F - Fluid strategy and feeding plan A - Agreed analgesia and sedation U - of the skin and gut L - Lines out T - Tidal volumes less than 8 ml/kg INTERACT II, Stop and Watch Tool (mnemonic) S - Seems different than usual T - Talks or communicates less O - Overall needs more help P - Pain – new or worsening; participated less in activities A - Ate less than usual N - No movement in three days; or diarrhoea D - Drank less W - Weight change A - Agitated or nervous more than usual T - Tired, weak, confused, or drowsy C - Change in skin colour or condition H - Help with walking, transferring, toileting more than Aspects to consider in transfer of older people between residential aged care facilities and emergency departments Name of tool, checklists and templates Description of tool Use I-PASS (mnemonic) I - Illness severity; stable, needs watching, unstable P - Patient summary; summary statement, events leading to admission, hospital course, ongoing assessment, plan A - Action list; to do list, time line and ownership; know what is going on, plan for what might happen Aspects to consider when paediatric patients move between acute care units and intensive care units
Table 14: Evidence of standardised tools, checklists and templates Standardised tools, checklists and templates Description Evidence that tool tool has been implemented Reliability and validity of evidence Gaps in evidence BEFORE YOU ADMIT tool Ash et al. 2014 Six areas to be asked about an older patient before admission: Polypharmacy Goals of care Delirium Frailty Aspiration Falls At one hospital, older patient readmission within 30 days reduced from 22.4% to 14.8% Emergency department of public teaching hospitals on SBAR format No further information about reliability and validity Needs research on application within residential aged care facilities BOOST (Better Outcomes for Older adults through Safe Transitions) tools Hansen et al. 2013 Series of tools that can be used during care transitions for older people: 8P Risk Assessment (problem medications, psychological, principal diagnosis, polypharmacy, poor health literacy, patient support, prior hospitalisation in last six months, palliative care) General assessment of preparedness Written discharge instructions Preparation to Address Situations Successfully (PASS) Discharge Patient Education Tool (DPET) Teach back At 11 hospitals, average rate of rehospitalisation in BOOST units was 14.7% prior to implementation and 12.7% 12 months after implementation (P = 0.010) Metropolitan public teaching hospitals, community teaching hospitals, community hospitals Widespread engagement with clinicians and policy makers tool development Not clear if further information available on reliability and validity Further work needed on how relate to patient movements to residential aged care facilities and community
C-CEBAR (mnemonic) Chau et al. 2015 C - Contact of case physiotherapist of acute hospital C - Contact details of patient E - Expectations of receiving physiotherapist for required rehabilitation therapy B - Background and history A - Assessments and function R - Responsibilities and risk management, including safety precautions and unanticipated patient's response 740 physiotherapy records at three hospitals examined Almost full compliance with tool was obtained for all audit criteria, except for ‘Expectations of receiving physiotherapist for therapy required’ and ‘Responsibilities and risk management’, where compliance was 90% Acute care hospitals, rehabilitation hospitals Based on the iSoBar tool No further information about reliability and validity Tool evaluation needed on whether it leads to improved functional outcomes for patients after physiotherapy Checklist of Safe Discharge Practices Soong et al. 2013 Seven areas examined in checklist Hospital: Assess if hospitalisation is still required Primary care: Identify active primary care provider Alert care team if no primary care provider Notify about patient’s admission, diagnosis, and predicted discharge date No evidence that tool has been tested Tool does not appear to have been implemented cycles of panel meetings approved final list No further information about reliability and validity Evaluation needed on how tool impacts on clinical outcomes at care transitions
Changes and new medications at discharge and opioids Weekly pill box needed Barriers to patient’s adherence Physician’s signature for the community or institutional pharmacist Prescription verified by the pharmacist before patient discharge DEFAULT (mnemonic) Sharma & Peters 2013 D - Do not resuscitate (DNR) status is clear E - Endotracheal tube and cuff is safe F - Fluid strategy and feeding plan A - Agreed analgesia and sedation U - of the skin and gut L - Lines out T - Tidal volumes less than 8 ml/kg In one hospital, increase in median days of accidental tube removal between pre- and post-intervention (14 vs 150 days, P<0.0001) towards an increase in proportion of patients who had tidal volumes in expected range between pre- and post-intervention (49% vs 61%, P=0.09) Public teaching hospital Paediatric intensive care unit Risk action group designed a mnemonic and feedback obtained from intensivists and senior nurses No further information about reliability and validity Evaluation needed on how tool impacts on clinical outcomes at care transitions
INTERACT II (Interventions to reduce acute care transfers): Stop and Watch Tool (mnemonic) Madan et al. 2012 S - Seems different than usual T - Talks or communicates less O - Overall needs more help P - Pain – new or worsening; participated less in activities A - Ate less than usual N - No bowel movement in three days; or diarrhoea D - Drank less W - Weight change A - Agitated or nervous, more than usual T - Tired, weak, confused, or drowsy C - Change in skin colour or condition H - Help with walking, transferring, toileting more than usual At 30 nursing homes, 31 transfers took place over period. Four deemed to be preventable and 27 non-preventable 100% of patients transferred to the emergency department were admitted to the hospital Nursing Public teaching hospitals Community hospitals Not clear whether reliability and validity testing has taken place Evaluation needed on how tool impacts on clinical outcomes at care transitions I-PASS (mnemonic) Sheth et al. 2016 I - Illness severity; stable, watching, unstable P - Patient summary; summary statement, events leading to admission, hospital course, ongoing assessment, plan A - Action list; to do list, time line and ownership; know what is going on, plan for what might happen For 278 paediatric patient transfers into one hospital, time between verbal hand-off and patient transfer decreased from baseline (397 +/- 167 minutes) to the post-intervention children's hospitals Cardiovascular ICUs Acute care units Developed from SBAR (Situation, Background, Assessment, Recommendation) Expert advisory group developed tool Different paediatric populations need to be tested for utility and efficacy of tool
