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Search All Research Studies
AHRQ Research Studies Date
Topics
- Adverse Events (1)
- Care Coordination (4)
- Catheter-Associated Urinary Tract Infection (CAUTI) (1)
- Children/Adolescents (1)
- Chronic Conditions (1)
- (-) Communication (15)
- Critical Care (1)
- Emergency Department (1)
- Emergency Medical Services (EMS) (1)
- Healthcare Delivery (2)
- Health Information Technology (HIT) (1)
- Home Healthcare (1)
- Hospital Discharge (5)
- Hospitals (3)
- Implementation (1)
- Inpatient Care (1)
- Intensive Care Unit (ICU) (1)
- Long-Term Care (1)
- Medical Errors (1)
- Medication (1)
- Nursing (1)
- Nursing Homes (4)
- Patient Safety (6)
- Provider (1)
- Provider: Clinician (1)
- Quality Improvement (3)
- Quality of Care (2)
- Quality of Life (1)
- Risk (1)
- Surgery (3)
- Teams (2)
- TeamSTEPPS (1)
- (-) Transitions of Care (15)
- Trauma (1)
AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 15 of 15 Research Studies DisplayedWooldridge AR, Carayon P, Hoonakker P
Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes.
This study investigated how team cognition occurs in care transitions from operating room (OR) to intensive care unit (ICU) and then sought to understand how the sociotechnical system and team cognition are related. The authors conducted the study in an academic, Level 1 trauma center in the Midwestern US. Semi-structured interviews were conducted with 28 healthcare workers that included physicians (surgery, anesthesia, pediatric critical care) and nurses (OR, ICU). Three cognition functions in hand-offs were described by participants: (1) information exchange, (2) assessment, and (3) planning and decision making; information exchange was mentioned most. Inter-professional handoffs facilitated information exchange but included large teams with diverse backgrounds communicating that can decrease efficiency. Intra-professional handoffs decreased team size and role diversity, which may simplify communication but can increase information loss. Participants in inter-professional handoffs reflected on outcomes significantly more in relation to system factors and team cognition, while participants in intra-professional handoffs discussed handoffs as a task.
AHRQ-funded; HS023837.
Citation: Wooldridge AR, Carayon P, Hoonakker P .
Team cognition in handoffs: relating system factors, team cognition functions and outcomes in two handoff processes.
Hum Factors 2024 Jan; 66(1):271-93. doi: 10.1177/00187208221086342..
Keywords: Teams, Transitions of Care, Communication
Starmer AJ, Spector ND, O'Toole JK
Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.
The purpose of this study was to assess I-PASS patient handoff intervention implementation across diverse settings to evaluate whether there it impacted pediatric patient safety and communication. External teams provided coaching over 18 months to hospital residents from diverse specialties across 32 hospitals (12 community, 20 academic) with 2735 resident physicians and 760 faculty champions from multiple specialties (16 internal medicine, 13 pediatric, 3 other) participating. The researchers collected 1942 error surveillance reports. Following I-PASS implementation, major and minor handoff-related reported adverse events decreased 47%. Intervention implementation was related with increased inclusion of all five key handoff data elements in verbal and written handoffs, as well as increased frequency of handoffs with high quality verbal and written patient summaries, verbal and written contingency plans, and verbal receiver syntheses.
AHRQ-funded; HS023291.
Citation: Starmer AJ, Spector ND, O'Toole JK .
Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.
J Hosp Med 2023 Jan; 18(1):5-14. doi: 10.1002/jhm.12979..
Keywords: Transitions of Care, Implementation, Communication
Alagoz E, Saucke M, Arroyo N
Communication during interhospital transfers of emergency general surgery patients: a qualitative study of challenges and opportunities.
