, and failure of the call to be documented. These failure modes informed the key drivers to achieving the study aim. Figure 2 depicts the final key drivers, which were revised through testing and learning.
Interventions Targeting Key Stakeholder Buy‐in
To improve resident buy‐in and participation, the purpose and goals of the projects were discussed at resident morning report and during monthly team meetings by the pediatric chief resident on our improvement team. Resident physicians were interested in participating to reduce interruptions during daily rounds and to improve interactions with PCPs. The PPL staff was interested in standardizing the discharge call process to reduce confusion in identifying the appropriate contact when PCPs called residents back to discuss discharges. PCPs were interested in ensuring good communication at discharge, and individual PCPs were engaged through person‐to‐person contact by 1 of the HM physician champions.
Interventions to Standardization the Communication Process
To facilitate initiation of calls to PCPs at hospital discharge, the improvement team created a standard process using the PPL service (Figure 3). All patients discharged from the HM service were included in the process. Discharging physicians (who were usually but not always residents, depending on the facility), were instructed to call the PPL operator at the time of discharge. The PPL operator would then page the patient's PCP. It was the responsibility of the discharging physician to identify a PCP prior to discharge. Instances where no PCP was identified were counted as process failures because no phone call could be made. The expectation for the PCPs was that they would return the page within 20 minutes. PPL operators would then page back to the discharging physician to connect the 2 parties with the expectation that the discharging physician respond within 2 to 4 minutes to the PPL operator's page. Standardization of all calls through PPL allowed efficient tracking of incomplete calls and operators to reattempt calls that were not completed. This process also shifted the burden of following up on incomplete calls to PPL. The use of PPL to make the connection also allowed the physician to complete other work while awaiting a call back from the PCP.
Leveraging the Electronic Health Record for Process Initiation
To ensure reliable initiation of the discharge communication pathway, the improvement team introduced changes to the electronic health record (HER) (EpicCare Inpatient; Epic Systems Corp., Verona, WI), which generated a message to PPL operators whenever a discharge order was entered for an HM patient. The message contained the patient's name, medical record number, discharge date, discharging physician, and PCP name and phone number. A checklist was implemented by PPL to ensure that duplicate phone calls were not made. To initiate communication, the operator contacted the resident via text page to ensure they were ready to initiate the call. If the resident was ready to place a call, the operator then generated a phone call to the PCP. When the PCP returned the call, the operator connected the HM resident with the PCP for the handoff.
As the project progressed, several adaptations were made to address newly identified failure modes. To address confusion among PPL operators about which resident physicians should take discharge phone calls after the discharging resident was no longer available (for example, after a shift change), primary responsibility for discharge phone calls was reassigned to the daily on‐call resident rather than the resident who wrote the discharge order. Because the on‐call residents carry a single pager, the pager number listed on the automated discharge notification to PPL would never change and would always reach the appropriate team member. Second, to address the anticipated increase in interruption of resident workflow by calls back from PCPs, particularly during rounds, operators accessed information on pending discharge phone calls in batches at times of increased resident availability to minimize hold times for PCPs and work interruptions for the discharging physicians. Batch times were 1 pm and 4 pm to allow for completion of morning rounds, resident conference at noon, and patient‐care activities during the afternoon. Calls initiated after 4 pm were dispatched at the time of the discharge, and calls initiated after 10 pm were deferred to the following day.
Transparency of Data
Throughout the study, weekly failure data were generated from the EHR and emailed to improvement team members, enabling them to focus on near real‐time feedback of data to create a visible and more reliable system. With the standardization of all discharge calls directed to the PPL operators, the team was able to create a call record linked to the patient's medical record number. Team‐specific and overall results for the 5 HM resident teams were displayed weekly on a run chart in the resident conference room. As improvements in call initiation were demonstrated, completion rate data were also shared every several months with the attending hospitalists during a regularly scheduled divisional conference. This transparency of data gave the improvement team the opportunity to provide individual feedback to residents and attendings about failures. The weekly review of failure data allowed team leaders to learn from failures, identify knowledge gaps, and ensure accountability with the HM physicians.
Planning the Study of the Intervention
Data were collected prospectively from July 2011 to March 2014. A weekly list of patients discharged from the HM service was extracted from the EHR and compared to electronic call logs collected by PPL on the day of discharge. A standard sample size of 30 calls was audited separately by PPL and 1 of the physician leads to verify that the patients were discharged from the HM service and validate the percentage of completed and initiated calls.
The percentage of calls initiated within 24 hours of discharge was tracked as a process measure and served as the initial focus of improvement efforts. Our primary outcome measure was the percentage of calls completed to the PCP by the HM physician within 24 hours of discharge.
Methods of Evaluation and Analysis
We used improvement science methods and run charts to determine the percentage of patients discharged from the HM service with a call initiated to the PCP and completed within 24 hours of discharge. Data on calls initiated within 24 hours of discharge were plotted on a run chart to examine the impact of interventions over time. Once interventions targeted at call initiation had been implemented, we began tracking our primary outcome measure. A new run chart was created documenting the percentage of calls completed. For both metrics, the centerline was adjusted using established rules for special cause variation in run charts.[9, 10, 11, 12, 13]
RESULTS
From July 2011 to March 2014, there were 6313 discharges from the HM service. The process measure (percentage of calls initiated) improved from 50% to 97% after 4 interventions (Figure 4). Data for the outcome measure (percentage of calls completed) were collected starting in August 2012, shortly after linking the EHR discharge order to the discharge call. Over the first 8 weeks, our median was 80%, which increased to a median of 93% (Figure 5). These results were sustained for 18 months.
Several key interventions were identified that were critical to achievement of our goal. Standardization of the communication process through PPL was temporally associated with a shift in the median rate of call initiation from 52% to 72%. Use of the discharge order to initiate discharge communication was associated with an increase from 72% to 97%. Finally, the percentage of completed verbal handoffs increased to more than 93% following batching of phone calls to PCPs at specific times during the day.
DISCUSSION
We used improvement and reliability science methods to implement a successful process for improving verbal handoffs from HM physicians to PCPs within 24 hours of discharge to 93%. This result has been sustained for 18 months.
