Interfacility Transfers to General Pediatric Floors: A Qualitative Study Exploring the Role of Communication

Interfacility Transfers to General Pediatric Floors: A Qualitative Study Exploring the Role of Communication Jennifer L. Rosenthal, MD; Megumi J. Okumura, MD, MAS; Lenore Hernandez, RN; Su-Ting T. Li, MD MPH; Roberta S. Rehm, RN, PhD, FAAN From the Department of Pediatrics (Drs Rosenthal and Li), University of California, Davis, Sacramento, California; Departments of Pediatrics and Internal Medicine (Dr Okumura), and Family Health Care Nursing (Ms Hernandez, and Dr Rehm), University of California, San Francisco, San Francisco, California The authors have no conflicts of interest to disclose. Address correspondence to Jennifer L. Rosenthal, MD, Department of Pediatrics, University of California Davis, 2516 Stockton Blvd, Ticon II, Suite 340, Sacramento, CA 95817 (e-mail: [email protected]). Received for publication December 15, 2015; accepted April 14, 2016.

ABSTRACT BACKGROUND: Children with special health care needs often require health services that are only provided at subspecialty centers. Such children who present to nonspecialty hospitals might require a hospital-to-hospital transfer. When transitioning between medical settings, communication is an integral aspect that can affect the quality of patient care. The objectives of the study were to identify barriers and facilitators to effective interfacility pediatric transfer communication to general pediatric floors from the perspectives of referring and accepting physicians, and then develop a conceptual model for effective interfacility transfer communication. METHODS: This was a single-center qualitative study using grounded theory methodology. Referring and accepting physicians of children with special health care needs were interviewed. Four researchers coded the data using ATLAS.ti (version 7, Scientific Software Development GMBH, Berlin, Germany), using a 2-step process of open coding, followed by focused coding until no new codes emerged. The research team reached consensus on the final major categories and subsequently developed a conceptual model.

RESULTS: Eight referring and 9 accepting physicians were interviewed. Theoretical coding resulted in 3 major categories: streamlined transfer process, quality handoff and 2-way communication, and positive relationships between physicians across facilities. The conceptual model unites these categories and shows how these categories contribute to effective interfacility transfer communication. Proposed interventions involved standardizing the communication process and incorporating technology such as telemedicine during transfers. CONCLUSIONS: Communication is perceived to be an integral component of interfacility transfers. We recommend that transfer systems be re-engineered to make the process more streamlined, to improve the quality of the handoff and 2-way communication, and to facilitate positive relationships between physicians across facilities.

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initially present to a local, nonspecialty hospital and require specialty care might experience a hospital-tohospital transfer. The decision to transfer a patient is most often for reasons indicating limited resources or expertise at the referring facility.4 Although transfers are intended to improve patient outcomes, decision-making such as selecting the destination facility are not always on the basis of patient outcomes.5,6 Other issues complicating the effectiveness of interfacility transfers involve verbal and written communication challenges between physicians, such as interpersonal conflicts and time-consuming processes.5–7 When patients transition between medical settings, communication can positively or negatively affect the quality of patient care.8,9 Most research on communication during transitions focuses on the intrafacility (eg, emergency-to-inpatient or day-to-night

KEYWORDS: children with special needs; hospital medicine; patient transfer

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We developed a conceptual model for effective pediatric interfacility transfer communication on the basis of perspectives from referring and accepting physicians. Physicians perceived streamlined transfer process, quality handoff and 2-way communication, and positive relationships across facilities as integral components of transfer communication.

