Yale Center for Healthcare Innovation, Redesign, and Learning

Principal Investigator: Sarwat Chaudhry, M.D., Yale University, New Haven, CT
AHRQ Grant No.: HS23554
Project Period: 09/30/14–09/29/19

Description: The goal of CHIRAL was to improve transitions of care. Patients being transferred from one setting to another or one clinical team to another are at increased risk for a host of failures. These include identification errors, delayed or missed diagnoses, redundant testing, treatment delays or errors, medication errors, and unexpected clinical deterioration.

The specific aims were to:

1. Improve patient safety at the time of transition through redesign of transfers of patients into Yale New Haven Hospital (YNHH) from outside hospitals and emergency departments (EDs).
2. Redesign transfers within YNHH between the ED or intensive care unit (ICU) and general hospital units.
3. Redesign transfers out of YNHH to skilled nursing facilities (SNFs).

Over the project lifecycle, this PSLL iteratively conducted indepth problem analysis of transitions of care (i.e., inter-, intra-, and out of YNHH). This analysis was followed by the design, implementation, and evaluation of multiple studies and programs to improve patient safety and outcomes while providing a better work environment for clinicians, frontline staff, and partnering hospitals.

This PSLL created a framework to improve intra- and interhospital transfers that can guide the intervention work of departments within a hospital and at outside facilities to address the domains of the transfer process, dimensions of the hospital context, and outcomes of transfers.^1-3 To support this work, it developed the following products:

• Multiple survey instruments.
• A new measure tool to assess staff experience of intrahospital patient transfers.
• Real-time dashboards.
• Redesigned call-in templates in Epic, and
• Training programs for staff.^{1, 4-6}

CHIRAL conducted a multimodal study to improve the quality and safety of interhospital transfer for clinically ill patients. Results included the reduced mortality rate of patients with atraumatic intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH) from 29 percent before intervention to 11 percent postintervention.7 Interventions included statewide clinical guidance dissemination, redesign of transfer acceptance process, patient arrival notification system, streamlined access to diagnostic imaging, and improved electronic medical record.

This study found significant improvement of median time to admission order and median ED boarding time. Communication among hospitals upon patient arrival improved from 38 percent to 91 percent.7 This project:

• Highlights the strengths and limitations of various data collection methods.
• Reinforces the need for engaging a multidisciplinary team.
• Illustrates the need for iterative approaches to quality improvement interventions, and
• Validates the benefits of using a learning laboratory approach to improving quality of care.^3,5,7-9

This PSLL's work has resulted in:

• At least 10 peer-reviewed journal publications—4 in 2019—with nearly 30 citations in other publications.
• Nearly a dozen presentations at institutions and conferences across the United States.
• A new website (https://medicine.yale.edu/chiral/); and
• Thirteen posters describing the studies conducted.

References

1. Sather J, et al. Real-time surveys reveal important safety risks during interhospital care transitions for neurologic emergencies. Am J Med Qual 2019;34(1):53-8. https://pubmed.ncbi.nlm.nih.gov/29987938/. MAccessed June 11, 2020.
2. Rosenberg A, et al. A taxonomy and cultural analysis of intra-hospital patient transfers. Res Nurs Health 2018 May 2. https://pubmed.ncbi.nlm.nih.gov/29722043/. Accessed June 11, 2020.
3. Campbell Britton M, et al. Mapping the care transition from hospital to skilled nursing facility. J Eval Clin Pract 2020 June;26(3):786-90. https://pubmed.ncbi.nlm.nih.gov/31309664/. Accessed June 11, 2020.
4. Fekieta R, et al. A New Measure To Assess Staff Experience of Intra-Hospital Patient Transfers. New Haven, CT: Yale Center for Healthcare Innovation, Redesign and Learning (CHIRAL); 2018. https://medicine.yale.edu/chiral/scholarlywork/posters/. Accessed June 11, 2020.
5. Finn E, et al. A Closer Look at Inter-Hospital Transfer to YNHH for Atraumatic Intracranial Hemorrhage: Areas for Quality and Safety Improvement. New Haven, CT: Yale Center for Healthcare Innovation, Redesign and Learning (CHIRAL); 2017. https://medicine.yale.edu/chiral/scholarlywork/posters/. Accessed June 11, 2020.
6. AFYA. Internal Communication. PSLL Learning Network Webinar #3 Report. AHRQ, Rockville, MD, 2017.
7. Finn E, et al. Improving the Quality and Safety of Inter-Hospital Transfers for Critically Ill Patients. New Haven, CT: Yale Center for Healthcare Innovation, Redesign and Learning (CHIRAL); 2018. https://medicine.yale.edu/chiral/scholarlywork/posters/. Accessed June 11, 2020.
8. Finn E, et al. CHIRAL Project 1: Improving Transitions of Care Into YNHH for Patients With Atraumatic ICH. New Haven, CT: Yale Center for Healthcare Innovation, Redesign and Learning (CHIRAL); 2016. https://medicine.yale.edu/chiral/scholarlywork/posters/. Accessed June 11, 2020.
9. Campbell Britton M, et al. Conversations Across the Continuum: Communication During the Transition of Care From the Hospital to the Skilled Nursing Facility. New Haven, CT: Yale Center for Healthcare Innovation, Redesign and Learning (CHIRAL); 2016. https://medicine.yale.edu/chiral/scholarlywork/posters/. Accessed June 11, 2020.

Grant Publications

All links below were accessed June 11, 2020.

2019

• Campbell Britton M, et al. Implementing a warm handoff between hospital and skilled nursing facility clinicians. J Patient Saf 2019;15(3):198-204.
• Campbell Britton M, et al. Mapping the care transition from hospital to skilled nursing facility. J Eval Clin Pract 2020 Jun;26(3):786-90. https://pubmed.ncbi.nlm.nih.gov/31309664/.
• Minges KE, et al. Hospital readmission from skilled nursing facilities (SNFs): perspectives of hospital and SNF providers. J Am Med Dir Assoc 2019;20(8):1050-1.
• Sather J, et al. Real-time surveys reveal important safety risks during interhospital care transitions for neurologic emergencies. Am J Med Qual 2019;34(1):53-8. https://pubmed.ncbi.nlm.nih.gov/29987938/. Accessed June 11, 2020.

2018

• Feder SL, et al. "They need to have an understanding of why they're coming here and what the outcomes might be." Clinician perspectives on goals of care for patients discharged from hospitals to skilled nursing facilities. J Pain Symptom Manage 2018;55(3):930-7.
• Gawel M, et al. A qualitative study of multidisciplinary providers' experiences with the transfer process for injured children and ideas for improvement. Pediatr Emerg Care 2018;34(2):125-31.
• Lord K, et al. Emergency department boarding and adverse hospitalization outcomes among patients admitted to a general medical service. Am J Emerg Med 2018;36(7):1246-8.
• Rosenberg A, et al. A taxonomy and cultural analysis of intra-hospital patient transfers. Res Nurs Health 2018 May 2.

2017

• Campbell Britton M, et al. Care transitions between hospitals and skilled nursing facilities: perspectives of sending and receiving providers. Jt Comm J Qual Patient Saf 2017;43(11):565-72.
• Clark B, et al. Perspectives of clinicians at skilled nursing facilities on 30-day hospital readmissions: a qualitative study. J Hosp Med 2017;12(8):632-8. https://pubmed.ncbi.nlm.nih.gov/28786429/.