The authors reviewed physician-to-physician conversations during emergency transfer of patients with ST-segment elevation myocardial infarction and found that higher-quality physician coordination was associated with faster time to acceptance.
Objectives: Interfacility transfer for time-sensitive emergencies involves rapid and complex care transitions between facilities. We sought to validate relational coordination, a 7-dimension measure of coordination in which a higher score reflects higher-quality coordination, to examine how the quality of coordination affects timeliness in an emergency care setting.
Study Design: Retrospective observational cohort design.
Methods: We used a novel method to examine how the quality of coordination between physicians at the time of transfer affects timeliness of physician acceptance. We recorded physician-to-physician conversations from the transfer of patients with ST-segment elevation myocardial infarction (STEMI), a time-sensitive emergency requiring immediate intervention to prevent morbidity and mortality.
Results: We identified 81 patients experiencing STEMI who were transferred between August 1, 2016, and March 31, 2018. Descriptive statistics, interrater reliability (Spearman correlation coefficients), and generalized linear models were used to examine the association between relational coordination and the physician time-to-acceptance duration. Median (IQR) relational coordination score was 445 (403-493) of a maximum of 700, and median (IQR) time to acceptance was 90.4 (60.2-140.8) seconds. Agreement between abstractors was high (ρ = 0.76). There was a significant, negative relationship between relational coordination and time to acceptance (ρ = –0.38; P < .001). Every 40-point increase in relational coordination was associated with a 25% reduction in time to acceptance.
Conclusions: Relational coordination not only demonstrated high interrater reliability, but higher-quality coordination also was associated with faster physician acceptance during time-sensitive transfers. Use of such measures may provide a mechanism to improve the quality of care and outcomes for patients with STEMI who experience interfacility transfers.
Am J Accountable Care. 2022;10(3):7-15. https://doi.org/10.37765/ajac.2022.89231
Interfacility transfers are complex interactions between transferring and receiving teams from different hospitals who often must act under substantial time pressure. ST-segment elevation myocardial infarction (STEMI) is one such emergent, life-threatening, and time-sensitive condition that can require interfacility transfer. Coordination delays that slow interfacility transfer can be harmful.1,2 Emergency medical services, hospitals, and professional organizations have undertaken substantial structural changes (ie, regionalization) to reduce delays to coronary reperfusion and to create more accessible and timely systems of care. Systemwide coordination of STEMI care in California (ie, regionalization) was associated with increased access to a hospital capable of percutaneous coronary intervention (PCI), greater use of PCI, and lower 7-day mortality and 30-day readmission rates in these high-risk patients.3 However, the interpersonal mechanisms through which structural changes such as regionalization smooth coordination and interfacility transfer remain unclear.
Relationships between organizations and their ability to coordinate complex transfers rapidly may help to explain high-performing STEMI systems of care.4 Prior research on coordination suggests that formal affiliation5 and existence of formal hospital-level relationships6 have a greater influence on transfer destinationthan the distance or quality of the receiving hospital.7,8 Alternatively, simplifying and standardizing processes during interfacility transfers can reduce total duration of transfers.9 Examination of communication during nursing home transfers to the emergency department (ED) has focused on the content and accuracy of communication in transferred documents.10 Prior work demonstrated that the time between electrocardiogram performance and cardiac catheterization laboratory activation is paramount to timeliness of transfer and is influenced by the communication between transferring and receiving centers.11 Given the challenges of capturing the content and quality of the interaction(s) that comprise the transfer during the event, prior work fails to capture the range and type of events that occur during transfers that may ultimately affect patient care and lead to delays. How physician interactions at the time of an emergency transfer affect processes of care that should otherwise be standardized is poorly understood. Whether the quality of real-time coordinating affects transfer processes is key to understanding and improving coordination among care professionals and their organizations.
