Interfacility Referral Communication for PICU Transfer.

Objectives: For patients requiring transfer to a higher level of care, excellent interfacility communication is essential. Our objective was to characterize verbal handoffs for urgent interfacility transfers of children to the PICU and compare these characteristics with known elements of high-quality intrahospital shift-to-shift handoffs.
Design: Mixed methods retrospective study of audio-recorded referral calls between referring clinicians and receiving PICU physicians for urgent interfacility PICU transfers.
Setting: Academic tertiary referral PICU.
Patients: Children 0-18 years old admitted to a single PICU following interfacility transfer over a 4-month period (October 2019 to January 2020).
Interventions: None.
Measurements and Main Results: We reviewed interfacility referral phone calls for 49 patients. Referral calls between clinicians lasted a median of 9.7 minutes (interquartile range, 6.8-14.5 min). Most referring clinicians provided information on history (96%), physical examination (94%), test results (94%), and interventions (98%). Fewer clinicians provided assessments of illness severity (87%) or code status (19%). Seventy-seven percent of referring clinicians and 6% of receiving PICU physicians stated the working diagnosis. Only 9% of PICU physicians summarized information received. Interfacility handoffs usually involved: 1) indirect references to illness severity and diagnosis rather than explicit discussions, 2) justifications for PICU admission, 3) statements communicating and addressing uncertainty, and 4) statements indicating the referring hospital's reliance on PICU resources. Interfacility referral communication was similar to intrahospital shift-to-shift handoffs with some key differences: 1) use of contextual information for appropriate PICU triage, 2) difference in expertise between communicating clinicians, and 3) reliance of referring clinicians and PICU physicians on each other for accurate information and medical/transport guidance.
Conclusions: Interfacility PICU referral communication shared characteristics with intrahospital shift-to-shift handoffs; however, communication did not adhere to known elements of high-quality handovers. Structured tools specific to PICU interfacility referral communication must be developed and investigated for effectiveness in improving communication and patient outcomes.
Competing Interests: Dr. Landrigan has consulted with and holds equity in the Illness severity, Patient summary, Action list, Situation awareness, Synthesis by receiver (I-PASS) Institute, which seeks to train institutions in best handoff practices and aid in their implementation. He has consulted with the Missouri Hospital Association/Executive Speaker’s Bureau regarding I-PASS. In addition, Dr. Landrigan has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety, and he has served as an expert witness in cases regarding patient safety and sleep deprivation. Dr. Singh is funded in part by the Houston Veterans Administration (VA) Health Services Research and Development (HSR&D) Center for Innovations in Quality, Effectiveness, and Safety (CIN13–413), the VA National Center for Patient Safety, and the Agency for Healthcare Research and Quality (R01HS028595 and R18 HS029347) . Drs. Thirnbeck’s, Espinoza’s, Herwaldt’s, Landrigan’s, and Cifra’s and Ms. Beaman’s institutions received funding from the Agency for Healthcare Research & Quality and the National Institutes of Health (NIH). Drs. Thirnbeck, Espinoza, Dukes, Herwaldt, Landrigan, and Cifra and Ms. Beaman received support for article research from the NIH. Drs. Beaman and Cifra received funding from De Gruyter and MedStar Health Research Institute. Dr. Dukes’ institution received funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (No. HD027748-28). Dr. Herwaldt received funding from the I-PASS Institute and Malpractice Law Firms. The remaining authors have disclosed that they do not have any potential conflicts of interest.
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