Utilization of the PPL call center for flexible call facilitation along with support for data analysis and leveraging the EHR to automate the process increased reliability, leading to rapid improvement. Prior to mandating the use of PPL to connect discharging physicians with PCPs, the exact rate of successful handoffs in our institution was not known. We do know, however, that only 52% of calls were initiated, so clearly a large gap was present prior to our improvement work. Data collection from the PPL system was automated so that accurate, timely, and sustainable data could be provided, greatly aiding improvement efforts. Flexibility in call‐back timing was also crucial, because coordinating the availability of PCPs and discharging physicians is often challenging. The EHR‐initiated process for discharge communication was a key intervention, and improvement of our process measure to 97% performance was associated with this implementation. Two final interventions: (1) assignment of responsibility for communication to a team pager held by a designated resident and (2) batching of calls to specific times streamlined the EHR‐initiated process and were associated with achievement of our main outcome goal of >90% completed verbal communication.
There are several reports of successful interventions to improve receipt or content of discharge summaries by PCPs following hospital discharge available in the literature.[14, 15, 16, 17, 18, 19, 20] Recently, Shen et al. reported on the success of a multisite improvement collaborative involving pediatric hospitalist programs at community hospitals whose aim was to improve the timely documentation of communication directed at PCPs.[21] In their report, all 7 hospital sites that participated in the collaborative for more than 4 months were able to demonstrate substantial improvement in documentation of some form of communication directed at PCPs (whether by e‐mail, fax, or telephone call), from a baseline of approximately 50% to more than 90%. A limitation of their study was that they were unable to document whether PCPs had received any information or by what method. A recent survey of PCPs by Sheu et al. indicated that for many discharges, information in addition to that present in the EHR was desirable to ensure a safe transition of care.[6] Two‐way communication, such as with a phone call, allows for senders to verify information receipt and for receivers to ask questions to ensure complete information. To our knowledge, there have been no previous reports describing processes for improving verbal communication between hospitalist services and PCPs at discharge.
It may be that use of the call system allowed PCPs to return phone calls regarding discharges at convenient stopping points in their day while allowing discharging physicians to initiate a call without having to wait on hold. Interestingly, though we anticipated the need for additional PPL resources during the course of this improvement, the final process was efficient enough that PPL did not require additional staffing to accommodate the higher call volume.
A key insight during our implementation was that relying on the EHR to initiate every discharge communication created disruption of resident workflow due to disregard of patient, resident, and PCP factors. This was reflected by the improvement in call initiation (our process measure) following this intervention, whereas at the same time call completion (our outcome measure) remained below goal. To achieve our goal of completing verbal communication required a process that was highly reliable yet flexible enough to allow discharging physicians to complete the call in the unpredictable environment of inpatient care. Ultimately, this was achieved by allowing discharging physicians to initiate the process when convenient, and allowing for the EHR‐initiated process to function as a backup strategy to identify and mitigate failures of initiation.
An important limitation of our study was the lack of PCPs on the improvement team, likely making the success of the project more difficult than it might have been. For example, during the study we did not measure the time PCPs spent on hold or how many reattempts were needed to complete the communication loop. Immediately following the completion of our study, it became apparent that physicians returning calls for our own institution's primary care clinic were experiencing regular workflow interruptions and occasional hold times more than 20 minutes, necessitating ongoing further work to determine the root causes and solutions to these problems. Though this work is ongoing, average PCP hold times measured from a sample of call reviews in 2013 to 2014 was 3 minutes and 15 seconds.
This study has several other limitations. We were unable to account for phone calls to PCPs initiated outside of the new process. It may be that PCPs were called more than 52% of the time at baseline due to noncompliance with the new protocol. Also, we only have data for call completion starting after implementation of the link between the discharge order and the discharge phone call, making the baseline appear artificially high and precluding any analysis of how earlier interventions affected our outcome metric. Communication with PCPs should ideally occur prior to discharge. An important limitation of our process is that calls could occur several hours after discharge between an on‐call resident and an on‐call outpatient physician rather than between the PCP and the discharging resident, limiting appropriate information exchange. Though verbal discharge communication is a desirable goal for many reasons, the current project did not focus on the quality of the call or the information that was transmitted to the PCP. Additionally, direct attending‐to‐attending communication may be valuable with medically or socially complex discharges, but we did not have a process to facilitate this. We also did not measure what effect our new process had on outcomes such as quality of patient and family transition from hospital or physician satisfaction. The existence of programs similar to our PPL subspecialty referral line may be limited to large institutions. However, it should be noted that although some internal resource reallocation was necessary within PPL, no actual staffing increases were required despite a large increase in call volume. It may be that any hospital operator system could be adapted for this purpose with modest additional resources. Finally, although our EHR system is widely utilized, there are many competing systems in the market, and our intervention required utilization of EHR capabilities that may not be present in all systems. However, our EHR intervention utilized existing functionality and did not require modification of the system.
This project focused on discharge phone calls to primary care physicians for patients hospitalized on the hospital medicine service. Because communication with the PCP should ideally occur prior to discharge, future work will include identifying a more proximal trigger than the discharge order to which to link the EHR trigger for discharge communication. Other next steps to improve handoff effectiveness and optimize the efficiency of our process include identifying essential information that should be transmitted to the primary care physician at the time of the phone call, developing processes to ensure communication of this information, measuring PCP satisfaction with this communication, and measuring the impact on patient outcomes. Finally, though expert opinion indicates that verbal handoffs may have safety advantages over nonverbal handoffs, studies comparing the safety and efficacy of verbal versus nonverbal handoffs at patient discharge are lacking. Studies establishing the relative efficacy and safety of verbal versus nonverbal handoffs at hospital discharge are needed. Knowledge gained from these activities could inform future projects centered on the spread of the process to other hospital services and/or other hospitals.
CONCLUSION
We increased the percentage of calls initiated to PCPs at patient discharge from 52% to 97% and the percentage of calls completed between HM physicians and PCPs to 93% through the use of a standardized discharge communication process coupled with a basic EHR messaging functionality. The results of this study may be of interest for further testing and adaptation for any institution with an electronic healthcare system.
Disclosure: Nothing to report.
- , , . Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(9B):36S–39S.
- , , , , . Evaluating communication between pediatric primary care physicians and hospitalists. Clin Pediatr. 2011;50(10):923–928.
