System-driven gaps in information transfer for residents of aged care : a mixed method document analysis

Due to our ageing population, emergency departments (ED) in acute care facilities are dealing with increased transfers of residents from Residential Aged Care Facilities (RACF). These patients are at risk of acts of provision of unwanted treatments, omission of care, and adverse outcomes including increased mortality directly associated with gaps in transfer information. For at least 30 years, research has attempted to address this frequency of information gaps, which in general are thought to be stemming from RACFs. Research to date has largely focused on identifying and quantifying gaps to highlight the magnitude of the problem, and on developing localised transitional minimum datasets. Further attempts have been made to define the appropriateness of transfer and the subsequent impacts of transfer on ED length of stay. As a result, numerous paper and electronic information transfer tools have been introduced. New transfer forms and formats have led to some success in improving the amount of documentation transferred with residents to ED. However, this has not been sustained over time, and there has been little agreement toward developing a uniform mandated transitional minimum dataset. Despite the focus on transfer documents and information gaps there is a dearth of research looking at clinician authorship or clinician documentation practices during transfer, and few studies include ambulance services and their role in information transfer. The aim of this study is to identify practice contributing to the stubbornness of information gaps in the transfer of aged residents from RACF to ED via ambulance. This study examined documents and clinician documentation practices as implemented across transfer from RACF via ambulance to emergency. A pragmatic approach guided the research design. Retrospective document review was used to examine the connection between documents, document content, the sites of practice and the practices of clinicians undertaking transfer of RACF residents. This approach acknowledged documents as collectively social products that represent organisations and users, and therefore also organisational work and work-practice complexities. Electronically scanned documents used across transfer by RACFs, the ambulance service and emergency triage were accessed via the study hospital's digital medical record system. The digital medical record provided easy access to information from all three groups of interest. Collection of transfer documents and transfer narratives from the same sources and transfer episodes facilitated examination of the relationship of documents to documentation and vice versa, as well as of the trackability of episodic transfer information across organisations. Samples were drawn from 89 transfers undertaken between 1 December 2013 and 31 January 2014. Eighty of these cases met the selection criteria. Data samples collected were: all transfer document types sent from RACFs, all electronic ambulance case records, and all ED triage documents, resulting in 240 cross-facility transfer episodes. From these, 199 verbatim free-text narratives authored by clinicians facilitating each transfer were collected. In addition, 48 yellow transfer envelopes used for transfer by RACFs (not available in the digital medical record) were also collected. A mixed method convergent parallel study design was employed in which quantitative and qualitative data are collected in parallel, analysed separately and then brought together in discussion. Practice Theory was selected as the primary lens for qualitative analysis, applying the concepts of doings, sayings and teleoaffectivity with the concepts of zooming in and zooming out to the overall interconnected web of transfer. Transfer narratives were quantitatively examined for standardisation of salient information using a common handover mnemonic, SBAR (Situation, Background, Assessment, Recommendation or Request). Results identified the foci of information and the presence or absence of salient information in transfer narratives, enabling theorisation of how information is cued by the design of tools and situational context in each of the three groups of interest. The findings showed that consistency, availability and predictability of information were negatively affected by a lack of standardisation of RACF transfer information, despite ambulance and ED triage documents being reasonably standardised. The different contextual perspectives of the three organisations gave rise to different information foci: RACF staff focused on access to resources; ambulance staff focused on identifying a primary physiological concern; and ED triage staff focused on aligning physiological issues with numerical scales of urgency. This thesis makes a novel contribution to understanding why information gaps from RACF to ED persist. All of the transfer tools in use were found to be predominately designed as records of care/event, rather than as information sharing tools that accommodate complex information. The results also show that socio-contextual practices narrowly focus narratives on the activities of the author, or on the context of the situation, to the exclusion of other relevant information. Information intended to avert risk is reliant on experiential prediction and subsequent experiential interpretation of the narrative. Transfers fitting the popular expectations of acute ED services are carried out with surprisingly little transfer information, often relying on implicit mutuality. However, resourcerelated transfers that have limited mutual consensus or underlying agreement pre-condition extensive justifications from RACFs to legitimise transfer, because the usual accepted services of the ED are pre-emptively broadened or strained. The detail of the narrative has little bearing on the type, completeness or availability of additional documents sent by RACF in transfer. Because each of these practices (mutuality and extensive narration and argument) work (i.e. the goal of transfer is successfully enacted) there is little incentive for RACFs to standardise practice. Ambulance case narratives implied on-site verbal exchanges between RACFs and paramedics, and generated content capable of filling some information gaps. This finding substantiated the value of the ambulance document and narrative and suggests that it may be a starting point on which to base an interdisciplinary information bridging tool. This study concludes that current transfer tools used by RACF, ambulance services and ED triage generate site-oriented information with little incentive for collaboration or social exchange. The results of this study have the potential to reduce information gaps common across transfer at the clinical, policy and system design levels. More importantly, these findings have the potential to improve continuity and safety for RACF residents transferred to ED.