Spotlight Case

1. Spotlight Case Transfer Troubles

2. Source and Credits • This presentation is based on the June 2012AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Isla M. Hains, PhD; Centre for Health Systems and Safety Research, Australian Institute of Health Innovation • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Bradley A. Sharpe, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Recognize that transfer of patients between hospitals is common • Understand the frequency of errors and adverse events in the transfer of patients between hospitals • Describe how communication lapses can lead to errors and adverse events in the transfer of patients between hospitals • List interventions, including the use of guidelines and standardization, which can make patient transfers between hospitals safer

4. Case: Transfer Troubles (1) An orthopedic surgeon at a small community hospital contacted an emergency department (ED) physician at a large academic medical center about a patient transfer. At this hospital, standard procedure called for all transfers from outside hospitals to be seen and evaluated in the ED. The orthopedic surgeon briefly described a 92-year-old woman with a history of dementia who had a left hip fracture. They had taken her to the operating room, but she developed low blood pressure before the case and the anesthesiologists were not comfortable managing her care at the community hospital.

5. Case: Transfer Troubles (2) The referring orthopedic surgeon also spoke with the on-call orthopedic surgery resident at the tertiary care center and conveyed the same brief history. Minimal other clinical details were discussed. The patient was transferred to the tertiary care center and was clinically stable on arrival to the ED. None of the notes or clinical documentation from the referring hospital arrived with the patient other than her demographic data. She was quickly admitted by the orthopedic surgery resident and prepped for surgery the following morning.

6. Case: Transfer Troubles (3) Early the next day, the patient was taken to the operating room for surgical repair of her hip fracture. During induction of anesthesia, the patient rapidly became hypotensive and required vasopressors. The surgical team proceeded, but the case was complicated by significant hemodynamic instability. The patient survived the surgery, but experienced persistent post-operative hypotension (shock) of unclear cause and could not be weaned from the ventilator. Ultimately, care was withdrawn and she died a few days after surgery.

7. Case: Transfer Troubles (4) Notably, following her operation on hospital day 2, medical records arrived from the referring hospital and the anesthesia notes were reviewed. They were handwritten and difficult to read but described “profound hypotension” at the start of the case and that the patient had actually suffered a full cardiac arrest (written as “unable to obtain BP…no palpable pulse…arterial access…case cancelled, to PACU.”). There were few other details in any of the notes about the cardiac arrest.

8. Case: Transfer Troubles (5) Although it was not completely clear to the orthopedic team or anesthesiologists what happened, all agreed that the patient’s case would have been managed much differently had they known more about the events at the referring hospital and that such knowledge could have potentially prevented her death.

9. Background: Transfers Between Hospitals (1) • Transfers between hospitals are common • As many as 1 in 20 critically ill patients admitted to an intensive care unit (ICU) in the United States will be transferred to a different ICU • Up to 90% of transfers can be non-emergent See Notes for references.

10. Background: Transfers Between Hospitals (2) • Transfers between hospitals may occur because: • Specialized care is not available • Particular studies or investigations cannot be done • A lack of ICU beds • To improve overall prognosis • As health care becomes increasingly centralized and specialized, transfers to other health care systems will increase

11. Errors in the Transfer Process • Errors can occur in the transfer process at any time—before, during, or after the transfer • These errors can lead to adverse events • Adverse events may occur in 1%–34% of critical care transfers • While the mortality rate remains low, up to 17% of these adverse events result in potential harm to patients See Notes for references.

12. Communication Errors (1) • Communication errors are the most common cause of errors associated with inter-hospital transport • In this case, at every stage of the process communication was inadequate • In one study, the majority of communication errors were from inaccurate or incomplete information • In another study, 42% of calls between facilities had errors of either commission or omission See Notes for references.

13. Communication Errors (2) • Upfront communication lapses can result in inadequate equipment or personnel at the receiving institution • Upon arrival, clinicians receiving the patient should have all key clinical information (including laboratory and imaging studies) • Lack of inter-operability of electronic systems between facilities may also contribute to poor communication and errors See Notes for references.

14. Other Factors Leading to Errors • Multiple other factors can contribute to errors in the transfer of patients between hospitals • Efficiency of the transfer • Technical problems (equipment failures, etc.) • Inappropriate transport method • Inappropriate personnel accompanying the patient See Notes for references.

15. Improving the Transport Process • Guidelines exist and highlight the need for clear communication regarding the process, personnel, equipment, monitoring, etc. (See Table) • Unfortunately, the guidelines are often not followed • Ongoing monitoring and educational programs may be needed See Notes for references.

17. Standardizing Transport • A systematic review recommended standardizing the transport process • Specific forms and/or checklists can be used effectively to improve the process • These may be in electronic formats • Using an electronic system and required fields has been shown to improve communication, efficiency, and appropriateness of transport services See Notes for references.

18. Other Interventions • Establishing a centralized transfer center or dedicated hotline for organizing transport may improve the process (especially if using electronic records) • Using specialized transport teams may also improve safety and patient outcomes See Notes for references.

19. Take-Home Points (1) • As health care becomes more centralized and specialized, the necessity for inter-hospital transport for critical and non-emergent patients will increase • Transporting patients entails inherent safety risks. While many factors can result in adverse events, communication errors are among the most frequent

20. Take-Home Points (2) • Standardization of practices may prevent or reduce errors. Such standardization can be facilitated through the use of guidelines, standard forms or checklists, and information and communication technologies • Both centralized transfer centers and specialized teams with highly trained personnel to facilitate transfers can improve safety