- , , , , , . Hospitalist handoffs: a systematic review and task force recommendations. J Hosp Med. 2009;4(7):433–440.
- , , , , . Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care. 2004;16(2):125–132.
- Agency for Healthcare Research and Quality. Patient safety primers: handoffs and signouts. Available at: http://www.psnet.ahrq.gov/primer.aspx?primerID=9. Accessed March 19, 2014.
- , , , , . We need to talk: primary care provider communication at discharge in the era of a shared electronic medical record. J Hosp Med. 2015;10(5):307–310.
- , , . Failure mode and effects analysis: a novel approach to avoiding dangerous medication errors and accidents. Hosp Pharm. 1994;29:319–330.
- , , , . Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Jt Comm J Qual Improv. 2002;28:248–267, 209.
- . Statistical quality control methods in infection control and hospital epidemiology, Part II: Chart use, statistical properties, and research issues. Infect Control Hosp Epidemiol. 1998;19(4):265–283.
- . Statistical quality control methods in infection control and hospital epidemiology, part I: Introduction and basic theory. Infect Control Hosp Epidemiol. 1998;19(3):194–214.
- , , . Statistical process control as a tool for research and healthcare improvement. Qual Saf Health Care. 2003;12(6):458–464.
- . The Improvement Guide: A Practical Approach to Enhancing Organizational +Performance. 2nd ed. San Francisco, CA: Jossey‐Bass; 2009.
- , . The Health Care Data Guide: Learning From Data for Improvement. 1st ed. San Francisco, CA: Jossey‐Bass; 2011.
- , . The initial hospital discharge note: send out with the patient or post? Health Trends. 1984;16(2):48.
- , . Which type of hospital discharge report reaches general practitioners most quickly? BMJ. 1989;298(6670):362–363.
- , . The application of a computer data base system to the generation of hospital discharge summaries. Obstet Gynecol. 1989;73(5 pt 1):803–807.
- . Hospital discharge medication: is seven days supply sufficient? Public Health. 1991;105(3):243–247.
- , , , et al. Electronic communication between providers of primary and secondary care. BMJ. 1992;305(6861):1068–1070.
- , , . Communication of discharge information for elderly patients in hospital. Ulster Med J. 1992;61(1):56–58.
- , , , , . A quality use of medicines program for continuity of care in therapeutics from hospital to community. Med J Aust. 2002;177(1):32–34.
- , , , , , . Pediatric hospitalists collaborate to improve timeliness of discharge communication. Hosp Pediatr. 2013;3(3):258–265.
Timely and reliable communication of important data between hospital‐based physicians and primary care physicians is critical for prevention of medical adverse events.[1, 2] Extrapolation from high‐performance organizations outside of medicine suggests that verbal communication is an important component of patient handoffs.[3, 4] Though the Joint Commission does not mandate verbal communication during handoffs per se, stipulating instead that handoff participants have an opportunity to ask and respond to questions,[5] there is some evidence that primary care providers prefer verbal handoffs at least for certain patients such as those with medical complexity.[6] Verbal communication offers the receiver the opportunity to ask questions, but in practice, 2‐way verbal communication is often difficult to achieve at hospital discharge.
At our institution, hospital medicine (HM) physicians serve as the primary inpatient providers for nearly 90% of all general pediatric admissions. When the HM service was established, primary care physicians (PCPs) and HM physicians together agreed upon an expectation for verbal, physician‐to‐physician communication at the time of discharge. Discharge communication is provided by either residents or attendings depending on the facility. A telephone operator service called Physician Priority Link (PPL) was made available to facilitate this communication. The PPL service is staffed 24/7 by operators whose only responsibilities are to connect providers inside and outside the institution. By utilizing this service, PCPs could respond in a nonemergent fashion to discharge phone calls.
Over the last several years, PCPs have observed high variation in the reliability of discharge communication phone calls. A review of PPL phone records in 2009 showed that only 52% of HM discharges had a record of a call initiated to the PCP on the day of discharge. The overall goal of this improvement project was to improve the completion of verbal handoffs from HM physicians (residents or attendings) to PCPs. The specific aim of the project was to increase the proportion of completed verbal handoffs from on‐call residents or attendings to PCPs within 24 hours of discharge to more than 90% within 18 months.
METHODS
Human Subjects Protection
Our project was undertaken in accordance with institutional review board (IRB) policy on systems improvement work and did not require formal IRB review.
Setting
This study included all patients admitted to the HM service at an academic children's hospital and its satellite campus.
Planning the Intervention
The project was championed by physicians on the HM service and supported by a chief resident, PPL administrators, and 2 information technology analysts.
At the onset of the project, the team mapped the process for completing a discharge call to the PCPs, conducted a modified failure mode and effects analysis,[7, 8] and examined the key drivers used to prioritize interventions (Figure 1). Through the modified failure modes effect analysis, the team was able to identify system issues that led to unsuccessful communication: failure of call initiation, absence of an identified PCP, long wait times on hold, failure of PCP to call back, and failure of the call to be documented. These failure modes informed the key drivers to achieving the study aim. Figure 2 depicts the final key drivers, which were revised through testing and learning.
Interventions Targeting Key Stakeholder Buy‐in
To improve resident buy‐in and participation, the purpose and goals of the projects were discussed at resident morning report and during monthly team meetings by the pediatric chief resident on our improvement team. Resident physicians were interested in participating to reduce interruptions during daily rounds and to improve interactions with PCPs. The PPL staff was interested in standardizing the discharge call process to reduce confusion in identifying the appropriate contact when PCPs called residents back to discuss discharges. PCPs were interested in ensuring good communication at discharge, and individual PCPs were engaged through person‐to‐person contact by 1 of the HM physician champions.
Interventions to Standardization the Communication Process
To facilitate initiation of calls to PCPs at hospital discharge, the improvement team created a standard process using the PPL service (Figure 3). All patients discharged from the HM service were included in the process. Discharging physicians (who were usually but not always residents, depending on the facility), were instructed to call the PPL operator at the time of discharge. The PPL operator would then page the patient's PCP. It was the responsibility of the discharging physician to identify a PCP prior to discharge. Instances where no PCP was identified were counted as process failures because no phone call could be made. The expectation for the PCPs was that they would return the page within 20 minutes. PPL operators would then page back to the discharging physician to connect the 2 parties with the expectation that the discharging physician respond within 2 to 4 minutes to the PPL operator's page. Standardization of all calls through PPL allowed efficient tracking of incomplete calls and operators to reattempt calls that were not completed. This process also shifted the burden of following up on incomplete calls to PPL. The use of PPL to make the connection also allowed the physician to complete other work while awaiting a call back from the PCP.
