Emergency General Surgery
Conditions
Keywords
Older adults, Communication, Health care provider, Interhospital transfer
Brief summary
Every year, nearly 240,000 patients age 60 and older are transferred between acute care hospitals for nontraumatic surgical emergencies, and these patients experience worse outcomes than patients admitted directly from an emergency department within a given hospital. Care coordination for older patients with emergency general surgery (EGS) diagnoses suffers because conversations between referring and accepting providers regarding decisions to transfer are ineffective, incomplete, and inefficient. To standardize a method to support transfer decisions that is tailored to older adults within extant transfer processes, the team will (1) engage key stakeholders to develop the intervention to Support Interhospital Transfer Decisions (SITe) for older EGS patients by adapting an existing intervention for interhospital handoffs and (2) assess the acceptability of the SITe intervention, test the feasibility of study procedures, and explore efficacy outcomes for evaluation in a future, larger clinical trial.
Detailed description
Aim 2 of the protocol qualifies as a clinical trial. Aim 2 will assess the acceptability of the intervention to Support Interhospital Transfer Decisions (SITe), test the feasibility of study procedures, and explore efficacy outcomes for evaluation in a future, larger clinical trial. Modeling a similar and successful pilot, the investigators will conduct a pre (control)/post (intervention) study with 50 transfers in each arm. They will collect pre- and post-intervention data after each eligible transfer through (1) chart review and transfer center logs and (2) Qualtrics surveys of referring and accepting providers. The team will collect baseline (pre) and post-intervention measures of the potential to avoid transfers, efficiency of transfer communication and execution, provider emotional labor, and patient health outcomes. accepting providers will utilize the SITe intervention during calls discussing transfer decisions regarding older emergency general surgery patients. Transfer center nurses and referring providers will be informed of the SITe intervention tool. The study was terminated early. The research team completed pre-intervention data collection and intervention training. No post-intervention data was collected. As of 3/21/2024, the UW-Madison IRB no longer considers training accepting surgeons on the intervention research.
Interventions
BEHAVIORALIntervention to Support Interhospital Transfer Decisions (SITe)
The SITe intervention and implementation toolkit was developed in Aim 1 through stakeholder activities. SITe, an intervention to support interhospital transfer decisions regarding older EGS patients, includes a checklist and script to be utilized by accepting providers during their conversations with referring providers. The investigators and stakeholders also developed a toolkit for implementation with resources to reduce barriers to and support facilitators of utilizing the tools. The toolkit includes: (1) the checklist and script; (2) methods to train accepting providers on the tools including a PowerPoint presentation and demonstration video; and (3) resources to familiarize other parties (transfer center nurses, referring providers, referring hospitals) with the SITe intervention.
Sponsors
National Institute on Aging (NIA)
University of Wisconsin, Madison
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Intervention model description
The intervention will target UW Health accepting providers. Referring providers do not receive the intervention. Patients have waiver of informed consent.
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patients (n=100): patients age 60 and older with an EGS diagnosis transferred from a referring ED or inpatient floor in Wisconsin to the UW ED or inpatient floor under care of UW surgeons * Providers: all UW (accepting) surgeons and all referring providers who execute transfers of the 100 eligible patients. There will be no exclusions regarding referring providers' position (e.g., physician, mid-level provider), specialty (e.g., emergency medicine, internal medicine), or affiliation (e.g., UW or non-UW).
