Background: Inter-hospital transfer (IHT) care is complex and suffers from inefficiencies in information and task organization, which can contribute to high cognitive load for clinicians.[1-4] Cognitive overload can lead to medical errors and clinician stress.[5-8] Our study identifies specific areas of high cognitive load experienced by hospital medicine physicians and advanced practice providers (APPs) who care for IHT patients.
Methods: This is part of a larger qualitative study using one-hour semi-structured interviews from 9-12/2021 with hospital medicine clinicians at an academic medical center (AMC) that accepts 5,000 IHT patients per year. We conducted thematic analysis using a combined inductive and deductive coding approach until thematic saturation was achieved. The Agency for Healthcare Research and Quality’s Care Coordination Measurement Framework was used to guide qualitative analysis.
Results: We interviewed 30 hospital medicine clinicians including 17 physicians (57%) and 13 APPs (43%) with 1-18 years of experience (mean 5.7 years). All physicians and one APP (60%) took transfer acceptance calls and all interviewees admitted IHT patients. Issues regarding cognitive load and trust emerged as domains not captured by a priori defined domains.Interviewees described task switching and data redundancy as factors that contributed to increased cognitive load during IHTs. Participants who took transfer acceptance calls, henceforth accepting clinicians, reported that switching between clinical duties to take calls negatively impacted the safety of patients on their service and the thoroughness of transfer calls by splitting their attention. Admitting clinicians described sifting through extraneous data to piece together a coherent narrative, making it difficult to quickly synthesize pertinent information, employ effective sense-making, and make confident clinical decisions.Participants also described trust as a facilitator and distrust as a barrier to seamless IHT workflows and information processing. In situations where trust was high (e.g., established relationships with nurses), admitting clinicians described being able to better prioritize admission tasks based on nursing assessment of IHT patients on arrival to the accepting facility. In contrast, accepting clinicians found decisions around appropriateness of transfer requests more challenging when clinical information was provided by clinicians with whom they had no prior interaction and trust was low.
Conclusions: Physicians and APPs at an AMC experienced increased cognitive load in IHTs when faced with frequent task switching, inefficient delivery of clinical information, and low trust between healthcare team members. Potential strategies to mitigate cognitive overload include: 1) dedicated IHT personnel to take acceptance calls and admit IHT patients to minimize competing responsibilities and build relational trust across clinicians and 2) standardization of IHT information collection and presentation to improve the consistency and quality of information exchanged. Addressing cognitive load experienced by clinicians in IHTs may lead to safer IHT care and less stressful working environments.