This study’s objective was to understand the nature of and challenges to communication between referring (RP) and accepting (AP) providers transferring emergency general surgery (EGS) patients from the transfer center nurse’s (TCN) perspective. Worse outcomes have been shown to be experienced by transferred EGS patients than directly admitted patients. The authors interviewed 17 transfer center nurses (TCNs) at an academic medical center regarding (in)efficient and (in)effective communication between RPs and APs. The in-person interviews were recorded, transcribed and managed in NVivo. Four researchers developed a codebook, which was then co-coded with the transcripts. A consensus was developed to discuss emergency themes and arrive at higher-level concepts. Issues relating to ineffective communication included RPs that provided incomplete information because of a lack of necessary infrastructure, personnel, or technical knowledge; competing clinical demands; or a fear of the transfer request being rejected. Inefficient communication resulted from RPs being unfamiliar with the information APs expected and the lack of a structured process to share information and communication also failed when providers disagreed about the necessity of the transfer.
AHRQ-funded; HS025224.
Citation: Alagoz E, Saucke M, Arroyo N .
Communication during interhospital transfers of emergency general surgery patients: a qualitative study of challenges and opportunities.
J Patient Saf 2022 Oct 1;18(7):711-16. doi: 10.1097/pts.0000000000000979..
Keywords: Care Coordination, Communication, Transitions of Care, Surgery
Chilakamarri P, Finn EB, Sather J
Failure mode and effect analysis: engineering safer neurocritical care transitions.
Investigators presented failure mode and effect analysis (FMEA) as a systems-engineering methodology to be applied to neurocritical care transitions to reduce failures in communication and improve patient safety. They described their local implementation of FMEA to improve the safety of inter-hospital transfer for patients with intracerebral and subarachnoid hemorrhage as evidence of success. They found that application of the FMEA approach yielded meaningful and sustained process change for patients with neurocritical care needs.
AHRQ-funded; HS023554.
Citation: Chilakamarri P, Finn EB, Sather J .
Failure mode and effect analysis: engineering safer neurocritical care transitions.
Neurocrit Care 2021 Aug;35(1):232-40. doi: 10.1007/s12028-020-01160-6..
Keywords: Patient Safety, Transitions of Care, Critical Care, Communication, Quality Improvement, Quality of Care
Frasier LL, Pavuluri Quamme SR, Wiegmann D
Evaluation of intraoperative hand-off frequency, duration, and context: a mixed methods analysis.
The authors sought a better understanding of the coordination and impact of intraoperative hand-offs. They found that intraoperative hand-offs were frequent and not well coordinated with intraoperative events including counts and other hand-offs. Anchoring and announced hand-offs occurred in a small proportion of cases. They recommended that future work focus on optimizing timing, content, and participation in intraoperative hand-offs.
AHRQ-funded; HS022403.
Citation: Frasier LL, Pavuluri Quamme SR, Wiegmann D .
Evaluation of intraoperative hand-off frequency, duration, and context: a mixed methods analysis.
J Surg Res 2020 Dec;256:124-30. doi: 10.1016/j.jss.2020.06.007..
Keywords: Surgery, Transitions of Care, Communication, Teams
Campbell Britton M, Petersen-Pickett J, Hodshon B
Mapping the care transition from hospital to skilled nursing facility.
Researchers used process mapping to illustrate the sequence of events involved with hospital discharge and admission to a skilled nursing facility (SNF). These transitions are often associated with breakdowns in communication that may place patients at risk for adverse events. A quality improvement (QI) team worked with frontline staff at an academic medical center and two local SNFs in the northeastern United States. The final process map included care management, medicine, nursing, admissions and physical therapy service staff. The process map showed numerous activities that need to be coordinated between care teams, and highlighted specific opportunities for improving communication between different teams.
AHRQ-funded; HS023554.
Citation: Campbell Britton M, Petersen-Pickett J, Hodshon B .
Mapping the care transition from hospital to skilled nursing facility.
J Eval Clin Pract 2020 Jun;26(3):786-90. doi: 10.1111/jep.13238..
Keywords: Transitions of Care, Care Coordination, Quality Improvement, Communication, Hospital Discharge, Hospitals, Nursing Homes, Quality of Care
Campbell Britton M, Hodshon B, Chaudhry SI
Implementing a warm handoff between hospital and skilled nursing facility clinicians.
This study focused on increasing better communication during transfers from hospitals and skilled nursing facilities (SNFs). Warm handoffs between hospital and SNF physicians was implemented. Participation in warm handoffs gradually increased – starting at 15.78% in stage 1 and increasing to 46.89% in stage 3. A total of 2417 patient discharges were included in this study.