Leveraging the Electronic Health Record for Process Initiation
To ensure reliable initiation of the discharge communication pathway, the improvement team introduced changes to the electronic health record (HER) (EpicCare Inpatient; Epic Systems Corp., Verona, WI), which generated a message to PPL operators whenever a discharge order was entered for an HM patient. The message contained the patient's name, medical record number, discharge date, discharging physician, and PCP name and phone number. A checklist was implemented by PPL to ensure that duplicate phone calls were not made. To initiate communication, the operator contacted the resident via text page to ensure they were ready to initiate the call. If the resident was ready to place a call, the operator then generated a phone call to the PCP. When the PCP returned the call, the operator connected the HM resident with the PCP for the handoff.
As the project progressed, several adaptations were made to address newly identified failure modes. To address confusion among PPL operators about which resident physicians should take discharge phone calls after the discharging resident was no longer available (for example, after a shift change), primary responsibility for discharge phone calls was reassigned to the daily on‐call resident rather than the resident who wrote the discharge order. Because the on‐call residents carry a single pager, the pager number listed on the automated discharge notification to PPL would never change and would always reach the appropriate team member. Second, to address the anticipated increase in interruption of resident workflow by calls back from PCPs, particularly during rounds, operators accessed information on pending discharge phone calls in batches at times of increased resident availability to minimize hold times for PCPs and work interruptions for the discharging physicians. Batch times were 1 pm and 4 pm to allow for completion of morning rounds, resident conference at noon, and patient‐care activities during the afternoon. Calls initiated after 4 pm were dispatched at the time of the discharge, and calls initiated after 10 pm were deferred to the following day.
Transparency of Data
Throughout the study, weekly failure data were generated from the EHR and emailed to improvement team members, enabling them to focus on near real‐time feedback of data to create a visible and more reliable system. With the standardization of all discharge calls directed to the PPL operators, the team was able to create a call record linked to the patient's medical record number. Team‐specific and overall results for the 5 HM resident teams were displayed weekly on a run chart in the resident conference room. As improvements in call initiation were demonstrated, completion rate data were also shared every several months with the attending hospitalists during a regularly scheduled divisional conference. This transparency of data gave the improvement team the opportunity to provide individual feedback to residents and attendings about failures. The weekly review of failure data allowed team leaders to learn from failures, identify knowledge gaps, and ensure accountability with the HM physicians.
Planning the Study of the Intervention
Data were collected prospectively from July 2011 to March 2014. A weekly list of patients discharged from the HM service was extracted from the EHR and compared to electronic call logs collected by PPL on the day of discharge. A standard sample size of 30 calls was audited separately by PPL and 1 of the physician leads to verify that the patients were discharged from the HM service and validate the percentage of completed and initiated calls.
The percentage of calls initiated within 24 hours of discharge was tracked as a process measure and served as the initial focus of improvement efforts. Our primary outcome measure was the percentage of calls completed to the PCP by the HM physician within 24 hours of discharge.
Methods of Evaluation and Analysis
We used improvement science methods and run charts to determine the percentage of patients discharged from the HM service with a call initiated to the PCP and completed within 24 hours of discharge. Data on calls initiated within 24 hours of discharge were plotted on a run chart to examine the impact of interventions over time. Once interventions targeted at call initiation had been implemented, we began tracking our primary outcome measure. A new run chart was created documenting the percentage of calls completed. For both metrics, the centerline was adjusted using established rules for special cause variation in run charts.[9, 10, 11, 12, 13]
RESULTS
From July 2011 to March 2014, there were 6313 discharges from the HM service. The process measure (percentage of calls initiated) improved from 50% to 97% after 4 interventions (Figure 4). Data for the outcome measure (percentage of calls completed) were collected starting in August 2012, shortly after linking the EHR discharge order to the discharge call. Over the first 8 weeks, our median was 80%, which increased to a median of 93% (Figure 5). These results were sustained for 18 months.
Several key interventions were identified that were critical to achievement of our goal. Standardization of the communication process through PPL was temporally associated with a shift in the median rate of call initiation from 52% to 72%. Use of the discharge order to initiate discharge communication was associated with an increase from 72% to 97%. Finally, the percentage of completed verbal handoffs increased to more than 93% following batching of phone calls to PCPs at specific times during the day.
DISCUSSION
We used improvement and reliability science methods to implement a successful process for improving verbal handoffs from HM physicians to PCPs within 24 hours of discharge to 93%. This result has been sustained for 18 months.
Utilization of the PPL call center for flexible call facilitation along with support for data analysis and leveraging the EHR to automate the process increased reliability, leading to rapid improvement. Prior to mandating the use of PPL to connect discharging physicians with PCPs, the exact rate of successful handoffs in our institution was not known. We do know, however, that only 52% of calls were initiated, so clearly a large gap was present prior to our improvement work. Data collection from the PPL system was automated so that accurate, timely, and sustainable data could be provided, greatly aiding improvement efforts. Flexibility in call‐back timing was also crucial, because coordinating the availability of PCPs and discharging physicians is often challenging. The EHR‐initiated process for discharge communication was a key intervention, and improvement of our process measure to 97% performance was associated with this implementation. Two final interventions: (1) assignment of responsibility for communication to a team pager held by a designated resident and (2) batching of calls to specific times streamlined the EHR‐initiated process and were associated with achievement of our main outcome goal of >90% completed verbal communication.
