Care transition of trauma patients: Processes with articulation work before and after handoff
Introduction
The publication of landmark reports, such as “Crossing the Quality Chasm: A New Health System for the 21st Century” (Institute of Medicine, 2001), brought attention to quality in health care. Handoff communication (i.e., the transfer of information, authority and responsibility for patient care, Abraham et al., 2014) is necessary to ensure safe, high quality care. Handoffs provide opportunities to detect and correct errors (Perry, 2004), but risk information loss, delays and decreased effectiveness/efficiency (Arora et al., 2009). Despite the 2006 National Patient Safety Goal by the Joint Commission to improve handoff communication, between 2009 and 2013 7149 instances of patient harm, including 1744 deaths, were attributed to communication failures (CRICO Strategies, 2015).
Some work has focused on improving care transitions with technology, particularly transitions between facilities (Marcotte et al., 2015) and across shifts (Arora et al., 2009). Less work has focused on transitions between different hospital inpatient units, i.e., intrahospital care transitions. We use care transition to include transport, handoff and other activities necessary to ensure the patients’ physical transition, with handoff referring to communication for exchanging information.
Published research on intrahospital care transitions has focused on information to communicate, developing mnemonics and checklists to ensure information transfer during handoffs (Abraham et al., 2017). These transitions include transitions between physical locations and organizational units – signifying changes in care team, equipment, support staff, technology and work environment – and can be conceptualized as processes, i.e., “set[s] of interrelated or interacting activities … to deliver an intended result” (ISO, 2015), including important work outside of transport and handoff (Aase and Waring, 2020). Research with this conceptualization has focused on the operating room (OR) to intensive care unit (ICU) care transitions and provides a broader insight on how transitions occur. For example, in a failure modes and effects analysis, McElroy et al., 2015a, McElroy et al., 2015b observed and described the process of OR-to-ICU care transitions, identifying 37 major steps in the process; these steps were grouped into five basic steps:
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Operation concludes;
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OR preparation;
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ICU preparation;
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Physical transfer and settling;
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Handoff communication and team disperses.
Other researchers have re-designed the OR to pediatric ICU (PICU) care transition of pediatric cardiac surgery patients (Agarwal et al., 2012; Catchpole et al., 2007; Craig et al., 2012). The redesigned processes began while the patient was in the OR when information was sent to the PICU, triggering preparation in both units before transport; the patient was stabilized in the PICU before an inter-professional handoff, with discussion of plans and questions. The redesigned processes improved:
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Information flow (Agarwal et al., 2012; Catchpole et al., 2007; Craig et al., 2012)
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Attentiveness and interruptions (Catchpole et al., 2007; Craig et al., 2012)
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Errors (Catchpole et al., 2007)
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Four clinical outcomes: cardiopulmonary resuscitation, placement on extracorporeal membrane oxygenation, need for mediastinal reexploration, and development of severe metabolic acidosis (Agarwal et al., 2012).
The redesigned processes use information on existing research and workshops with stakeholders (Craig et al., 2012), lessons from motorcar racing and aviation (Catchpole et al., 2007) and feedback from handoff participants (Agarwal et al., 2012). However, the studies did not describe the care transition process before the redesign nor how those practices were considered in the redesign. Lane-Fall and colleagues (2018; Ross Perfetti et al., 2020) conducted interviews and focus groups with clinicians participating in OR-to-ICU transitions to identify barriers and supporting factors. They identified barriers including time pressure, unclear expectations and lack of understanding of the information needs of others; the supporting factors included pre-notification of patient arrival to ICU team, presence of extra nurses upon patient arrival and predictable handoff format, in the existing care transition process. They combined this analysis with published literature to develop a standardized process for OR-to-ICU care transitions, with findings indicating improvements in teamwork and information transfer (Lane-Fall et al., 2016, 2020). Nonetheless, they too did not describe or analyze the existing process in detail, although their recent protocol does call for in-depth process analysis prior to implementing their tool (Lane-Fall et al., 2021). Their subsequent work has focused on interprofessional communication training (Massa et al., 2021), which – while important – may inadvertently increase workload of clinicians and contribute to the ongoing epidemic of clinician burnout (National Academies of Sciences, Engineering, and Medicine, 2019).