AHRQ-funded; HS023554.
Citation: Campbell Britton M, Hodshon B, Chaudhry SI .
Implementing a warm handoff between hospital and skilled nursing facility clinicians.
J Patient Saf 2019 Sep;15(3):198-204. doi: 10.1097/pts.0000000000000529..
Keywords: Communication, Patient Safety, Hospital Discharge, Transitions of Care, Care Coordination, Hospitals, Nursing Homes
Hoonakker PLT, Wooldridge AR, Hose BZ
Information flow during pediatric trauma care transitions: things falling through the cracks.
In order to investigate information flow during pediatric trauma care transitions, researchers interviewed 18 clinicians about communication and coordination between the emergency department, operating room, and pediatric intensive care unit, then surveyed the clinicians about patient safety during these transitions. They found that, despite the fact that the many services and units involved in pediatric trauma cooperate well together during trauma cases, important patient care information is often lost when transitioning patients between units. To manage the transition of this fragile and complex population better, they recommend finding ways to manage the information flow during these transitions better by, for instance, providing technological support to ensure shared mental models.
AHRQ-funded; HS023837.
Citation: Hoonakker PLT, Wooldridge AR, Hose BZ .
Information flow during pediatric trauma care transitions: things falling through the cracks.
Intern Emerg Med 2019 Aug;14(5):797-805. doi: 10.1007/s11739-019-02110-7..
Keywords: Children/Adolescents, Communication, Emergency Department, Healthcare Delivery, Intensive Care Unit (ICU), Patient Safety, Provider, Provider: Clinician, Surgery, Transitions of Care, Trauma
Wyatt DL
AHRQ Author: Wyatt DL
Employing technology to make care transitions safer.
This commentary discusses the potential for errors in patient handoffs; important information about medications and instructions regarding patient care may be overlooked when the patient is referred to special care, moved to a new hospital setting, or discharged. The problem is especially acute for patients with multiple chronic conditions who often undergo frequent transitions to new care settings and healthcare providers. The author describes AHRQ’s funding opportunities for health information technology interventions that aim to improve communication and coordination during care transitions, such as location-based smartphone alerts, a patient-centered discharge toolkit, and a ‘smart pillbox’ electronic medication adherence reporting project.
AHRQ-authored.
Citation: Wyatt DL .
Employing technology to make care transitions safer.
J Nurs Care Qual 2019 Jul/Sep;34(3):185-88. doi: 10.1097/ncq.0000000000000417..
Keywords: Adverse Events, Care Coordination, Chronic Conditions, Communication, Health Information Technology (HIT), Healthcare Delivery, Hospital Discharge, Medical Errors, Medication, Patient Safety, Transitions of Care
Jones CD, Jones J, Bowles KH
Quality of hospital communication and patient preparation for home health care: results from a statewide survey of home health care nurses and staff.
The purpose of this study was to evaluate the quality of communication between hospitals and home health care (HHC) clinicians and patient preparedness to receive HHC in a statewide sample of HHC nurses and staff. The authors concluded that communication between hospitals and HHC was suboptimal, and patients were often not prepared to receive HHC. They suggest that providing EHR access for HHC clinicians is a promising solution to improve the quality of communication.
AHRQ-funded; HS024569.
Citation: Jones CD, Jones J, Bowles KH .
Quality of hospital communication and patient preparation for home health care: results from a statewide survey of home health care nurses and staff.
J Am Med Dir Assoc 2019 Apr;20(4):487-91. doi: 10.1016/j.jamda.2019.01.004..
Keywords: Transitions of Care, Home Healthcare, Hospital Discharge, Hospitals, Communication
Jones CD, Burke RE
Web exclusive. Annals for Hospitalists Inpatient Notes - getting past the "black box"-opportunities for hospitalists to improve postacute care transitions.
In this article, the authors outline 3 key problems in postacute care (PAC) transitions and offer potential solutions. They assert that improving hospitalists' knowledge of PAC, improving communication after hospital discharge, and creating mechanisms for feedback to hospitalists are all possible ways of getting past the PAC “black box.”
