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BackgroundWith emerging global payment structures, medical systems need to understand longer-term impacts of care transition strategies.ObjectiveTo determine the effect of a care transition program using patient navigators (PNs) on health service utilization among high-risk safety-net patients over a 180-day period.DesignRandomized controlled trial conducted October 2011 through April 2013.ParticipantsPatients admitted to the general medicine service with ≥1 readmission risk factor: (1) age ≥ 60; (2) in-network inpatient admission within prior 6 months; (3) index length of stay ≥ 3 days; or (4) admission diagnosis of heart failure or (5) chronic obstructive pulmonary disease. The analytic sample included 739 intervention patients, 1182 controls.InterventionsThrough hospital visits and 30 days of post-discharge telephone outreach, PNs provided coaching and assistance with medications, appointments, transportation, communication with primary care, and self-care.Main MeasuresPrimary outcomes: (1) hospital-based utilization, a composite of ED visits and hospital admissions; (2) hospital admissions; (3) ED visits; and (4) outpatient visits. We evaluated outcomes following an index discharge, stratified by patient age (≥ 60 and < 60 years), using a 180-day time frame divided into six 30-day periods.Key ResultsThe PN program produced starkly different outcomes by patient age. Among older PN patients, hospital-based utilization was consistently lower than controls, producing an 18.7% cumulative decrease at 180 days (p = 0.038); outpatient visits increased in the critical first 30-day period (p = 0.006). Among younger PN patients, hospital-based utilization was 31.7% (p = 0.038) higher at 180 days, largely reflecting sharply higher utilization in the initial 30 days (p = 0.002), with non-significant changes thereafter; outpatient visits experienced no significant changes.ConclusionsA PN program serving high-risk safety-net patients differentially impacted patients based on age, and among younger patients, outcomes varied over time. Our findings highlight the importance for future research to evaluate care transition programs among different subpopulations and over longer time periods.

This study examined differences in learning outcomes among newborn intensive care unit (NICU) workers who underwent virtual reality simulation (VRS) emergency evacuation training versus those who received web-based clinical updates (CU). Learning outcomes included a) knowledge gained, b) confidence with evacuation, and c) performance in a live evacuation exercise. A longitudinal, mixed-method, quasi-experimental design was implemented utilizing a sample of NICU workers randomly assigned to VRS training or CUs. Four VRS scenarios were created that augmented neonate evacuation training materials. Learning was measured using cognitive assessments, self-efficacy questionnaire (baseline, 0, 4, 8, 12 months), and performance in a live drill (baseline, 12 months). Data were collected following training and analyzed using mixed model analysis. Focus groups captured VRS participant experiences. The VRS and CU groups did not statistically differ based upon the scores on the Cognitive Assessment or perceived self-efficacy. The virtual reality group performance in the live exercise was statistically (P<.0001) and clinically (effect size of 1.71) better than that of the CU group. Training using VRS is effective in promoting positive performance outcomes and should be included as a method for disaster training. VRS can allow an organization to train, test, and identify gaps in current emergency operation plans. In the unique case of disasters, which are low-volume and high-risk events, the participant can have access to an environment without endangering themselves or clients. (Disaster Med Public Health Preparedness. 2019;13:301-308).

Background Elderly living in a Nursing Home (NH) are frequently transferred to an Emergency Department when they need acute medical care. A proportion of these transfers may be considered inappropriate and may be avoidable. Methods Systematic review. Literature search performed in September 2018 using PubMed, Web of Science, the Cochrane Library and the Cumulative Index to Nursing and Allied Health Literature database. Titles and abstracts were screened against inclusion and exclusion criteria. Full-texts of the selected abstracts were read and checked for relevance. All years and all languages were included provided there was an English, French, Dutch or German abstract. Results Seventy-seven articles were included in the systematic review: 1 randomised control trial (RCT), 6 narrative reviews, 9 systematic reviews, 7 experimental studies, 10 qualitative studies and 44 observational studies. Of all acute transfers of NH residents to an ED, 4 to 55% were classified as inappropriate. The most common reasons for transfer were trauma after falling, altered mental status and infection. Transfers were associated with a high risk of complications and mortality, especially during out-of-hours. Advance directives (ADs) were usually not available and relatives often urge NH staff to transfer patients to an ED. The lack of availability of GPs was a barrier to organise acute care in the NH in order to prevent admission to the hospital. Conclusions The definition of appropriateness is not uniform across studies and needs further investigation. To avoid inappropriate transfer to EDs, we recommend to respect the patient’s autonomy, to provide sufficient nursing staff and to invest in their education, to increase the role of GPs in the care of NH residents both in standard and in acute situations, and to promote interprofessional communication and collaboration between GPs, NH staff and EDs.

