James S. Todd Memorial Research Award

Improving Patient Trajectory Management and Care Coordination with a Multidisciplinary Checklist

Ayse Gurses, PhD, Johns Hopkins University School of Medicine

The objective of this project is to identify barriers to and principles and strategies for effective care coordination and patient trajectory management. A trajectory is a sequence of actions toward a goal (e.g., safe patient discharge) including any contingencies and interactions among care providers, patients and families. Effective patient trajectory management is essential for improving patient safety and reducing costs of care. Human factors and cognitive systems engineering can provide a strong theoretical framework for developing the practices and tools needed to improve coordination and trajectory management.

We have been conducting ethnographic studies (direct observations during rounds and handoff reports as well as semistructured interviews) in two different sites. Preliminary results indicate that there are several barriers to effective trajectory management such as ineffective and inadequate communication among multidisciplinary care providers, inadequate and misleading communication with patients and families regarding discharge planning, ambiguity regarding when to pass the baton to the primary care provider, problems in medication reconciliation due to multiple and poorly designed information systems, and delays in writing medical orders necessary to start the home care and rehabilitation arrangements. Based on the preliminary findings, we designed and pilot tested a paper-based daily communication tool that provides an overview of each patient’s trajectory, including anticipated discharge date and location, major milestones, goals, and possible threats to a safe and timely discharge, teaching needs, other tasks-to-do, future plans, and assignment of responsibility. Currently, we are in the process of implementing the daily communication tool in one of the study units.

The study has major implications as it will lay the foundation for identifying practices and developing tools to improve coordination and safety in multidisciplinary care environments. Furthermore, this initial study was pivotal in allowing Dr. Ayse P. Gurses to obtain a Career Grant (K01) from the Agency for Healthcare Research and Quality aimed at improving the safety of care transitions (from operating room to ICU, ICU to floor, at discharge and at first visit with the primary care doctor).

NPSF Board Grant

Identifying the Cognitive Dimensions of ‘Failure to Rescue’

Alexa Doig, PhD, RN, University of Utah College of Nursing

Training programs designed to enhance nurse performance in areas affecting patient safety must be based on a thorough understanding of the cognitive psychology of the nurse. The purpose of this research is to identify the cognitive patterns that help nurses successfully detect life threatening complications versus those that consistently lead to missed opportunity or ‘failure to rescue.’ In this study we are observing novice and experienced oncology nurses as they monitor hospitalized cancer patients in a high-fidelity simulated environment. Following the observations, video-based debriefing interviews are used to capture the thought processes underlying observed behaviors. The goal of the analysis will be to compare and contrast observed behaviors and thought processes among successfully detected events and potential failure to rescue situations.

Successful and unsuccessful strategies used for patient surveillance and heuristics used as the basis for clinical decision making will be examined.

Based on the findings from the first part of this study, we will develop and evaluate a cognitive training intervention to help novice oncology nurses rapidly acquire expertise in the surveillance for and detection of life threatening complications. With this refined method for clinical training we hope to promote early detection and recognition of situations that have a high potential of leading to failure to rescue.