Project 1: Improving the Safety and Quality of Transitions into Yale New Haven Hospital

Intracranial hemorrhage, including both intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH), is associated with significant morbidity and mortality.1 One risk to patient safety for this population is the multiple handoffs involved in their care. Ultimately, this clinical condition often necessitates inter-hospital transfer for specialized neurocritical care, but this transfer itself presents unique risks including further handoffs, potential delays in diagnostic testing and treatment, and duplicate testing, among others.2,3 However, clinical care and outcomes can be improved through timely, evidence-based interventions supported by structured and safe care transitions.4 The primary aim of Project 1 is to assess and improve care transitions for patients with atraumatic ICH/SAH.

Process Analysis

The main units of study for this project are outside sending hospitals (OSH) and all involved services at Yale New Haven Hospital (YNHH): the patient transfer service, Emergency Department (ED), Neurology, Neurosurgery, Diagnostic Radiology, Pharmacy, Blood Bank, and Bed Management. The Project 1 team undertook a comprehensive process analysis to understand the care transition process, including existing threats to patient safety from both the provider and patient perspectives.

Data collection utilized both qualitative and quantitative research methods, including:

  • Process mapping to define the current state of care transitions, identify decision points and current process challenges suitable for intervention, and develop cycle metrics
  • Ethnographic observations to contribute to development of an open-ended interview guide for use with staff from the YNHH units of study and hospital management
  • Semi-structured interviews to describe latent safety threats to care transitions that result in poor process and outcome performance
  • Real-time surveys to capture provider and patient assessments of individual care transitions
  • Medical record review to establish baseline processes and outcome performance and to select metrics for intervention evaluation
  • Audits and content analysis to qualitatively and quantitatively assess baseline communication content and patterns between all units involved in each patient's transfer.
These data were triangulated to allow a better understanding of the current state of care transitions, envision an ideal state, and propose interventions to move transitions towards that ideal state. The Project 1 team shared findings and solicit feedback from all involved parties to inform and validate our analyses. These analyses then informed the design and implementation of a multi-modal intervention that will be evaluated and iterated on an ongoing basis to ensure their success.


1 Intracranial Hemorrhage, Cerebral Hemorrhage and Hemorrhagic Stroke. 2013; http://my.clevelandclinic.org/services/neurological_institute/cerebrovascular-center/diseases-conditions/hic-intracranial-hemorrhage. Accessed August 12, 2016.


2 Catalano AR, Winn HR, Gordon E, Frontera JA. Impact of Interhospital Transfer on Complications and Outcome After Intracranial Hemorrhage. Neurocritical Care. 2012;17:324-333.


3 Drazin D, Rosner J, Nuño M, et al. Type of admission is associated with outcome of spontaneous subarachnoid hemorrhage. International Journal of Stroke. 2015;10:529-533.


4 Transitions of Care (ToC) Portal, 2016. https://www.jointcommission.org/toc/aspx Accessed August 17, 2016.
P1 Process Map

The Transfer Process into the Hospital

This process map illustrates the complete care transition for patients sent to YNHH with atraumatic ICH/SAH.