9Interhospital transfer of rural patients: an audit of ‘patient expect’ documentation

Fiona Geddes, Phillip Della, Edward Stewart-Wynne and Dorothy Jones

9.1Setting the scene

Shirley Lloyd,11 born 12 October 1937, lives with her husband Brian in their own home on the outskirts of a remote mining town in. Shirley has been a one-pack-a-day smoker for most of her life but recently has worked hard to cut back to just one pack a week. She suffers from asthma, hypertension, and osteoarthritis. At 74 years of age, both Shirley and Brian are still coping relatively well. Shirley is taking multiple medications and supplements – a cocktail of 19 tablets and inhalants, many on a daily basis. Shirley also has allergies to several drugs, including ace inhibitors and some antibiotics. A few years ago she experienced a severe anaphylactic reaction to an antibiotic but she is not sure which one.

On Thursday morning Shirley trips on a rug at home and has a nasty fall. She is in terrible pain so Brian calls for an ambulance. With a suspected hip injury, Shirley is provided with pain relief for the 400-kilometer six-hour drive by ambulance to the regional hospital’s emergency department, where she is handed over for assessment. The attending emergency department medical officer diagnoses Shirley with a fracture of the right neck of her femur and places a call to the orthopedic department of a large teaching hospital in Australia. In consultation, the regional doctor and the metropolitan teaching hospital’s orthopedic registrar make the decision to transfer Shirley to the city for further review and possible surgery. This decision sets in train a series of logistical protocols for patient transfer, including triggering the arrangement of St John Ambulance, and the Royal Flying Doctor Service transfers between the rural and metropolitan sites. The regional hospital calls the ambulance service and the Royal Flying Doctor Service with Shirley’s clinical, demographic and transfer information. A final phone call to the metropolitan hospital at 19:16 results in the emergency department operation’s manager confirming and recording the following patient expect record on the hospital’s computer system:

{Patient Expect: R # NOF – SUBCAPITAL

NV INTACT

FEMBLOCK + IDC

PMHX – ARTHRITIS. ASTHMA. HT.

EX KALGOOLIE. ACCEPTED BY ORTHO.}

Shirley’s expected arrival time is recorded in the hospital’s electronic records as 21:00 but after unexpected delays the ambulance officer hands over to the Royal Flying Doctor Service flight nurse on the local airstrip and Shirley’s flight departs at 21:30. Shirley is collected by the St John Ambulance patient transfer service at the general aviation airport in the capital city at 23:30 hours. The flight records indicate an uneventful flight, and a handover from the flight nurse to the ambulance officers is conducted in an airport hangar at 23:45. During the transfer into the ambulance Shirley’s injury is unfortunately aggravated, so the flight nurse provides her with more pain medication (morphine) via her intravenous (IV) line. Exhausted, Shirley falls asleep on the drive to the hospital but wakes as she is moved into the emergency department. A handover by the ambulance officer to the triage nurse takes place in the emergency department corridor at 00:08. Shirley is seen by the emergency department Intern at 01:55 and attended to by an orthopedic resident shortly thereafter. She is finally transferred to the orthopedic ward at 03:30 Friday morning. It has been a very long day.

Shirley’s journey to hospital has seen her travel over one thousand kilometers by ambulance and light aircraft. Excluding internal hospital shift-to-shift handovers during her rural emergency department admission, Shirley’s clinical information has already been handed over multiple times by phone, fax and face-to-face interactions across five explicit care transitions between ambulance, Royal Flying Doctor Service and hospital services. In all handover instances, the supporting record systems have shared no common documentation or integrated computer software. At every step the paper trail is completed, with each clinician judiciously recording their small but vital piece of Shirley’s journey.

As we will show in the examples in this chapter, taken from Shirley’s and other rural patients’ records, aspects of information continuity, accuracy and accessibility can open holes of vulnerability in the patient safety filter that have the potential to cause a life-threatening event. In Shirley’s case it all started with a patient expect call: a simple yet crucial link in the interhospital transfer and admission process. As we recount below, from the moment of that patient expect all many issues directly impacted on the safety and quality of Shirley’s care. We begin by situating our research in the contemporary health care context and outlining our approach and data.

