Towards the development of a national patient transfer document between residential and acute care—A pilot study

Abstract Background A lack of standardisation of documentation accompanying older people when transferring from residential to acute care is common and this may result in gaps in information and in care for older people. In Ireland, this lack of standardisation prompted the development of an evidence based national transfer document. Objectives To pilot a new national transfer document for use when transferring older people from residential to acute care and obtain the perceptions of its use from staff in residential and acute care settings. Methods This was a pre‐ and post‐study design using purposive sampling following the STROBE guidelines. The pilot was conducted in 26 sites providing residential care and three university hospitals providing acute care. Pre‐pilot questionnaires focused on current documentation and were distributed to staff in residential care (n = 875). A pilot of the new paper‐based transfer document was then conducted over three months and post‐pilot questionnaires distributed to staff from both residential and acute care settings (n = 1085). The findings of the pilot study were discussed with multidisciplinary expert advisory and stakeholder groups who recommended some revisions. This consensus informed the development of the final design of the new revised transfer document. Results Pre‐pilot: 23% response rate; 83% (n = 168) participants agreed/strongly agreed that existing documentation was straightforward to complete but could be more person‐centred. Post‐pilot: 11% response rate; 75% (n = 93) of participants agreed/strongly agreed that the new transfer document promoted person‐centred care but recommended revisions to the new document regarding layout and time to complete. Conclusions This study highlighted some of the challenges of providing safe, effective and relevant transfer information that is feasible and usable in everyday practice. Implications for practice Standardisation and being person‐centred are important determining factors in the provision of relevant up to date information on the resident being transferred.


| INTRODUC TI ON
Internationally, older people account for a high proportion of transfers to emergency departments and admissions to acute hospitals (Barbadoro et al., 2015;Franchi et al., 2017). Older people are the largest group presenting with illness to Irish acute services, accounting for one-fifth of all emergency department admissions (Department of Health, 2018). Older people transferred from residential care to acute services are accompanied by a transfer document outlining their care needs. However, transfer document information is not always standardised across healthcare settings.
International evidence highlights that standardised documentation improves communication between staff by recording important clinical and personal information (Morphet et al., 2014;Tsai & Tsai, 2018).
Recognising the importance of using a standardised document to improve communication, the National Clinical Programme for Older People, supported by Office of Nursing and Midwifery Services Director, Health Services Executive, Ireland, commissioned a project to develop a person-centred national transfer document for use when an older person is being transferred from residential to acute care settings. This paper reports on the piloting of the document and multidisciplinary expert advisory and stakeholder groups who recommended some revisions. This consensus informed the development of the final design of the new revised transfer document.
Results: Pre-pilot: 23% response rate; 83% (n = 168) participants agreed/strongly agreed that existing documentation was straightforward to complete but could be more person-centred. Post-pilot: 11% response rate; 75% (n = 93) of participants agreed/ strongly agreed that the new transfer document promoted person-centred care but recommended revisions to the new document regarding layout and time to complete.

Conclusions:
This study highlighted some of the challenges of providing safe, effective and relevant transfer information that is feasible and usable in everyday practice.
Implications for practice: Standardisation and being person-centred are important determining factors in the provision of relevant up to date information on the resident being transferred.

K E Y W O R D S
older people, older person, person-centred care, pilot, residential setting

What does this research add to existing knowledge about gerontology?
• This research identifies the components of transfer documentation necessary for safe and effective transfer of older people from residential to acute care.
• The results highlight the importance of balancing the need for person-centred documentation and pertinent medical information when older people transfer between residential and acute care settings.
What are the implications for this new knowledge for nursing care with older people?
• Having person-centred holistic information about older people and their care needs will improve communication and encourage safer and better patient care on transfer.
• Transfer documentation needs to be comprehensive but easy to use and preferably electronic to reduce errors, particularly in cases of emergency transfers.
How could the findings be used to influence policy or practice or research or education?
• This study has highlighted the value of involving all stakeholders including older people themselves in the design and development of a person-centred and effective transfer documentation.
• The results demonstrate the importance of staff acceptability, ease of use and availability in electronic format, to implement this documentation at national level.
presents the findings of the pre-study (existing transfer document) and post-study (pilot of a newly developed standardised national transfer document).

