What is the pertinent information that should be included in a transfer report?

Mo Med. 2010 Mar-Apr; 107(2): 127–130.

PMCID: PMC6188263

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Copyright 2010 by the Missouri State Medical Association

Patient care during inter-facility transfer depends not only on the expertise provided by the receiving facility, but also on timely and accurate patient information received from the transferring institution. Our prospective study quantified compliance with inter-facility transfer communication and revealed an opportunity for improvement. Introduction of a simple written template to enhance communication between providers improved the quality of transfer information

Communication among care givers is the focus of one of the Joint Commission’s National Patient Safety Goals (See Table 1). Patients are usually transferred to other facilities for a critical medical condition requiring a higher level of care or expertise. Communication of key information about a transferred patient to the accepting physician is crucial for high-quality patient care. However, communication and transfer of patients can be fraught with challenges (See Table 2). Some challenges transferring physicians face with communication include physician shift changes, ancillary staff changes, delays between ordering tests and receiving results, and competing attention of other active patients. Accepting physicians also face their own challenges related to patient transfers. A couple of these challenges include difficulty in obtaining urgent laboratory and radiological imaging results. Tracking down the transferring physician to obtain missing and pertinent data can consume the accepting physician’s attention and time. Calls back to the transferring facility are far from efficient and are often routed through emergency departments, medical records departments, and radiology reading rooms making information gathering cumbersome

National Patient Safety Goal # 2: Improve the Effectiveness of Communication Among Caregivers (adapted from Joint Commission Resources Official Publication of National Patient Safety Goals)1

Potential Causes of Inadequate Communication during Transfer of Patients2

Several studies have looked at essential components of effective care transition.2 Inherent problems in communication during inter-facility transfers in regards to patient characteristics3 and implementation of the Health Insurance Portability and Accountability Act4 have highlighted some of the issues that physicians face when transferring or receiving patients. Models using internet databases to improve the flow of patient information during patient transfers have been proposed and used (Consumer Assessment, Referral and Enrollment CARE tool used by San Francisco Department of Aging and Adult Services)2 but these are not available and feasible for use as yet for the general patient population. We found studies of standardized hand-off protocols for physician shift changes within the same department5, 6 but use of active interventions between different facilities to improve transfer communication has not been reported

The University of Missouri is a 223-bed hospital located on the flagship campus of the University of Missouri in Columbia, Missouri. As the only Level 1 trauma center on I–70 between St. Louis and Kansas City, the hospital provides a wide variety of medical and surgical referral services for numerous other health systems throughout Missouri. On average, 318 outside calls are received monthly by the University of Missouri Health Care center requesting the transfer of patients. Calls are initially received by an admission advisor who then identifies the appropriate physician to assist the caller in facilitating the transfer. The admission advisor connects and expedites the verbal communication between the referring and accepting physicians and then arranges the logistics of the transfer after the patient has been accepted by the appropriate university on-call team. The accepting physician usually asks for most pertinent information over the phone. Depending on urgency of the clinical situation, distance from the medical center, and the mode of transport, patients may arrive hours after the initial call. With these delays patient conditions may change during transfer

One less than ideal patient hand-off between two institutions was presented at the Department of Internal medicine Mortality and Morbidity Conference, University of Missouri. In the case reviewed, vital information was not transferred along with the patient from an outside facility leading to complications and a delay in diagnosis. The components of effective care transition were discussed (See Table 2) and perceived often to be lacking in our general practice. Recognizing the potential hazards involved with the delay of transfer information, the Medicine Department established a Quality Improvement Team (QIT) in conjunction with the University of Missouri Health Care Office of Clinical Effectiveness. This team included two resident physicians, an internal medicine attending physician, and quality improvement administrative staff. The goal was to identify ways to improve comprehensive communication of medical information during patient hand-offs between institutions. The team hypothesized that there would be improved communication via scripted verbal or written templates

The QIT team created 3×5 cards to be used for baseline data collection (See Figure 1). The cards were passed out to the residents accepting patients on ward rotations. The residents were asked to record data on patients transferred from outside institutions to University of Missouri University hospital. Data obtained for the baseline study included total cards collected (one card per patient), and whether discharge summaries, serum laboratories, medication lists, and imaging studies and/or reports arrived with the transferred patients