REGIONALIZATION OF MEDICAL care is recognized to improve outcomes in pediatric patients.1 Many hospitals lack pediatric specialists and resources, limiting their ability to provide definitive care to some pediatric patients.2,3 Patients with specialized diagnoses, such as children with special health care needs (CSHCN), might therefore be directed to hospitals with specialized care. CSHCN who

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shift) or inpatient-to-outpatient handoff.8–10 This body of literature shows that communication challenges exist during these handoffs, such as negative effect on patient care, interpersonal provider conflict, being timeconsuming or inconvenient, or leaving physicians with unanswered questions.9,10 It is likely that in the acute setting of hospital-to-hospital interfacility transfers similar and potentially heightened communication difficulties are encountered. Improving processes of care requires understanding the perspectives of those involved in the system. Although qualitative research on adult interfacility transfers has been published, perspectives of medical providers on pediatric interfacility transfers is lacking.6,11 Our objectives were to: 1) use grounded theory methods to identify barriers and facilitators to effective interfacility pediatric transfer communication to general pediatric floors from the perspectives of referring and accepting physicians of CSHCN, and then 2) develop a conceptual model for effective interfacility transfer communication. Physicians of CSHCN were the group of interest because of these children’s needs for frequent hospitalizations and specialty care of a type or amount beyond that required by children in general.12,13 Thus, CSHCN potentially have a greater need for interfacility transfers. Furthermore, there might be more information to transmit when these children with special needs are transferred, and failure to transmit such information might be more likely to lead to patient harm in this population. The experiences of physicians for this population of children might be applicable to improving the interfacility transfer experience for all pediatric patients, not just CSHCN.

METHODS STUDY DESIGN We conducted a single-center qualitative study using grounded theory methodology.14 Two researchers (J.L.R., L.H.) conducted semistructured interviews with referring and accepting physicians. We developed an interview guide on the basis of a literature review of interfacility transfers.4–7 Existing literature shows that interfacility transfer have challenges with physician-physician communication, decision-making that is not on the basis of optimizing patient outcomes, and conflicts and burdens to those involved in the process. Thus, interview guide questions focused on 3 major topic areas: 1) communication, 2) decision-making, and 3) the transfer process and roles of those involved. Initial interview guides were revised to include more specific questions on the same topics as initial data were analyzed and new categories of findings developed. Interviews were conducted within 45 days of the transfer. They were conducted in the hospital library, hospital office, or by phone. Interviews were audio recorded, professionally transcribed, and checked for accuracy by the researchers. Interviewers maintained field notes with informal contextual observations and/or verbal and nonverbal cues. We provided a $25 gift card to each participant who completed an interview. The institutional

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review board at the University of California, San Francisco, approved the study protocol. STUDY POPULATION The participants of interest were physician providers for CSHCN patients who experienced an interfacility transfer to a single-center tertiary/quaternary care children’s hospital in California between July 1, 2014 and November 1, 2014. Physicians who referred and accepted these patients were identified from an existing hospital transfer center database that is continuously updated as new transfers occur. The database was screened daily for eligible patients. Patients eligible for the study were those aged 0 to 25 years with a chronic medical or behavioral condition, as defined by components in the CSHCN screener,15 admitted to a pediatric general pediatric floor via an interfacility transfer. A child was screened positive with the CSHCN screener if they met 1 or more of the following: 1) limited/prevented in his/her ability to do things most children the same age can do, 2) needs/uses prescribed medications (other than vitamins), 3) needs/uses specialized (physical, occupational, speech) therapies, 4) has greater than routine need/use of medical, mental health, or educational services, and 5) needs/receives treatment or counseling for an emotional, behavioral, or developmental problem. Interfacility transfer was defined as a transfer to the receiving hospital from a different facility’s clinic, emergency department, or inpatient hospital. Affiliate hospitals were categorized as a different facility if their electronic medical record system was a system separate from the receiving hospital system. Referring and accepting physicians included fellows and attending physicians. These physicians were identified from the transfer center database and recruited for participation by phone, fax, or e-mail. Demographic information of the physician participants and the transferred CSHCN patients was collected through surveying participants and through electronic medical record and transfer center database review. Physician demographic characteristics included age, gender, years of experience, clinical location type, training, transfer practices, and frequency of providing care to CSHCN. The hospital characteristics of transferring physicians’ facilities included freestanding children’s status and access to pediatric subspecialty care, teaching status, and urban versus rural location. Patient characteristics included age, gender, insurance status, primary reason for transfer, transport distance, originating unit type (clinic, emergency department, inpatient ward), and post-transfer service. To identify the CSHCN patients with increased medical complexity, we additionally recorded the presence of 1 or more complex chronic conditions using the International Classification of Diseases, Ninth Revision, Clinical Modification codes identified by Feudtner et al.16 DATA ANALYSIS Data were analyzed in a multistep, iterative analytic process beginning with initial open-coding of the transcripts,

