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Transitions of care have been a bugaboo of medicine for years. And the problem isn’t getting easier. With accountable care organizations and the increased emphasis on various spokes of the healthcare wheel being able to talk clearly across the radius to each other, it has become more and more important to find simple, proven ways to ensure that handing a patient from one part of the system to the other happens quickly, yet with all the pertinent information.
Two projects may offer some help in those areas. First, from Pittsburgh UPMC system comes the Ticket to Ride program, which came about after several patients who had been traveling within a hospital from one unit to ancillary testing — radiology, for instance — appeared without adequate information for care to proceed. It could be that there wasn’t a complete patient history, explains Carol Scholle, RN, MSN, the nursing clinical director at UPMC Presbyterian Hospital, or there weren’t recent vital signs in the record.
Around the same time, there were external pressures to consider the topic of transitions, as well, says Deborah Pesanka, RN, MS, corporate investment specialist for the UPMC system, as The Joint Commission’s National Patient Safety Goals were focusing on transitions of care.
The system decided if it was going to tackle the problem, why not start at Presbyterian, which had something like 12,000 transfers between units and ancillary departments every single month. They could come up with some ideas, test fixes, and then roll them out to the rest of the system if they worked.
As an outcome measure, Pesanka says they decided to look at how many patients were going out of one unit without any issue and arriving at their destination with a condition A (cardiac arrest) or a condition C (in some other sort of crisis). Many patients were having to travel great distances, up to a quarter mile, to a test or procedure. Some were decompensating because they ran out of oxygen or their breathing became labored during the long trip.
So distance was a known factor. In addition, there appeared to be issues about communication between the transporter and the unit and the transporter and the ancillary provider. "The transporters felt like they were moving cargo," Pesanka notes. "They were not engaged or empowered at all in terms of safety."
They designed process measures as they designed changes. They considered each trip to an ancillary department as a flight, and created a "preflight" checklist. Transporters were encouraged to go through a checklist the same as any pilot would do — where are they going, is this the right patient, is all the right information here, is there enough oxygen for the trip? More importantly, they began to introduce themselves to the patients. Many of the transporters were not accustomed to doing these things. And the patients loved it, Pesanka says.
The transporter checklist led to one for the unit nurses, as well as one for the ancillary technicians on arrival. This made sure everyone was on the same page regarding the patient and his or her care, says Scholle. "It was never a drop off, always a hand-off."
The entire project was handled by front-line staff — transporters, technicians, receptionists, health unit coordinators, respiratory therapists. Managers played little role, Scholle notes. "The front line knows what is broken and have the ideas to fix it."
The initial iteration of the project has changed since it started at Presbyterian and has then been rolled out throughout the UPMC system. There is now a red sticker added if a patient has an invasive procedure done that needs an assessment for bleeding on return to the unit. Front-line workers have asked for restraints to be added to transports, as well as for ideas on how to work with patients who have disabilities or use service dogs or sign language interpreters. Those particular projects will be coming forward in the next couple of weeks.
"This can work anywhere," Pesanka says. UPMC has everything from a 900-bed academic medical center to a 52-bed facility that still uses paper documentation and volunteer transporters rather than paid staff, and it works for all of them. "It’s a scalable program."
Scholle says there were some departments that took longer to get it hard-wired into. Drivers had to call people out who hadn’t completed part of their checklist, and staff members who had thought of themselves as delivery people had to reach deeper to become something more. "We were asking them to be accountable and to hold other people accountable. That was hard for some of them," she says.
But it works. Patients don’t leave without their ticket. And after a year, conditions A and C dropped by 43% at pilot site. "I don’t think we can get to zero," says Pesanka. "There will be clinical reasons why they will have an event off unit. But we tackled what we could impact."
The things going on at your hospital may be different, as may be the solutions. But the point is this: ask the staff. Ask them what’s not working and how it might be fixed and then test the product out.
At Children’s Hospital in Boston and eight other pediatric facilities, they have tested and validated a way to hand off patients that reduces harm by ensuring that more, and more accurate information gets transmitted between providers of whatever sort. The I-PASS program was first piloted at just a single hospital (see article in the January 2014 issue of HPR) before spreading out around the country for further testing and validation. The latest iteration was published this fall in the New England Journal of Medicine.1
While the I-PASS bundle has been tested only at pediatric facilities, lead author Amy Starmer, MD, MPH, of Children’s Hospital in Boston, says it not only can be replicated in other kinds of facilities, it has. There have been inquiries from 48 states and 17 countries — thousands of requests for materials from the website, where anyone can make use of materials for free or request more in-depth consulting services related to the project (http://ipasshandoffstudy.com/).
The main element of the I-PASS bundle is a mnemonic device along with training modules. In the studies, there were reductions in preventable adverse events of 30%.
The anecdotal feedback she’s getting from other hospitals that have tried it since the studies have been published is positive, although it’s not instantaneous satisfaction. "It’s not just a mnemonic you slap up on the wall and hope leads to change, though," Starmer says. "You do need to transform the culture of communication."
She says we are so ingrained in how we interact — whether we transport patients like cargo or are used to some kind of shorthand method of speaking to other doctors. But change can improve outcomes if you are willing to do the work. And the work? Well, it was a three-year process in the pilot she oversaw. It took the life cycle of residents to get the new mode of behavior through to the point that it was standard operating procedure.
"It’s fantastic to know we can do something about the issue of hand-offs," she says. "There are probably some errors that don’t relate to communication, but communication is an issue that cuts across every single aspect of medicine. It’s not just about heart failure patients or just about orthopedic patients. It’s potentially about every single patient."
Figuring out how to improve the way providers in and out of the hospital get information about the patients they care for is, thus, monumentally more important than figuring out how to help every single patient in any single disease state, according to Starmer.
I-PASS is going to roll out in 32 hospitals around the country in the next part of the study — half in pediatric facilities, half in other kinds of hospitals. Starmer and her peers are also looking at issues of standardizing communication with patients and family. That may require a different kind of ticket, or pass, but she says she’s totally up for the ride.
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