9.2Background: research question, approach and data

Due to multiple changes and complexity in the health care working environment, the notion of care continuity and the transfer of clinical information should be considered in the context of the shift from the notion of personal continuity, which is highly valued by both patients and clinicians, to team-based care and responsibility, which is supported by and relies more heavily on system continuity (Productivity Commission 2005). As the patient’s medical condition becomes more complex and his/her length of hospitalization increases, the potential for clinical errors in care continuity increases. According to Reason’s (1990) model of error causation, it is the compounding effects of latent organizational failures, underpinning overt communication and clinical errors, that ultimately lead to adverse outcomes and compromised care. These latent failures include ineffective workplace systems, poor supervisory practices, workspace and time pressures, dysfunctional power gradients in work teams and personal factors such as fatigue or sub-optimal mental states. When a patient’s transition of care occurs across a variety of health care services with independent yet interfacing systems, the potential for errors and adverse outcomes can be further compounded.

In this chapter we explore the research question: How effectively do clinicians manage the exchange of clinical information during the interhospital transfer of rural patients? A graphical representation of the rural transfer process is provided in Fig. 9.1. More specifically, we examine whether the documentation used to support handovers is meeting the criteria for the systematic transfer of a minimum dataset as recommended in the Australian clinical handover standard (ACSQHC 2012b) and, if so, whether this information can be communicated efficiently using a flexible, standardized format. We use examples from our data to show how non-compliance with standard operating procedures, poor format design, replication, redundancy and readback issues can compromise patient safety and quality care. Recognizing that time-constrained clinicians are over-burdened with paperwork and are struggling to manage the interface between different paper-based and new electronic systems, we offer recommendations on what patient information should be made available to support handover and issues to be considered when preparing documentation.

9.2.1Research approach and sample

To assist rural practitioners in the jurisdiction to navigate the process of interhospital transfer a group of clinicians and researchers developed an iSoBAR checklist (Porteous et al. 2009). The checklist is designed to be a tool for preparing relevant clinical and logistic information and for providing written evidence of the communications between the sending health care facility, transport agencies and the receiving emergency department. Local issues identified by Porteous and colleagues as problematic in interhospital transfers included:

Fig. 9.1: Sequencing of rural interhospital transfer

The specific aim of this component of the ECCHo Project was to better understand communications relating to interhospital patient transfers. To achieve our objective, we conducted an audit of documents and electronic records used to support clinical handovers during the transfer of patients from emergency departments in two regional country hospitals to a metropolitan tertiary hospital. University and hospital ethics approvals were obtained to conduct the clinical audit. A purposeful sample of records for the 127 rural patients transferred within a six-month period between January and June 2012 were extracted from the receiving hospital’s electronic database.

The main focus of this chapter is Stage 1 of the analysis, which examined information recorded from the patient expect call between the regional emergency department medical officer and metropolitan emergency department operations. We undertook an audit of the receiving hospital’s electronic records to identify the characteristics of the patient presentations and content of the communication in the patient expect call. De-identified data for the primary sample was provided by the research site in password-protected Excel format. On the basis of this information, a stratified random sample of 20 patients was selected for further review of their medical records. Strata included site, gender, triage code and diagnostic classification. A flowchart of data sampling methods is provided in Fig. 9.2.

For the stage 1 sample, patient transfers involved 18 specialties:

Pediatric, obstetrics and gynecological patients were not handled at the receiving hospital. Descriptive statistics of age and gender characteristics for the sample population in all phases of the study are provided in Tab. 9.1.