Relational coordination theory provides a framework for examining interorganizational relationships and why some organizations may work together better than others.12 Recognized by the Agency for Healthcare Research and Quality as a conceptual model to guide development, implementation, and evaluation of care coordination interventions, relational coordination is characterized by the domains of communication and relationships. Four dimensions involve communication: frequency, timeliness, accuracy, and problem-solving; 3 dimensions involve relationships: shared goals, shared knowledge, and mutual respect.12 Research on relational coordination suggests that higher-quality interactions are associated with improved patient outcomes, higher quality of care, and reduced hospital and intensive care unit length of stay.12,13 For patients experiencing transfers for out-of-hospital cardiac arrest, relational coordination was a valid construct.14 Thus, better communication and stronger relationships could theoretically be highly applicable to and potentially enhance the quality of time-sensitive care transitions between unaffiliated organizations. Therefore, we sought to evaluate the reliability of relational coordination as a scale to measure the quality of care coordination through these conversations and whether there is an association with the timeliness of transfer acceptance for patients with STEMI.
We conducted a retrospective analysis of interfacility transfers for patients with suspected STEMI presenting to an ED without primary PCI capabilities. PCI is the preferred method to achieve coronary reperfusion for a patient with STEMI.15 To conduct this analysis, we used retrospective data from the electronic health record along with recorded phone calls between transferring and receiving physicians.
This work was conducted at Vanderbilt University Medical Center (VUMC) and was approved by the institutional review board as minimal risk. VUMC is a quaternary care center that provides comprehensive cardiovascular care for middle Tennessee’s nearly 3 million inhabitants, including 24/7 interventional cardiac catheterization services to approximately 40 to 60 EDs. Despite the presence of an auto-accept policy allowing patients with STEMI to be automatically accepted from all surrounding facilities as an interfacility transfer in order to initiate emergency medical services transportation, a physician hand-off and acceptance was still necessary as part of the transfer process. Otherwise, the transfer could be cancelled. We reasoned that although acceptance was expected as a result of the auto-acceptance policy, the event was still time-dependent because failure to make a decision could result in an unnecessary transfer. Further, our primary outcome, duration until acceptance, was uncertain and may be dependent upon the communication between physicians.
Phone Call Recordings
When a patient with suspected STEMI presented to a transferring ED, a physician-to-physician phone call was initiated by the transferring emergency physician with the cardiologist at VUMC. Physicians on both sides were notified that the conversation was audio recorded. The recorded conversation was stored by VUMC using Encore Recording Software (DVSAnalytics), a cloud-based web application that timestamps conversations.
Patients accepted and transferred from an outside ED to VUMC between August 1, 2016, and March 31, 2018, with a STEMI as determined by activation for STEMI or STEMI equivalents by electrocardiogram (eg, chest pain with new left bundle branch block) were included. Cases were identified using the transfer center database for STEMI activations. Records with incomplete phone call conversations between physicians were excluded. To limit heterogeneity of the transfer situations and patient populations, we limited the setting to transferring EDs. Thus, patients transferred from an inpatient setting, those transferred directly from the scene without first visiting an ED, and patients with cardiac arrest transferred for therapeutic hypothermia were excluded because these represented distinct care processes, which could be highly variable in the duration and content of care; the conversations between physicians may reflect this variability. Timestamps, patient demographics, and clinical data were abstracted from transferring ED records and the VUMC electronic health record.
Our abstraction team consisted of 3 researchers (M.J.W., T.J.V., K.M.) with experience in qualitative research, human subjects research, organization science, and emergency medicine. Each transfer call was scored by 2 abstractors (M.J.W., T.J.V.)using a standardized relational coordination scoring guide that was developed and piloted prior to use.12 The scoring guide reflected each of the 7 relational coordination dimensions: frequency, timeliness, and accuracy of communication; problem-solving; shared goals; shared knowledge; and mutual respect, with anchors for the lowest and highest scores (eAppendix Figure [eAppendix available at ajmc.com]). Pilot testing consisted of independent scoring of recorded phone calls with a planned reconciliation at the completion of each call. Reconciliation consisted of a review of the overall call along with score justification for each of the 7 dimensions. From the pilot phase, anchors on the scoring guide were modified to reflect an improved understanding of the conversations and how to recognize calls with higher or lower scores. When all abstractors agreed that they had achieved convergence across all 7 dimensions and were scoring in the same direction and approximately the same magnitude, the pilot phase was concluded. This required 10 phone calls to complete. Next, the 2 scoring abstractors reviewed and scored every complete call in the data set including re-review and scoring of the 10 calls in the training data set.