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by 4 members of the research team (J.L.R., L.H., M.J.O., R.S.R.). Results of open coding were distilled into 10 categories. Two investigators (J.L.R., L.H.) then performed focused, line-by-line coding of all data using these categories. These investigators were from different disciplines and coded the transcripts independently before codes were compared and subsequently discussed to ensure consensus around application of codes. During the focused coding process, new codes were added and definitions of codes were adjusted as transcripts were analyzed. Data collection continued until no new codes were added. Through a series of team meetings and shared analytic memos, the team of researchers reached consensus on the construction of the 3 major analytic categories comprising the theoretical code, interfacility transfer communication, and the development of the conceptual model. The research team included nurse researchers, inpatient pediatric hospitalists, and an outpatient medicinepediatrics generalist. Three of the researchers had extensive qualitative research experience. We used the qualitative data analysis software ATLAS.ti (version 7, Scientific Software Development GMBH, Berlin, Germany) to organize and store coding and data analysis.17 After analyzing all transcripts and developing the major categories and theoretical code, results were reviewed with 8 physicians who participate in interfacility transfers, none of whom participated in the study. These peer reviewers all agreed that these findings supported their own experiences and did not identify further themes; therefore, we concluded we had reached saturation on the final results.

RESULTS During the study period, 44 referring and 36 accepting physicians met inclusion criteria and were invited to participate. Thirty-five referring and 25 accepting physicians did not respond to the invitation to participate, and 1 referring and 2 accepting physicians declined to participate. We conducted seventeen 45- to 60-minute interviews with referring physicians (n ¼ 8) and accepting physicians (n ¼ 9) (Table 1). Eight interviews were in-person; 9 interviews were by phone. Among referring physicians, more than half were pediatricians; only 1 of those pediatricians had specialty training. Two of the 8 physicians were emergency medicine physicians. Most of them worked in nonchildren’s hospitals. They had varying clinical experience with CSHCN, ranging from infrequent to daily clinical practice with CSHCN. Among accepting physicians, all were pediatricians working at a children’s hospital. Half of this group had pediatric specialty training. All accepting physicians reported working with CSHCN every day or on most days of their clinical practice. The referring and accepting physicians in this study were not dyads reflecting on the same patient. Participants thus represented 17 separate patient transfers. An unintended outcome was that every participant described their experiences transferring all types of pediatric patients, including CSHCN and other children. All referring physicians did not limit their reflections of their transfer

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experiences to the single-center in this study, but rather discussed transfer experiences with other facilities as well. Characteristics of the transferred pediatric patients of the physician participants are presented in Table 1. Half of the CSHCN in this study had at least 1 complex chronic condition. The primary reason for transfer for most of these patients was to access a specialist and/or pediatrician. The mean transport distance was 58 miles (95% confidence interval, 34–81). We found 3 major categories across the transcripts, each influencing the effectiveness of interfacility transfer communication. These categories are explored in subsequent paragraphs. Representative quotes are provided in Table 2 to illustrate the categories. Interaction of these categories and outcomes for the theoretical codes are illustrated in the conceptual model (Fig). CATEGORY 1: STREAMLINED TRANSFER PROCESSES Referring and accepting physicians wanted a less cumbersome, more streamlined transfer process. Almost every referring physician described the inefficient communication processes that occur during transfers. Inefficient processes were especially burdensome to referring physicians working in busy emergency departments. Part of the inefficiency was due to “clunky” processes. Clunky communication examples included multiple phone calls, multiple conversations, and difficulty contacting specialty providers. Sometimes, it was a challenge to even identify the appropriate accepting physician to approve transfer of a patient. With multiple providers involved, there were multiple handoffs, resulting in communication breakdowns. Almost every referring physician reported that they wanted to talk with 1 accepting physician rather than multiple physicians. Referring physicians additionally explained that their decision of where to transfer a patient was largely influenced by how streamlined the accepting facility’s transfer systems was. When patients had existing clinical relationships with a particular hospital facility, the patient would be transferred to their primary facility to maintain continuity of care. However, when such existing clinical relationships with a particular hospital facility did not exist, physicians would choose to refer patients to hospitals with efficient, easy to navigate processes. CATEGORY 2: QUALITY HANDOFF AND 2-WAY COMMUNICATION Most accepting physicians perceived the verbal information they received from referring physicians to be the most important component in determining a patient’s illness severity and thus needed level of care. Unfortunately, multiple accepting physicians reported patients sometimes arrive “not as billed” or that the verbal handoff was of poor quality or inadequate. Additionally, a few accepting physicians stated that they rarely receive a verbal handoff from the transport team. Regarding the written transmission of information, many accepting physicians discussed the common occurrence of patients transferring with records that are

