In 2015, a reported 136.9 million emergency department (ED) visits occurred with around 12 million resulting in hospital admission and 1.5 million resulting in critical care admission.1 The average cost of an inpatient stay has been estimated to be $10,900, with annual critical care costs reported to represent an estimated $82 billion.2–4
Patients are likely to experience transitions (e.g., movement or transfers) between units including from the ED to hospital units of varying acuity level (e.g., intensive care, stepdown, and medical floor) and between units of varying acuity level. Transitional care represents collective actions performed to support continuity of care as individuals, especially older adults, transition between different care settings or within the same setting.5 However, existing transitional care models have primarily targeted transitions occurring between hospitals and community settings.6–8 Less attention has been placed on transitions between community-based care settings such as between the skilled nursing facility and home.9
Transitions place individuals at risk of experiencing negative clinical outcomes such as medication errors or adverse events.10 Existing research on transitional care models has shown that smoother, more coordinated transitions improve a host of clinical outcomes, including reduction in medication errors, health care utilization and costs,11 and improved patient and caregiver experiences.12 Models have not, however, been developed around facilitating effective intra-hospital transitions to reduce potential negative clinical outcomes occurring during hospitalization.
Intrahospital transitions refer to transitions occurring within the hospital setting, including transfer from the ED to a hospital unit, between different hospital units, or between different beds on the same floor or unit.13,14 Transitions occurring within hospitals represent a set of complex activities. Environmental challenges, professional conflicts, communication errors, crowding, and heavy workloads may negatively affect the quality of transitional care occurring within hospital settings.15,16 There is a large body of research on transitions in general.8 Previous research has focused on outcomes relating to intensive care unit (ICU) discharge,17–19 or on specific components such as handoffs, transport teams, and workload. However, there is a gap in research on the concept of intrahospital transitions.13 The purpose of this systematic review was to examine reported clinical outcomes in association with intrahospital transitions.
This review used the PRISMA guidelines.20 Because this was a review based on published literature, institutional review board approval was not required. Searches were conducted in PubMED/MEDLINE, CINAHL, and PsycINFO. All databases were searched using the following limits: language (English), adults (18+), peer-reviewed journals and publication date between January 2003 and December 2018.
The following combinations of key terms were used (including medical subject headings) along with the Boolean operator “AND”: intrahospital transitions, transitions, patient transfers, patient journeys, hospital, hospital unit, ED, critical care, clinical, and outcomes. The terms ED, critical care, and hospital unit were used to identify transitions occurring between the ED and adult hospital units, excluding psychiatric specialties or admissions to gynecological services.
A manual review of the selected articles' bibliographies and reference lists also occurred to identify additional relevant articles. Manual searches were conducted to check for further articles fitting the inclusion criteria that were not identified during search of the databases.
After completion of the database searches, removal of duplicate articles was performed. Article titles and abstracts were reviewed by the first author to screen out irrelevant article entries. Full-text articles were reviewed independently by the first and last authors. The final decision to include an article was based on consensus of the two reviewers after in-person discussion.
Articles were included if they focused on intrahospital transitions and identified clinical outcomes relating to intrahospital transitions. Articles were excluded if they did not specifically focus on transitions or transfers, focused on transitions occurring between hospital and nonhospital settings, included transitions to psychiatric or gynecology units, were review articles, concentrated on actions relating to discharge planning, postdischarge follow-up, hospital readmissions, or included a mix of transitions including transitions between and within different organizations or settings.
Data Abstraction and Synthesis
Articles were evaluated according to the level of evidence guidelines adapted from Sackett et al21 (Table 1). A lack of Level I evidence became apparent during this review. Instead, articles included in this review represented a Level II or Level IV evidence (Table 2), demonstrating a need for more high-quality research to understand how intrahospital transitions directly influence the occurrence of clinical outcomes. Studies were additionally evaluated based on the type of intrahospital transition reported.
Data abstracted from each manuscript included the purpose/aim, level of evidence, study design, and sample characteristics (e.g., sample size, type of intrahospital transition, and sample demographics focusing on age of patients) (Table 2). Extraction was performed and reviewed until consensus was reached by the first and last authors. Transition type, study methods, and reported outcomes varied widely across the selected articles; therefore, a meta-analysis of pooled data was not performed.