There are several reports of successful interventions to improve receipt or content of discharge summaries by PCPs following hospital discharge available in the literature.[14, 15, 16, 17, 18, 19, 20] Recently, Shen et al. reported on the success of a multisite improvement collaborative involving pediatric hospitalist programs at community hospitals whose aim was to improve the timely documentation of communication directed at PCPs.[21] In their report, all 7 hospital sites that participated in the collaborative for more than 4 months were able to demonstrate substantial improvement in documentation of some form of communication directed at PCPs (whether by e‐mail, fax, or telephone call), from a baseline of approximately 50% to more than 90%. A limitation of their study was that they were unable to document whether PCPs had received any information or by what method. A recent survey of PCPs by Sheu et al. indicated that for many discharges, information in addition to that present in the EHR was desirable to ensure a safe transition of care.[6] Two‐way communication, such as with a phone call, allows for senders to verify information receipt and for receivers to ask questions to ensure complete information. To our knowledge, there have been no previous reports describing processes for improving verbal communication between hospitalist services and PCPs at discharge.
It may be that use of the call system allowed PCPs to return phone calls regarding discharges at convenient stopping points in their day while allowing discharging physicians to initiate a call without having to wait on hold. Interestingly, though we anticipated the need for additional PPL resources during the course of this improvement, the final process was efficient enough that PPL did not require additional staffing to accommodate the higher call volume.
A key insight during our implementation was that relying on the EHR to initiate every discharge communication created disruption of resident workflow due to disregard of patient, resident, and PCP factors. This was reflected by the improvement in call initiation (our process measure) following this intervention, whereas at the same time call completion (our outcome measure) remained below goal. To achieve our goal of completing verbal communication required a process that was highly reliable yet flexible enough to allow discharging physicians to complete the call in the unpredictable environment of inpatient care. Ultimately, this was achieved by allowing discharging physicians to initiate the process when convenient, and allowing for the EHR‐initiated process to function as a backup strategy to identify and mitigate failures of initiation.
An important limitation of our study was the lack of PCPs on the improvement team, likely making the success of the project more difficult than it might have been. For example, during the study we did not measure the time PCPs spent on hold or how many reattempts were needed to complete the communication loop. Immediately following the completion of our study, it became apparent that physicians returning calls for our own institution's primary care clinic were experiencing regular workflow interruptions and occasional hold times more than 20 minutes, necessitating ongoing further work to determine the root causes and solutions to these problems. Though this work is ongoing, average PCP hold times measured from a sample of call reviews in 2013 to 2014 was 3 minutes and 15 seconds.
This study has several other limitations. We were unable to account for phone calls to PCPs initiated outside of the new process. It may be that PCPs were called more than 52% of the time at baseline due to noncompliance with the new protocol. Also, we only have data for call completion starting after implementation of the link between the discharge order and the discharge phone call, making the baseline appear artificially high and precluding any analysis of how earlier interventions affected our outcome metric. Communication with PCPs should ideally occur prior to discharge. An important limitation of our process is that calls could occur several hours after discharge between an on‐call resident and an on‐call outpatient physician rather than between the PCP and the discharging resident, limiting appropriate information exchange. Though verbal discharge communication is a desirable goal for many reasons, the current project did not focus on the quality of the call or the information that was transmitted to the PCP. Additionally, direct attending‐to‐attending communication may be valuable with medically or socially complex discharges, but we did not have a process to facilitate this. We also did not measure what effect our new process had on outcomes such as quality of patient and family transition from hospital or physician satisfaction. The existence of programs similar to our PPL subspecialty referral line may be limited to large institutions. However, it should be noted that although some internal resource reallocation was necessary within PPL, no actual staffing increases were required despite a large increase in call volume. It may be that any hospital operator system could be adapted for this purpose with modest additional resources. Finally, although our EHR system is widely utilized, there are many competing systems in the market, and our intervention required utilization of EHR capabilities that may not be present in all systems. However, our EHR intervention utilized existing functionality and did not require modification of the system.
This project focused on discharge phone calls to primary care physicians for patients hospitalized on the hospital medicine service. Because communication with the PCP should ideally occur prior to discharge, future work will include identifying a more proximal trigger than the discharge order to which to link the EHR trigger for discharge communication. Other next steps to improve handoff effectiveness and optimize the efficiency of our process include identifying essential information that should be transmitted to the primary care physician at the time of the phone call, developing processes to ensure communication of this information, measuring PCP satisfaction with this communication, and measuring the impact on patient outcomes. Finally, though expert opinion indicates that verbal handoffs may have safety advantages over nonverbal handoffs, studies comparing the safety and efficacy of verbal versus nonverbal handoffs at patient discharge are lacking. Studies establishing the relative efficacy and safety of verbal versus nonverbal handoffs at hospital discharge are needed. Knowledge gained from these activities could inform future projects centered on the spread of the process to other hospital services and/or other hospitals.
CONCLUSION
We increased the percentage of calls initiated to PCPs at patient discharge from 52% to 97% and the percentage of calls completed between HM physicians and PCPs to 93% through the use of a standardized discharge communication process coupled with a basic EHR messaging functionality. The results of this study may be of interest for further testing and adaptation for any institution with an electronic healthcare system.
Disclosure: Nothing to report.
Timely and reliable communication of important data between hospital‐based physicians and primary care physicians is critical for prevention of medical adverse events.[1, 2] Extrapolation from high‐performance organizations outside of medicine suggests that verbal communication is an important component of patient handoffs.[3, 4] Though the Joint Commission does not mandate verbal communication during handoffs per se, stipulating instead that handoff participants have an opportunity to ask and respond to questions,[5] there is some evidence that primary care providers prefer verbal handoffs at least for certain patients such as those with medical complexity.[6] Verbal communication offers the receiver the opportunity to ask questions, but in practice, 2‐way verbal communication is often difficult to achieve at hospital discharge.
At our institution, hospital medicine (HM) physicians serve as the primary inpatient providers for nearly 90% of all general pediatric admissions. When the HM service was established, primary care physicians (PCPs) and HM physicians together agreed upon an expectation for verbal, physician‐to‐physician communication at the time of discharge. Discharge communication is provided by either residents or attendings depending on the facility. A telephone operator service called Physician Priority Link (PPL) was made available to facilitate this communication. The PPL service is staffed 24/7 by operators whose only responsibilities are to connect providers inside and outside the institution. By utilizing this service, PCPs could respond in a nonemergent fashion to discharge phone calls.