S - Situation awareness and contingency planning S - Synthesis by receiver; receiver summarises what has been heard, asks questions, restates key actions period (24 +/- 21 minutes) (P < .01) No differences in rates of readmission, rapid response team calls, or mortality were observed No further information about reliability and validity MDS for PICU (Minimum Data Set for Paediatric Intensive Care Unit) Hansen et al. 2014 bar highlights patient’s trajectory in red, yellow or green Allergies Medications Pertinent patient history Body system areas 12-hour follow-up plan Contingency plan Read-back from sender to receiver Utility tested: doctors that patient data were not redundant or excluded in the tool Metropolitan teaching hospitals Paediatric intensive care units Tool development with four non-PICU intensivists and 10 paediatric residents No further information about reliability and validity Evaluation needed on how tool impacts on clinical outcomes at care transitions Mind the Gap Tool Sonneveld et al. 2013 Health professional-related characteristics: If are unrealistic expectations of health professionals providing adult care If providers from child and adult care settings know each other well enough 127 adolescents with chronic conditions, 166 parents, and 19 care providers Audit using the tool showed there was Public teaching hospitals Rehabilitation hospitals Face and content validity Factor analysis Cronbach’s alpha reliability Evaluation needed on how too impacts on clinical outcomes at care transitions Identification
7Ps flowchart (mnemonic) Khan et al. 2010 P - Problem medications P - Punk (depression) P - Principal diagnoses P - Polypharmacy P - Poor health literacy P - Patient support P - Prior hospitalisation Mnemonic identified barriers to communication Primary care physician in the discharge summary (55%) Summary was transmitted to the primary care physician 73% of the time Patient was seen in clinic 73% of the time 20% of patients received follow-up calls within 72 hours Acute Care for Elders Units Metropolitan teaching hospitals Expert group review in developing tool No further information about reliability and validity Evaluation needed on how tool impacts on clinical outcomes at care transitions RAPaRT (Rapid Assessment Prioritisation and Referral Tool) McPhail et al. 2015 Set of seven items: Previous regular help Hospitalised in past six months More than three medications prescribed Walking aids or assistance Someone else shopping Lost weight recently, eating poorly Tool was able to predict when a referral was warranted in 80% of situations Medical assessment and planning units Emergency departments Public teaching hospital Prospective evaluation and consultation with Delphi No further information about reliability and validity Evaluation needed on how tool impacts on clinical outcomes at care transitions
Falls in the past six months PSOST (Providers’ Signout for Scope of Treatment) Newport et al. 2010 Brief history of present illness Past medical history Resuscitation code status laboratory or diagnostic test results, ‘‘to do’’ list of laboratory and procedures Care plan Residents reported great level of satisfaction in using the tool Fellows reported interventions aligned with patients’ goals Nurses reported the tool assisted in their Cancer care hospitals Hospices Palliative care units Haematology oncology units Expert group review with palliative care fellows and medicine residents in developing tool No further information about reliability and validity Evaluation needed on how tool impacts on clinical outcomes at care transitions 3-Ds—diet, drugs, discharge plan Romagnuolo et al. 2005 Diet Proton pump inhibitor use Helicobacter Pylori eradication regimen Non-steroidal anti-inflammatory drug use Complete blood count Discharge plan time Follow-up in gastroenterology clinic, general practitioner or endoscopy clinic Median in-patient stay was 7.0 (95% CI 2–24) versus 3.5 (95% CI 1–12) days for the (n=39) and periods (n=22), respectively (P = 0.003) Public teaching hospitals Emergency departments General internal medicine departments Endoscopy units Consensus development of tool No further information about reliability and validity Evaluation needed of the tool’s impact on patients with various levels of vulnerability, such as low socioeconomic groups, patients with alcohol problems or mental illness intervention
Authors (year), country Type of Sample, nature of complexity Settings for transitions Chemali et al. (2015)39 Australia Retrospective clinical audit and survey 200 sequential electronic discharge letters 240 general practitioners managing patients with diverse acute and chronic conditions Public teaching hospital Choromanski et al. (2014)11 USA Descriptive survey study 216 anaesthesia providers Patients moving from peri-operative to post-surgical environments Anaesthesia providers employed in diverse healthcare institutions Operating rooms and post-anaesthetic care units Coleman et al. (2006)28 USA Randomised controlled 750 community-dwelling adults, aged 65 years or older admitted to hospital with one of 11 selected conditions Conditions were selected as patients had high likelihood of transferring to a skilled nursing facility or home healthcare services, or requiring anticoagulant treatment One hospital Eight skilled nursing facilities One home healthcare agency Cornu et al. (2012)36 Belgium Retrospective, single-centre, cohort 189 patients aged 65 years or older 76% residing at home, and 24% residing in nursing home before hospitalisation Metropolitan teaching hospital Acute geriatric unit Inpatient medical and surgical units Dedhia et al. (2009)32 USA Pre- and study 237 patients at pre-intervention 185 patients at post-intervention Patients aged 65 years or older Many comorbidities Academic medical centre Community teaching hospital Community non-teaching hospital General medicine wards Dressler and Shutt (2013)14 USA Feasibility study for tool 264 paediatric critical care transports to hospital Critical Care Transport Metropolitan teaching hospital intervention