Nursing home residents are often colonized with antibiotic-resistant bacteria. In this trial involving 28 nursing homes, decolonization with chlorhexidine and povidone–iodine reduced the risk of hospitalization for infection.

AbstractObjectiveTo determine if postnatal transfer or birth in a non-tertiary hospital is associated with adverse outcomes.DesignObservational cohort study with propensity score matching.SettingNational health service neonatal care in England; population data held in the National Neonatal Research Database.ParticipantsExtremely preterm infants born at less than 28 gestational weeks between 2008 and 2015 (n=17 577) grouped based on birth hospital and transfer within 48 hours of birth: upward transfer (non-tertiary to tertiary hospital, n=2158), non-tertiary care (born in non-tertiary hospital; not transferred, n=2668), and controls (born in tertiary hospital; not transferred, n=10 866). Infants were matched on propensity scores and predefined background variables to form subgroups with near identical distributions of confounders. Infants transferred between tertiary hospitals (horizontal transfer) were separately matched to controls in a 1:5 ratio.Main outcome measuresDeath, severe brain injury, and survival without severe brain injury.Results2181 infants, 727 from each group (upward transfer, non-tertiary care, and control) were well matched. Compared with controls, infants in the upward transfer group had no significant difference in the odds of death before discharge (odds ratio 1.22, 95% confidence interval 0.92 to 1.61) but significantly higher odds of severe brain injury (2.32, 1.78 to 3.06; number needed to treat (NNT) 8) and significantly lower odds of survival without severe brain injury (0.60, 0.47 to 0.76; NNT 9). Compared with controls, infants in the non-tertiary care group had significantly higher odds of death (1.34, 1.02 to 1.77; NNT 20) but no significant difference in the odds of severe brain injury (0.95, 0.70 to 1.30) or survival without severe brain injury (0.82, 0.64 to 1.05). Compared with infants in the upward transfer group, infants in the non-tertiary care group had no significant difference in death before discharge (1.10, 0.84 to 1.44) but significantly lower odds of severe brain injury (0.41, 0.31 to 0.53; NNT 8) and significantly higher odds of survival without severe brain injury (1.37, 1.09 to 1.73; NNT 14). No significant differences were found in outcomes between the horizontal transfer group (n=305) and controls (n=1525).ConclusionsIn extremely preterm infants, birth in a non-tertiary hospital and transfer within 48 hours are associated with poor outcomes when compared with birth in a tertiary setting. We recommend perinatal services promote pathways that facilitate delivery of extremely preterm infants in tertiary hospitals in preference to postnatal transfer.