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Table 1. Profiles of the Referring and Accepting Physician Participants and of the Transferred Pediatric Patients of the Physician Interviewees Referring and Accepting Physician Participants Physician Characteristic Mean age (95% CI), years Female gender, n (%) Mean years of experience (95% CI) Employed full-time, n (%) Clinical locations, n (%) Outpatient Urgent care Emergency department Wards Nursery NICU PICU Formal Training, n (%) Pediatrics, no specialty training Pediatrics, with specialty training* Emergency medicine Other Transfer practices, n (%) Only refer Mostly refer Both refer and accept equally Mostly accept Only accept Providing care to CSHCN, n (%) Every day of clinical practice Most days of clinical practice Infrequently during clinical practice Unknown Referring practices, n (%) Exclusively refer all transfers to study site Refer most transfers to study site Infrequently refer transfers to study site Unknown Hospital characteristics Hospital type, n (%) Freestanding children’s Children’s hospital within a hospital Nonchildren’s with subspecialty† Nonchildren’s without subspecialty† Teaching hospital, n (%) Urban location, n (%)

Referring Physicians (n ¼ 8)

Accepting Physicians (n ¼ 9)

46 (39–54) 3 (37.5) 14 (8–20) 7 (87.5)

40 (31–49) 6 (66.7) 11 (1–20) 7 (77.8)

3 (37.5) 2 (25.0) 4 (50.0) 6 (75.0) 3 (37.5) 2 (25.0) 0 (.0)

5 (55.6) 4 (44.4) 3 (33.3) 9 (100) 3 (33.3) 4 (44.4) 4 (44.4)

5 (62.5) 1 (12.5) 2 (25.0) 0 (.0)

5 (55.6) 4 (44.4) 0 (.0) 0 (.0)

1 (12.5) 2 (25.0) 1 (12.5) 4 (50.0) 0 (.0)

0 (.0) 0 (.0) 0 (.0) 7 (77.8) 2 (22.2)

3 (37.5) 2 (25.0) 2 (25.0) 1 (12.5)

6 (66.7) 2 (22.2) 0 (.0) 1 (1.1)

Transferred Pediatric Patients of the Physician Interviewees Patient characteristic Mean age (95% CI), years Female gender, n (%) Medicare or Medicaid, n (%) CCC, n (%) 0 CCC 1 CCC $2 CCC Primary reason for transfer, n (%) Needed a higher level of care‡ Needed a specialist and/or pediatrician Continuity of care with accepting facility Referring provider request

0 (.0)

–

5 (62.5)

–

2 (25.0)

–

1 (12.5)

–

2 (25.0) 1 (12.5) 3 (37.5) 2 (25.0) 4 (50.0) 6 (75.0)

0 (.0) 9 (100.0) 0 (.0) 0 (.0) 9 (100.0) 9 (100.0) Pediatric Patients (n ¼ 17) 12 (8–15) 6 (35.3) 7 (41.2) 8 (47.0) 3 (17.6) 6 (35.3) 0 (.0) 10 (58.8) 6 (35.3) 0 (.0) (Continued )

