O2060: Referral Communication Practices for Inter-facility Transfer and Admission to the Pediatric Intensive Care Unit

Background: Up to 80% of serious medical errors during transitions of care involve miscommunication during patient handoffs. Critically ill children requiring a higher level of care are especially vulnerable to harm due to poor communication during inter-facility transfers. Standardizing information exchange by adapting evidence-based handoff interventions to inter-facility referral communication may prevent adverse events and improve outcomes. Our objective was to determine the characteristics of referral communication practices across tertiary referral pediatric intensive care units (PICUs) in the U.S. Doing so will help identify opportunities for improvement during PICU inter-facility referral communication.

Methods: We conducted a cross-sectional electronic survey of administrative leaders (division chief or medical/transport director) of U.S. PICUs with >10 beds. We identified PICUs by cross-referencing the Fellowship and Residency Electronic Interactive Database Access (FREIDA™) list of pediatric critical care fellowship programs, Virtual PICU Systems list of participating U.S. PICUs, and the Children’s Hospital Association members list. Survey respondents and contact information were identified through publicly-available online sources. The survey instrument was developed, iteratively revised, and pilot-tested by a group of pediatric intensivists practicing in 7 different PICUs. The survey was designed to gather information on PICU characteristics, inter-facility referral structure and process, and referral communication characteristics. REDCap® was used for survey distribution, administration, and tracking.

Results: Of 167 survey invitations sent to respondents with working email addresses, 61 completed surveys were returned (37% response rate). All U.S. continental regions were represented with a majority of PICUs (99%) being either medical-surgical (no cardiac patients) or mixed units. PICUs had a median of 1200 (IQR 1000-1560) admissions/year with a median of 27% (IQR 15%-39%) admitted as direct transfers from other institutions. For inter-facility transfers in 93% of PICUs, a verbal handoff occurs between the referring clinician and a receiving PICU provider (typically the attending physician in 67% of PICUs); however, only 24% of handoffs are guided by a standard communication tool. In 72% of PICUs, medical records are only sometimes available prior to patient arrival. Most PICUs (58%) formally track outcomes of directly-transferred patients but only 30% of PICUs have a formal program to deliver patient outcome feedback to referring clinicians (Table). Interviews of purposively selected survey respondents are pending, which will provide qualitative information regarding referral communication practices.

Conclusion: Information exchange for inter-facility patient transfers to the PICU occur mostly through unstructured verbal handoffs between referring clinicians and PICU physicians. Many PICUs track outcomes of transferred patients but most do not have formal feedback systems in place. Interventions to improve inter-facility referral communication between frontline clinical settings and PICUs must be developed and tested to improve the safety and quality of acute care transitions to the PICU.