Hignett et al. (2015) argue that the integration of quality improvement science (QIS) and human factors and ergonomics (HFE) is key to improving quality of care. Fundamentally, although defined in various ways, QIS is a set of strategies to increase quality, such as Plan-Do-Study-Act, Total Quality Improvement, Lean and Six Sigma. HFE is “the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance” (International Ergonomics Association (IEA), 2020). Both HFE and QSI identify a required change, apply various methods to describe the current situation and develop an intervention, which is implemented and evaluated before the cycle repeats (Hignett et al., 2015). We believe the overlap goes beyond the similarities identified by Hignett et al. (2015). For instance, process mapping is one of the strategies used in QIS, which also has a rich history in HFE (Huang and Gramopadhye, 2014; Jun et al., 2010; Lane et al., 2006; Siemieniuch and Sinclair, 2015; Wooldridge et al., 2017). Clearly understanding the current work situation, i.e., work system, before developing and implementing any interventions aimed to improve outcomes is necessary (Daniellou, 2005). Further, it is important to understand the work as it is done, not just as is prescribed or imagined by management (Hollnagel et al., 2015; Leplat, 1989). Process mapping approaches are one way to do this and are useful in identifying risks from various sources (Simsekler et al., 2018), a key element of quality improvement.
We have previously described the Systems Engineering Initiative for Patient Safety (SEIPS)-based process modeling method to clearly understand the work system and process. We demonstrated the application of SEIPS-based process modeling to three processes in primary care: previsit planning, patient outreach for panel management and checkout (Carayon and Wooldridge, 2020; Wooldridge et al., 2017). The SEIPS-based process modeling method builds on HFE tools for process modeling, incorporates sociotechnical system theory and represents all six work system elements: people, tasks, technologies, organization, physical environment and external environment (Carayon et al., 2006, 2014, 2020). The six work system elements and interactions between them must be addressed together, as they dictate how the process occurs and are key to designing new processes that result in improved outcomes for both patients and healthcare professionals (Berg, 1999).
SEIPS-based process maps are similar to swim-lane diagrams and flowcharts: columns represent physical locations and organizational units, while rows represent temporality (Carayon and Wooldridge, 2020; Wooldridge et al., 2017). Major steps are shown in boxes located in the cells created by the rows and columns; details about who performs tasks with what technologies are in those boxes. The process models can be used to describe processes to increase awareness in stakeholders (Schultz et al., 2007) and can be used to evaluate processes to identify opportunities for improvement (Wetterneck et al., 2006; Wooldridge et al., 2020).
In this study, we identify activities in the OR-to-PICU and OR-to-ICU care transitions associated with preparation, handoff and follow up activities using SEIPS-based process maps, comparing and contrasting the two processes. We explore process scope (i.e., beginning and end) from the perspective of the healthcare professionals involved in the care transitions. We focus on pediatric and adult trauma patients as trauma is the leading cause of death among children and adults aged one to 44 years old (Stewart et al., 2003). These patients are typically critical and unstable, and care transitions occur with additional time pressure and uncertainty due to the nature of trauma, increasing the complexity of the system and process (Wooldridge et al., 2018a, Wooldridge et al., 2018b).
Section snippets
Methods
This study is part of a larger study on health information technology (IT) for teamwork and care transitions in pediatric trauma care (http://cqpi.wisc.edu/teamwork-and-care-transitions-in-pediatric-trauma/). Approval for this study was obtained from the IRB at the University of Wisconsin-Madison; approval for secondary data analysis was obtained from the IRB at the University of Illinois at Urbana-Champaign. Fig. 1 provides an overview of the study methods.
Process maps
Table 2 shows guidelines we use to created SEIPS-based process maps and how we operationalized these guidelines in this study. Fig. 3 shows the process map of the OR-to-PICU care transition and Fig. 4 shows the process map of the OR-to-ICU care transition.
The OR-to-PICU care transition has 12 activities (four preparation, six transition and two follow-up) and 55 groups of tasks (23 preparation, 18 transition and 14 follow-up). The OR-to-ICU care transition has 15 activities (four preparation,
Discussion
Our results show that OR-to-PICU and OR-to-ICU care transitions of trauma patients are complex, temporal processes involving many healthcare professionals, and include both physical transitions (i.e., transport) and cognitive transitions (i.e., handoffs). Clinicians involved in the care transition had varying perceptions of when the care transitions begin and end, perhaps explained by differing professional perspectives or their roles as sender or receiver. The care transition was often
Conclusion
Our study demonstrates that care transitions are complex processes distributed over time and space, involving many individuals; even though they occur frequently (i.e., are routine), they remain high risk. Care transitions include readily acknowledged work – handoffs and transport – as well as articulation work. As human factors professionals and systems engineers, we must account for articulation work because it impacts system performance and human well-being. Without considering the
Funding
This work was supported by the Agency for Healthcare Research and Quality [Grant No. R01 HS023837] and the Clinical and Translational Science Award (CTSA) program, through the National Institutes of Health National Center for Advancing Translational Sciences (NCATS), [Grant UL1TR002373]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agencies.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
We would like to thank the study participants, as our research would not be possible without them.
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