Department of Medicine, Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
Harvard Medical School, Boston, Massachusetts, USA.
BMJ Open Qual. 2023 Oct;12(4). doi: 10.1136/bmjoq-2023-002518.
The transfer of patients between hospitals (interhospital transfer, IHT), exposes patients to communication errors and gaps in information exchange.
To design and implement a standardised accept note to improve communication during medical service transfers, and evaluate its impact on patient outcomes.
Prospective interventional cohort study.
A 792-bed tertiary care hospital.
All patient transfers from any acute care hospital to the general medicine, cardiology, oncology and intensive care unit (ICU) services between August 2020 and June 2022.
A standardised accept note template was developed over a 9-month period with key stakeholder input and embedded in the electronic health record, completed by nurses within the hospital's Access Centre.
Primary outcome was clinician-reported medical errors collected via surveys of admitting clinicians within 72 hours after IHT patient admission. Secondary outcomes included clinician-reported failures in communication; presence and 'timeliness' of accept note documentation; patient length of stay (LOS) after transfer; rapid response or ICU transfer within 24 hours and in-hospital mortality. All outcomes were analysed postintervention versus preintervention, adjusting for patient demographics, diagnosis, comorbidity, illness severity, admitting service, time of year, hospital COVID census and census of admitting service and admitting team on date of admission.
Of the 1004 and 654 IHT patients during preintervention and postintervention periods, surveys were collected on 735 (73.2%) and 462 (70.6%), respectively. Baseline characteristics were similar among patients in each time period and between survey responders and non-responders. Adjusted analyses demonstrated a 27% reduction in clinician-reported medical error rates postimplementation versus preimplementation (11.5 vs 15.8, adjusted OR (aOR) 0.73, 95% CI 0.53 to 0.99). Secondary outcomes demonstrated lower adjusted odds of clinician-reported failures in communication (aOR 0.88; 0.78 to 0.98) and rapid response/ICU transfer (aOR 0.57; 0.34 to 0.97), and improved presence (aOR 2.30; 1.75 to 3.02) and timeliness (-21.4 hours vs -8.7 hours, p<0.001) of accept note documentation. There were no significant differences in LOS or mortality.
Among 1658 medical patient transfers, implementing a standardised accept note was associated with improved presence and timeliness of accept note documentation, clinician-reported medical errors, failures in communication and clinical decline following transfer, suggesting that improving communication during IHT can improve patient outcomes.
患者在医院之间的转移（院内转移，IHT）使患者面临沟通错误和信息交换的差距。
设计并实施标准化的接受说明，以改善医疗服务转移过程中的沟通，并评估其对患者结局的影响。
前瞻性干预性队列研究。
一家拥有 792 张床位的三级护理医院。
2020 年 8 月至 2022 年 6 月期间，从任何急性护理医院转至普通内科、心脏病学、肿瘤学和重症监护病房（ICU）服务的所有患者。
经过 9 个月的关键利益相关者投入，制定了标准化的接受说明模板，并嵌入电子病历中，由医院接入中心的护士填写。
主要结果是通过对 IHT 患者入院后 72 小时内入院医生的调查收集的临床医生报告的医疗错误。次要结果包括临床医生报告的沟通失败；接受说明文件的存在和“及时性”；转移后患者的住院时间（LOS）；24 小时内快速反应或 ICU 转移以及院内死亡率。所有结果均在干预后与干预前进行分析，调整了患者人口统计学、诊断、合并症、疾病严重程度、入院服务、时间、医院 COVID 人口普查以及入院日期的入院服务和入院团队的人口普查。
在干预前和干预后期间，1004 名和 654 名 IHT 患者中，分别收集了 735 名（73.2%）和 462 名（70.6%）的调查。每个时间段的患者基线特征相似，且调查应答者和非应答者之间的特征相似。调整后的分析表明，与干预前相比，实施后临床医生报告的医疗错误率降低了 27%（11.5%比 15.8%，调整后的比值比（aOR）为 0.73，95%CI 为 0.53 至 0.99）。次要结果表明，临床医生报告的沟通失败（aOR 0.88；0.78 至 0.98）和快速反应/ICU 转移（aOR 0.57；0.34 至 0.97）的可能性降低，接受说明文件的存在（aOR 2.30；1.75 至 3.02）和及时性（-21.4 小时与-8.7 小时，p<0.001）得到改善。住院时间或死亡率无显著差异。
在 1658 例内科患者转移中，实施标准化接受说明与接受说明文件的存在和及时性、临床医生报告的医疗错误、沟通失败以及转移后的临床恶化改善相关，这表明改善 IHT 期间的沟通可以改善患者结局。