We calculated descriptive statistics on demographic and clinical characteristics using percent (frequency) and median (IQR). Spearman correlation coefficients were used to determine interrater reliability. Our primary outcome was time to acceptance, defined as the time from both physicians being present on the phone call until verbal acknowledgment of a willingness to accept the transferred patient with STEMI. The secondary outcome was length of stay at the transferring ED. For both outcomes of interest, we examined the relationship between relational coordination overall and by its individual components with the outcome univariately using Spearman correlations. For the multivariable analysis, we used a generalized linear regression model with log-link function and quasi-likelihood approach to examine the relationship between the outcomes and the overall relational coordination score. This approach was adopted to avoid any distributional assumptions while accounting for the nonnegative values of the outcomes. We adjusted for the following covariates: historical facility-level transfers to VUMC in the past year, visit time of day (weekday [Monday-Friday, 0800-1700 hours] vs after hours [all other hours]), and presence of the transferring facility within the existing STEMI network. No model fitting was performed as the covariates were selected a priori based on relevance to the quality of coordination during transfers. We hypothesized that higher relational coordination scores would be associated with shorter time to acceptance and shorter ED length of stay.
From 88 calls, we identified 81 STEMI patients with complete recordings who were accepted by and transferred to VUMC between August 2016 and March 2018. Descriptive statistics of the patient population (n = 81) can be found in Table 1. Patients were transferred from 22 facilities with a median (IQR) distance of 46 (34-75) miles from VUMC. Among these, 45% were within VUMC’s existing network of hospitals with preexisting protocols for STEMI transfer, a common practice among hospitals with a regional catchment area for cardiovascular emergencies. The median (IQR) overall relational coordination score was 445 (403-492.5) of a maximum of 700, median (IQR) time to acceptance was 90.4 (60.2-140.8) seconds, and median (IQR) ED length of stay was 61.0 (40.3-90.3) minutes. Descriptive statistics suggest variability across the 7 dimensions and overall relational coordination but good interrater reliability between reviewers, and the resulting measures were highly correlated across coders (eAppendix Table).
As depicted in the scatterplots in the Figure, there was a significant, negative relationship between overall relational coordination and time to acceptance (ρ = –0.38; P < .001), indicating that as relational coordination improved, time to acceptance decreased. However, this relationship was not found with ED length of stay. Of all the individual dimensions of relational coordination, only the dimensions of problem-solving communication and mutual respect were not significantly associated with time to acceptance.
Results from the generalized linear modeling (Table 2) showed that higher overall relational coordination was significantly associated with reduced time to acceptance (relative effect, 0.75; 95% CI, 0.69-0.82; P < .001). In other words, for every 40-point increase in overall relational coordination score, there was a 25% reduction in time-to-acceptance duration, or approximately 23 seconds. In addition, for every 5 additional historical transfers from a given transferring facility, there was a 21% reduction in time to acceptance (relative effect, 0.79; 95% CI, 0.63-0.99; P = .03). Finally, as time of day may influence the ability to access decision makers (ie, accepting cardiologists) who may be performing clinical responsibilities unrelated to STEMI during the day, transfers after hours (including weekends) were associated with a 37% reduction in time to acceptance. Results from the model assessing the relationship between relational coordination and the secondary outcome, ED length of stay, failed to show a significant association.
