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Things Falling Through the Cracks: Information Loss During Pediatric Trauma Care Transitions

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Part of the book series: Advances in Intelligent Systems and Computing ((AISC,volume 818))

Abstract

Pediatric trauma is one of the leading causes of morbidity and mortality in children in the USA. Several clinical teams converge to support trauma care in the Emergency Department (ED); the most severe trauma cases often need surgery in the operating room (OR) and/or are admitted to the pediatric intensive care unit (PICU). These care transitions can result in loss of information or transfer of incorrect information, We interviewed 18 clinicians about communication and coordination during care transitions between the ED, OR and PICU. Clinicians completed a short questionnaire about patient safety during transitions. Results show that, although many services and units involved in pediatric trauma work well together, important patient care information may be lost in the transitions. To safely manage transitions of this fragile, unstable, complex population, we need to better manage the information flow during these transitions.

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References

  1. CDC. https://www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_age_group_2015_1050w740h.gif

  2. Apker J, Mallak LA, Gibson SC (2007) Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med 14:884–894

    Google Scholar 

  3. Wooldridge AR, Carayon P, Hoonakker P, Hose B-Z, Ross J, Kohler J, Brazelton T, Eithun B, Kelly M, Dean S, Rusy D, Gurses A (2017) Understanding team complexity in pediatric trauma care. Human Factors and Ergonomics in Healthcare, New Orleans

    Google Scholar 

  4. Horwitz LI, Meredith T, Schuur JD, Shah NR, Kulkarni RG, Jenq GY (2009) Dropping the baton: a qualitative analysis of failures during the transition from Emergency Department to Inpatient Care. Ann Emerg Med 53:701.e704–710.e704

    Article  Google Scholar 

  5. Abraham J, Kannampallil T, Patel VL (2014) A systematic review of the literature on the evaluation of handoff tools: implications for research and practice. J Am Med Inform Assoc 21:154–162

    Article  Google Scholar 

  6. American Academy of Pediatrics Committee on Emergency Medicine (2016) Handoffs: transitions of care for children in the Emergency Department. Pediatrics 138:1–12

    Article  Google Scholar 

  7. Joint Commission (2012) Joint Commission Center for Transforming Healthcare releases targeted solutions tool for hand-off communications. Joint Commission perspectives. Joint Commission on Accreditation of Healthcare Organizations 32, 1, 3

    Google Scholar 

  8. Arora VM, Johnson JK, Lovinger D, Humphrey HJ, Meltzer DO (2005) Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care 14:401–407

    Article  Google Scholar 

  9. Bigham MT, Logsdon TR, Manicone PE, Landrigan CP, Hayes LW, Randall KH, Grover P, Collins SB, Ramirez DE, O’Guin CD, Williams CI, Warnick RJ, Sharek PJ (2014) Decreasing handoff-related care failures in children’s hospitals. Pediatrics 134:e572

    Article  Google Scholar 

  10. Sorra J, Gray L, Streagle S, Famolaro T, Yount N, Behm J (2016) AHRQ Hospital survey on patient safety culture: user’s guide. Agency for Healthcare Research and Quality (AHRQ), Rockville

    Google Scholar 

  11. Zakrison TL, Rosenbloom B, McFarlan A, Jovicic A, Soklaridis S, Allen C, Schulman C, Namias N, Rizoli S (2016) Lost information during the handover of critically injured trauma patients: a mixed-methods study. BMJ Qual Saf 25:929–936

    Article  Google Scholar 

  12. Joy BF, Elliott E, Hardy C, Sullivan C, Backer CL, Kane JM (2011) Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatr Crit Care Med 12:304–308

    Article  Google Scholar 

  13. Bernstein J, MacCourt DC, Jacob DM, Mehta S (2010) Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions. Clin Orthop Relat Res 468:2627–2632

    Article  Google Scholar 

  14. Starmer AJ, Landrigan CP (2015) Changes in medical errors with a handoff program. N Engl J Med 372:490–491

    Article  Google Scholar 

  15. Joint Commission: Inadequate Hand-Off Communication (2017). Sentinel Alert Event, pp 1–6

    Google Scholar 

Download references

Acknowledgements

Funding for this research was provided by the Agency for Healthcare Research and Quality (AHRQ) [Grant No. R01 HS023837]. The project described was supported by the Clinical and Translational Science Award (CTSA) program, through the National Institutes of Health (NIH) 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. We thank the study participants, as our research would not be possible without them.

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Correspondence to Peter Hoonakker .

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Hoonakker, P. et al. (2019). Things Falling Through the Cracks: Information Loss During Pediatric Trauma Care Transitions. In: Bagnara, S., Tartaglia, R., Albolino, S., Alexander, T., Fujita, Y. (eds) Proceedings of the 20th Congress of the International Ergonomics Association (IEA 2018). IEA 2018. Advances in Intelligent Systems and Computing, vol 818. Springer, Cham. https://doi.org/10.1007/978-3-319-96098-2_60

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