Following the release of the Institute of Medicine's seminal report To Err is Human,1 health system redesign has focused on improving the safety and quality of care delivered to patients. Two key components of this system redesign include: greater cooperation among healthcare providers, and greater access and sharing of patient health information.2 These components highlight continuity as a key feature in the provision of high quality safe care to patients. Gaps in the continuity of care can arise when patients transition from one care provider or setting to another. The transition from hospital to community care is one of the most frequent transitions in care. Previous research has indicated that nearly 25% of patients experience an adverse event (e.g. drug interaction, infection, fall) after hospital discharge, with upwards of half of these being preventable.3-5 Many of these adverse events arise from ineffective communication and management of care between hospital providers and the patient or primary care provider.3 The risk is further increased when patients see four or more doctors within two years, experience a care coordination problem or use an emergency department (ED).6 Other challenges identified to improving care transitions after discharge from acute care include: inpatient-outpatient physician discontinuity, changes and discrepancies in medication regimens, self-care responsibilities and social support, and ineffective physician-patient communication.7
Discharge summaries are the most common form of communicating patient information between hospital and primary care (PC) providers.8 Previous research has identified the 12 most important elements of a high quality discharge summary for patients who transition between hospital and primary care, including discharge diagnosis, admission diagnosis, discharge medications, active medical problems at discharge and important pending tests.9 Importantly, standardized and structured forms of discharge summaries have been shown to be preferred over narrative descriptions.10 However, discharge summaries are often not available to PC providers upon patient follow-up.11 A 2015 survey of PC providers in Canada indicated that 68% of PC providers rarely or never receive notification when a patient is seen in the ED.12 Results from a recent systematic review also support this finding, with only 55% of discharge summaries available to PC providers within 48 hours after discharge.13 Lower readmission rates have been found with the availability of a discharge summary during PC provider follow-up.11
Transitions in care between ED and PC are of vital importance to the safety and quality of care provided to patients. Nearly 40% of Canadians have self-reported visiting an ED in the past two years.14 Further, the vast majority of patients (83%) are discharged home.15 While many of these patients are discharged with instructions to follow-up with their PC provider, the format and content of communications between healthcare providers at this interface are often ineffective, inefficient and lack important information about the results of diagnostic testing, discharge medications and follow-up plans.8,13 Further, information that is provided in discharge summaries often contains numerous reporting errors.16 These communication gaps often involve critical patient information that is essential to providing safe care17,18 which can lead to serious adverse events and unnecessary hospital readmissions.19,20
A previous systematic review on improving patient handovers between acute and primary care identified several strategies that significantly improved patient and health system outcomes: medication reconciliation, electronic summaries, discharge planning, shared involvement between acute and primary care providers, electronic discharge notifications and web-based discharge information for primary care providers.21 However, while electronic discharge summaries have been shown to improve timeliness of information exchange between acute and primary care providers, they have not been shown to improve the quality of information.13
To our knowledge, studies evaluating interventions or strategies to improve communication between ED and PC healthcare providers have not been systematically scoped. A search of the JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, PubMed, CINAHL and Embase found no relevant completed or in progress scoping reviews or systematic reviews. We propose to conduct a scoping review to explore the factors influencing communication and information exchange between ED and PC healthcare providers. Our scoping review will consider a broad range of study designs, including quantitative, qualitative and mixed methods, as well as gray literature pertaining to position statements, policies and processes in place in differing health system contexts.
Results from this scoping review will be used to better understand the breadth of current communication and information exchange strategies and to identify current gaps in knowledge that may inform future research directions. This scoping review will use the methodology outlined in the scoping reviews chapter of the Joanna Briggs Institute Reviewer's Manual.22 Broadly, our methods will comprise five major steps: i) identifying the research question; ii) searching for relevant studies; iii) selecting studies; iv) charting data; and v) collating, summarizing and reporting the results.
This scoping review will consider all studies that examine strategies to communicate and exchange patient health information between emergency and primary care settings. Communication in this review pertains to any and all channels through which health information is communicated or exchanged between healthcare providers.
Emergency settings include any hospital or health centre that provides emergent or urgent care for patients in an acute care facility. Primary care refers to care that is provided by a physician or nurse practitioner within the community. Studies will be excluded if they examine communication or information exchange between providers within one setting.
Types of sources
This review will consider both quantitative and qualitative study designs.
Quantitative designs include any experimental study designs, including randomized controlled trials, non-randomized controlled trials, quasi-experimental studies, studies related to analyzing the reliability, validity and accuracy of existing tools, and observational studies.
Qualitative designs include any studies that collect qualitative data, such as, but not limited to, grounded theory and thematic analysis.
Systematic reviews that report on aspects of communication between emergency and primary care settings will be considered for inclusion. Gray literature will also be considered for inclusion in the review and will include papers or reports regarding policies, strategies and policies in use by professional bodies, hospitals and/or health centres for the communication of patient information between emergency and primary care settings.
Our search strategy will aim to find both published and unpublished literature. A three-step strategy will be used to finalize the search strategy for this review. An initial limited search using PubMed and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. The reviewers will contact authors of primary studies or reviews for further information, if necessary. Studies published in English will be considered for inclusion in this review. No date limit will be imposed on this search strategy.
Databases to be searched as part of this review include: PubMed, CINAHL, Embase, and ProQuest Dissertations and Theses. A search using Google Scholar will also be performed.
The search for unpublished literature will include: Canadian Electronic Library, Grey Literature Report, OpenGrey, Health Services Research Projects in Progress, Scopus and relevant organizational websites including, but not limited to, Royal College of Physicians and Surgeons, College of Family Physicians Canada, NHS Evidence, Centre for Reviews and Dissemination, the Agency for Healthcare Research and Quality, and MedNar.
Initial keywords to be used in the initial search include: emergency department, emergency care, primary care, family physician, doctor, resident, nurse, nurse practitioner, interprofessional, interdisciplinary, exchange, communication, document, inform, transfer, transition, handoff, handover, discharge, refer, consult, coordination and continuity. The search strategy for CINAHL is shown in Appendix I.
Extraction of the results
A draft data extraction chart (Appendix II) has been developed by the review team to extract the following study information:
- Year of publication
- Country of origin
- Aim of study
- Study population
- Study setting
- Use of theory or framework
- Communication barriers identified
- Communication strategy details
- Mode of communication
- Health care provider roles involved
- Author conclusions.
Two reviewers will independently extract study data. Reviewers will meet after data extraction has been completed for the first three studies to identify any discrepancies and ensure consistency. Any disagreements will be resolved through discussion and consensus.
Presentation of findings
The results of the scoping review will be presented, where appropriate, as a tabular summary and with the aid of narratives and figures. The tabular summary will highlight the major categories of the data extraction form as described above. A narrative description of key barriers identified by the studies and common strategies to overcome them will be provided to discuss apparent gaps in current knowledge. Common causes and points of communication breakdown identified through the review will be presented as a figure to help illuminate where continuity of information requires improvement.
Stipend support for AB has been provided through a Postdoctoral Fellowship Award from the Maritime Support for Patient Oriented Research (SPOR) Support Unit.
Appendix I: CINAHL search strategy
Appendix II: Data extraction instrument
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2. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century [Internet]. Washington (DC): National Academies Press (US); 2001 [internet]. [cited 2017 Mar 30]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK222274/
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