From these 81 STEMI transfer phone calls, 5 dimensions of relational coordination were significantly associated with shorter time to acceptance: frequency, timeliness, and accuracy of communication; shared goals; and shared knowledge. To add nuance and specificity to our findings, we identified representative examples of each of these aspects of relational coordination as expressed by transferring and receiving physicians. Examples of these conversations are provided in Table 3. For example, transferring physicians demonstrated accurate communication by using precise language such as “I have a 53-year-old male with an inferior STEMI who I think needs to go to the cath lab.” The receiving cardiologist demonstrated accurate communication through active listening and avoided misunderstandings and repetitive questions.
Our study can be summarized by 2 key findings: (1) Relational coordination can be reliably derived from real-time conversational data (eg, recorded transfer calls) with novel application to time-sensitive, emergent interfacility transfers; and (2) higher physician coordination, as reflected by relational coordination scores, was associated with reduced time to physician acceptance.
We adapted and internally validated a measure of relational coordination using the real-time audio from transfer calls.Measures of coordination during transfers that are linked to specific events are necessary, particularly because patients who experience care transitions during acute illness are especially vulnerable,16 and even when strong relationships might exist between facilities, coordination quality likely varies across individuals and is situationally dependent.Investigating transfer and coordination quality at the event level rather than the systems level provides an opportunity for identifying more grounded and focused interventionswhen necessary. Our results suggest that phone conversations may be an opportunity to measure the coordination that occurs between individuals and organizations.
As interfacility transfers are an increasingly important source of access to care for time-sensitive emergencies such as STEMI,17 enhancing the quality of communication and coordination extends beyond just the conversations between transferring and receiving physicians that were studied here. Another example of interorganizational coordination includes the activities occurring with emergency medical service agencies when patients are transported. Such interorganizational relationships may be further strengthened through the number of historical interactions that occur. This may help to explain why we found that the number of interfacility transfers for STEMI in the past year was associated with a 21% reduction in time to acceptance. High-quality coordination in general, and relational coordination specifically, has been shown to be associated with improved patient outcomes.12,18 This secondary finding should be explored in future research to better examine its influence on interorganizational coordination at more macroscopic levels—in other words, evaluating the multitude of coordination events that occur and how the summative quality of coordination affects timeliness of care.
The novel contribution of our study is examining the quality of coordination and the context of individual transfers during the actual event. We found that the timeliness of physician acceptance was improved (ie, shorter) when calls had higher-quality coordination. Not surprisingly, we did not find a significant association with the timeliness of the overall transfer. The relative brevity of the physician conversations occurring after the patient presentation, diagnosis, and decision-making about the location of care likely diminished the importance of the conversation. Further, the timing of the conversation—when it occurs relative to the activation of the receiving hospital—may play a larger contributing role in improving STEMI transfer timeliness.19 We suspect that for conditions requiring involvement of the physician prior to transfer decisions (eg, consultation), the quality of coordination at the time of the transfer will have a larger influence on timeliness and potentially on patient outcomes. The presence of auto-accept policies, those in which a transfer patient is automatically accepted, allows the longest step (the arrival of transportation) to be initiated prior to the physician conversation. Thus, for facilities and conditions where auto-accept is not in place, these conversations may have a much bigger impact on timely transfer. Finally, given the multiple interorganizational communications required to transfer a patient with STEMI, our use of relational coordination to assess a single conversation may have failed to detect other dimensions of the coordination required to successfully transfer patients with STEMI between facilities.
Beyond this study, our work reveals that real-time conversations (eg, transfer phone calls) provide insight into the quality of consequential coordination across organizational boundaries. However, interfacility transfers are typically excluded from quality recording due to a lack of data. Policy that encourages and rewards collecting such measures, and that requires hospitals to capture calls and other real-time transfer information, would potentially enhance transfer quality and STEMI outcomes. Our research shows that transfer calls can be reliably scored and linked to important processes, but these methods are time consuming. Policy that encourages and rewards use of analytical methods (eg, natural language processing and artificial intelligence) to improve quality could both enrich our conceptual and empirical understanding of coordination at important moments (eg, interfacility transfers) and improve care quality, at scale.