Exclusion criteria
* Providers who do not speak English * Patients younger than 60 years * Other interhospital transfers other than EGS transfers * Prisoners
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Acceptability of the Intervention to Support Interhospital Transfer Decisions (SITe) | 3 months | The team will identify 50 study-eligible patient transfers post-intervention training. The team will ask the accepting provider and referring provider who executed the eligible transfer to rate the following statements on a Likert-scale (1=completely disagree to 5=completely agree): * This intervention meets my approval. * This intervention is appealing to me. * I like this intervention. * I welcome this intervention. Acceptability is defined as a minimum average score of 4 per item. |
| Fidelity to the Intervention to Support Interhospital Transfer Decisions (SITe) | 3 months | The team will identify 50 study-eligible patient transfers post-intervention training. The team will measure missingness of the tool elements. Fidelity is defined as \<15% missing patient information. |
| Feasibility of Study Procedures | pre-intervention at 3 months, post-intervention at 7 months | The team will measure the rate of survey completion for study-eligible patient transfers and examine rates of and reasons for missing outcome data. |
| Potential to Avoid Transfer: Chart Review | 7 months | The team will evaluate the quality outcome: potential to avoid transfer. Through chart review, the team will look at number of transfers with no intervention and discharge to home within 72 hours. |
| Potential to Avoid Transfer- Second Related Question on Survey - Should Have Been Able | pre-intervention at 3 months, post-intervention at 7 months | The team will evaluate the quality outcome: potential to avoid transfer. Accepting Providers were asked: I felt that the referring hospital should have been able to care for the patient. A similar question was not asked of Referring Providers |
| Efficiency of Transfer Communication | 7 months | Following the Relational Model of Organizational Change and through chart review and review of transfer center logs, the team will evaluate the efficiency of transfer communication. The team will review the number of calls required to complete the transfer and time required to complete transfer calls. |
| Efficiency of Transfer Execution | 7 months | The team will evaluate the efficiency of transfer execution. The team will review the time from initial call to patient arrival. |
| Emotional Labor - First Related Question on Survey - Respect | pre-intervention at 3 months, post-intervention at 7 months | Following the Relational Model of Organizational Change and specific Qualtrics questions, the team will evaluate the emotional labor of providers. The team will ask about providers' feelings about being listened to and supported when discussing patient care and difficult patient issues. Question for Referring Providers: I felt respected by the referring provider. Question for Accepting Providers: I felt respected by the UW surgeon. |
| Patient Health Outcomes | 7 months | The team will evaluate patient health outcomes. The team will measure the number of admissions to the emergency department vs inpatient floor, the number of changes in level of patient care (general, intermediate, intensive) within 24 hours of arrival, and the number of adverse events (inpatient mortality, morbidity, extended length of stay.) |
| Emotional Labor - Second Related Question on Survey - Listening | pre-intervention at 3 months, post-intervention at 7 months | Following the Relational Model of Organizational Change and specific Qualtrics questions, the team will evaluate the emotional labor of providers. The team will ask about providers' feelings about being listened to and supported when discussing patient care and difficult patient issues. Question for Referring Providers: The UW Surgeon listened to my concerns about the patient. A similar question was not asked of Accepting Providers |
| Emotional Labor - Third Related Question on Survey - Understanding | pre-intervention at 3 months, post-intervention at 7 months | Following the Relational Model of Organizational Change and specific Qualtrics questions, the team will evaluate the emotional labor of providers. The team will ask about providers' feelings about being listened to and supported when discussing patient care and difficult patient issues. Question for Referring Providers: I felt that the UW Surgeon understood my reason for transfer. A similar question was not asked of Accepting Providers |
| Emotional Labor - Fourth Related Question on Survey - Doubt | pre-intervention at 3 months, post-intervention at 7 months | Following the Relational Model of Organizational Change and specific Qualtrics questions, the team will evaluate the emotional labor of providers. The team will ask about providers' feelings about being listened to and supported when discussing patient care and difficult patient issues. Question for Referring Providers: I felt that the UW Surgeon doubted whether the transfer was necessary. A similar question was not asked of Accepting Providers |
| Potential to Avoid Transfer- First Related Question on Survey - Justifiable | pre-intervention at 3 months, post-intervention at 7 months | The team will evaluate the quality outcome: potential to avoid transfer. Accepting Providers were asked: I felt that the reason for transfer was justifiable. A similar question was not asked of Referring Providers |
Countries
United States
Participant flow
Recruitment details
For the intervention training, 9 accepting surgeons were invited to be trained on the transfer tools; 3 accepting surgeons have accepted the invitation and were trained. Six accepting surgeons were invited but did not accept the invitation to complete the training. 25 unique providers took surveys, 3 accepting surgeons trained on the intervention were among them.
Pre-assignment details
60 calls met the initial screening criteria, 12 calls were excluded do to errors in screening, 48 transfer calls were eligible for 59 unique providers. Of those, 24 unique providers declined to take 28 surveys, and the team did not have contact information for 14 providers. Therefore 25 unique providers started the intervention.