Authors (year), country Type of study Sample, nature of complexity Settings for transitions Ellis et al. (2013)15 USA Multi-centre, descriptive study 300 critical care encounters 27% of patients had hospital admission in past six months Three hospitals Four adult medical intensive care units Primary care clinics Halverson et al. (2014)42 USA Tool development study by consensus method Panel of 11 clinicians (colorectal surgery, surgical oncology, general surgery, geriatrics, and hospital medicine) with expertise in surgical outcomes measurement, hospital readmissions, gerontology, and nursing For patients following gastro-surgery Various settings Hansen et al. (2013)43 Canada Pre- and study people with diverse comorbidities (n not stated) 11 hospitals varying in geography, size, and academic affiliation Hansen et al. (2014)16 Canada Tool development and testing Children admitted to paediatric intensive care unit Four non-PICU intensivists 10 paediatric residents Metropolitan teaching hospital Paediatric intensive care unit et al. (2012)44 Canada survey study 79 dialysis centre directors 21 (27%) completed the survey Patients with end-stage renal disease requiring dialysis and other comorbidities Dialysis centres of hospitals and satellite regions Henderson and Corke (2015)17 Australia Prospective cohort study using surveys 124 medical subscribers comprising specialists and trainees of Australian and New Zealand College of Intensive Care Medicine online newsletter Intensive care settings in Australia and New Zealand intervention
Lane et al. (2013)48 Australia Retrospective review of medical records High-care residents aged 65 years and over presenting to a hospital from residential aged care facilities (n=228 presentations) Metropolitan teaching hospital Residential aged care facilities Emergency department Inpatient wards Day units Emergency department presentations, elective admissions to inpatient wards and admissions to medical or surgical day units LeBlanc et al. (2014)49 Canada Development of handover checklist for orthopaedic trauma by consensus method 247 members of the Canadian Orthopaedic Association (COA) Orthopaedic surgeons, surgical residents and fellows Patients following orthopaedic trauma Diverse environments in public and private hospitals Liem et al. (2013)50 Austria Development of outcome guidelines for management of hip fractures in older people by consensus method 17 orthopaedic surgeons, trauma surgeons and geriatricians involved in care of people following hip fractures Diverse environments comprising acute, subacute and community care et al. (2012)51 USA Prospective evaluation study of Interventions to Reduce Acute Care Transfers (INTERACT) tools All patients transferred from nursing home to hospital over May-September 2011 (N value not given) 30 nursing homes and associated hospitals
Authors (year), country Type of study Sample, nature of complexity Settings for transitions Manias et al. (2016)37 Australia Cross-sectional prospective survey study 707 health professionals completed survey (response rate 14%), represented by nursing (60%), medicine (22%) and allied health (18%) Patients situated in diverse settings Metropolitan tertiary hospitals Metropolitan general community hospitals Country hospitals Community health centres Mental health services Manias et al. (2016)38 Australia Retrospective clinical audit 127 patient transfers to emergency department of metropolitan hospital Two rural public hospitals One metropolitan public teaching hospital Diverse clinical settings of rural hospitals Royal Flying Doctor Service Emergency department of metropolitan hospital McBride et al. (2014)52 United Kingdom Pre- and post- quality improvement study 160 patients, > 40 years, with patients having an average of three comorbidities with chronic kidney disease (25%) More than half of patients (54%) were New York Heart Association class III, 26% were class II and 4% were class IV Patients of low socioeconomic backgrounds Public teaching hospital Outpatient case management Specialist cardiology wards, general medical wards McMurray et al. (2013)12 Canada Multi-site ethnographic field study Patients aged 65 years and older following hip fracture surgery who move across care setting transitions Interviews with hip fracture patients (n=23), their informal carers (n=19) and health professionals (n=100) Three Canadian sites (large urban, smaller urban, rural)
Authors (year), country Type of Sample, nature of complexity Settings for transitions Sonneveld et al. (2013)56 Netherlands Cross-sectional survey study 127 adolescents with juvenile rheumatoid arthritis, neuromuscular disorder with chronic ventilation, or diabetes Type I 166 parents and 19 care providers Public teaching hospitals Rehabilitation hospitals Soong et al. (2013)57 Canada Development of an evidence-based checklist of safe discharge practices for hospitalised patients Expert panel from multiple disciplines, including primary care practitioners, hospital clinicians, rehabilitation clinicians, nurses, researchers, pharmacists, academics, and hospital administrators (n=not mentioned) Focus on patients discharged home Diverse hospitals and healthcare settings Stoneley et al. (2012)25 United Kingdom Retrospective clinical audit Hospitalised patients with dementia and frailty syndromes of limited prognosis (n=82) Public teaching hospital Sujan et al. (2014)58 United Kingdom Qualitative study with interviews and observations 270 hours of handover between ambulance officers, emergency department staff and acute medical staff Two ambulance services Three National Health Service hospitals Emergency departments Acute medical wards Terrell et al. (2009)1 USA Development of quality indicators with a consensual approach 23 members of a task force, 30 members of a geriatric special interest group, and 110 participants at two conferences. Older patients needing emergency care Geriatricians, emergency physicians, nurses, social workers, and non-medical gerontologists employed in diverse settings Terrell and Miller (2011)59 USA Qualitative focus group study 18 participants comprising nursing home administrators, nursing home and emergency department nurses, physicians, emergency medical services directors, paramedic staff, emergency medicine technicians, and policy makers from Department of Health Public teaching hospital Emergency department Nursing home