Over the last several years, PCPs have observed high variation in the reliability of discharge communication phone calls. A review of PPL phone records in 2009 showed that only 52% of HM discharges had a record of a call initiated to the PCP on the day of discharge. The overall goal of this improvement project was to improve the completion of verbal handoffs from HM physicians (residents or attendings) to PCPs. The specific aim of the project was to increase the proportion of completed verbal handoffs from on‐call residents or attendings to PCPs within 24 hours of discharge to more than 90% within 18 months.
METHODS
Human Subjects Protection
Our project was undertaken in accordance with institutional review board (IRB) policy on systems improvement work and did not require formal IRB review.
Setting
This study included all patients admitted to the HM service at an academic children's hospital and its satellite campus.
Planning the Intervention
The project was championed by physicians on the HM service and supported by a chief resident, PPL administrators, and 2 information technology analysts.
At the onset of the project, the team mapped the process for completing a discharge call to the PCPs, conducted a modified failure mode and effects analysis,[7, 8] and examined the key drivers used to prioritize interventions (Figure 1). Through the modified failure modes effect analysis, the team was able to identify system issues that led to unsuccessful communication: failure of call initiation, absence of an identified PCP, long wait times on hold, failure of PCP to call back, and failure of the call to be documented. These failure modes informed the key drivers to achieving the study aim. Figure 2 depicts the final key drivers, which were revised through testing and learning.
Interventions Targeting Key Stakeholder Buy‐in
To improve resident buy‐in and participation, the purpose and goals of the projects were discussed at resident morning report and during monthly team meetings by the pediatric chief resident on our improvement team. Resident physicians were interested in participating to reduce interruptions during daily rounds and to improve interactions with PCPs. The PPL staff was interested in standardizing the discharge call process to reduce confusion in identifying the appropriate contact when PCPs called residents back to discuss discharges. PCPs were interested in ensuring good communication at discharge, and individual PCPs were engaged through person‐to‐person contact by 1 of the HM physician champions.
Interventions to Standardization the Communication Process
To facilitate initiation of calls to PCPs at hospital discharge, the improvement team created a standard process using the PPL service (Figure 3). All patients discharged from the HM service were included in the process. Discharging physicians (who were usually but not always residents, depending on the facility), were instructed to call the PPL operator at the time of discharge. The PPL operator would then page the patient's PCP. It was the responsibility of the discharging physician to identify a PCP prior to discharge. Instances where no PCP was identified were counted as process failures because no phone call could be made. The expectation for the PCPs was that they would return the page within 20 minutes. PPL operators would then page back to the discharging physician to connect the 2 parties with the expectation that the discharging physician respond within 2 to 4 minutes to the PPL operator's page. Standardization of all calls through PPL allowed efficient tracking of incomplete calls and operators to reattempt calls that were not completed. This process also shifted the burden of following up on incomplete calls to PPL. The use of PPL to make the connection also allowed the physician to complete other work while awaiting a call back from the PCP.
Leveraging the Electronic Health Record for Process Initiation
To ensure reliable initiation of the discharge communication pathway, the improvement team introduced changes to the electronic health record (HER) (EpicCare Inpatient; Epic Systems Corp., Verona, WI), which generated a message to PPL operators whenever a discharge order was entered for an HM patient. The message contained the patient's name, medical record number, discharge date, discharging physician, and PCP name and phone number. A checklist was implemented by PPL to ensure that duplicate phone calls were not made. To initiate communication, the operator contacted the resident via text page to ensure they were ready to initiate the call. If the resident was ready to place a call, the operator then generated a phone call to the PCP. When the PCP returned the call, the operator connected the HM resident with the PCP for the handoff.
As the project progressed, several adaptations were made to address newly identified failure modes. To address confusion among PPL operators about which resident physicians should take discharge phone calls after the discharging resident was no longer available (for example, after a shift change), primary responsibility for discharge phone calls was reassigned to the daily on‐call resident rather than the resident who wrote the discharge order. Because the on‐call residents carry a single pager, the pager number listed on the automated discharge notification to PPL would never change and would always reach the appropriate team member. Second, to address the anticipated increase in interruption of resident workflow by calls back from PCPs, particularly during rounds, operators accessed information on pending discharge phone calls in batches at times of increased resident availability to minimize hold times for PCPs and work interruptions for the discharging physicians. Batch times were 1 pm and 4 pm to allow for completion of morning rounds, resident conference at noon, and patient‐care activities during the afternoon. Calls initiated after 4 pm were dispatched at the time of the discharge, and calls initiated after 10 pm were deferred to the following day.
Transparency of Data
Throughout the study, weekly failure data were generated from the EHR and emailed to improvement team members, enabling them to focus on near real‐time feedback of data to create a visible and more reliable system. With the standardization of all discharge calls directed to the PPL operators, the team was able to create a call record linked to the patient's medical record number. Team‐specific and overall results for the 5 HM resident teams were displayed weekly on a run chart in the resident conference room. As improvements in call initiation were demonstrated, completion rate data were also shared every several months with the attending hospitalists during a regularly scheduled divisional conference. This transparency of data gave the improvement team the opportunity to provide individual feedback to residents and attendings about failures. The weekly review of failure data allowed team leaders to learn from failures, identify knowledge gaps, and ensure accountability with the HM physicians.
Planning the Study of the Intervention
Data were collected prospectively from July 2011 to March 2014. A weekly list of patients discharged from the HM service was extracted from the EHR and compared to electronic call logs collected by PPL on the day of discharge. A standard sample size of 30 calls was audited separately by PPL and 1 of the physician leads to verify that the patients were discharged from the HM service and validate the percentage of completed and initiated calls.
The percentage of calls initiated within 24 hours of discharge was tracked as a process measure and served as the initial focus of improvement efforts. Our primary outcome measure was the percentage of calls completed to the PCP by the HM physician within 24 hours of discharge.
Methods of Evaluation and Analysis
We used improvement science methods and run charts to determine the percentage of patients discharged from the HM service with a call initiated to the PCP and completed within 24 hours of discharge. Data on calls initiated within 24 hours of discharge were plotted on a run chart to examine the impact of interventions over time. Once interventions targeted at call initiation had been implemented, we began tracking our primary outcome measure. A new run chart was created documenting the percentage of calls completed. For both metrics, the centerline was adjusted using established rules for special cause variation in run charts.[9, 10, 11, 12, 13]
RESULTS
From July 2011 to March 2014, there were 6313 discharges from the HM service. The process measure (percentage of calls initiated) improved from 50% to 97% after 4 interventions (Figure 4). Data for the outcome measure (percentage of calls completed) were collected starting in August 2012, shortly after linking the EHR discharge order to the discharge call. Over the first 8 weeks, our median was 80%, which increased to a median of 93% (Figure 5). These results were sustained for 18 months.