Background and purpose Patients with acute ischaemic stroke and a large vessel occlusion who present to a non‐endovascular‐capable centre often require inter‐hospital transfer for thrombectomy. Whether the inter‐hospital transfer time is associated with 3‐month functional outcome is poorly known. Methods Acute stroke patients enrolled between January 2015 and December 2022 in the prospective French multicentre Endovascular Treatment of Ischaemic Stroke registry were retrospectively analysed. Patients with an anterior circulation large vessel occlusion transferred from a non‐endovascular to a comprehensive stroke centre for thrombectomy were eligible. Inter‐hospital transfer time was defined as the time between imaging in the referring hospital and groin puncture for thrombectomy. The relationship between transfer time and favourable 3‐month functional outcome (modified Rankin Scale 0–2) was assessed through a mixed logistic regression model adjusting for centre and symptom‐onset‐to‐referring‐hospital imaging time, age, sex, diabetes, referring hospital National Institutes of Health Stroke Scale score, Alberta Stroke Programme Early Computed Tomography Score, occlusion site and intravenous thrombolysis use. Results Overall, 3769 patients were included (median inter‐hospital transfer time 161 min, interquartile range 128–195; 46% with favourable outcome). A longer transfer time was independently associated with lower rates of favourable outcome (p < 0.001). Compared to patients with transfer time below 120 min, there was a 15% reduction in the odds of achieving favourable outcome for transfer times between 120 and 180 min (adjusted odds ratio 0.85; 95% confidence interval 0.67–1.07), and a 36% reduction for transfer times beyond 180 min (adjusted odds ratio 0.64; 95% confidence interval 0.50–0.81). Conclusions A shorter inter‐hospital transfer time is strongly associated with favourable 3‐month functional outcome. A speedier inter‐hospital transfer is of critical importance to improve outcome.

Transfer of patient care from an intensive care unit (ICU) to a hospital ward is often challenging, high risk and inefficient. We assessed patient and provider perspectives on barriers and facilitators to high-quality transfers and recommendations to improve the transfer process. We conducted semistructured interviews of participants from a multicentre prospective cohort study of ICU transfers conducted at 10 hospitals across Canada. We purposively sampled 1 patient, 1 family member of a patient, 1 ICU provider, and 1 ward provider at each of the 8 English-speaking sites. Qualitative content analysis was used to derive themes, subthemes and recommendations. The 35 participants described 3 interrelated, overarching themes perceived as barriers or facilitators to high-quality patient transfers: resource availability, communication and institutional culture. Common recommendations suggested to improve ICU transfers included implementing standardized communication tools that streamline provider–provider and provider–patient communication, using multimodal communication to facilitate timely, accurate, durable and mutually reinforcing information transfer; and developing procedures to manage delays in transfer to ensure continuity of care for patients in the ICU waiting for a hospital ward bed. Patient and provider perspectives attribute breakdown of ICU-to-ward transfers of care to resource availability, communication and institutional culture. Patients and providers recommend standardized, multimodal communication and transfer procedures to improve quality of care.

BackgroundIn 2012, nearly one-third of adults 65 years or older with Medicare discharged to home after hospitalization were referred for home health care (HHC) services. Care coordination between the hospital and HHC is frequently inadequate and may contribute to medication errors and readmissions. Insights from HHC nurses could inform improvements to care coordination.ObjectiveTo describe HHC nurse perspectives about challenges and solutions to coordinating care for recently discharged patients.Design/ParticipantsWe conducted a descriptive qualitative study with six focus groups of HHC nurses and staff (n = 56) recruited from six agencies in Colorado. Focus groups were recorded, transcribed, and analyzed using a mixed deductive/inductive approach to theme analysis with a team-based iterative method.Key ResultsHHC nurses described challenges and solutions within domains of Accountability, Communication, Assessing Needs & Goals, and Medication Management. One additional domain of Safety, for both patients and HHC nurses, emerged from the analysis. Within each domain, solutions for improving care coordination included the following: 1) Accountability—hospital physicians willing to manage HHC orders until primary care follow-up, potential legislation allowing physician assistants and nurse practitioners to write HHC orders; 2) Communication—enhanced access to hospital records and direct telephone lines for HHC; 3) Assessing Needs & Goals—liaisons from HHC agencies meeting with patients in hospital; 4) Medication Management—HHC coordinating directly with clinician or pharmacist to resolve discrepancies; and 5) Safety—HHC nurses contributing non-reimbursable services for patients, and ensuring that cognitive and behavioral health information is shared with HHC.ConclusionsIn an era of shared accountability for patient outcomes across settings, solutions for improving care coordination with HHC are needed. Efforts to improve care coordination with HHC should focus on clearly defining accountability for orders, enhanced communication, improved alignment of expectations for HHC between clinicians and patients, a focus on reducing medication discrepancies, and prioritizing safety for both patients and HHC nurses.