residential aged care facility and hospital Aspiration Readmission rates for patients with pneumonia reduced from 21.9% to 14.5% Cornu et al. 201236 Belgium Discharge medication list Medical secretary completed discharge letter using information from discharge medication list and pre-admission medication list. Physician completed discharge medication list. For older people aged 65 years and older moving between residential aged care, and acute medical and surgical and acute geriatric units Discharge medication list: Medication name, dose, frequency, 90 patients (47.6%) had one or more discrepancies in medication information at discharge Polypharmacy (five medications or more) in discharge medication list (OR 1.19; p = 0.001) and discharge letter (OR 1.18; p = 0.001) associated with medication discrepancies *** Authors (year), country Form (text type) of documentation Structure (ordering of information) of documentation Summary of the evidence for content of information Findings Quality Appraisal* Dedhia et al. 200932 USA Assessment form Set of five forms and approaches, which began at admission and Assessment form: Fall risk Return to the emergency department within three days of discharge: ****
continued throughout hospitalisation For patients aged 65 years and older with multiple chronic conditions Barriers to patient’s safe return home Recommendations for management 10% for control group vs 3% for group 30 day-readmission: 22% for control group vs 14% for intervention group Visits to the emergency department: 21% for control group vs 14%, for group Dedhia et al. 200932 USA collaborative medication reconciliation Set of five forms and approaches, which began at admission and continued throughout hospitalisation For patients aged 65 and older with multiple chronic conditions Physician–pharmacist collaborative medication reconciliation: Pre-admission medication regimen Prompts to decide whether to continue, change, or hold medications Return to the emergency department within three days of discharge: 10% for control group vs 3% for intervention group 30 day-readmission: 22% for control vs 14% for group Visits to the emergency department: 21% for control group vs 14%, for group **** Authors (year), country Form (text type) of documentation Structure (ordering of information) of documentation Summary of the evidence for content of information Findings Quality Appraisal*
Dedhia et al. 200932 USA Medication discharge instructions Set of five forms and approaches, which began at admission and continued throughout hospitalisation For patients aged 65 years and older with multiple chronic conditions Medication discharge instructions: Dose, frequency, purpose of each medication Return to the emergency department within three days of discharge: 10% for control vs 3% for group 30 day-readmission: 22% for control group vs 14% for group Visits to the emergency department: 21% for control group vs 14%, for intervention group **** Hansen et al. 201343 Canada Better Outcomes for Older adults through Safe Transitions (BOOST) program of work on care across transitions 8P approach Health professionals could assess for these problems in all hospitalised patients For older people with diverse comorbidities Problems with medications: Patients prescribed several medications, or who are on high-risk medications including anticoagulants, warfarin, heparin, Factor Xa or thrombin inhibitors, antiplatelet agents in combination (e.g. aspirin and clopidogrel), insulin, oral hypoglycaemic agents, digoxin, and opioids Psychological: Patients who screen positive for depression or who have a history of depression Average rate of 30-day rehospitalisation in BOOST units was 14.7% prior to implementation and 12.7% 12 months after implementation (p = 0.010) ****
Lane et al. 201348 Australia Admission tool Communication residents aged 65 years and over presenting to a hospital from residential aged care Explanation of the natural history of major illnesses experienced Agreed goals Limits of care Key people and involved in care Patient wishes, if possible Resuscitation status was documented in 50 (55%) and family discussion in 38 (42%) of 91 admissions Documented family discussion was associated with complications or new events occurring during admission (odds ratio 1.56) **** Madan et al. 201251 USA INTERACT II tools Stop and Watch Early Warning Tool, SBAR Communication Form, Medication Reconciliation Worksheet, Hospital to Post Acute Transfer Form, to Hospital Transfer Form Involving communication between health professionals in hospitals and residential aged care settings for patients transferring between these settings Stop and Tool: different than usual Talks or communicates less Overall needs more help Pain – new or worsening Participated less in activities Ate less than usual No bowel movement in three days, or diarrhoea Drank less Weight change Agitated or nervous more than Tired, weak, confused, or drowsy 31 transfers took place from May to September. Four deemed to be preventable and 27 non-preventable 100% of patients transferred to the ED were admitted to the hospital None of the preventable and 33% non-preventable transfers had end-of-life planning ****
Key transitional care information for pending laboratory results, follow-up and procedures Attached documents and notes Reid et al. 201355 Canada Transition tracking tool for whole pathway Information conveyed between hospital and nursing home staff as older people moved between the nursing home and hospital Medication list Resident summary Allergies Do not resuscitate order Advance directive Patient care plan Non-clinical resident data Clinical resident data Physicians’ notes Diagnosis Emergency department summary Inpatient summary Transfer record Laboratory results Emergency department nurses’ Patient follow-up Consultations Residents were associated with trigger events that led to movements across transitions Trigger events comprised the following common types: falls (30.9%), change in physical condition (14.7%), nausea, vomiting and diarrhoea (11.8%) ***
administered in the nursing home Terrell & Miller 201159 USA Whole pathway Documentation of care that nursing home residents should have before, during, and after an emergency department visit Individuals’ details involved in care Medication list Request to have bidirectional uniform transfer form to guide practice Current forms were long, tedious and unworkable Belief that verbal communication should complement written communication. Belief that relationship building strategies would help with completing care pathways **** Walker et al. 201535 USA Adherence to quality indicators for communication between nursing homes and emergency departments Care provided to nursing home residents before, during, and an emergency department visit Reason for transfer Resuscitation status Medication allergies Contact information for the nursing home, the primary care doctor, and the resident’s legal health care representative or closest family member Medication list for medications prescribed to the resident in the nursing home 85% of nursing home paperwork contained a reason for transfer 85% listed medication allergies 52% noted advanced directives 46% contained contact information for the nursing home provider should urgent communication be required ***