| Background
International evidence highlights elements that should be included in transfer documentation. This includes medical information, vital signs and medications (Cwinn et al., 2009;McCloskey, 2011;Zamora et al., 2012), and information on the older person's comprehensive needs (Campbell et al., 2017;Matic et al., 2011). However, there is a dearth of evidence on what constitutes person-centred information within transfer documents (Boltz et al., 2013) and research is needed to determine essential components of transfer documentation for effective and safe transfer of older persons (LaMantia et al., 2010).
The funded project aimed to improve the quality and standardisation of transfer documentation for the older person between a residential and an acute care setting . Informed by evidence from a literature review, a qualitative study with stakeholders , consultation with a multidisciplinary expert advisory group 1 (advisory group) and an expert in person-centred care, the components and format of a transfer document were identified and developed. It consisted of two sections: one contained biographical and essential medical information, and the other profiled the person's personal preferences and usual health status. As the proposed transfer document would be used nationally, it was agreed to pilot it across several institutions to identify any areas that needed revision before it was put into general use.
This paper presents the results of the pre-and post-study, which explored participants' perceptions of the design, layout and usability of the pilot, transfer document, as well as compared it with existing transfer documentation. These findings together with advisory group and postpilot stakeholder group 2 consultations were used to further revise and refine the design of the eventual national transfer document. Table 1 outlines the steps in the development of national transfer document.

| Design
This study was a pre-post survey design, using a questionnaire with a purposive sampling strategy. The aim was twofold. In the pre-pilot survey, participants in residential care settings were asked to give their views on their existing transfer documentation.
In the post-pilot survey, participants in both residential and acute care settings were asked to give their views on the new transfer document. Participating sites were provided with an onsite study information session and introduction to the pilot transfer document. An explanatory pack (copy of presentation, example of a completed transfer, new transfer document and guidance document) was provided.
Computer-based documentation is advocated as a way of decreasing time spent on paperwork (Yu et al., 2006) and facilitating multidisciplinary access to accurate and comprehensive information across a variety of care settings (Devriendt et al., 2013). However, paper transfer documentation was used in this study as it was anticipated that changes to the documentation would be required once the data were analysed and electronic formats would not be accessible to all sites at the time of the pilot. This study is reported in line with reports of cohort studies; the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) (Equator Network, 2019).

| Participants
A purposive sample of 26 residential care sites and acute care sites (in three university hospitals) in Ireland's Midwest, South and East regions were recruited. Participants in the residential care setting comprised nurses and health care staff, and participants in the acute care settings comprised nursing, medical, health care and allied health professionals. Participant cohorts were reflective of the staff mix of both settings. Participation included the completion of a questionnaire on their current documentation (residential care settings), agreement to use the new documentation in paper format for a period of 3 months (residential care settings) and completion of a post-pilot survey (both residential care and acute care settings). were assigned to each site.

| Ethical considerations
Ethical approval was obtained from the Research Ethics Committees of the three University Hospitals and University leading the research study. The study information and purpose were provided in written participant information sheets. Residential care and hospital site staff were provided with onsite information, explanation and queries answered by researchers. Participant consent was implied by return of the questionnaire(s), and participants were informed that they could exit the study at any stage.

| Data analysis
Descriptive statistical analysis was conducted using the SPSS  Table 2.

| Pre-pilot results
Twenty-six residential settings agreed to participate in the study and returned questionnaires. Pre-pilot questionnaires sought the perceptions of residential staff (nursing and health care) (n = 875) on the transfer documentation currently in use. There was a 23% response rate (n = 202) specifically comprising 47(23%) (Midwest), 68 (33%) (South) and 87 (44%) (East) regions.

| Site and participant demographics
The majority (n = 137, 68%) were nurses providing direct care. The remaining 32% (n = 65) comprised clinical nurse managers, clinical nurse specialists, directors of nursing/person in charge, and healthcare assistant/health manager/student nurse. The highest level of education among staff was a bachelor's degree (48%, n = 96). Table 3 provides an overview of pre-pilot participants.

| Current transfer document components
Participants expressed their views about their current transfer document on a scale of strongly agree, agree, no opinion, disagree and strongly disagree.

