Improving Inter-Hospital Transfer for Critically Ill Patients Emily - - PowerPoint PPT Presentation

Yale Center for Healthcare Innovation, Redesign and Learning (CHIRAL)

Improving Inter-Hospital Transfer for Critically Ill Patients

Emily B. Finn, MPH, John Sather, MD, Andrew Ulrich, MD, Vivek Parwani, MD, Kevin N. Sheth, MD, Charles Matouk, MD, Laura Pham, MD, Sarwat Chaudhry, MD, Beth Hodshon, JD MPH RN, Arjun Venkatesh, MD MBA MHS

10 10 TH

TH ANNUAL CONFERENCE ON THE SCIENCE AND DISSEMINATION AND IMPLEMEN TATION IN HEALTH

4 DECEMBER 2017 Yale New Haven Hospital and Yale School of Medicine

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Acknowledgements

Data were collected through the Yale Center for Healthcare Innovation, Redesign and Learning (CHIRAL). This research was supported by a grant (#P30HS023554-01) from the Agency for Healthcare Research and Quality (AHRQ) and receives support from Yale New Haven Hospital and the Claude D. Pepper Older Americans Independence Center at Yale School of Medicine (#P30AG021342 NIH/NIA). The content is solely the responsibility of the authors and does not necessarily represent the

• fficial views of these organizations.

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Background

Patients diagnosed with intracranial hemorrhage at a community hospital and transferred to Yale Who Inter-hospital transfer (IHT) via Yale Emergency Department (ED) What IHT confers unique risk Why January 2016 - present When

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Investigator Team

• Emergency Medicine (EM)
• Neuro-intensive care unit (NICU)
• Neurovascular surgery
• Y-Access (Yale IHT coordination center)

Additional partners

• Community hospitals
• Diagnostic Radiology
• Pharmacy
• Blood Bank
• Transport teams
• Hospital IT/communications

Project Partners

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Project Goals

• 2. Develop and implement

an intervention

• 1. Define the baseline

transfer process

Problem Analysis

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Mixed methods approach

Retrospective chart review (n=1338) Process mapping (n=17) Semi- structured interviews (n=32) Real-time clinician surveys (n=138) Content analysis of transfer requests (n=26)

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Three challenges identified

Gaps in clinical knowledge and practice Insufficient communication Lack of structure / “system”

Intervention

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Collaborative design

Investigator team developed intervention bundle Bundle proposed to stakeholders Feedback solicited Bundle refined

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Multi-modal intervention

Transfer acceptance process redesign Order set added to EMR Statewide clinical guidance dissemination EMR call-in template redesign ED-based alert protocol

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Comprehensive evaluation

Case-by-case audit and feedback EMR-based dashboard Meetings with stakeholders

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Early results show improvements

Timeliness of care Interdepartmental collaboration

64.5 72 63 57 51.5 33 30 47.5 108.5 23

February (n=8) March (n=12) April (n=16) May (n=11) June (n=13) July (n=12) August (n=22) September (n=10) October (n=16) November (n=13)

Median time from ED arrival to admit order, in minutes

“I had spoken to the ED before the patient arrived and asked them to initiate blood pressure control with nicardipine and

• btain a CTA CTV on arrival” (Neuro

resident)

5/10/17: intervention launched

“NS resident in ED waiting for patient

• arrival. Immediate read of community

hospital CT. Near immediate CTA. Admitted to NICU within 30 minutes.” (ED attending)

Implications for D&I research

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Reflections

D&I research may benefit from a focus on end-users’ perceptions of problems and solutions Early and regular leadership engagement and sponsorship is essential Multi-modal approach can be time-intensive but engages broader range of end-users QI initiatives live within the broader culture, are difficult to change processes for a subset of patients Clinically focused process improvement is more engaging for clinicians