Participants by arm
| Arm | Count |
|---|---|
| Referring Providers Referring providers who called to discuss potential transfer of a patient (who was at least 60 years old with an emergency general surgery diagnosis) with an accepting provider | 13 |
| Accepting Providers Accepting providers who discussed potential transfer of a patient (who was at least 60 years old with an emergency general surgery diagnosis) with a referring provider | 12 |
| Total | 25 |
Baseline characteristics
| Characteristic | Referring Providers | Total | Accepting Providers |
|---|---|---|---|
| Age, Continuous | 45.46 years | 45.42 years | 45.4 years |
| Ethnicity (NIH/OMB) Hispanic or Latino | 1 Participants | 1 Participants | 0 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 11 Participants | 23 Participants | 12 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 1 Participants | 1 Participants | 0 Participants |
| Number of years practiced since training was finished | 12.12 years | 11.18 years | 10.2 years |
| Profession Advanced Practice Provider (NP, PA) | 0 Participants | 0 Participants | 0 Participants |
| Profession Other | 1 Participants | 1 Participants | 0 Participants |
| Profession Physician | 12 Participants | 24 Participants | 12 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 0 Participants | 2 Participants | 2 Participants |
| Race (NIH/OMB) Black or African American | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 1 Participants | 1 Participants | 0 Participants |
| Race (NIH/OMB) White | 12 Participants | 22 Participants | 10 Participants |
| Region of Enrollment United States | 13 participants | 25 participants | 12 participants |
| Sex/Gender, Customized Man | 10 Participants | 15 Participants | 5 Participants |
| Sex/Gender, Customized Non-binary | 0 Participants | 0 Participants | 0 Participants |
| Sex/Gender, Customized Prefer not to say | 1 Participants | 1 Participants | 0 Participants |
| Sex/Gender, Customized Prefer to self describe | 0 Participants | 0 Participants | 0 Participants |
| Sex/Gender, Customized Woman | 2 Participants | 9 Participants | 7 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 0 / 0 |
| other Total, other adverse events | 0 / 0 |
| serious Total, serious adverse events | 0 / 0 |
Outcome results
Primary
Acceptability of the Intervention to Support Interhospital Transfer Decisions (SITe)
The team will identify 50 study-eligible patient transfers post-intervention training. The team will ask the accepting provider and referring provider who executed the eligible transfer to rate the following statements on a Likert-scale (1=completely disagree to 5=completely agree): * This intervention meets my approval. * This intervention is appealing to me. * I like this intervention. * I welcome this intervention. Acceptability is defined as a minimum average score of 4 per item.
Time frame: 3 months
Population: The study terminated early and the team mainly completed pre-intervention surveys and training activities. The study team did not complete post-intervention activities and analysis.
Primary
Efficiency of Transfer Communication
Following the Relational Model of Organizational Change and through chart review and review of transfer center logs, the team will evaluate the efficiency of transfer communication. The team will review the number of calls required to complete the transfer and time required to complete transfer calls.
Time frame: 7 months
Population: Study terminated early and these data were not collected.
Primary
Efficiency of Transfer Execution
The team will evaluate the efficiency of transfer execution. The team will review the time from initial call to patient arrival.
Time frame: 7 months
Population: Study terminated early and these data were not collected.
Primary
Emotional Labor - First Related Question on Survey - Respect
Following the Relational Model of Organizational Change and specific Qualtrics questions, the team will evaluate the emotional labor of providers. The team will ask about providers' feelings about being listened to and supported when discussing patient care and difficult patient issues. Question for Referring Providers: I felt respected by the referring provider. Question for Accepting Providers: I felt respected by the UW surgeon.