Because the aim of this study was to consider intrahospital transitions and clinical outcomes, each study's reporting of clinical outcomes was specifically examined. The reported outcomes were organized into delirium, hospital length of stay (LOS) and mortality, and adverse events categories. Categories emerged based on the clinical outcomes reported in the literature. The first and last authors agreed on the clinical outcome being reported (Table 3). As several studies presented outcomes relating to more than one outcome, organization occurred based on the major outcome reported.
Description of Studies
The electronic database search yielded 1,888 articles total (Figure 1). During the title/abstract screening, 1,841 articles were excluded; 21 articles were excluded during full text screening. This resulted in 14 articles that met inclusion criteria. Articles were excluded primarily because of a focus on transitions occurring between community settings or discharge-related events, or because they failed to address clinical outcomes. The articles used quantitative methods including six cohort studies and three cross-sectional studies, both of which included prospective and retrospective designs. In addition, one article used a case–control, and four performed retrospective chart reviews (Table 2). Most articles included transfers of patients 18 years or older, with 3 focusing specifically on adults 60 years or older.
Most articles addressed controlling for the effect of co-morbidities on clinical outcomes. Most articles included the Charlson comorbidity index, acute physiology and chronic health evaluation (APACHE), acute physiology score, and simplified acute physiology score to account for illness severity of the patients experiencing intrahospital transitions. In contrast, one article used the clinical classification system, all patient disease-related groups classification system, and a comorbidity medical condition scale developed by Elixhauser et al.22
Three articles addressed the relationship between delirium and intrahospital transitions, and the impact of transitions on other clinical outcomes such as medical condition and hospital LOS.23–25 The articles23–25 were Level II evidence and the remaining article was a Level IV descriptive comparison. The type of intrahospital transition varied across the articles; however, three articles focused on a specific single transition event, such as from the ED to a hospital unit24,25 or between ICU and a step-down unit.23
In addition, the methods used to screen or diagnose the presence of delirium and the association between the timing of transfers and outcomes differed across articles. One study used the Confusion Assessment Method to diagnose delirium.25 Goldberg et al24 used chart reviews and followed a checklist created by Inouye et al to determine the likely presence of delirium. One article relied on ICD-10 codes and another article used the Intensive Care Delirium Screening Checklist.23
Delirium occurrence was associated with older and sicker patients, resulting in increased hospital LOS.23 A significant association was found between the number of transitions and occurrence of delirium, LOS, and mortality of older adults.24,26 Another study found delirium frequently developed within the first 3 days of transfer between the ED and hospital unit.25 In this study, however, assessment of delirium was often absent during transitions.25 Early detection of delirium represents a critical aspect of care for hospitalized individuals. Moreover, early development of delirium during hospitalization was associated with increased risk of ICU transfer and in-hospital death.25
Hospital Length of Stay and Mortality
In addition to the articles linking delirium to medical condition and LOS, seven articles focused on the association between intrahospital transitions and hospital LOS and mortality rates.26–32 Two additional articles also considered hospital LOS and adverse events.33,34 Most articles addressing LOS and mortality represented Level II evidence.27,28,30,31
Length of time in the ED or ICU before transition event was associated with in-hospital mortality.30,32 Delayed transfers from the ICU to general units was associated with increased hospital LOS and mortality.27 Moreover, one study found that each hour of delay increased the mortality rate.27 Patients transferred to higher levels of care were three times more likely to die, even after controlling for the severity of illness.28 One study found intrahospital transitions occurring from a lower level of care to higher level of care predicted higher mortality risk.28 Hospital LOS increased as individuals experienced three or more transitions.35 Hospital LOS and costs increased as transfers occurred.23,28,33–35 Another study found transfers to potentially inappropriate units demonstrated an increased risk of dying within 48 hours of admission and individuals were more likely to be transferred to another facility, such as a nursing home, upon hospital discharge.26 Finally, two studies found that patients admitted to units based on bed availability instead of appropriateness led to increased in-hospital mortality.26,29
Two articles specifically examined adverse events associated with intrahospital transitions occurring throughout the hospital stay.14,35 Both articles defined intrahospital transitions as including transfers within the same units, such as between rooms, and transfers between hospital units.
