Development and Pilot Testing the SITe Intervention

Study Overview
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Brief Summary
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Every year, nearly 240,000 patients age 65 and older are transferred between acute care hospitals for nontraumatic surgical emergencies, and these patients experience worse outcomes than patients admitted directly from an emergency department within a given hospital. Care coordination for older patients with emergency general surgery (EGS) diagnoses suffers because conversations between referring and accepting providers regarding decisions to transfer are ineffective, incomplete, and inefficient. To standardize a method to support transfer decisions that is tailored to older adults within extant transfer processes, the team will (1) engage key stakeholders to develop the intervention to Support Interhospital Transfer Decisions (SITe) for older EGS patients by adapting an existing intervention for interhospital handoffs and (2) assess the acceptability of the SITe intervention, test the feasibility of study procedures, and explore efficacy outcomes for evaluation in a future, larger clinical trial.

Detailed Description
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Aim 2 of the protocol qualifies as a clinical trial. Aim 2 will assess the acceptability of the intervention to Support Interhospital Transfer Decisions (SITe), test the feasibility of study procedures, and explore efficacy outcomes for evaluation in a future, larger clinical trial. Modeling a similar and successful pilot, the investigators will conduct a pre (control)/post (intervention) study with 50 transfers in each arm.They will collect pre- and post-intervention data after each eligible transfer through (1) chart review and transfer center logs and (2) Qualtrics surveys of referring and accepting providers. The team will collect baseline (pre) and post-intervention measures of the potential to avoid transfers, efficiency of transfer communication and execution, provider emotional labor, and patient health outcomes. accepting providers will utilize the SITe intervention during calls discussing transfer decisions regarding older emergency general surgery patients. Transfer center nurses and referring providers will be informed of the SITe intervention tool.

Official Title
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Development and Pilot Testing of an Intervention to Support Interhospital Transfer Decisions (SITe) Regarding Older Adults With Emergency General Surgery Diagnoses

Conditions
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Emergency General Surgery

Intervention / Treatment
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* Behavioral: Intervention to Support Interhospital Transfer Decisions (SITe)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients (n=100): patients age 60 and older with an EGS diagnosis transferred from a referring ED or inpatient floor in Wisconsin to the UW ED or inpatient floor under care of UW surgeons Providers: all UW (accepting) surgeons and all referring providers who execute transfers of the 100 eligible patients. There will be no exclusions regarding referring providers' position (e.g., physician, mid-level provider), specialty (e.g., emergency medicine, internal medicine), or affiliation (e.g., UW or non-UW). Exclusion Criteria: Providers who do not speak English Patients younger than 60 years Other interhospital transfers other than EGS transfers Prisoners

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Intervention Model: Single Group Assignment
Interventional Model Description: The intervention will target UW Health accepting providers.
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: SITe training for accepting providers<br>UW Health (accepting) providers will participate in a training to learn how to utilize SITe intervention tools during EGS transfer calls. | Behavioral: Intervention to Support Interhospital Transfer Decisions (SITe)<br>* The SITe intervention and implementation toolkit was developed in Aim 1 through stakeholder activities. SITe, an intervention to support interhospital transfer decisions regarding older EGS patients, includes a checklist and script to be utilized by accepting providers during their conversations with referring providers. The investigators and stakeholders also developed a toolkit for implementation with resources to reduce barriers to and support facilitators of utilizing the tools. The toolkit includes: (1) the checklist and script; (2) methods to train accepting providers on the tools including a PowerPoint presentation and demonstration video; and (3) resources to familiarize other parties (transfer center nurses, referring providers, referring hospitals) with the SITe intervention.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Acceptability of the intervention to Support Interhospital Transfer Decisions (SITe) | The team will identify 50 study-eligible patient transfers post-intervention training. The team will identify the number of transfers for which accepting providers utilized the SITe intervention tools. Adequate acceptability is defined as >85% utilization of the SITe tools for eligible patient transfers. The team will ask the accepting provider and referring provider who executed the eligible transfer to rate the following statements on a Likert-scale (1=completely disagree to 5=completely agree): This intervention meets my approval. This intervention is appealing to me. I like this intervention. I welcome this intervention. Acceptability is defined as a minimum average score of 4 per item. | 3 months | 
| Fidelity to the intervention to Support Interhospital Transfer Decisions (SITe) | The team will identify 50 study-eligible patient transfers post-intervention training. The team will measure missingness of the tool elements. Fidelity is defined as <15% missing patient information. | 3 months | 
| Feasibility of study procedures | The team will measure the rate of survey completion for study-eligible patient transfers and examine rates of and reasons for missing outcome data. | 7 months | 
| Potential to avoid transfer: chart review | The team will evaluate the quality outcome: potential to avoid transfer. Through chart review, the team will look at number of transfers with no intervention and discharge to home within 72 hours. | 7 months | 
| Potential to avoid transfer: survey | The team will evaluate the quality outcome: potential to avoid transfer. From Qualtrics surveys, the team will review responses to questions about was the transfer potentially avoidable. | 7 months | 
| Efficiency of transfer communication | Following the Relational Model of Organizational Change and through chart review and review of transfer center logs, the team will evaluate the efficiency of transfer communication. The team will review the number of calls required to complete the transfer and time required to complete transfer calls. | 7 months | 
| Efficiency of transfer execution | The team will evaluate the efficiency of transfer execution. The team will review the time from initial call to patient arrival. | 7 months | 
| Emotional Labor | Following the Relational Model of Organizational Change and specific Qualtrics questions, the team will evaluate the emotional labor of providers. The team will ask about providers' feelings about being listened to and supported when discussing patient care and difficult patient issues. | 7 months | 
| Patient Health Outcomes | The team will evaluate patient health outcomes. The team will measure the number of admissions to the emergency department vs inpatient floor, the number of changes in level of patient care (general, intermediate, intensive) within 24 hours of arrival, and the number of adverse events (inpatient mortality, morbidity, extended length of stay.) | 7 months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Older adults, Communication, Health care provider, Interhospital transfer