Our study should be considered in light of several limitations. First, the retrospective nature of this work may have limited our sample size because these data were not collected prospectively. The relatively small sample size may further have limited our ability to detect a difference in our analyses. Second, this study occurred at a single PCI center in middle Tennessee that may be affected by cultural differences and the presence of auto-accept STEMI transfer protocols, potentially reducing generalizability to other sites. Despite these limitations, demonstrating a relationship between the quality of coordination and an aspect of timeliness in a highly protocolized process is novel and consequential. In fact, it represents a conservative test of our hypothesis, because relational coordination should be less necessary and less influential under such conditions. Future work should investigate how relational coordination affects timeliness and outcomes of care in other geographical and clinical settings (eg, admissions to the inpatient setting) and emergent conditions (eg, trauma transfers), or identify key moments of intersection of different individuals’ roles and assessing relational coordination in real time at those interfaces.
We found that the application of a measure of coordination to interfacility transfers for patients with STEMI demonstrated high interrater reliability and that the quality of real-time coordination between transferring physicians for patients with STEMI was negatively associated with timeliness of acceptance, but not overall transfer timeliness. Use of such measures may enhance our understanding, quality, and outcomes for patients with STEMI who experience interfacility transfers.
Author Affiliations: Department of Emergency Medicine (MJW, SPC, KM) and Department of Biomedical Informatics (MJW), Vanderbilt University Medical Center, Nashville, TN; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee (MJW, SPC), Nashville, TN; Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Center for Clinical Quality and Implementation Research, Vanderbilt University School of Medicine (SK), Nashville, TN; Division of Cardiology, Vanderbilt University School of Medicine (DM), Nashville, TN; Department of Biostatistics, Vanderbilt University School of Medicine (CAJ, DL), Nashville, TN; Owen Graduate School of Management, Vanderbilt University (TJV), Nashville, TN.
Source of Funding: Dr Ward is supported by K23 HL127130 and VA ORH-10808. This project and the use of REDCap was supported by UL1 TR000445 from the National Center for Advancing Translational Sciences/National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH nor the US Department of Veterans Affairs. All authors had full access to all the data in the study and had final responsibility for the decision to submit for publication.
Author Disclosures: Dr Kripalani has received an investigator-initiated research grant from Bristol Myers Squibb (BMS) and Sanofi. Dr Collins has performed consulting for Boehringer Ingelheim and BMS and has received grants from NIH, the Patient-Centered Outcomes Research Institute, and BMS. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (MJW, SK, DM, CAJ, DL, TJV); acquisition of data (MJW, KM, CAJ); analysis and interpretation of data (MJW, DM, SPC, CAJ, DL, TJV); drafting of the manuscript (MJW, TJV); critical revision of the manuscript for important intellectual content (MJW, SK, DM, SPC, CAJ, DL, TJV); statistical analysis (MJW, DL); provision of study materials or patients (MJW, KM); obtaining funding (MJW); administrative, technical, or logistic support (MJW, SPC, KM); and supervision (MJW, SK, SPC).
Send Correspondence to: Michael J. Ward, MD, PhD, MBA, Department of Emergency Medicine, Vanderbilt University Medical Center, 1313 21st Ave S, Oxford House #330, Nashville, TN 37232. Email: firstname.lastname@example.org.