If parents are dominantly present in the consulting room If over-concerned or protective parents Tregay et al. United Kingdom Discharge tool Health professionals communicating after children were discharged home after cardiac surgery Contact information about health professionals involved in child’s care Information provided to parents Need for interpreter Specialist technical terminology and the absence of key basic information rendered discharge documents less useful to community professionals and families Discharge documents were sometimes delayed Inconsistent pathways noted Potential loss of information between multiple teams involved *** White et al. 20126 Australia 12 key pieces of information that should be included in a referral letter Movement from the paediatric hospital to the adult hospital For children with type 1 diabetes Date of diagnosis Mode of presentation Antibody status at diagnosis Current insulin regimen Previous insulin regimens Current HbA1c level Previous HbA1c levels Transition letters were written for 149 out of 180 (82.8%) youth who attended clinics. Transition occurred in an unplanned way or without physician input in 30.6% (55/180) of cases Information contained in transition letters was as follows: current insulin ***
3. Patients with mental illness on complex medication regimens Authors (year), country Form (text type) of documentation Structure (ordering of information) of documentation Summary of the evidence for content of information Findings Quality Appraisal* Brunero et al. 20088 Australia Blue Card, a patient record Used by patients with schizophrenia and shared with health professionals during outpatient visits and upon admission to hospital New card given if patient’s condition and circumstances changes Details of specialist doctor and case manager Mental health assessment Medication names, dose and frequency Blood glucose level Weight Blood pressure Cholesterol level Helpful information for patient Advance care directive for acute hospitalisation 69% of patients retained their card at three-month follow-up Patient’s knowledge of blood pressure: 8.5% at pre-test, and 34% at (P=0.002) Patients’ knowledge of cholesterol: 8.5% at pre-test and 25.5% at post-test (P=0.02) Patients’ knowledge of current weight: 66% at and 85% at post-test (P=0.016) Patients’ knowledge of blood glucose level: 6.4% at pre-test and 40% at (P=0.0001) **** 4. Patients with multiple comorbidities test
Authors (year), country Form (text type) of documentation Structure (ordering of information) of documentation Summary of the evidence for content of information Findings Quality Appraisal* Balaban et al. 200829 USA Patient Discharge Form provided to patients, in one of three languages Electronic transfer of the Patient Discharge Form to nurses at the patient’s primary care site Control patients: Discharge instructions handwritten in English, communication between discharging physician and primary care provider on an as needed basis. For patients with multiple chronic conditions between residential aged care facilities and hospital Patient demographics Discharge diagnosis Names of hospital doctor (including residents, general physician and specialists) Vaccinations given New allergies Dietary and activity instructions Home services ordered Scheduled appointments with primary care provider, specialists, and for diagnostic studies Pending medical test results Recommended outpatient work-ups Discharge medications list – Continued medications (with dose changes highlighted), new medications and discontinued medications Nursing comments Reminder to patients to the form to their next appointment 14.9% of the patients failed to follow-up within 21 days 40.8% of the concurrent and 35.0% of the historical controls failed follow-up within 21 days 11.5% of recommended work-ups in the intervention group were incomplete 31.3% of the concurrent controls and 31.0% of the historical controls had incomplete recommended work-ups *
Boxer et al. 201040 USA Heart Failure Disease Management Program comprising four clinical care measures and three discharge care measures Information to be included from acute care to primary care For patients with diverse chronic conditions Clinical care measures: Ejection fraction Symptom and activity assessment weight and dietary surveillance Medication titration Discharge care measures: Patient and education Discharge instructions, and follow-up appointment seven days post-discharge Intervention resulted in increased inclusion of key elements in the discharge instructions from 61% to 80% and in the discharge summary from 61% to 72% ** Chau et al. 201541 Hong Kong – adaptation for allied health professionals from the iSoBar tool Use of tool between physiotherapists situated in acute hospital and rehabilitation hospital. For patients with diverse chronic conditions Contact of case physiotherapist of acute hospital Contact details of the patient Expectations of receiving physiotherapist at rehabilitation hospitals for therapy required. Background and history including previous of function Assessments and function. Responsibilities and risk management 740 physiotherapy (PT) records (6% of all patients) examined Almost full compliance with tool was obtained for all audit criteria, except for ‘Expectations of receiving physiotherapist for therapy required’ and ‘Responsibilities and risk management’, where compliance was 90% **
Chemail et al. 201539 Australia Electronic discharge letters Electronic discharge letters sent from hospital doctors to general practitioners. For patients with diverse acute and chronic conditions Understanding of 20 commonly used abbreviations: SNT (soft, non-tender) TTE (transthoracic echocardiogram) EST (exercise stress test) NKDA (no known drug allergies) CTPA (computed tomography pulmonary angiography) ORIF (open reduction and internal fixation) HSDNM (heart sounds dual and no murmur) B/G (background) GCS (Glasgow coma scale) ADLs (activities of living) PMHx (past medical history) CT (computed tomography) ECG (electrocardiogram) CXR (chest x-ray) O/E (on examination) BP (blood pressure) Six abbreviations were misinterpreted by > 25% of surveyed GPs These were: SNT (soft TTE (transthoracic echocardiogram), EST (exercise stress test), NKDA (no known drug allergies), CTPA (computed tomography pulmonary angiography), and ORIF (open reduction and internal fixation) ***