Table 1. Continued Transferred Pediatric Patients of the Physician Interviewees Family request Mean home-to-hospital distance (95% CI)§ Mean transported distance (95% CI)k Originating unit type, n (%){ Clinic Emergency department Inpatient ward Post-transfer service, n (%) Hospitalist Transplant Pediatric surgery Hematology-oncology Neurosurgery Cardiology

Pediatric Patients (n ¼ 17) 1 (5.9) 76 (48–104) 58 (34–81) 2 (11.8) 8 (47.0) 7 (41.2) 6 (35.3) 5 (29.4) 2 (11.8) 2 (11.8) 1 (5.9) 1 (5.9)

CI indicates confidence interval; NICU, neonatal intensive care unit; PICU, prenatal intensive care unit; CSHCN, children with special health care needs; and CCC, complex chronic conditions. *Specialty training included fellowship training in specialties including cardiology, infectious diseases, and gastroenterology. †Refers to nonchildren’s hospitals that have and do not have pediatric subspecialty services, respectively. Such services refer to the presence or lack of a pediatric ward or pediatric specialist(s) (eg, pediatric cardiologist, pediatric anesthesia, pediatric surgery). ‡Includes needing a hospital facility with an intensive care unit. §Refers to the distance (miles) between the patient’s home and the accepting, post-transfer hospital. kRefers to the distance (miles) between the referring, pretransfer hospital and the accepting, post-transfer hospital. {Refers to the type of unit from which the patient was transferred while at the referring, pre-transfer hospital.

incomplete or not helpful. At times, patients transfer without pertinent imaging or studies. Consequently, studies are frequently repeated at the receiving facility. Referring physicians explained that preparing records for the transfer is a process that takes away from patient care, thus it is not always prioritized. Suggestions to address these handoff inadequacies included increasing the capabilities of sharing electronic medical records between facilities, receiving records before the arrival of the patient, standardizing the handoff process, and expanding the use of telemedicine. Many referring and accepting physicians stated that communicating updates during and after a transfer is imperative. During the transfer, accepting physicians wanted to be updated if the patient had a clinical change. After the transfer, referring physicians wanted to be updated on the clinical management of the patient. Barriers to keeping physicians updated included lack of time and difficulty reaching physicians at other facilities. There was an assumption among accepting physicians that hospital-based referring physicians (eg, emergency medicine), in contrast to primary clinic physicians, did not want updates. However, the referring emergency physicians in our study verbalized they did want updates. Referring and accepting physicians also explained that feedback was a valuable interfacility transfer process. Although feedback can flow in both directions between the referring and accepting physicians, the participants

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Table 2. Exemplary Quotes Supporting the Major Categories and Subcategories Category