BackgroundStudying diagnostic error at the population level requires an understanding of how diagnoses change over time.ObjectiveTo use inter-hospital transfers to examine the frequency and impact of changes in diagnosis on patient risk, and whether health information exchange can improve patient safety by enhancing diagnostic accuracy.DesignDiagnosis coding before and after hospital transfer was merged with responses from the American Hospital Association Annual Survey for a cohort of patients transferred between hospitals to identify predictors of mortality.ParticipantsPatients (180,337) 18 years or older transferred between 473 acute care hospitals from NY, FL, IA, UT, and VT from 2011 to 2013.Main MeasuresWe identified discordant Elixhauser comorbidities before and after transfer to determine the frequency and developed a weighted score of diagnostic discordance to predict mortality. This was included in a multivariate model with inpatient mortality as the dependent variable. We investigated whether health information exchange (HIE) functionality adoption as reported by hospitals improved diagnostic discordance and inpatient mortality.Key ResultsDiscordance in diagnoses occurred in 85.5% of all patients. Seventy-three percent of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11 95% CI 1.10–1.11, p < 0.001) and allowed for improved mortality prediction. Bilateral hospital HIE participation was associated with reduced diagnostic discordance index (3.69 vs. 1.87%, p < 0.001) and decreased inpatient mortality (OR 0.88, 95% CI 0.89–0.99, p < 0.001).ConclusionsDiagnostic discordance commonly occurred during inter-hospital transfers and was associated with increased inpatient mortality. Health information exchange adoption was associated with decreased discordance and improved patient outcomes.

Background The transfer of patients from a pre‐hospital emergency environment to a qualified healthcare centre is a critical aspect of emergency care. Due to the unpredictable and uncontrolled nature of pre‐hospital environments, emergency care providers often encounter multiple challenges during the patient transfer process. Aim/Objective This study aimed to explore the patient transfer process from pre‐hospital to the hospital emergency department, identify the areas of main concern, strategies that emergency care providers used to address these concerns and generate a coherent underlying theory. Methods A qualitative research method using a grounded theory approach was carried out to develop a comprehensive theoretical framework based on the experiences of emergency care providers, patients and their relatives in pre‐hospital settings and hospital emergency departments. This study, conducted from September 2022 to January 2024, involved 24 participants: 18 emergency care providers, four patients' relatives and two patients with transfer experience. Sampling began purposefully and transitioned to theoretical sampling to ensure diversity and enrich the emerging theory. Data were collected through in‐depth, individual, semi‐structured interviews, along with note‐taking, observation and document review. The Corbin‐Strauss 5‐step analysis approach was used to develop a coherent theory capturing the essence of the study phenomenon. The steps included open coding to identify concepts, developing concepts based on their features and dimensions, analysing data for context, incorporating processes into the analysis and integrating categories. Results The main category as the main concern of the participants was ‘the tension of delay in safe transfer and patient survival threat’. The central variable was ‘diligent avoidance of tense confrontation’, which was used as a conscious, deliberate and purposeful effort to prevent the escalation of tensions in various situations and included a set of different strategies such as situational resourcefulness, persuasive communication and forbearance. Ultimately, the emergency care providers' efforts caused different outcomes, from successful persuasion and safe transfer of the patient to unsuccessful persuasion, surrendering, escaping from responsibility and long‐lasting hidden tensions. Conclusions Emergency care providers use different strategies to manage the tension of delay in safe transfer and patient survival threat as their main concern. While successful strategies can inform practical guidelines, negative consequences highlight the need for more efficient and effective approaches. A prescriptive model based on the contextual theory from this study can be designed. This model should take a comprehensive, multifaceted view of the underlying causes of tension, support emergency care providers and improve their experience of delays during patient transfers in pre‐hospital emergency settings, ultimately leading to safe care. Implications for the Profession and/or Patient Care Emergency care providers should balance the urgency of transfer with patient safety and the patient's relative concerns. Impact This study underscores the need for patient‐centred care, effective communication and practical strategies to improve patient transfer processes. Reporting Method This article has been presented based on the COnsolidated Criteria for REporting Qualitative Research (COREQ) checklist. Patient or Public Contribution No Patient or Public Contribution.