A Quality Improvement Project to Improve Transfers from a Neonatal Intensive Care Unit to a Special Care Nursery

Purpose/Objectives: Transitions of care are an inevitable occurrence in medical care, with severe implications if handled improperly. In our Neonatal Intensive Care Unit (NICU), a transition of care between teams occurs when a patient is transferred to the Special Care Nursery (SCN). We noticed several problems with our transfer process and designed a Quality Improvement (QI) project to decrease the number of suboptimal transfers from the NICU to the SCN by 50% in 9 months. We defined sub-optimal transfers as discharges within 72 hours of transfer to SCN, or return to the NICU within 5 days of transfer.

Design/Methods: Our team consists of an attending neonatologist, neonatology fellow, SCN nurse practitioner, NICU, and SCN charge nurses. After baseline data collection, a staff survey was conducted to determine staff attitudes and knowledge about NICU to SCN transfers. A repeat survey was carried out midway through the project with a plan for a final survey at the end. In the first plan-do-study-act (PDSA) cycle, we implemented a checklist to be completed by the neonatology fellows that addressed steps to be completed before transfer to SCN. In the second PDSA cycle, we designed an algorithm outlining the transfer process, including notification of a point person for transfer decisions. In the third PDSA cycle (ongoing), the goal is to further increase staff awareness by posting the algorithm in strategic locations around the NICU and SCN, as well as involving the NICU and SCN bedside nurses in verification of checklist completion. Our outcome measures are the percentage of suboptimal transfers ,and the percentage of parents notified before transfer (goal 95%). Process measures include the percentage of completed checklists and the percentage of staff that report being very satisfied with the transfer process (goal 30%). Our balancing measure is the percentage of providers who report a burdensome transfer process (goal is less than 50%).

Results: We collected baseline data over 15 months revealing a 7% sub-optimal transfer rate and parent notification rate of 80%. Initial survey results indicated the lack of a clear person in charge of transfer decisions, lack of well-defined transfer process and failure to consistently inform parents before transfer. On the baseline survey, 15% of staff reported satisfaction with the transfer process, which increased to 29% in the second survey. Checklist completion is currently at 55% and parent notification has increased to 90%. 50% of staff reported not experiencing increased burden by the transfer process at baseline, increasing to 66% in the second survey

Conclusion/Discussion: A well-defined transfer process can address problems such as poor parent notification, staff satisfaction and sub-optimal transfers with their attendant risks. This project is ongoing with 3 months remaining in the improvement period and another 6 months to monitor for sustainability.