Several key interventions were identified that were critical to achievement of our goal. Standardization of the communication process through PPL was temporally associated with a shift in the median rate of call initiation from 52% to 72%. Use of the discharge order to initiate discharge communication was associated with an increase from 72% to 97%. Finally, the percentage of completed verbal handoffs increased to more than 93% following batching of phone calls to PCPs at specific times during the day.
DISCUSSION
We used improvement and reliability science methods to implement a successful process for improving verbal handoffs from HM physicians to PCPs within 24 hours of discharge to 93%. This result has been sustained for 18 months.
Utilization of the PPL call center for flexible call facilitation along with support for data analysis and leveraging the EHR to automate the process increased reliability, leading to rapid improvement. Prior to mandating the use of PPL to connect discharging physicians with PCPs, the exact rate of successful handoffs in our institution was not known. We do know, however, that only 52% of calls were initiated, so clearly a large gap was present prior to our improvement work. Data collection from the PPL system was automated so that accurate, timely, and sustainable data could be provided, greatly aiding improvement efforts. Flexibility in call‐back timing was also crucial, because coordinating the availability of PCPs and discharging physicians is often challenging. The EHR‐initiated process for discharge communication was a key intervention, and improvement of our process measure to 97% performance was associated with this implementation. Two final interventions: (1) assignment of responsibility for communication to a team pager held by a designated resident and (2) batching of calls to specific times streamlined the EHR‐initiated process and were associated with achievement of our main outcome goal of >90% completed verbal communication.
There are several reports of successful interventions to improve receipt or content of discharge summaries by PCPs following hospital discharge available in the literature.[14, 15, 16, 17, 18, 19, 20] Recently, Shen et al. reported on the success of a multisite improvement collaborative involving pediatric hospitalist programs at community hospitals whose aim was to improve the timely documentation of communication directed at PCPs.[21] In their report, all 7 hospital sites that participated in the collaborative for more than 4 months were able to demonstrate substantial improvement in documentation of some form of communication directed at PCPs (whether by e‐mail, fax, or telephone call), from a baseline of approximately 50% to more than 90%. A limitation of their study was that they were unable to document whether PCPs had received any information or by what method. A recent survey of PCPs by Sheu et al. indicated that for many discharges, information in addition to that present in the EHR was desirable to ensure a safe transition of care.[6] Two‐way communication, such as with a phone call, allows for senders to verify information receipt and for receivers to ask questions to ensure complete information. To our knowledge, there have been no previous reports describing processes for improving verbal communication between hospitalist services and PCPs at discharge.
It may be that use of the call system allowed PCPs to return phone calls regarding discharges at convenient stopping points in their day while allowing discharging physicians to initiate a call without having to wait on hold. Interestingly, though we anticipated the need for additional PPL resources during the course of this improvement, the final process was efficient enough that PPL did not require additional staffing to accommodate the higher call volume.
A key insight during our implementation was that relying on the EHR to initiate every discharge communication created disruption of resident workflow due to disregard of patient, resident, and PCP factors. This was reflected by the improvement in call initiation (our process measure) following this intervention, whereas at the same time call completion (our outcome measure) remained below goal. To achieve our goal of completing verbal communication required a process that was highly reliable yet flexible enough to allow discharging physicians to complete the call in the unpredictable environment of inpatient care. Ultimately, this was achieved by allowing discharging physicians to initiate the process when convenient, and allowing for the EHR‐initiated process to function as a backup strategy to identify and mitigate failures of initiation.
An important limitation of our study was the lack of PCPs on the improvement team, likely making the success of the project more difficult than it might have been. For example, during the study we did not measure the time PCPs spent on hold or how many reattempts were needed to complete the communication loop. Immediately following the completion of our study, it became apparent that physicians returning calls for our own institution's primary care clinic were experiencing regular workflow interruptions and occasional hold times more than 20 minutes, necessitating ongoing further work to determine the root causes and solutions to these problems. Though this work is ongoing, average PCP hold times measured from a sample of call reviews in 2013 to 2014 was 3 minutes and 15 seconds.
This study has several other limitations. We were unable to account for phone calls to PCPs initiated outside of the new process. It may be that PCPs were called more than 52% of the time at baseline due to noncompliance with the new protocol. Also, we only have data for call completion starting after implementation of the link between the discharge order and the discharge phone call, making the baseline appear artificially high and precluding any analysis of how earlier interventions affected our outcome metric. Communication with PCPs should ideally occur prior to discharge. An important limitation of our process is that calls could occur several hours after discharge between an on‐call resident and an on‐call outpatient physician rather than between the PCP and the discharging resident, limiting appropriate information exchange. Though verbal discharge communication is a desirable goal for many reasons, the current project did not focus on the quality of the call or the information that was transmitted to the PCP. Additionally, direct attending‐to‐attending communication may be valuable with medically or socially complex discharges, but we did not have a process to facilitate this. We also did not measure what effect our new process had on outcomes such as quality of patient and family transition from hospital or physician satisfaction. The existence of programs similar to our PPL subspecialty referral line may be limited to large institutions. However, it should be noted that although some internal resource reallocation was necessary within PPL, no actual staffing increases were required despite a large increase in call volume. It may be that any hospital operator system could be adapted for this purpose with modest additional resources. Finally, although our EHR system is widely utilized, there are many competing systems in the market, and our intervention required utilization of EHR capabilities that may not be present in all systems. However, our EHR intervention utilized existing functionality and did not require modification of the system.
This project focused on discharge phone calls to primary care physicians for patients hospitalized on the hospital medicine service. Because communication with the PCP should ideally occur prior to discharge, future work will include identifying a more proximal trigger than the discharge order to which to link the EHR trigger for discharge communication. Other next steps to improve handoff effectiveness and optimize the efficiency of our process include identifying essential information that should be transmitted to the primary care physician at the time of the phone call, developing processes to ensure communication of this information, measuring PCP satisfaction with this communication, and measuring the impact on patient outcomes. Finally, though expert opinion indicates that verbal handoffs may have safety advantages over nonverbal handoffs, studies comparing the safety and efficacy of verbal versus nonverbal handoffs at patient discharge are lacking. Studies establishing the relative efficacy and safety of verbal versus nonverbal handoffs at hospital discharge are needed. Knowledge gained from these activities could inform future projects centered on the spread of the process to other hospital services and/or other hospitals.
