Background: Outside hospital (OSH) transfer processes vary across institutions. The fragmented and complex nature of OSH transfers pose patient safety risks. A recent implementation of a standardized OSH transfer process with templated note for hospital medicine patients at our institution demonstrated promising patient safety outcomes and a significant increase in physician satisfaction. This pilot study expanded the standardized process and note to all Department of Medicine specialties at a single academic medical center.
Methods: In February 2022 the department chair sent an e-mail to all medicine residents, fellows, and attendings outlining rationale, expectations, and instructions to use the standardized process. Data suggested limited e-mail engagement or action so further face-to-face communication was provided to division directors in August, then to each division – gastroenterology on 8/10/22; pulmonology on 9/15/22; cardiology on 11/22/22.Physician utilization of any transfer note, templated or non-templated, and objective clinical outcomes within 24 hours of admission including code, ICU transfer, and death and death within 30 days of admission were obtained through retrospective manual chart review and automated data export.
Results: We reviewed 1,037 OSH transfers between 4/2022-10/2022. Patients who had an OSH note in the chart as compared to no note had significantly lower chance of death within 24 hours of admission (0.00% vs 1.12%, p=0.031) and death within 30 days of admission (4.60% vs 8.97%, p=0.0078). There were non-significant trends in code within 24 hours of admission (0.24% vs 0.64%, p=0.36) and ICU transfer within 24 hours (1.94% vs 1.28%, p=0.3988). There were no significant differences between templated and non-templated notes across these same four metrics although there was a trend toward fewer codes within 24 hours of admission for the templated-note group (0.00% vs 0.92%, p=0.094). Regarding process utilization, 413/1,037 (39.8%) had an OSH note in their chart. When examining the effect of face-to-face division meeting communication, there was a non-significant trend toward increased process utilization by gastroenterology: 14.12% (pre) to 21.59% (post) (p=0.12) and a significant increase in utilization by pulmonology: 12.78% (pre) to 50.00% (post) (p=0.0001). Hospital Medicine, which has been utilizing variants of this process since 2018, demonstrates monthly utilization of any note from 87.76% to 97.62% (mean: 92.53%). Cardiology, which received education intervention after the data collection period, demonstrates utilization of any note from 14.89 to 46.67% (mean: 25.49%).
Conclusions: A standardized transfer communication process and supporting note significantly reduces risk of death within 24 hours or 30 days of admission. There were no significant differences in code or ICU transfer within 24 hours. Face-to-face communication at a division level rather than via e-mail significantly increased pulmonology utilization rates while gastroenterology showed a non-significant similar trend. Our institution is working to increase process adoption to allow further study, adequate powering, and refinement to improve the process.