Baseline Data Collection Cards

After review of the baseline data confirmed a problem with completeness of the information accompanying many transferred patients, the QIT developed a template checklist to be faxed from the University Hospital to referring physicians (See Figure 2) by the admissions advisor at the time of the request for transfer. The expectation was that transferring physician would receive the fax, collect the pertinent information about the patient and fax it back to the given number in a timely fashion. The inpatient medical service nursing station was designated as the accepting portal for incoming faxes as it was easiest to access by admitting residents and all paperwork received was added to the active medical chart of the transferred patient by the unit clerk. After this intervention, same collection cards as used for baseline data were used again to obtain post-intervention information (See Figure 1). The Institutional Review Board (IRB) reviewed the project and deemed it exempt. Data was analyzed using non parametric analysis with chi square test, p value <0.05 considered significant

Transfer of Care Reminder Template

Table 3 summarizes the results of baseline data collection. From November 2005 through July 2006, 60 cards were collected, representing data on approximately 30% of patient transfers form outside facilities. Discharge summaries were received in about 30% of the cases. A list of current patient medications arrived in 63% of cases, which was felt to represent a significant patient safety concern. Laboratory data was sent with patients in more than 80% of cases. Other missing data identified by admitting residents were lack of pertinent radiological imaging and/or reports such as X-rays and CT scans. This data was obtained from responses to the open ended question, “What information about the patient was needed but was not sent from the transferring institution?” (See Figure 1)

Summary of Data Collection

Table 3 summarizes the results of post intervention data collection. We observed the greatest increase in number of patients who arrived with appropriate radiological studies, rising from 23% at baseline to 74% after the checklist was introduced (p<0.01). There was also a statistically significant improvement in number of patients that arrived with a current medication list, rising from 63% to 88% after the intervention (p<0.01). Laboratory data, which was sent in 83% of patients at baseline, was sent in 95% post-intervention. Despite using the template, the number of discharge summaries received did not increase. Ten percent of patients did not come with any documents at all at baseline; after intervention this number decreased to 5%

We observed that the use of a simple template reminder made a significant difference in the amount of important clinical data sent with patients at the time of patient transfer. Significant increases in number of radiological studies and medication lists transferred with the patients were also seen (See Table 3). Although not statistically significant, the number of patients arriving with laboratory data increased by 12% (See Table 3). We did not find a significant decrease in number of patients arriving without any clinical information however a 5% improvement was seen

Patients arriving with a discharge summary likely did not increase in this study due to multiple reasons. In the emergency department setting dictation may not be feasible or timely. Moreover, discharge summaries are not required as a routine part of emergency medical documentation. The urgency in transferring a patient may also have played a part in the number of discharge summaries found. Our study did not differentiate patient transfers from inpatient services and the emergency departments

Our study had several limitations. First, we were only able to collect information on 30% of transferred patients during the study period. The small sample size was in part likely due to resident workload and the reluctance of some residents to complete data collection cards. Additionally, we did not study the financial costs incurred at the admission office, the time spent for the faxes, measures of physician satisfaction, or most importantly, patient outcomes as a result of using the template

The initial intervention prior to the faxed template was targeted at improving verbal communication. This did not prove successful and was discarded in favor of the faxed template

As is often true in the improvement of complex systems, multiple change hypotheses were tested before a change was introduced that was acceptable to key stakeholders and produced some of the desired results

As we seek to further improve the robustness of communication during hand-offs, collaboration with referring health providers and institutions will improve the likelihood of success. Adoption of state-wide standards to guide the information forwarded between health providers and systems at the time of patient transfers would potentially advance the quality of communication and would decrease adverse impacts on patient outcomes from missing data

Introduction of a simple written template to augment communication between providers and facilities at the time of inter-hospital transfers increased the completeness of health information forwarded with the patient. We believe that wider adoption of such practices would increase compliance with the Joint Commission National Patient Safety Goal regarding communication, and would improve patient care. Health providers should seek additional opportunities to work with existing regional and statewide health organizations to promote and standardize similar best practices on behalf of improved patient care

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