Patient self-management capacity: Cognition, health literacy, depression, anxiety, competency after discharge Family self-management support capacity: Family’s understanding of plan of care and their involvement, competency after discharge Follow-up appointment: Staff awareness, follow-up appointment is scheduled after discharge home Manias et al. 201637 Australia Use of handover sheets, mental prompts or checklists, electronic devices and lanyard card Senior health professional providing feedback to junior health professionals about their handover practices. For patients with various comorbidities in diverse settings, including public, private, metropolitan and rural hospitals Assessment tool results Clinical information Critical incident analysis. Evidence of communication with other health professionals Evidence of involvement of patients and family members 41% (n=290) of health professionals believed that from their experience, adverse events were a possible consequence of poor handover ***
Manias et al. 201638 Australia iSoBAR format comprising identification, situation, observations, background, agreed plan and readback Doctor to doctor information transfer from Royal Flying Doctor Service to emergency department doctor For seriously ill patients moving from rural to metropolitan hospital Identification: Date and time of interaction, patient name, age, date of contact address, medical record number, doctor’s name at transferring hospital, clinical area, speciality, and contact details of receiving clinician Situation: current medical diagnosis Observations: Temperature, blood pressure, respirations, pulse, oxygen saturation, neurological state Background: Relevant past medical history Agreed plan: Expected arrival time at receiving hospital, recommended tests and procedures, medications to be ordered Readback: Ready access of information relating to patients Lack of information on who made and who received ‘patient expect’ calls Information on identification sticker for name and gender did not always correspond with details in ‘patient expect’ calls Name of clinicians in receiving hospital provided in 11% of calls Actions to be taken included in 19% of calls Planning was restricted to who to contact to review instructions Inconsistency and overuse of abbreviations ****
McBride et al. 201452 United Kingdom of patient with heart failure, and key diagnostic findings Request to notify community nurse in case of hospital admission Need to identify patients with left ventricular, dysfunction, heart failure, and problems with ejection fraction as these influence management during the inpatient stay and risks to prognosis. For patients with heart failure and comorbidities Card indicates the patient has heart failure Card references the last echocardiogram and provides data on ejection fraction and left ventricular function Contact details of general practitioner and community nurse Instruction to contact the community nurse in the case of hospital admission Alert cards were issued to 119 patients. At 12 months, 38 patients from community nurses’ caseloads experienced 61 hospital admissions. Community nurses were informed of 80% of admissions by hospital clinicians and general practitioners (61%) and family members (38%). They were also informed of 59% of discharges Notification of admissions by hospital increased from 0 notifications in the previous 12 months to 19 notifications during the intervention period *** McPhail et al. 201553 Australia Set of seven items in the Rapid Assessment Prioritisation and Referral Tool (RAPaRT) Well-resourced allied health teams in emergency care settings may use RAPaRT instrument to trigger an allied health referral pathway from a single positive response. Less well-resourced teams may elect to use a two positive response cut-off before a Previous regular help Hospitalised in past 6 months More than three medications prescribed Walking aids or assistance Someone else shopping Lost weight recently, eating poorly Falls in the past six months Area under the receiver operating characteristic curve was 0.803 for these seven items in predicting when a referral was warranted ***
referral is triggered, which could eliminate inappropriate treatment. For patients with non-life threatening acuity and with chronic conditions in emergency care settings National Transition Authority Ltd, 201154 Australia Summary document produced during a patient’s stay in hospital as an admitted or patient, and issued when or after a patient leaves hospital Discharge summary to support continuity of care as the patient returns to community healthcare providers For patients with diverse health conditions Patient name and details Nominated primary healthcare providers Facility Document author Document recipients Encounter details Problems/diagnoses Clinical synopsis Diagnostic investigations Clinical interventions Current medications on discharge Ceased medications Allergies and adverse drug reactions Alerts Arranged services Recommendations Consultation and feedback obtained from stakeholders of 24 health professional and consumer organisations ***
Information provided to patient and other relevant parties Reilly et al. 201331 USA on medication management Communication through documentation to be transferred before the patient’s next outpatient session, which was one to two days after discharge For haemodialysis patients with comorbidities moving between units Medication list: Especially intravenous antibiotics to be administered during treatment Summary of hospitalisation Dialysis procedure: Dry weight to guide fluid removal targets Changes in dialysis prescription: Electrolyte composition Plans for follow-up care Risks of poor communication: or omitting a course of antibiotics Follow-up for appointments often missed Incompatibilities in outpatient and inpatient electronic medical records **** Romagnuolo et al.33 2005 USA One-page checklist, outlining detailed recommendations (3-Ds—diet, drugs, discharge plan) Gastroenterologist communicating to admitting service on hospital stay for upper gastrointestinal bleeding. Completed checklist addressing factors relevant to discharge planning was added to the procedure report For patients with upper gastrointestinal bleeding Diet Proton pump inhibitor use Helicobacter Pylori eradication regimen Non-steroidal drug use Complete blood count Discharge plan time Follow-up in gastroenterology clinic, general practitioner or endoscopy clinic Median in-patient stay was 7.0 (95% CI 2–24) versus 3.5 (95% CI 1–12) days for the pre-intervention and post-intervention periods, respectively (P=0.003) ****
