Elucidating Non-Routine Events Arising from Interhospital Transfers

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Veterans experienced more than 3 million emergency department visits in 2021 and nearly one-third of these are in non-VA settings. Non-VA emergency care is the single largest contributor to community care with an estimated $500 million in monthly costs. Interhospital transfers are used either to repatriate Veterans during acute episodes of care or to provide access specialty care (e.g., cardiology) should such skilled services not be available at the initial hospital. However, such transfers are burdensome for Veterans and their families, and are associated with worsened clinical outcomes. The field of Human Factors Engineering uses system science to examine what may contribute to suboptimal clinical outcomes through the evaluation of “Non-Routine Events.” These are sub-optimal deviations from the standards of care or unexpected events that are identified through validated surveys of staff, clinicians, and patients. In this pilot application, we seek to advance the study of Non-Routine Events (NREs) through their application to interhospital transfers from VA and non-VA emergency departments. We will use validated surveys of NREs along with transfer documentation to study transfers for evidence of NREs. Finally, in order to automate NRE data collection, we seek to train an optical character recognition and natural language processing informatics cool, “MIRROR EHR,” to extract data of NRE components from scanned medical records for Veterans who experienced interhospital transfers. Guided by the principles of high reliability, our innovative pilot proposal directly addresses multiple ORD-wide and HSR&D priority areas including Access to Care, Quality & Safety, and Healthcare Informatics by using cross-cutting methods of Health Systems Engineering to study interhospital transfers and addressing data quality and how to integrate non-VA data. This work addresses a major legislative priority of the MISSION Act to address the quality and safety of non-VA emergency care. The Specific Aims are: 1) Examine Non-Routine Events arising from interhospital transfers of Veterans; 2) Identify NREs in transferring hospital clinical documentation amongst Veterans experiencing interhospital transfer; and 3) Demonstrate the feasibility of the MIRROR EHR informatics tool to collect and categorize data that are indicators of NREs. The team is uniquely qualified to accomplish these Aims, with expertise in systems science, human factors engineering, biomedical informatics, implementation science, qualitative methods, and acute hospital-based care (emergency and hospital medicine). The institutional environment at the VA Tennessee Valley Healthcare System and Vanderbilt University Medical Center is outstanding, including the Geriatric Research, Education and Clinical Center (GRECC), a site for VA Quality Scholars, an innovative qualitative research center; nationally ranked graduate programs in the relevant fields of study; and the national CTSA coordinating center. This application will conduct necessary pilot work to evaluate the feasibility of NRE data collection arising from interhospital transfers from both VA and non-VA settings using validated NRE surveys. This is a highly innovative proposal to advance the methods of safety science and biomedical informatics designed to improve the quality and safety for Veterans experiencing care transitions in the form of interhospital transfers. Should this work prove feasible, we plan to use these pilot data to prepare a larger Merit award application to evaluate NREs in interhospital transfers and to develop interventions to mitigate their potential harm of Veterans.