(1336) Improving Handoffs to Bridge the Diagnostic Process for Interfacility Transitions to Intensive Care

Introduction: Urgent inter-facility transitions of children to the PICU increase the risk of harm from diagnostic errors. We previously created a standard inter-facility handoff program (“I-PASS-to-PICU”) to reduce medical errors across these transitions but the program was not designed to optimize diagnosis-related communication. We sought to evaluate how well I-PASS-to-PICU facilitates diagnosis-related handoff communication to inform iterative redesign to better support the diagnostic process.

Methods: We conducted a mixed methods study in a single PICU by analyzing audio-recorded PICU referral calls to characterize diagnostic handoff communication before and after I-PASS-to-PICU implementation. Two pediatric intensivists trained to review calls provided quantitative ratings of the presence/quality of diagnosis-relevant information on unstructured handoffs vs. handoffs facilitated by I-PASS-to-PICU. Qualitative observations were made by the same reviewers on sufficiency of overall diagnosis-related discussions. Preliminary results are reported pending consensus on review discrepancies.

Results: Forty-four referral calls were reviewed (16 pre- and 28 post-I-PASS-to-PICU implementation). Compared with unstructured handoffs, I-PASS-to-PICU use resulted in a greater proportion of calls with discussions of illness severity (21 [75%] vs. 9 [56%]), a statement of the primary diagnosis by either the referring clinician (18 [64%] vs. 7 [44%]) or PICU physician (9 [32%] vs. 4 [25%]), and a discussion of diagnostic uncertainty (10 [36%] vs. 3 [19%]), although these findings were not statistically significant likely due to a small sample. However, I-PASS-to-PICU significantly increased the proportion of calls wherein the PICU physician gave a synthesis of information provided to ensure accurate understanding (10 [36%] vs. 1 [6%], p=0.036). Thematic analysis of qualitative observations are ongoing.

Conclusions: I-PASS-to-PICU appears to support diagnosis-related information exchange for children urgently referred for PICU transfer. However, communication regarding the primary diagnosis and diagnostic uncertainty can still be substantially improved. Additional work will be needed to redesign I-PASS-to-PICU to better support the diagnostic process across inter-facility transitions of critically ill children.