Project 2: Transitions Within the Hospital

Over 15 million transfers occur from hospital emergency rooms to inpatient floors each year1, and most of the more than 4 million patients that spend time in an intensive care unit transfer to an inpatient unit during their hospital stay2. The literature has documented abundant risks for error in such transfers, including different sending and receiving perspectives and priorities, lack of communication or incorrect communication, lack of teamwork, and patient flow problems to name a few. Yet, much of the research on handoffs focuses on shift to shift transitions, and little evidence exists on how to improve unit to unit transitions.   The primary aims of Project 2 are to study the process of transitioning patients from the Emergency Department (ED) and Medical Intensive Care Unit (MICU) to the General Medicine floors at Yale New Haven Hospital (YNHH); identify challenges and opportunities for improvement; and develop interventions to reduce adverse patient events as well as increase staff satisfaction with transfer processes.

Process Analysis

Process analysis took place over a year and included day-in-the-life observations on our units of study; in-depth interviews with key stakeholders including frontline staff; process mapping exercises; and baseline electronic medical record data. Drawing on these diverse data sources, we developed a nuanced understanding of the processes involved in transitions between units at YNHH, as well as the challenges and strengths of the current transfer system. We also received feedback from staff on ways to improve processes.

After analyzing the data collected, we held feedback sessions with staff and leaders from each unit of study to confirm findings and discuss intervention ideas that were grounded in staff suggestions collected during process analysis. We then convened a group of representative hospital and unit leaders for a joint session to further hone our intervention ideas and develop a path forward.

Intervention Design and Development

Intervention development has been a collaborative and iterative process that requires CHIRAL to be embedded in hospital procedures. CHIRAL staff attend weekly meetings in the ED and MICU that focus on throughput, as well as the Hospital Handoff Charter meetings. We have held a series of additional meetings with unit leadership to move interventions forward.

To improve the process of transferring patients from the MICU to the General Medicine floors, we are piloting a verbal nursing handoff for patients with special circumstances. To improve the process of transferring patients from the Emergency Department to the General Medicine floors, we are investigating cases of contested disposition for patients admitted to General Medicine, from both the physician and nurse perspective. Once we understand how often patient disposition deviates from written protocols on General Medicine admission guidelines, we will work with our hospital partners to enhance patient and unit fit.

1 National Hospital Ambulatory Medical Care Survey: 2011 Emergency Department Summary Tables. 2011; http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2011_ed_web_tables.pdf. Accessed April 21, 2016.
2 Mullins, PM, Goyal, M, Pines JM. National growth in intensive care unit admissions from emergency department in the United States from 2002 to 2009. Acad Emerg Med. May 2013; 20 (5):479-486.
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Defining Intra-hospital Transfers: Five Domains

When you have a relationship with a person, it always goes much more smoothly than when you don’t know who’s calling you [about a transferred patient].