Scott et al. 201434 Australia Quality of care using routinely collected data on completed episodes of care during patients’ hospital stay Documentation of assessment and management strategies at transitions of care Patients with comorbidities admitted within 30 days of discharge Diagnosis Assessment and management of active comorbid disease Management of primary clinical problem during admission Management of preventable complication of procedure or therapy undertaken or initiated during admission Assessment of needs and limitations Patient and education about clinical management of disease Communication of discharge information to post-hospital care providers Advance care plan Palliative care plan Organise appropriate medical follow-up Referral to chronic disease management and outreach service where indicated readmitted patients, 50 (44.3%) were associated with at least one quality factor versus 23 (11.6%) controls (P < 0.001). Most common factors were: failure to develop or activate an advance care plan (18, 15.9% vs 2, 1.0%; P < 0.001); sub-optimal management of presenting illness (13, 11.4% vs 0, 0%; P < 0.001); inadequate assessment of functional limitations (11, 9.7% vs 0, 0%; P < 0.001); and potentially preventable complication of therapy (8, 7.1% vs 1, 0.5%, P = 0.002) **
Authors (year), country Form (text type) of documentation Structure (ordering of information) of documentation Summary of the evidence for content of information Findings Quality Appraisal* LeBlanc et al. 201449 Canada Diagnosis, associated injuries, comorbidities, readiness for the operating room, stability of the patient, history or mechanism of injury and outstanding issues Checklist for use in trauma patient handover from emergency department to assessment clinic Patient demographics Injury Pre-operative considerations Patient factors such as substance abuse, functional status, use of walking aids results Consent obtained Issues preventing patient from being admitted to operating room Most important aspects identified for handover by experts: Having the handover the same way each day Having access to all appropriate radiographs at the time of handover Having adequate time for handover Having access to all appropriate laboratory work/patient information at the time of handover Being able to spend time with severely ill patients ** Liem et al. 201350 Austria Subjective and objective outcome parameters and measurement relating to mortality, length of stay, time to surgery, complications, readmission rate, mobility, quality of life, pain, activities of daily living, Outcome parameters collected and documented by health professionals on admission, discharge, at 30 days, 90 days and at one-year post-admission and communicated between health professionals. For people following hip fracture Length of stay: Midnight census method Time to surgery: Time from admission until arrival in operating room Complications: Type and rate Medical and surgical readmission: Consensus of outcome parameters among 17 health professional experts in orthogeriatric hip fracture after a two-day interdisciplinary meeting ****
Authors (year), country Form (text type) of documentation Structure (ordering of information) of documentation Summary of the evidence for content of information Findings Quality Appraisal* McMurray et al. 201312 Canada Whole pathway For communication between health professionals about patients aged 65 years and older following hip fracture surgery Provider details Post-operative care Documentation is a control mechanism that identifies service needs and informs resource allocation in subsequent settings Documentation provides some data about patients but it is rarely complete Information exchanges within organisations are more likely to consider the needs of clinicians rather than those exchanges occurring between organisations Continuity of care is affected by missing, late or unnecessary documentation; duplication of data collection; and lack of integration of electronic systems **** Weinger et al. 20155 USA Elements of key information following SBAR format Post-operative handovers between anaesthesia providers (APs) and PACU registered nurses. For adult and child movements following anaesthesia Situation: Patient name, age and weight Anaesthetic type Fitness of surgery Procedure information Allergies Proportion of acceptable handovers increased significantly from 7% to 70% in the PACU from the baseline to the time period and from 22% to 72% in the paediatric ***
Post-operative management and patient disposition 6. Complex patients admitted to intensive care Authors (year), country Form (text type) of documentation Structure (ordering of information) of documentation Summary of the evidence for content of information Findings Quality Appraisal* Bates et al. 201413 USA 10 item checklist Acts as a measure of level of shared clinical understanding regarding the condition and treatment plan for handover in paediatric intensive care. Includes health professionals within unit and external treatment teams Clinical condition over last 12 Cardiovascular plan for care Airway goal Primary anatomic source of pulmonary blood flow Changes in pulmonary versus systemic perfusion flow in patient Indication for current anticoagulant Barrier to discharge home or to ward Other active cardiovascular issues Non-cardiovascular issues needing therapy or monitoring Inter-rater agreement with video simulation: 0.89% Mean levels of agreement ranged from 0.41 to 0.87 (median 0.77) 100% compliance with in situ testing ***
Dressler & Shutt 201314 USA Paediatric Warning Score, standardised tool with SBAR format that identifies patients who are at risk for deterioration Used in transport of children to hospital, emergency departments and inpatient wards by clinicians. Children with a score of five or higher deemed at risk of problems Behaviour: Playing, sleeping, irritable, lethargic Cardiovascular: Pink, pale or dusky, grey or cyanotic, tachycardic Respiratory: Normal, using accessory muscles, grunting, using oxygen 33 children had a score of five or above out of 264 transports 85% had the entire receiving team assemble at bedside for a collaborative report Paediatric Early Warning score sent with estimated time of arrival at emergency department 98% of the time ** Ellis et al. 201315 USA Guide for telephone and written follow-up with primary care providers Liaison between acute care provider and primary care provider following patients’ admission to intensive care Questions to pose from acute care provider to primary care provider: were you aware that the patient is in the hospital? who let you know the illness or hospitalisation? did the patient contact your service the present illness before coming to the hospital? was any prehospital intervention recommended by you? have you seen the patient in clinic in the last six months? Primary care providers implemented pre-hospital management for 8/300 episodes 21% of primary care providers were aware of the acute illness before their patient was admitted 33% of primary care providers were not aware that their patient was in intensive care ****
