Primary care provider perceptions of intake transition records and shared care with outpatient cardiac rehabilitation programs.

BACKGROUND: While it is recommended that records are kept between primary care providers (PCPs) and specialists during patient transitions from hospital to community care, this communication is not currently standardized. We aimed to assess the transmission of cardiac rehabilitation (CR) program intake transition records to PCPs and to explore PCPs' needs in communication with CR programs and for intake transition record content. METHOD: 144 PCPs of consenting enrollees from 8 regional and urban Ontario CR programs participated in this cross-sectional study. Intake transition records were tracked from the CR program to the PCP's office. Sixty-six PCPs participated in structured telephone interviews. RESULTS: Sixty-eight (47.6%) PCPs received a CR intake transition record. Fifty-eight (87.9%) PCPs desired intake transition records, with most wanting it transmitted via fax (n = 52, 78.8%). On a 5-point Likert scale, PCPs strongly agreed that the CR transition record met their needs for providing patient care (4.32 ± 0.61), with 48 (76.2%) reporting that it improved their management of patients' cardiac risk. PCPs rated the following elements as most important to include in an intake transition record: clinical status (4.67 ± 0.64), exercise test results (4.61 ± 0.52), and the proposed patient care plan (4.59 ± 0.71). CONCLUSIONS: Less than half of intake transition records are reaching PCPs, revealing a large gap in continuity of patient care. PCP responses should be used to develop an evidence-based intake transition record, and procedures should be implemented to ensure high-quality transitional care.

Bridging the communication gap between public and private radiology services.

The delay in transfer of imaging studies when a patient moves between hospitals and between public and private systems has been a barrier to expedient and safe patient management. There is also suboptimal reporting when patients have serial imaging undertaken partly in the private sector and partly in the public sector, because of inability to access previous imaging for comparison. Availability of a DICOM (Digital Imaging and Communications in Medicine) server enables sharing of health information, including imaging data, across various sites and jurisdictions. In Perth, Western Australia, we have successfully introduced electronic image transfer between five public teaching hospitals and three large private practices with different picture archiving and communication systems.

Survey of primary care pediatricians on the transition and transfer of adolescents to adult health care.

The transition and transfer from pediatrics to adult health care of youth with and without special health care needs has become a focus of professional organizations, health care insurers, national policy makers, and providers. To understand transition and transfer at a primary care practice level, all primary care pediatricians in Rhode Island were surveyed. Responses were received from 103 of 169 (60.9%) practicing pediatricians. Few responders had practice policies on transfer. Most reported that transition should begin later than recommended. Few practices communicated with adult providers at transfer. Most reported that health insurers were of little help in transfer. Many pediatric practices had young adults after age 22 and many with special needs. Responders reported adolescents left their practices by 1 of 6 methods. The survey indicates the need for further study of transition and transfer and the need for additional training and education if transfers are to be successful.

Promoting effective rehabilitation via nurse-initiated patient transfer.

The transfer of patients from a district general hospital to community hospitals for rehabilitation is a key part of their care. Thorough assessment and preparation of the patient and his or her relatives is essential. Senior nurses in one trust set up a project to improve this transfer process for patients by introducing a nurse-to-nurse referral project.

Up-front centralized data review and individualized treatment proposals in a multicenter pediatric Hodgkin's disease trial with 71 participating hospitals: the experience of the German-Austrian pediatric multicenter trial DAL-HD-90.

BACKGROUND AND PURPOSE: A systematic procedure for up-front centralized data review and the set-up of individualized treatment proposals was integrated prospectively into the German-Austrian multicenter trial DAL-HD-90 for pediatric Hodgkin's disease (HD) in order to introduce local radiotherapy according to the individual patient's spread of disease within a combined-modality treatment. This paper investigates the feasibility of such a procedure and its impact on the final definition of the extent and stage of disease as well as on the choice of treatment. PATIENTS AND METHODS: Between October 1990 and July 1995, 578 children and adolescents <18 years (259 girls, 319 boys, median age 12.9 years) with HD were enrolled into the HD-90 trial. After clinical and pathological staging (66.4/33.6%), patients were allocated to treatment groups (TG) 1 'early stage', TG2 'intermediate stage', or TG3 'advanced stage'. All groups underwent two cycles of OPPA (vincristine, prednisone, procarbazine, doxorubicin) (girls) or OEPA (E, etoposide) (boys) for induction chemotherapy. TG2 and TG3 continued on as two or four cycles, respectively, of COPP (C, cyclophosphamide). Low-dose local radiotherapy was given to the initially involved sites, with radiation doses of 25 Gy in TG1/TG2, and 20 Gy in TG3. All documentation forms, radiographs, and chest and abdominal computed tomography (CT) scans were centrally reviewed, addressing in particular the individual patient's extent and stage of disease. This review and the set-up of individualized treatment proposals were in the hands of the study coordinator, one additional pediatrician and two radiation oncologists and radiologists at the study center. During a time slot of at least 8 weeks (two cycles of standard chemotherapy in all three TGs) the individualized treatment proposals were to be sent to the participating hospital. RESULTS: Complete sets of documentation from 564/578 patients (97.6%) were submitted sufficiently early to the study center. A total of 285 out of 574 chest radiographs, 468 out of 553 chest CT scans and 421 out of 548 abdominal CT scans were available from 71 hospitals. A total of 564 individualized treatment proposals were worked out by the review group and sent to the hospitals before radiotherapy began. Re-analysis of images and documentation forms, including laboratory and clinical data, resulted in a revision of stage in 115/571 patients (20.1%) and of TG in 76/571 patients (13.3%). A total of 67/76 patients were shifted into a higher TG, 60 patients on account of additionally detected extralymphatic involvement, five patients because of additionally detected lymph node involvement and two patients due to clinical data which had to be classified as B-symptoms. A total of 9/76 patients were shifted into a lower TG; in three patients extranodal disease and in six patents local lymph node involvement could not be confirmed. CONCLUSIONS: The up-front centralized review of patient data and consecutive set-up and delivery of individualized treatment proposals for almost every patient are feasible within a large multicenter trial. Sufficient time and manpower at the study center are needed for the review process and the set-up of individualized treatment proposals. Such a procedure has a significant impact on the homogeneity of stage definition, allocation to TG, and individualized treatment proposals.

Using a CQI team to produce a more efficient nursing home placement process.

BACKGROUND: Caldwell Memorial Hospital, a 120-bed not-for-profit community facility in a rural area in western North Carolina, is within a 12-mile radius of three 120-bed skilled nursing facilities. Generally, one-fourth to one-third of its inpatients are from a nursing home. THE NURSING HOME PLACEMENT PROCESS PROJECT: Since 1992 Caldwell has utilized the data-driven, six-step Juran method for its continuous quality improvement (CQI) projects. A CQI team working on social workers' efficiency and visibility recommended that another team begin work on the nursing home placement process. Area nursing homes complained that they were not receiving their fair share of referrals and that transfer documentation was, at times, lacking. THE TEAM ARRIVES AT REMEDIES: The nursing home placement process was streamlined and forms were improved and standardized. A notebook was created and procedures for nursing home placement and for using forms were placed in this notebook. In addition, the team identified and created the long term care fax list, which included all 28 facilities within a 50-mile radius. IMPLEMENTATION: A pilot project involving 23 patients was conducted from July 24, 1995, until August 31, 1995. With successful results, the decision was made to replicate the new nursing home placement process with all other nursing homes. The team held an open house at the hospital. RESULTS: There have been no complaints from the nursing homes through 1996. The team spirit that originated during the team time carried over into everyday work, resulting in a better relationship between the hospital and nursing home staffs.