Background: Interhospital transfer (IHT) processes vary across institutions. The fragmented and complex nature of IHTs pose patient safety risks. The implementation of a standardized IHT process with a templated note for hospital medicine patients at our institution demonstrated promising patient safety outcomes and a significant increase in physician satisfaction. A second, iterative intervention expanded this process and note to all Department of Medicine (DOM) specialties in February 2022. Templated note use was associated with significant decrease in unadjusted and adjusted 24-hour-post arrival mortality; significant decrease in unadjusted 30-day mortality but not adjusted 30-day mortality; and nonsignificant promising trends in decreased RRTs and codes within 24 hours of arrival. Whether process adherence would continue after educational outreach and initial implementation is unknown. In this study, we seek to determine if process adherence across DOM is maintained distant from initial implementation.
Methods: We completed a retrospective chart review using combined automated data export and manual chart review. We defined the close-to-implementation “close” period as the previously reported 1,037 IHTs reviewed between 4/1/2022-10/31/2022. We then reviewed a “distant” period approximately a year later between 6/6/2023-10/24/2023 (note: we started on 6/6/2023 to allow for a transition of transfer center software vendors; we concluded a week prior to 10/31/2023 due to data availability timing). Close period analysis suggested good correlation between manual review and automated export for templated note identification so automated export without manual confirmation was utilized for the distant period. Given the prior analysis suggested the templated note was more beneficial than non-templated notes, only templated note use was compared across DOM subspecialties. Data analysis was completed in Excel.
Results: In the close period, 304/1,037 (29%) IHTs had a templated note in their chart prior to admission. Templated note use varied by specialty: Cardiology-13% (33/255), Gastroenterology/Hepatology-5.6% (18/323), Pulmonary/Critical Care-9% (16/178), and Hospital Medicine-84% (237/281). In the distant period, 313/975 (32%) IHTs had a templated note in their chart prior to admission. Templated note use varied by specialty: Cardiology-7% (16/227), Gastroenterology/Hepatology-22% (58/263), Pulmonary/Critical Care-27% (40/150), and Hospital Medicine-59% (199/335).
Conclusions: In the distant period, subspeciality templated note use remains well below the department goal of 100%. It is notable, however, that Gastroenterology/Hepatology and Pulmonary/Critical Care have increased usage rates. This may reflect key leadership and clinician interest within these groups who reached out after initial education and implementation to engage in the process in an unstructured way. It is both surprising and concerning that the Hospital Medicine group who pioneered this note and created a Medical Officer of the Day (MOD) role, in part, to systematize its use has fallen off in adherence, dropping 30% from 84% to 59% adherence. Given the ephemeral nature of education interventions and staff/fellow turnover it is likely important for recurrent education as well as identification and implementation of just-in-time clinical decision support reminders and systems to drive adherence improvement and, we hope, improved outcomes.