1. Chakrabarti A, Krumholz HM, Wang Y, Rumsfeld JS, Nallamothu BK; National Cardiovascular Data Registry. Time-to-reperfusion in patients undergoing interhospital transfer for primary percutaneous coronary intervention in the U.S: an analysis of 2005 and 2006 data from the National Cardiovascular Data Registry. J Am Coll Cardiol. 2008;51(25):2442-2443. doi:10.1016/j.jacc.2008.02.071
2. Wang TY, Nallamothu BK, Krumholz HM, et al. Association of door-in to door-out time with reperfusion delays and outcomes among patients transferred for primary percutaneous coronary intervention. JAMA. 2011;305(24):2540-2547. doi:10.1001/jama.2011.862
3. Shen YC, Krumholz HM, Hsia RY. Association of cardiac care regionalization with access, treatment, and mortality among patients with ST-segment elevation myocardial infarction. Circ Cardiovasc Qual Outcomes. 2021;14(3):e007195. doi:10.1161/CIRCOUTCOMES.120.007195
4. Shah R, Goldstein SM, Unger BT, Henry TD. Explaining anomalous high performance in a health care supply chain. Decis Sci. 2008;39(4):759-789. doi:10.1111/j.1540-5915.2008.00211.x
5. Everson J, Adler-Milstein J, Ryan AM, Hollingsworth JM. Hospitals strengthened relationships with close partners after joining accountable care organizations. Med Care Res Rev. 2020;77(6):549-558. doi:10.1177/1077558718818336
6. Lu LX, Lu SF. Distance, quality, or relationship? interhospital transfer of heart attack patients. Prod Oper Manag. 2018;27(12):2251-2269. doi:10.1111/poms.12711
7. Iwashyna TJ, Kahn JM, Hayward RA, Nallamothu BK. Interhospital transfers among Medicare beneficiaries admitted for acute myocardial infarction at nonrevascularization hospitals. Circ Cardiovasc Qual Outcomes. 2010;3(5):468-475. doi:10.1161/CIRCOUTCOMES.110.957993
8. Iwashyna TJ. The incomplete infrastructure for interhospital patient transfer. Crit Care Med. 2012;40(8):2470-2478. doi:10.1097/CCM.0b013e318254516f
9. Young JQ, Wachter RM. Applying Toyota Production System principles to a psychiatric hospital: making transfers safer and more timely. Jt Comm J Qual Patient Saf. 2009;35(9):439-448. doi:10.1016/s1553-7250(09)35061-8
10. Tupper JB, Gray CE, Pearson KB, Coburn AF. Safety of rural nursing home-to-emergency department transfers: improving communication and patient information sharing across settings. J Healthc Qual. 2015;37(1):55-65. doi:10.1097/01.JHQ.0000460120.68190.15
11. Zeitouni M, Al-Khalidi HR, Roettig ML, et al. Catheterization laboratory activation time in patients transferred with ST-segment-elevation myocardial infarction: insights from the Mission: Lifeline STEMI Accelerator-2 Project. Circ Cardiovasc Qual Outcomes. 2020;13(7):e006204. doi:10.1161/CIRCOUTCOMES.119.006204
12. Gittell JH, Fairfield KM, Bierbaum B, et al. Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients. Med Care. 2000;38(8):807-819. doi:10.1097/00005650-200008000-00005
13. Baggs JG, Ryan SA, Phelps CE, Richeson JF, Johnson JE. The association between interdisciplinary collaboration and patient outcomes in a medical intensive-care unit. Heart Lung. 1992;21(1):18-24.
14. Holby SN, Muñoz D, Collins SP, et al. Quality of physician care coordination during inter-facility transfer for cardiac arrest patients. Am J Emerg Med. 2020;38(2):339-342. doi:10.1016/j.ajem.2019.10.002
15. O’Gara PT, Kushner FG, Ascheim DD, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4):e362-e425. doi:10.1161/CIR.0b013e3182742cf6
16. Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003;51(4):549-555. doi:10.1046/j.1532-5415.2003.51185.x
17. Ward MJ, Kripalani S, Zhu Y, et al. Role of health insurance status in interfacility transfers of patients with ST-elevation myocardial infarction. Am J Cardiol. 2016;118(3):332-337. doi:10.1016/j.amjcard.2016.05.007
18. Gittell JH, Logan C, Cronenwett J, et al. Impact of relational coordination on staff and patient outcomes in outpatient surgical clinics. Health Care Manage Rev. 2020;45(1):12-20. doi:10.1097/HMR.0000000000000192
19. Schneider MA, McMullan JT, Lindsell CJ, et al. Reducing door-in door-out intervals in helicopter ST-segment elevation myocardial infarction interhospital transfers. Air Med J. 2017;36(5):244-247. doi:10.1016/j.amj.2017.04.004