Safer hospital transitions

Every year Yale-New Haven Hospital (YNHH) admits more than 50,000 patients. Once in the hospital, patients may move, for example, from the emergency department to intensive care or from medicine to Smilow Cancer Hospital. Each of these transfers carries a degree of risk. Health care providers and hospital administrators have long studied the “handoff,” when a new doctor takes over patient care during a shift change or a move from one service to another and crucial information can fall through the cracks. But now a team of doctors and providers is taking a broader look at those transitions to anticipate problems and find ways to mitigate them.

Over much of the past year, Alana Rosenberg, M.P.H., has spent many hours in the hospital standing in hallways, at nurses’ stations and, in the emergency department, watching residents, attending physicians, nurses, business associates, and patients. With an anthropologist’s eye, Rosenberg, a research associate in internal medicine, is part of a team that observed those moments when a patient enters the hospital, moves from one part of the hospital to another, or leaves the hospital for home, hospice, or a care facility. Then the team interviewed the people involved‒doctors, nurses, staff, and patients. Part of the impetus for the study comes from the Institute of Medicine’s 1999 report, To Err Is Human: Building a Safer Health System. The report, which estimated that between 44,000 and 98,000 people die each year because of preventable medical errors, convinced clinicians and investigators that new studies of patient safety were needed.

“Patients are moving through the health system at a very fast pace, and the technology that we have is increasingly complex and sophisticated,” said Sarwat Chaudhry, M.D., FW ’05, associate professor of medicine. “The diagnostic evaluations that we’re doing and the data that we as clinicians are juggling are mind-boggling compared to 20 or 30 years ago. You really need multiple checks and systems in place to make sure that things are happening the way they’re supposed to.”

While past efforts have followed the traditional route of devising an intervention, testing it, and analyzing the results, the Center for Healthcare Innovation, Redesign and Learning (CHIRAL) is taking a new approach. Funded by a grant from the U.S. Department of Health & Human Services’ Agency for Healthcare Research and Quality, CHIRAL starts with an in-depth problem analysis of patient safety in three areas, and then works with clinicians and experts from such industries as aviation and engineering to devise solutions.

“We have a lot to learn from other industries that are ahead of medicine, where you just count on the individual remembering to do the right thing,” said Chaudhry, principal investigator for the part of the project that involves transfers within YNHH. The other projects, headed by Marc Auerbach, M.D., assistant professor of pediatrics, and Grace Y. Jenq, M.D., FW ’04, associate professor of medicine (geriatrics), will look at patients entering the Yale-New Haven Children’s Hospital emergency department, and patients moving out of YNHH into skilled nursing facilities. “Clinical deterioration can happen during transport because you’re not monitored like you were on a floor,” said Beth Hodshon, J.D., M.P.H., R.N., project director for CHIRAL.

CHIRAL, a joint venture between the School of Medicine and YNHH, was among the first centers funded by the AHRQ initiative. “We’re one of the largest health systems in the country,” Chaudhry noted. “We have the medical school and a world-class hospital and health system, but bringing together expertise from both sides and both perspectives was an important opportunity.”

Following a year of ethnographic observations for each of the three projects, CHIRAL looked at such specific issues as communication, handoffs, and data flow. Team members observed and interviewed everyone involved in transitions‒health care providers, ancillary staff, business associates, and patients‒while the data team studied information collected in Epic, the electronic medical record. In August, the team met with national and local experts to study interventions that might be effective. Unlike traditional studies that end after an intervention is tested and the results are reported, the interventions devised by CHIRAL will be continuously designed, implemented, and tested in a process that will end only when a solution is shown to be effective.

“Protocols can be put in place, but it’s everyone’s reaction [to how things are done] that really matters in the end,” Rosenberg said.