The medical record audit was split into a further two stages: scoping the types of documents available in the sample; and completing a content analysis of documents for a purposeful subsample of patient records to identify communication trends and issues. Stage 2 of the study focused on identifying the type and accessibility of documents retained in the medical file for rural patients undergoing interhospital transfers. Ten patient medical records from each rural site were selected for this purpose. Documents identified were those relating directly to handovers during the patient’s transfer to and within the city emergency department department. Discharge-related documentation was also included to understand the outcome of the patient’s journey. Over 300 electronic records and paper-based documents, retained in the sample patient medical records, representing ambulance, Royal Flying Doctor Service and hospital records were accessed. Except for the interhospital transfer checklist no documents used by the participating health services at the time of the data collection were organized according to an iSoBAR structure.

Fig. 9.2: Flowchart for interhospital transfer sampling

For stage 3 of the project a standardized audit tool was developed to identify common content and data organization issues in the documents used to support verbal handover during the initial phases of interhospital transfer. Our review examined compliance with professional, institutional and national safety standards and procedures. In addition to item content counts, we assessed Likert scale ratings of quality of content coverage within iSoBAR categories and the general quality of written communication , including legibility (results to be presented in upcoming publications).

Tab. 9.1: Gender and age characteristics of sample (Jan–June 2012)

Note: N = Sample Size: SD = Standard deviation: % = Percentage of sample

9.2.2iSoBAR for interhospital transfer and audit

Development priorities for the iSoBAR checklist (Porteous et al. 2009) stressed that any handover tool implemented should provide flexibility across clinical contexts and be suitable for use in written and verbal handovers. In this study we have used an iSoBAR handover framework to identify and evaluate the minimum dataset for interhospital transfer. Given the diverse clinical contexts represented in the series of care transitions targeted in this project, our intention was to show how details in existing documentation and electronic records correspond and can be reconfigured to fit with a standardized informational structure for handover. In accordance with the Australian clinical handover standard:

Clinical handover must be structured, fit for local purpose and be appropriate to the clinical context in which handover occurs … Standardization of clinical handover should not minimize communication or set guidelines that interfere with what the workforce deems to be the most critical information. Flexible standardization provides a structure to convey important clinical information with relevant defined patient information (a minimum dataset of information). (ACSQHC 2012b:14)

Table 9.2 lists the core elements of the iSoBAR framework. Porteous et al.’s (2009) mnemonic modifies the most commonly used SBAR components (Situation–Background–Assessment–Recommendations) to include Identify and Observations as separate components. Both the Situation and Observations involve identification of the presenting problem and clinical assessment of the patient’s condition based on vital signs and observations. Background is retained for the provision of relevant past medical, psychosocial history, existing medication, allergies, medic-alerts and identified risk information that should be considered in the ongoing treatment plan. It includes both pre-admission and updated post-admission information depending on the stage of the patient journey.

Tab. 9.2: The iSoBAR clinical handover protocol

iSoBAR Protocol
i	identify	Identify/Introduce self & patient
S	Situation	The presenting problem (diagnosis and relevant issues)
o	observations	Recent vital signs and clinical assessment
B	Background	Pertinent information related to the patient (past medical history, medications, allergies, psychosocial, alerts)
A	Agreed Plan	What needs to happen. Actions to be taken
R	Readback	Clarify and check for shared understanding. Who is responsible for what and when

Adapted from Porteous et al. (2009)

Assessment was changed by Porteous et al. (2009) to Agreed Plan, with the emphasis being on the decisions and actions to be taken by the care team, anticipatory guidance (Flemming & Hübner 2013) and rationale for decisions made. Topics included allocation of responsibility and time frame for tasks; requirements for tests, consultations and procedures; the nursing plan, medication needs and management of patient logistics. For the early stages of the interhospital transfer context the focus is largely on both logistical and care plans, such as coordinating expected patient pick-up, flight departure and arrival times, accepting unit and clinician details, intended observations frequency, patient dietary requirements, oxygen requirements and positioning directions. Consequently, Recommendations was also changed by Porteous and colleagues to Readback. The intention of this rewording was to highlight the importance of achieving a shared understanding of information and responsibilities during handover by setting an expectation that the receiver will provide an appropriate and comprehensive confirming response or request clarification if needed.