was this telephone call useful to you? Hansen et al. 201416 Canada Minimum Data Set (MDS) mnemonic To be used by PICU clinicians when communicating with each other and external colleagues. For children admitted to paediatric intensive care unit bar highlights patient’s trajectory in red, yellow or green Allergies Medications Pertinent patient history Body system 12-hour follow-up plan Contingency plan Read-back from sender to receiver needs to be ticked Residents found that patient data were not redundant or excluded in the tool Handover time was appropriate Format was easy to comprehend Transition to the iPad device was smooth ** Henderson & Corke 201517 Australia Personal Values Report with 60 questions posed to patients about medical treatment Personal Values Report developed by Barwon Health Victoria, for doctors to determine patients’ attitudes and beliefs about medical treatments. Information relayed between intensive care doctors and doctors external to the unit. For intensive care patients Patients’ decisions about life saving treatment Preferences for receiving treatment if patients become incapacitated 121 of 124 participants (97.6%) agreed or strongly agreed that the Personal Values Report (PVR) helped them to have an understanding of the patient’s wishes 90.3% felt that it gave them adequate information to enable them to feel reasonably confident in their treatment decision *
Sharma & Peters 201318 United Kingdom DEFAULT mnemonic comprising 7 Addressed by health professionals attending ward round discussions in intensive care. For mechanically ventilated paediatric patients D: Do not resuscitate (DNR) status is clear E: Endotracheal tube and cuff is safe F: Fluid strategy and feeding plan A: Agreed analgesia and sedation U: Ulcers of the skin and gastrointestinal tract L: Lines out T: Tidal volumes <8 ml/kg Increase in median days of accidental tube removal (14 vs 150 days, P<0.0001) Trend towards an increase in proportion of patients who have tidal volumes in expected range (49% vs 61%, P=0.09) * Sheth et al. 201619 USA I-PASS mnemonic: I: Illness severity P: Patient summary A: Action list S: Situation awareness and contingency planning S: Synthesis by receiver Handover process from intensive care to acute care unit For paediatric patient transfers from the cardiovascular intensive care to acute care unit I: Illness severity; stable, needs watching, unstable P: Patient summary; summary statement, events leading to admission, hospital course, ongoing assessment, plan A: Action list; to do list, time line and ownership; know what is going on, plan for what might happen S: Situation awareness and contingency planning S: Synthesis by receiver; receiver summarises what Time between verbal and patient transfer decreased from baseline (397 +/- 167 minutes) to the post-intervention period (24 +/- 21 minutes) (P < .01) No differences in rates of readmission, rapid response team calls, or mortality were observed ****
has been heard, asks questions, restates key actions Wittwer et al. 201520 USA List of specific items for patients following cardiac surgery Anaesthesia provider completed a paper handoff form, which was given to the ICU nurse on arrival to the ICU. For patients admitted to intensive care following cardiac surgery Operating room providers: Procedure performed, name, invasive lines, pacing wires, and cardiac index at closure Intensive care providers: Cardiac index at closure, excessive bleeding, pacing wires, intubation difficulty, and haemoglobin level Some information was common and important to both groups (cardiac index at closure and pacing wires). Differences related to name, procedure performed, invasive lines, intubation difficulty, and haemoglobin level * Zavalkoff et al. 201121 Canada Pre-operative information, medical intra-operative information, surgical intra-operative information, and information about the patient’s “current” (immediate status To guide the information transmitted by the surgeon and anaesthesiologist to the paediatric intensive care unit team during handover of post-cardiac surgery patients Pre-operative considerations: Age Weight Pre-operative diagnosis Past medical history Preoperative status and condition Medications Allergies Intra-operative surgical considerations: New diagnosis Pump time Trend toward more patients being free from high-risk events in the group (31.2% vs. 6.7%), but not statistically (P=0.1) ***
Protamine described and time given Electrolyte problems Glucose problems Lactate (max, last) Last gas given Current status Peak inspiratory pressure or tidal volume Peak end expiratory pressure Fraction of inspired oxygen Nitric oxide use Vasoactive medication given and dose Pacing given with settings and if dependent pacing Post-operative echocardiogram results Anticipated issues Goal for oxygen saturation Overall goal
Consultation liaison service instigated legal interventions in 25% of cases 45 patients were referred for psychiatric admission following assessment Mental health follow-up was arranged in 43.8% of cases Complex health care needs for palliative care patients Authors (year), country Form (text type) of documentation Structure (ordering of information) of documentation Summary of the evidence for content of information Findings Quality Appraisal* Newport et al. 201024 USA Providers’ Signout for Scope of Treatment (PSOST) Assists in smooth transitions of care on nights and weekends, especially when the patient is near death, and aimed at preventing of care and underuse of lifesaving treatments such as resuscitation. For palliative care patients in Brief history of present illness Past medical history Resuscitation code status laboratory or diagnostic test results, ‘‘to do’’ list of laboratory tests and procedures Care plan Residents reported great level of satisfaction in using the tool Fellows reported interventions aligned with patients’ Nurses reported the tool assisted in their *