AHRQ-funded; HS024569.
Citation: Jones CD, Burke RE .
Web exclusive. Annals for Hospitalists Inpatient Notes - getting past the "black box"-opportunities for hospitalists to improve postacute care transitions.
Ann Intern Med 2018 May 15;168(10):H02 - H03. doi: 10.7326/m18-0940..
Keywords: Communication, Hospital Discharge, Inpatient Care, Transitions of Care
Britton MC, Ouellet GM, Minges KE
Care transitions between hospitals and skilled nursing facilities: perspectives of sending and receiving providers.
This study was conducted to identify the perspectives of sending and receiving providers regarding care transitions between the hospital and skilled nursing facilities. Four main themes emerged: increasing patient complexity, identifying an optimal care setting, rising financial pressure, and barriers to effective communication. The investigators indicated that the data highlighted hospital and SNF providers' shared concerns about patient-level risk factors and escalating costs of care.
AHRQ-funded; HS023554.
Citation: Britton MC, Ouellet GM, Minges KE .
Care transitions between hospitals and skilled nursing facilities: perspectives of sending and receiving providers.
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Keywords: Communication, Long-Term Care, Nursing Homes, Risk, Transitions of Care
Natafgi N, Zhu X, Baloh J
Critical access hospital use of TeamSTEPPS to implement shift-change handoff communication.
Implementation of handoff as part of TeamSTEPPS initiatives for improving shift-change communication is examined via qualitative analysis of on-site interviews and process observations in 8 critical access hospitals. Comparing implementation attributes and handoff performance across hospitals shows that the purpose of implementation did not differentiate between high and low performance, but facilitators and barriers did.
AHRQ-funded; HS018396.
Citation: Natafgi N, Zhu X, Baloh J .
Critical access hospital use of TeamSTEPPS to implement shift-change handoff communication.
J Nurs Care Qual 2017 Jan/Mar;32(1):77-86. doi: 10.1097/ncq.0000000000000203.
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Keywords: Communication, Patient Safety, Quality Improvement, TeamSTEPPS, Transitions of Care
Harrod M, Montoya A, Mody L
Challenges for nurses caring for individuals with peripherally inserted central catheters in skilled nursing facilities.
The researchers sought to understand the perceived preparedness of frontline nurses (registered nurses (RNs), licensed practical nurses (LPNs)), unit nurse managers, and skilled nursing facility (SNF) administrators in providing care for residents with peripherally inserted central catheters (PICCs) in SNFs. They noted differences between resident self-reported PICC concerns (quality of life) and those described by frontline nurses.
AHRQ-funded; HS019979; HS022835.
Citation: Harrod M, Montoya A, Mody L .
Challenges for nurses caring for individuals with peripherally inserted central catheters in skilled nursing facilities.
J Am Geriatr Soc 2016 Oct;64(10):2059-64. doi: 10.1111/jgs.14341.
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Keywords: Catheter-Associated Urinary Tract Infection (CAUTI), Communication, Nursing, Quality of Life, Transitions of Care
Tupper JB, Gray CE, Pearson KB
Safety of rural nursing home-to-emergency department transfers: Improving communication and patient information sharing across settings.
This paper reports on the evaluation of a demonstration in 10 rural communities to improve the safety of nursing facility (NF) transfers to hospital emergency departments by forming interprofessional teams of hospital, emergency medical service, and NF staff to develop and implement tools and protocols for standardizing critical interfacility communication pathways and information sharing. Study findings showed significant improvement in key areas, including infection status and baseline mental functioning. Accurate and consistent information sharing of advance directives and medication lists remains a challenge.
AHRQ-funded; HS019064.
Citation: Tupper JB, Gray CE, Pearson KB .
Safety of rural nursing home-to-emergency department transfers: Improving communication and patient information sharing across settings.
J Healthc Qual 2015 Jan-Feb;37(1):55-65. doi: 10.1097/01.jhq.0000460120.68190.15.
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Keywords: Communication, Emergency Medical Services (EMS), Nursing Homes, Patient Safety, Transitions of Care