Time frame: pre-intervention at 3 months, post-intervention at 7 months
Population: Data was collected over 3 months prior to intervention, planned post-intervention data collection did not occur due to termination of the study.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Accepting Providers Trained on SITe Tools | Emotional Labor - First Related Question on Survey - Respect | Disagree | 0 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - First Related Question on Survey - Respect | Agree | 5 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - First Related Question on Survey - Respect | Neutral | 2 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - First Related Question on Survey - Respect | Strongly agree | 6 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - First Related Question on Survey - Respect | Strongly disagree | 0 surveys |
| Accepting Providers | Emotional Labor - First Related Question on Survey - Respect | Strongly agree | 10 surveys |
| Accepting Providers | Emotional Labor - First Related Question on Survey - Respect | Strongly disagree | 0 surveys |
| Accepting Providers | Emotional Labor - First Related Question on Survey - Respect | Disagree | 2 surveys |
| Accepting Providers | Emotional Labor - First Related Question on Survey - Respect | Neutral | 5 surveys |
| Accepting Providers | Emotional Labor - First Related Question on Survey - Respect | Agree | 24 surveys |
Primary
Emotional Labor - Fourth Related Question on Survey - Doubt
Following the Relational Model of Organizational Change and specific Qualtrics questions, the team will evaluate the emotional labor of providers. The team will ask about providers' feelings about being listened to and supported when discussing patient care and difficult patient issues. Question for Referring Providers: I felt that the UW Surgeon doubted whether the transfer was necessary. A similar question was not asked of Accepting Providers
Time frame: pre-intervention at 3 months, post-intervention at 7 months
Population: Data was collected over 3 months prior to intervention, planned post-intervention data collection did not occur due to termination of the study.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Accepting Providers Trained on SITe Tools | Emotional Labor - Fourth Related Question on Survey - Doubt | Strongly disagree | 8 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - Fourth Related Question on Survey - Doubt | Disagree | 4 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - Fourth Related Question on Survey - Doubt | Agree | 0 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - Fourth Related Question on Survey - Doubt | Strongly agree | 1 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - Fourth Related Question on Survey - Doubt | Neutral | 0 surveys |
Primary
Emotional Labor - Second Related Question on Survey - Listening
Following the Relational Model of Organizational Change and specific Qualtrics questions, the team will evaluate the emotional labor of providers. The team will ask about providers' feelings about being listened to and supported when discussing patient care and difficult patient issues. Question for Referring Providers: The UW Surgeon listened to my concerns about the patient. A similar question was not asked of Accepting Providers
Time frame: pre-intervention at 3 months, post-intervention at 7 months
Population: Data was collected over 3 months prior to intervention, planned post-intervention data collection did not occur due to termination of the study.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Accepting Providers Trained on SITe Tools | Emotional Labor - Second Related Question on Survey - Listening | Strongly disagree | 0 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - Second Related Question on Survey - Listening | Disagree | 1 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - Second Related Question on Survey - Listening | Neutral | 0 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - Second Related Question on Survey - Listening | Agree | 5 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - Second Related Question on Survey - Listening | Strongly agree | 7 surveys |
Primary
Emotional Labor - Third Related Question on Survey - Understanding
Following the Relational Model of Organizational Change and specific Qualtrics questions, the team will evaluate the emotional labor of providers. The team will ask about providers' feelings about being listened to and supported when discussing patient care and difficult patient issues. Question for Referring Providers: I felt that the UW Surgeon understood my reason for transfer. A similar question was not asked of Accepting Providers
Time frame: pre-intervention at 3 months, post-intervention at 7 months
Population: Data was collected over 3 months prior to intervention, planned post-intervention data collection did not occur due to termination of the study.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Accepting Providers Trained on SITe Tools | Emotional Labor - Third Related Question on Survey - Understanding | Strongly disagree | 0 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - Third Related Question on Survey - Understanding | Disagree | 1 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - Third Related Question on Survey - Understanding | Neutral | 0 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - Third Related Question on Survey - Understanding | Agree | 5 surveys |
| Accepting Providers Trained on SITe Tools | Emotional Labor - Third Related Question on Survey - Understanding | Strongly agree | 7 surveys |
Primary
Feasibility of Study Procedures
The team will measure the rate of survey completion for study-eligible patient transfers and examine rates of and reasons for missing outcome data.