Definition and discussion of adverse events varied across both articles. One article represented Level IV evidence and specifically identified adverse events of interest, such as falls with injury and wound infection, associated with intrahospital transitions based on the Classification of Hospital Acquired Diagnoses approach (CHADx).14 The CHADx helps differentiate hospital complications from comorbidities that are present on admission.36 The other article, representing Level II evidence, created a composite score consisting of pressure ulcer occurrence, number of falls, any medication error, and a general other category consisting of various events. Adverse events were reported as a single outcome, increasing the difficulty in understanding the relationship between intra-hospital transitions and specific adverse event related outcomes.
Overall, the two articles demonstrated risk of adverse events increased as individuals experienced three or more transitions.35 Transfers between beds within the same unit and transfers between units were also associated with an increased risk for falls and wound infection.14,35 Delayed transfer in the ED was also found to increase the negative condition of patients during hospital discharge.30
Several limitations were found in the process of compiling this systematic review. This review focused on transitions occurring within the hospital setting. However, the influence of transitions before hospital admission and transitions focusing on discharge planning or posthospital care was excluded. These transitions may provide an important link and influence on intrahospital transitions. Second, the use of the term intrahospital also may not have captured all relevant articles relating to transitions occurring within the hospital setting. Third, the articles included represented a broad range of participants and methodologies hindering the ability to perform either a meta-analysis or meta-synthesis of the results presented. In addition, articles displayed a wide range of purposes regarding the concept of intrahospital transitions, including the impact of delays, predictors of transitions to higher levels of care, and transfers occurring at night time or to outlier units. Finally, this review addresses a wide spectrum of ages as few articles targeted specific adult populations.
This systematic review identified several negative clinical outcomes associated with intrahospital transitions, including delirium, increased hospital LOS, and adverse events such as risk of falls and infection. Importantly, this review found the number of transitions and delays in transitions resulted in higher mortality rates.
Intrahospital transitions occur frequently. Previous research addressing the impact of transfers on workload found patients experienced an average transfer rate of 2.4 during hospitalization. In addition, a reported 94.6% of patients experienced at least one transfer while hospitalized.37 Intrahospital transitions challenge the ability of health care professionals to manage and provide appropriate care during transfers. Differences in culture and environment between units in the hospital can create communication challenges and competing priorities in care.38–40 In addition, intrahospital transitions have demonstrated the potential for negative impact on workload.37
This review demonstrates the influence of intrahospital transitions on clinical outcomes. Most articles addressed morbidity/mortality rates and hospital LOS. A limited number also highlighted the potential relationship between delirium and hospital transfers. For example, delirium occurring within the first 3 days of hospitalization was associated with unexpected transfers to the ICU and hospital mortality.25 Furthermore, the occurrence of delirium after transfer to another unit increased in-hospital death, rate of transfer to the ICU, hospital LOS, and morbidity and mortality rates.23–26 Thus, delirium can be both an adverse outcome caused by some intrahospital transfers, and a predictor of other serious adverse outcomes if present before transfer.
Delirium can occur early during hospitalization,25 such as during a prolonged stay in the ED. However, delirium assessment may not occur during transfer from the ED to hospital unit.25 The challenges associated with organizational culture and competing priorities may limit health care professionals' ability to perform the care necessary to prevent negative clinical outcomes during intrahospital transitions. The lack of timely delirium assessment and management during and following intrahospital transitions represents a key area of possible intervention to improve quality and safety.
Furthermore, associations were found between transitions from the ED to inappropriate units or longer wait times before transfers, worsening of the medical condition, and increased in-hospital morbidity and mortality rates.23–26 Previous research has also demonstrated a link between longer ED wait times and increased hospital LOS.41,42 However, conflicting outcomes for patient mortality have been reported.42–44 Emergency department environmental factors and severity of patients' presentation of illness44 may affect LOS, resulting in transfer to inappropriate units and negative clinical outcomes.26,29 The association between time spent in the ED before intrahospital transitions requires more attention to increase understanding regarding the link between the ED and clinical outcomes of transitions.