CONCLUSION
We increased the percentage of calls initiated to PCPs at patient discharge from 52% to 97% and the percentage of calls completed between HM physicians and PCPs to 93% through the use of a standardized discharge communication process coupled with a basic EHR messaging functionality. The results of this study may be of interest for further testing and adaptation for any institution with an electronic healthcare system.
Disclosure: Nothing to report.
- , , . Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(9B):36S–39S.
- , , , , . Evaluating communication between pediatric primary care physicians and hospitalists. Clin Pediatr. 2011;50(10):923–928.
- , , , , , . Hospitalist handoffs: a systematic review and task force recommendations. J Hosp Med. 2009;4(7):433–440.
- , , , , . Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care. 2004;16(2):125–132.
- Agency for Healthcare Research and Quality. Patient safety primers: handoffs and signouts. Available at: http://www.psnet.ahrq.gov/primer.aspx?primerID=9. Accessed March 19, 2014.
- , , , , . We need to talk: primary care provider communication at discharge in the era of a shared electronic medical record. J Hosp Med. 2015;10(5):307–310.
- , , . Failure mode and effects analysis: a novel approach to avoiding dangerous medication errors and accidents. Hosp Pharm. 1994;29:319–330.
- , , , . Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Jt Comm J Qual Improv. 2002;28:248–267, 209.
- . Statistical quality control methods in infection control and hospital epidemiology, Part II: Chart use, statistical properties, and research issues. Infect Control Hosp Epidemiol. 1998;19(4):265–283.
- . Statistical quality control methods in infection control and hospital epidemiology, part I: Introduction and basic theory. Infect Control Hosp Epidemiol. 1998;19(3):194–214.
- , , . Statistical process control as a tool for research and healthcare improvement. Qual Saf Health Care. 2003;12(6):458–464.
- . The Improvement Guide: A Practical Approach to Enhancing Organizational +Performance. 2nd ed. San Francisco, CA: Jossey‐Bass; 2009.
- , . The Health Care Data Guide: Learning From Data for Improvement. 1st ed. San Francisco, CA: Jossey‐Bass; 2011.
- , . The initial hospital discharge note: send out with the patient or post? Health Trends. 1984;16(2):48.
- , . Which type of hospital discharge report reaches general practitioners most quickly? BMJ. 1989;298(6670):362–363.
- , . The application of a computer data base system to the generation of hospital discharge summaries. Obstet Gynecol. 1989;73(5 pt 1):803–807.
- . Hospital discharge medication: is seven days supply sufficient? Public Health. 1991;105(3):243–247.
- , , , et al. Electronic communication between providers of primary and secondary care. BMJ. 1992;305(6861):1068–1070.
- , , . Communication of discharge information for elderly patients in hospital. Ulster Med J. 1992;61(1):56–58.
- , , , , . A quality use of medicines program for continuity of care in therapeutics from hospital to community. Med J Aust. 2002;177(1):32–34.
- , , , , , . Pediatric hospitalists collaborate to improve timeliness of discharge communication. Hosp Pediatr. 2013;3(3):258–265.
- , , . Passing the clinical baton: 6 principles to guide the hospitalist. Am J Med. 2001;111(9B):36S–39S.
- , , , , . Evaluating communication between pediatric primary care physicians and hospitalists. Clin Pediatr. 2011;50(10):923–928.
- , , , , , . Hospitalist handoffs: a systematic review and task force recommendations. J Hosp Med. 2009;4(7):433–440.
- , , , , . Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care. 2004;16(2):125–132.
- Agency for Healthcare Research and Quality. Patient safety primers: handoffs and signouts. Available at: http://www.psnet.ahrq.gov/primer.aspx?primerID=9. Accessed March 19, 2014.
- , , , , . We need to talk: primary care provider communication at discharge in the era of a shared electronic medical record. J Hosp Med. 2015;10(5):307–310.
- , , . Failure mode and effects analysis: a novel approach to avoiding dangerous medication errors and accidents. Hosp Pharm. 1994;29:319–330.
- , , , . Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. Jt Comm J Qual Improv. 2002;28:248–267, 209.
- . Statistical quality control methods in infection control and hospital epidemiology, Part II: Chart use, statistical properties, and research issues. Infect Control Hosp Epidemiol. 1998;19(4):265–283.
- . Statistical quality control methods in infection control and hospital epidemiology, part I: Introduction and basic theory. Infect Control Hosp Epidemiol. 1998;19(3):194–214.
- , , . Statistical process control as a tool for research and healthcare improvement. Qual Saf Health Care. 2003;12(6):458–464.
- . The Improvement Guide: A Practical Approach to Enhancing Organizational +Performance. 2nd ed. San Francisco, CA: Jossey‐Bass; 2009.
- , . The Health Care Data Guide: Learning From Data for Improvement. 1st ed. San Francisco, CA: Jossey‐Bass; 2011.
- , . The initial hospital discharge note: send out with the patient or post? Health Trends. 1984;16(2):48.
- , . Which type of hospital discharge report reaches general practitioners most quickly? BMJ. 1989;298(6670):362–363.
- , . The application of a computer data base system to the generation of hospital discharge summaries. Obstet Gynecol. 1989;73(5 pt 1):803–807.
- . Hospital discharge medication: is seven days supply sufficient? Public Health. 1991;105(3):243–247.
- , , , et al. Electronic communication between providers of primary and secondary care. BMJ. 1992;305(6861):1068–1070.
- , , . Communication of discharge information for elderly patients in hospital. Ulster Med J. 1992;61(1):56–58.
- , , , , . A quality use of medicines program for continuity of care in therapeutics from hospital to community. Med J Aust. 2002;177(1):32–34.
- , , , , , . Pediatric hospitalists collaborate to improve timeliness of discharge communication. Hosp Pediatr. 2013;3(3):258–265.
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