Time frame: pre-intervention at 3 months, post-intervention at 7 months
Population: Data was collected over 3 months prior to intervention, planned post-intervention data collection did not occur due to termination of the study.
| Arm | Measure | Group | Value (COUNT_OF_UNITS) |
|---|---|---|---|
| Accepting Providers Trained on SITe Tools | Feasibility of Study Procedures | Pre-Intervention Surveys | 13 Surveys |
| Accepting Providers Trained on SITe Tools | Feasibility of Study Procedures | Post-Intervention Surveys | 0 Surveys |
| Accepting Providers | Feasibility of Study Procedures | Pre-Intervention Surveys | 41 Surveys |
| Accepting Providers | Feasibility of Study Procedures | Post-Intervention Surveys | 0 Surveys |
Primary
Fidelity to the Intervention to Support Interhospital Transfer Decisions (SITe)
The team will identify 50 study-eligible patient transfers post-intervention training. The team will measure missingness of the tool elements. Fidelity is defined as \<15% missing patient information.
Time frame: 3 months
Population: Study terminated early and these data were not collected.
Primary
Patient Health Outcomes
The team will evaluate patient health outcomes. The team will measure the number of admissions to the emergency department vs inpatient floor, the number of changes in level of patient care (general, intermediate, intensive) within 24 hours of arrival, and the number of adverse events (inpatient mortality, morbidity, extended length of stay.)
Time frame: 7 months
Population: Study terminated early and these data were not collected.
Primary
Potential to Avoid Transfer: Chart Review
The team will evaluate the quality outcome: potential to avoid transfer. Through chart review, the team will look at number of transfers with no intervention and discharge to home within 72 hours.
Time frame: 7 months
Population: Study terminated early and these data were not collected.
Primary
Potential to Avoid Transfer- First Related Question on Survey - Justifiable
The team will evaluate the quality outcome: potential to avoid transfer. Accepting Providers were asked: I felt that the reason for transfer was justifiable. A similar question was not asked of Referring Providers
Time frame: pre-intervention at 3 months, post-intervention at 7 months
Population: Data was collected over 3 months prior to intervention, planned post-intervention data collection did not occur due to termination of the study.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Accepting Providers Trained on SITe Tools | Potential to Avoid Transfer- First Related Question on Survey - Justifiable | Strongly Disagree | 3 surveys |
| Accepting Providers Trained on SITe Tools | Potential to Avoid Transfer- First Related Question on Survey - Justifiable | Disagree | 4 surveys |
| Accepting Providers Trained on SITe Tools | Potential to Avoid Transfer- First Related Question on Survey - Justifiable | Neutral | 13 surveys |
| Accepting Providers Trained on SITe Tools | Potential to Avoid Transfer- First Related Question on Survey - Justifiable | Agree | 13 surveys |
| Accepting Providers Trained on SITe Tools | Potential to Avoid Transfer- First Related Question on Survey - Justifiable | Strongly agree | 8 surveys |
Primary
Potential to Avoid Transfer- Second Related Question on Survey - Should Have Been Able
The team will evaluate the quality outcome: potential to avoid transfer. Accepting Providers were asked: I felt that the referring hospital should have been able to care for the patient. A similar question was not asked of Referring Providers
Time frame: pre-intervention at 3 months, post-intervention at 7 months
Population: Data was collected over 3 months prior to intervention, planned post-intervention data collection did not occur due to termination of the study.
| Arm | Measure | Group | Value (NUMBER) |
|---|---|---|---|
| Accepting Providers Trained on SITe Tools | Potential to Avoid Transfer- Second Related Question on Survey - Should Have Been Able | Strongly agree | 4 surveys |
| Accepting Providers Trained on SITe Tools | Potential to Avoid Transfer- Second Related Question on Survey - Should Have Been Able | Agree | 12 surveys |
| Accepting Providers Trained on SITe Tools | Potential to Avoid Transfer- Second Related Question on Survey - Should Have Been Able | Neutral | 15 surveys |
| Accepting Providers Trained on SITe Tools | Potential to Avoid Transfer- Second Related Question on Survey - Should Have Been Able | Disagree | 8 surveys |
| Accepting Providers Trained on SITe Tools | Potential to Avoid Transfer- Second Related Question on Survey - Should Have Been Able | Strongly Disagree | 2 surveys |