Intrahospital transitions may also affect the incidence of adverse events. Delayed transfer from the ED was found to result in adverse events such as higher rates of sepsis, mechanical ventilation, and central venous cathorization.31 Other adverse events such as fall risks and infections were higher in patients experiencing multiple transfers.14 The direct linkage between increased fall and infection rates and number of transfers may be unclear, due to differing levels of patients' illness severity. However, increased vigilance and monitoring for adverse events is necessary as patients experience multiple intra-hospital transitions. Monitoring for potential adverse events during intrahospital transitions may support a reduction in hospital costs and mortality rates.
Previous reviews have been performed in the areas of handoffs, discharge related activities, nursing workloads, communication, and experiences.17–19,45,46 Handoffs and other communication strategies may be limited to interactions within one set of health care professionals, such as nurse-to-nurse or physician-to-physician communication.13,47 Moreover, the impact of intrahospital transitions on clinical outcomes, such as how to best transfer patients while limiting unintended adverse events, remains unclear.
Communication represents a key factor toward potentially ameliorating adverse outcomes during intrahospital transitions. Breakdown in communication during handoffs between HCPs challenges patient safety.45 Poor handoffs between the ED and units may delay care and result in adverse events.45 However, handoffs represent only one factor associated with intrahospital transitions.13 To the authors' knowledge, no other systematic review exists exploring clinical outcomes associated with intrahospital transitions.
This review found a limited number of articles specifically identifying intrahospital transitions' impact on clinical outcomes. Intrahospital transitions have been linked to occurrence of delirium, increased hospital LOS, mortality, and adverse events. Nonetheless, most intrahospital transition research has concentrated on experiential or emotional outcomes and used terminology that may not be reflective of transitional care. Furthermore, this systematic review found few studies addressing the specific population of older adults.
Most articles included in this systematic review addressed a wide age range of experiences. During initial consideration of published literature regarding intrahospital transitions, special focus on older adults was attempted. Older adults are prone to higher rates of admission and adverse health outcomes on entry to the ED.48 Nonetheless, a limited number of articles specifically targeted older adults and demonstrated a variation in the definition of older adult age. For example, one article included older adults aged 60 years or older,33 one targeted 65 years or older,25 and one targeted individuals 70 years or older.24 Another article did not specifically address age, but sampled from individuals admitted with a diagnosis of dementia or delirium, suggesting a sample primarily comprised of older adults.26 Older adults represent a key patient population in the ED, ICU, and general units, prompting the need for additional consideration of outcomes relating to older adults.
Intrahospital transitions represent a key period of time to consider and address patient safety and clinical outcomes and mortality rates and cost. Patients are likely to experience several transitions during hospitalization. Consistent recognition and communication of the potential for the occurrence of delirium and adverse events is needed throughout the entire length of hospital stay. Policies regarding assessment of delirium and risk for adverse events before and after each intrahospital transition is needed to support delivery of high quality of care. Moreover, as the population continues to age, the need for research on older adults during intrahospital transitions requires further research addressing clinical outcomes and promoting development of hospital care environments supportive of care for older adults.
Alycia A. Bristol, PhD, RN, AGCNS-BC, is a Postdoctoral Associate at the Hartford Institute for Geriatric Nursing at NYU Rory Meyers College of Nursing in New York, NY.
Catherine E. Schneider, PhD, is a Postdoctoral Associate at the Hartford Institute for Geriatric Nursing at NYU Rory Meyers College of Nursing in New York, NY.
Shih-Yin Lin, PhD, MM, MPH, is a Senior Research Scientist and Project Director at the Hartford Institute for Geriatric Nursing at NYU Rory Meyers College of Nursing in New York, NY.
Abraham A. Brody, PhD, RN, FAAN, is an Associate Professor of Nursing and Medicine and Associate Director at the Hartford Institute for Geriatric Nursing at NYU Rory Meyers College of Nursing in New York, NY. He is also the founder of Aliviado Health.
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