Exemplary Quote

Category 1: streamlined transfer processes Inefficient communication processes “The lag time between the last time we talked to the referring physician and the arrival here can then introduce some delays in getting a plan activated once the patient arrives.” (accepting physician) Clunky communication “I was trying to admit directly to the floor, and it took actually several phone calls trying to know: where is that baby gonna go, which floor is he gonna go to, and who is the accepting physician. There was a fellow, there was a resident, there was an attending. There was the general floor versus does he need to be on a subspecialty floor. So that was exhausting from my side as a primary care provider trying just to get that baby somewhere he needs to be.” (referring physician) Category 2: quality handoff and 2-way communication Breakdowns in the verbal handoff “For the most part [the transport team members] just don’t even call us; they show up, they drop the kid off, they give the report to the nurse and they leave.I think there is the potential to lose something.” (accepting physician) “The big worry comes when you’re speaking with somebody and I guess this is it—you can’t possibly get every bit of information all the time; so if you’re trying to be efficient, people will say the x-ray was reassuring, the CBC was normal, the chem panel was okay. And one of those numbers might not be normal and they didn’t communicate that or they didn’t think an important piece was so important to tell us about. And you can’t always ask for everything.” (accepting physician) Breakdowns in transmitting “We get a lot of records that aren’t useful, it’s like every lab that they’ve ever had done for the past written communication month was not in an appropriate summary of what’s happened during their time there. Or for a lot (medical records) of patients, they have had a lot of outside studies, specifically echos, chest x-rays—and not sending the imaging or the reports of the imaging.” (accepting physician) “It would be nice to have a system where I could print out my note and hand it to the paramedic and then they can hand it to the resident and the resident could just read my note like the second that the patient rolls in through your doors. I have worked really hard personally to achieve that.But all the acute care transfers I do contemporaneously, which means I am out of the room a lot doing that instead of being at the bedside managing little things and communicating to the parents or whatever more.” (referring physician) Keeping physicians updated “A lot of times we don’t [communicate updates] with ED providers because it seems like they don’t really, like once the patient is out of their site it is out of their mind; but we always communicate with every primary care doctor and so if it was a primary care doctor that sent them to us, then they get an update on what happened.” (accepting physician) “I think it would be nice if there could be a systems build-in that if there is something unexpected that happens, that I get a ping. if there could be some sort or automatic way if an unexpected event happened, at least alerting somebody there was an unexpected event.” (accepting physician) Feedback is a beneficial process “Of course if they think that down here we did something wrong we need to know about so we can either disagree or we can agree and modify our behavior.” (referring physician) “I think also referring facilities could use some feedback on like your assessment was right or your assessment was wrong and usually we’re calling back the kid’s PCP. We’re very rarely calling back the emergency department; in fact we almost never call back the ED.” (accepting provider) Category 3: positive relationships between physicians across facilities Conflict and disrespectful “Sometimes accepting physicians are not so nice and probably even rude or like “why did you do this, communication why didn’t you do that” and like you know questioning your management.” (referring physician) “It is infuriating when you transfer people to [hospital] that often times, well not often times, they always make you read every lab that you did to them over the phone.” (referring physician) “Asking questions in regard to a patient’s status can sometimes—I hope it’s not—but I kind of feel it can be misconstrued specifically when we ask for specific vital signs and lab results to determine if that patient stays on that floor.” (accepting physician) Trust between physicians “There are many people that I love hearing from that we have a history together. It is like old friends kind of thing because they either trained here or we worked together in some way and it is kind of quick, friendly chit-chat, get up to speed; it is efficient, it is accurate, there is quite a bit of relief on their part, thankfulness.” (accepting physician) “Most of the time the decisions on where I send [patients] are based on who I know at the facility on the receiving end to care for the patient and the quality of care that has happened in the past and sort of established a track record more or less.” (referring physician)

mostly talked of the importance of feedback provided from the accepting physician to the referring physician about medical management. Other types of desired feedback content included feedback to the referring facility about breakdowns in transmitting medical records. Although perceived to be an important process, physicians expressed that feedback did not routinely happen. One commonly reported barrier to proving feedback was the fear of feedback being perceived as an act of disrespect.

CATEGORY 3: POSITIVE RELATIONSHIPS BETWEEN PHYSICIANS ACROSS FACILITIES Many referring physicians described communication with accepting physicians as sometimes rude, difficult, and unpleasant. Views from accepting physicians were that referring physicians were defensive. Some accepting physicians, especially those more junior, were hesitant to ask referring physicians for additional clinical information, fearing their inquiries would be interpreted to be coming

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Figure. Conceptual model on effective interfacility transfer communication as experienced by referring and accepting physicians.