The content and organization of this chapter is intended to show how a standardized structure (iSoBAR) can be used to integrate critical patient care issues targeted in the Australian national health care standards (ACSQHC 2012a) including the communication of information relating to governance (standard 1); patient identification and procedure matching (standard 5 – discussed under the Identify, Situation and Agreed Plan headings); recognition and responding to clinical deterioration (standard 9 – discussed within Situation, Observations and Agreed Plan headings); and infection control, medication safety, pressure injuries and falls risk (standards 3, 4, 8 and 10 – described in the Situation, Background and Agreed Plan sections). Handover recommendations outlined in the Australian clinical hand-over standard and issues specific to the ECCHo project will also be discussed under Readback.

While the majority of ECCHo project evaluation criteria relate to the conduct of spoken handover, in our analysis we considered how ECCHo criteria applied to written documentation in the interhospital transfer context. These criteria include the allocation of a dedicated time and location for handover; interprofessional involvement; active patient or family involvement; reinforcement of key messages; relevance and currency of covered content; availability of senior staff; ready availability of pathology and diagnostic results; and importantly, opportunities to clarify information.

As indicated above, the Readback section of iSoBAR provides an opportunity for handover recipients to seek clarification, summarize and confirm their understanding of critical information provided and verify their intention and capacity to perform required actions. This includes acknowledging that the responsibility for completing handover tasks falls within the receiving personnel’s scope of practice. The change in wording from Recommendations in SBAR to Readback was a proactive initiative to shift handover practice from being a unidirectional dumping of information to a more effective two-way dialogue. By closing the communication loop the opportunity or ‘space for subjective issues to be communicated’ is provided (Flemming & Hüber 2013, p. 587), allowing the ‘active co-construction of understanding by parties with potentially dissimilar mental models’ (Cohen et al. 2012: 306).

For documentation, the Readback heading relates to the enduring nature of written accounts, compared to the transitory nature of verbal handover. In its most literal sense it is the capacity for the critical clinical information recorded to be accessed, read, interpreted and actioned. If documents are missing, incomplete or illegible, or if the content is ambiguous, inaccurate or in a form inaccessible to the audience, the capacity for reading back is reduced. Ways in which ‘the inadequacy in recording detail, contemporaneous clinical notes and regular incidence of notes being lost’ can be a contributing factor in sentinel events was highlighted in the inquest into the death of Caroline Barbara Anderson (Coroner’s Court, Westmead, 9 March 2004).

To work towards compliance with the Australian standards for continued improvement in patient safety and greater use of standardized formats in handover practice, in some jurisdictions iSoBAR has been mandated as the recommended framework for clinical handover. By providing a comprehensive minimum dataset within a structured iSoBAR framework the interhospital transfer checklist provides a patient transfer ‘do’ list (Dekker 2011) and illustrates how a flexible standardization of handover practice can be implemented to support handover across diverse clinical settings. While Porteous et al.’s (2009) iSoBar checklist was originally developed as a written handover tool, it can also be used as a verbal communication strategy. At the time this study was undertaken discussions with emergency department personnel indicated that even though the interhospital iSoBAR forms were made available at the participating rural health sites, the use of the checklist was discretionary. This demonstrated a potential disconnect between central Department of Health policy and implementation at a local health service level.

Emergency department personnel also explained that, due to a procedural change shortly before the audit period, responsibility for receiving patient expect calls had shifted from an emergency department medical officer to the emergency department operations manager (nursing). This meant that the patient expect call functioned to provide a brief logistical handover rather than to meet more specific clinical management purposes as would be expected in normal rural transfers. This may account for the brevity of some of the calls.

