Improving Hospital to Hospital Transfer Documentation in the Inpatient Setting Samy AbdelghaniVicki Cheng Kevin CookJennifer Kumar Calvin LuiPejman Solaimani Faculty Mentors: Dr. Rucker, Dr. Butteri Other group members: Pamela Findley, Director Admissions & Registration Kori Roberts, Asst. Director, Transfer Center Steven Wilson, Transfer Center Care Coordinator

FOCUS Statement Finding the Problem: Documentation provided with transferred patients is insufficient which sometimes delays and otherwise negatively impacts patient care. Organize Resources: Key participants in the transfer process include the transfer center (Kori Roberts), accepting physicians both medical and surgical (department heads), Dr. Rucker, and the medical admitting residents. Clarify Goals: Receipt of pre-defined vital documents increases by ≥ 10%. Obstructions: Agreeing upon a standardized form acceptable to medical and surgical services, obtaining approval for implementation. Select a Plan: Outline the current transfer process to assess for points amenable to intervention. Create a checklist of vital documents requested from outside hospitals. Obtain approval for the new process.

Opportunity Statement An opportunity exists to improve the adequacy of outside hospital documentation provided with patients accepted as transfers to UC Irvine Health This process should be improved because incomplete documentation may delaying care and negatively impact patient outcomes We will know our project has been successful when the there has been a ≥10% improvement in each category of documentation (hospital course, imaging, etc.) provided with transfer patients

PDCA – Plan Step 1 – Obtained a better understanding of the current transfer process Important parties were interviewed to obtain a better understand of the transfer process: Dr. Rucker, Dr. Butteri, Kori Roberts – Transfer Center

Transfer Process Call from OSH Transfer Center (TC) Direct to medical or surgical specialist TC Requests documents MD to MD ACCEPT REJECT Case review TC Requests updated documents Points of possible intervention – before or after patient is accepted

PDCA – Plan / Do Generated a checklist of critical items pertinent to providing effective and timely care to transfer patient. Elements included: 1. Hospital course 2. Reason for transfer/treatment goals 3. Active issues 4. Medication List 5. Contact information for transferring MD 6. Contact information for transferring RN 7. Imaging (and disc, if applicable) 8. Procedure/operative report (if applicable) 9. Microbiology/pathology results (if applicable) 10. All consultation notes 11. History and physical 12. Last progress note

PDCA – Plan / Do 1 Inventoried 50 “pre-intervention” e-fax medical record packets 2 Distributed our checklist for review and feedback to the department heads of other services 3 Finalized a checklist for distribution 4 Transfer Center distributed our checklist to transferring facilities after patients have been accepted 5 Inventoried “post-intervention” e-fax medical record packets

PDCA – Plan / Do Form design and layout by Steven Wilson – Transfer Center

PDCA - Check Hospital Course Reason for txf Active issues Med List MD contact RN contactImaging Op Reports Path/ Microbio Consult notesH&P Last prog. note Pre Sum Pre Total Pre %2%58%98%36%26%98%75%80%40%67%82%36% Post Sum Post Total Post %53%59%76%82%76%41%94%90%50%87%94%69% ≥10% increase 0-9% increase decrease

PDCA – Act / Analyze The goal was to achieve objective improvement in chart completion for each checklist item Persistent areas of deficiency may be targets for future intervention Why is documentation still lacking: We did not request specific documents Inadequate documentation at OSH Documentation at OSH is stored in multiple locations (Hospital EMR, paper chart, specialist’s EMR) Documentation obtained from OSH is not updated from the time the transfer process is initiated and the time of patient transfer

Plan for Sustainability Continued distribution by the transfer center given successful improvement in transfer documentation The form is amenable to revisions, deletions, or edits as deemed appropriate by faculty or housestaff Inclusion of non medical services in the use of this form will be at the discretion of their corresponding department heads

Obstructions Encountered Design – form acceptable to UC Irvine branding Point intervention – early point of intervention my deter transfers to UC Irvine Non medical services – reluctance to slow or provide barrier to transfer of “favorable” transfer patients at any point in the transfer process Avoidance of use of our form by OSH – not transmitted with patient/documents Form used but initialed inappropriately – checklist items noted as included though they were not

Lessons Learned Understanding the current process is necessary before attempting to intervene Barriers arise when goals are not aligned amongst parties Success was achieved by: Narrowing the scope of our intervention - medicine transfers only Limiting unintended consequences - utilizing the document request form only after patients are accepted

Future Projects Form distribution prior to chart review by hospitalist provides an opportunity for complete review of transfer candidates prior to transfer allows for selection of transfer patients that would truly benefit from the diagnostic and therapeutic services in we are able to provide Inclusion of non medical services in form distribution provides a standardized approach to obtaining transfer documentation at UC Irvine Health many of these patients require hospitalist/wards services during their hospitalization anyway

Acknowledgements Thank you to: Dr. Rucker Dr. Butteri Pamela Findley Kori Roberts Steven Wilson The rest of the transfer center for distributing our form