from a place of disrespect. In fact, some referring physicians did state that such questioning was disrespectful and casted doubt on their capabilities as physicians. Although most participants discussed negative relationships with physicians at other facilities, some participants described experiences of positive relationships. Although positive interactions did occur between physicians who did not know each other, participants specifically discussed how the interfacility transfer process was easier when the communication and transfer of care was with a physician whom they knew and trusted. CONCEPTUAL MODEL After reviewing the relationships between the major categories, we developed a conceptual model illustrating the theoretical code, effective interfacility transfer communication, as experienced by referring and accepting physicians (Fig). Process, quality, and relationships are the overarching influences. These influences pertain to the 3 major categories: streamlined transfer process, quality handoff and 2-way communication, and positive relationships between physicians across facilities. In addition to directly affecting the effectiveness of interfacility transfer communication, these factors in the conceptual model affect each other. The presence or lack of a streamlined transfer process influences the quality of the handoff and communication. For example, clunky systems result in less timely and less frequent communication: “If you have multiple different phone conversations happening and plans are getting sort of reshifted but not everybody is aware, then that can cause some problems in terms of efficiency of transfer and then efficiency of getting a plan started when the patient arrives.” (accepting physician).

The quality of the handoff and communication content influences the trust between the communicators: “I have developed an internal system of—if you will—a roster of people that I can trust or not or places that are more likely to give accurate information.” (accepting physician). Also, the existing relationships affect the quality of the handoff: “If they are familiar with the [hospital] system, a lot of times they give us all the information we need; name, date of birth, weight, etc.” (accepting physician). The influences these various components have on each other are not isolated to single transfer cases, but instead persist and carryover into future interfacility transfers.

DISCUSSION To our knowledge, this study is the first qualitative analysis to examine the barriers and facilitators to effective interfacility pediatric transfer experiences to general pediatric floors from the perspectives of physicians of CSHCN. This explorative study identified that streamlined transfer process, quality handoff and 2-way communication, and positive relationships between physicians across facilities are perceived to be essential aspects of effective interfacility transfer communication. Importantly, participants expressed that the system of interfacility transfers needs re-engineering. For their identified interfacility transfer challenges, participants provided suggestions for interventions—including standardizing the communication process and incorporating more technology—that can be explored in future research. Although this study intended to explore perspectives of physicians of transferred CSHCN, the findings are not necessarily limited to CSHCN. The physician participants

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were identified on the basis of their caring for a transferred patient meeting CSHCN criteria, but these physicians also care for transferred patients who are not CSHCN. As result, their experiences and thus the results of this study pertain to not just CSHCN, but rather the broader group of pediatric patients experiencing an interfacility transfer. Results of our study support previous research suggesting that interfacility transfers can be burdensome to physicians.6 The perceptions from our participants of the cumbersome telephone communication required to arrange transfers aligns with previous data showing that 24% of transfer arrangements require 4 or more phone calls, and sometimes upward of 11 calls.7 The burdens caused by the cumbersome systems seem to be exacerbated by the interpersonal relationship problems between some referring and accepting physicians. The experiences of our participants of conflicts and disrespectful communication are not unique. The transfer process has been recognized to require negotiations between these 2 provider types, and such negotiations can be a fractured and contentious process.6 One potential source of these negative communication relations might be the lack of understanding of the other provider’s situation, such as the limitations of the referring facilities’ resources.7 Participants identified interfacility transfer challenges that are not only burdensome to physicians but also pose safety and quality threats. Our results suggest that deficiencies in verbal and written transmission of information are contributing features of these threats. Although there is limited research on transmission of information during interfacility transfers, the intrahospital and inpatient-tooutpatient handoffs have been more thoroughly studied. The intrahospital handoff is associated with delays in diagnosis or treatment, redundant provider work, adverse events, and near misses.18,19 The discharge handoff is associated with medication discrepancies, dissatisfied primary physicians, missed abnormal laboratory results, and missed clinically urgent actions.9,20,21 Our study results indicate the interfacility transfer handoff is associated with similar adverse patient care problems. Further research is needed to quantify the adverse verbal and written communication measures that occur during interfacility transfers to understand the gravity of the problem and to develop and test targeted interventions to improve these potential safety and quality threats. Suggestions from referring and accepting physicians in our study for how to improve verbal communication included standardizing the communication process with a uniform interfacility handoff tool. Standardized handoffs are proven to reduce medical errors and preventable adverse events.22 A standardized handoff tool might also clarify expectations for the components of a verbal handoff and thus alleviate conflicts that arise from the perceived disrespect that occurs when physicians ask questions to gather additional information. After the transfer, standardizing a system to provide and receive feedback is another intervention worthy of exploration. Generating and testing quality measures on transfer handoffs and feedback processes would be a valuable next step.