Our finding in stage 2 of the audit that only one iSoBAR checklist was retained in the patient medical records corresponds with emergency department management’s expectations that the uptake of checklists in medical settings is notoriously poor, a finding consistent with extant literature (Gawande 2010; Winter’s et al. 2009). However, the absence of iSoBAR forms in this small sample of medical records does not exclude the possibility that the checklist was being used for preparatory purposes but not being forwarded with the patient as intended. The rural emergency department medical officers’ reluctance to use the checklist may be due in part to the lack of staff involvement in development of the protocol (which was undertaken in other rural jurisdictions), the absence of formal training in the use of the protocol and a lack of promotion of the tool at the sites.

9.2.3Qualities of the ‘patient expect’ call

Acknowledging the shift in emphasis in the function of the patient expect call, results of the stage 1 audit of the electronic records showed that the average notation length was only 23 words. As shown in Tab. 9.3 the minimum record consisted of only two words and the maximum 81 words. The stage 2 audit verified that the receiving hospital’s first record of the patient transfer request was the electronic record of the patient expect call to the emergency department. No written or electronic records generated by the receiving specialists for the clinical inquiry call were found in patient files.

In some patients’ files a referral (e.g. a brief fax or formal referral letter) from the sending rural medical officer citing the clinical call were retained. However, the information provided was limited. Information including patient identification (e.g. name, age/date of birth and gender), time of initial contact and expected time of patient arrival occupied separate headings within the patient’s electronic record and was therefore not included in the patient expect notation or word count reported. The patient expect script is stored within the Triage Comments heading of the electronic patient record. This section is populated further by the triage nurse on the patient’s arrival and the combined summary is generated in the standard Triage Nursing Assessment form under the Presenting History heading.

Tab. 9.3: Word count for rural transfer patient expect records (stage 1)

Note: N = Sample Size: SD = Standard Deviation

On arrival at the city emergency department, rural transfer patients were triaged Fig. 9.3, Patients identified as triage code 1 for immediate attention tended to have no more information included in the patient expect call than lower priority categories. However, in four of the five triage code 1 cases (and one code 2 case), a second patient expect call had been placed to update the receiving emergency department team with logistical information, clinical findings and observations. Examples of the content typically included in the patient expect calls for triage codes 1 to 4 are provided in Tab. 9.4. The examples represent different diagnostic categories, variations in content and a cross-section of abbreviation usages. Even though the patient expect call was considered a brief logistical exercise, a considerable quantity of clinical information was communicated

As the notation field patient expect record was free text, receiving personnel had the opportunity to include as much or as little of the patient information provided as they considered warranted. As illustrated in Tab. 9.4 the communication style used in the patient expect record was typically telegraphic or truncated, with significant use of medical abbreviations. The patient expect calls provided information on the identity of the patient, sending site, the accepting medical speciality, expected time and mode of arrival and a brief diagnosis.

Observations, clinical findings and background information such as past medical history and allergies were communicated to a lesser extent. Our review of the data indicated that while no standard format had been imposed for the inclusion or sequencing of clinical information, there was some evidence to suggest that the iSoBAR framework could be useful.

Fig. 9.3: Word count of patient expect call by triage code (electronic record)

Tab. 9.4: Examples of patient expect calls by triage code (electronic record notations)

The scope of the clinical content was inconsistent in quantity, type and organization. However, it was encouraging to find that in several cases the information conveyed – although brief – complied with the iSoBAR format (Tab. 9.5: Example 1). Despite the diversity of diagnoses and areas of medical specialization represented in the sample, the majority of records could be easily reconfigured into the iSoBAR standardized format as shown in Tab. 9.5: Examples 2 and 3. We argue that adopting this type of standardized approach would make it easier to identify information deficiencies in the minimum dataset for each medical specialty and would promote greater consistency in the organization and delivery of relevant information. The impact of this approach has implications for the future development and application of electronic records and the use of structured or free text modalities in handover tools.

Having briefly described the purpose and form of the patient expect call, we next discuss the content and quality of the patient information communicated in the patient expect calls and to a lesser extent in the audited patient records under the specific iSoBAR headings: Identify, Situation, Observations, Background, Agreed Plan and Readback.