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Additional intervention recommendations included increased incorporation of technology. The specific suggestion of increased use of telemedicine to improve interfacility transfer communication is an intervention supported by research. Compared with telephone consultations, pediatric telemedicine consultations are associated with higher parent-perceived quality of care and lower odds of physician-related medication errors.23,24 Furthermore, the use of telemedicine has suggested a high level of physician satisfaction.25 Improving physician satisfaction during interfacility transfer communication might have positive effects on physician-physician relationships. Considering the finding in our study of the importance of positive relationships between physicians across facilities, further research on the effect of telemedicine on physician relationships is warranted. This study has several limitations. Transferability is limited by use of a single receiving facility. However, without being prompted to do so, the referring physician participants reflected on transfer experiences with all facilities to which they referred. Approximately half of participating referring physicians had experience working in settings that accept and refer patients. They were recruited on the basis of the experience of referring a transferred patient as listed in the transfer center database. We recognize that other experiences, such as accepting transferred patients, might influence their perceptions reported in this study. We recruited approximately equal numbers of physicians who had recent experience as referring or accepting physicians. Within the small group of referring physicians, there was diversity in training backgrounds and clinical practice locations. Of note, there was only 1 pediatrician with specialty training and only 2 emergency medicine trained physicians. However, no new themes were found in review of transcripts from pediatricians with specialty training or emergency trained physicians. Additionally, the peer-review process showed that we reached saturation on the final results. Among the 17 transferred patients of the physician interviewees, none of the patients’ primary reason for transfer was for a higher level of care. It is possible that this population of patients that was not represented in this study have different barriers and facilitators to effective interfacility transfers. Finally, there exists concern for potential response bias among participants, especially because of the low recruitment rate. Potentially, participants who agreed to be in this study had atypical perceptions because of unusually negative or positive interfacility transfer experiences. Despite these limitations, we provided valuable insight into the perceptions from referring and accepting physicians of barriers and facilitators to effective interfacility transfer communication.

CONCLUSION Referring and accepting physicians in our study perceived streamlined transfer process, quality handoff and 2-way communication, and positive relationships between physicians across facilities to be integral component a of effective interfacility transfer communication. Efforts

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to improve interfacility pediatric transfer communication will require re-engineering of our transfer communication systems. Specific areas of focus should target fostering positive relationships between physicians across facilities by building trust and addressing conflict and disrespectful communication. They should also target improving the quality of the handoff process and 2-way communication by improving verbal and written transmission of information, keeping physicians updated, and providing feedback to each other. Finally, areas of focus should target streamlining the transfer process by making communication processes more efficient and less clunky. Standardizing the communication process and incorporating more technology during interfacility transfers are recommended interventions to be explored in future research.

ACKNOWLEDGMENTS Financial disclosure: Funding provided by the Lucile Packard Foundation for Children’s Health (LPFCH): 2014 Young Investigator Award supporting Children and Youth with Special Health Care Needs. The funding source had no involvement in the study design, data collection, data analysis, writing of the report, or decision to submit the article for publication. Authorship statement: J.L.R. conceptualized and designed the study, conducted the data collection (interviews) and data analysis, interpreted the results, drafted the initial manuscript, and revised and approved the final manuscript as submitted. M.J.O. contributed to the conceptualization and design of the study, conducted the data analysis and interpretation of the results, revised the manuscript, and approved the final manuscript as submitted. L.H. contributed to the conceptualization and design of the study, conducted the data collection (interviews), data analysis, and interpretation of the results, revised the manuscript, and approved the final manuscript as submitted. S.T.L. contributed to the data analysis and interpretation of the results, revised the manuscript, and approved the final manuscript as submitted. R.S.R. contributed to the conceptualization and design of the study, conducted the data analysis and interpretation of the results, revised the manuscript, and approved the final manuscript as submitted.

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