| Open-ended text results
Three open-ended questions were asked: 'In general what are your thoughts on the Transfer Document', 'Do you have any specific areas of concern about the documentation' and 'Do you have suggestions for improvement'. 293 comments were provided (60.9% of total).
Themes and codes are outlined in Table 2. Participants commented that information was identified as relevant and person-centred but was time-consuming and not always read by acute care staff.
Electronic documentation was advocated for.

| Thoughts
Participants' thoughts on the current transfer document included their views on the length of the document and time required to complete, level of detail and relevancy of information and the personcentredness of the document. Many participants believed that in the current document, 'information recorded about the patient was relevant' (S18).
Participants also perceived that their current transfer document was person-centred. They could pre-populate areas in consultation with the resident about their personal needs and clinical needs.
It is a very person-centred document and give a holistic assessment of the resident being transferred to the acute sector (S3) Additionally, participants identified that sufficient time is required to highlight essential clinical and personal information.

| Concerns
Participants raised concerns about current transfer documents relating to clarity, detail, repetition, missing relevant information, incompletion and the length of time it took to complete. This was of particular concern in emergency situations when a patient needed to be transferred quickly. Most times, we had filled in more than enough into our own transfer letter, A&E would still ring us and ask about the information that was written on the transfer letter (S17)

| Suggestions for improvement
Participants had a number of suggestions for improvement including having essential information with pre-population of non-acute information, having a more user-friendly design and being electronic.
Participants identified the challenge of balancing the requirements of providing essential information (clinical and personal) with wanting a form which is short, quick and easy to complete.
A transfer letter should be a document that contains all the relevant information of a resident which helps to commence patient-centred care in a new setting, it should be easy to complete but not too long (S15) The layout of the document was thought by participants to have a direct impact on whether it was completed correctly. Furthermore, it was clear that some residential care sites already used electronic documents and staff in these sites were reluctant to return to a paper-based system, indicating an area of improvement.
It (a new document) could be uploaded to (software name) and have most of the sections pre-populated (S20)

| Post-pilot results
Nineteen residential sites and three acute care sites agreed to par-

| Site and participant demographics
Fifty per cent (n = 62) of participants were nurses who provided direct care, 29% (n = 37) were clinical nurse managers and advanced nurse practitioners; 10% (n = 12) were allied and medical professionals, 6% (n = 7) were persons in charge; and 5% (n = 6) were student nurse/healthcare assistants/health manager. The highest level of education among staff was a bachelor's degree (40%, n = 50). Table 4 provides an overview of post-pilot participants.

| Pilot transfer document components
Participants expressed their views on a scale of strongly agree, agree, no opinion, disagree and strongly disagree.

| Open-ended text results
In  and codes are outlined in Table 2, and 188 comments were provided (39.09% of total). The participants commented that the pilot document was useful and comprehensive and promoted more personcentred care. The layout and length of the document and therefore time to complete in practice were problematic, along with the fact that the document was in paper format.

| Thoughts
Participants' thoughts on the pilot transfer document centred on comprehensiveness, relevancy, clarity, person-centredness, length of the document, ease of completion and time required to complete.
In general, they reported that the document was easy to complete, comprehensive and useful.
Easy and clear to follow The document has more information and detail is provided on it…now there is no need to ring nursing home for information anymore (S20) Participants also endorsed the person-centred nature of the document and identified its focus beyond acute problems to including personal aspects and care needs of the individual. Identified as being key to being person-centred was the involvement of the person, and it was suggested this aspect of the document could be completed when the resident is not unwell.

| Concerns
Participants voiced several concerns about the pilot transfer document, and these related specifically to lack of specific information, design, poor compliance and time. Most participants stated that completing the document was very time-consuming. This was anticipated as a problem if the resident required an emergency transfer. However, participants agreed it could be beneficial if correctly completed.
Time consuming but could be excellent if filled out properly (S3) Too time consuming; one would have to start completing it and then call the ambulance, just to make sure it is accurate and whole (S15) Some participants were concerned with the prioritisation and/or omission of certain information. They also felt that due to design and layout, that important information could be lost or not emphasised enough.
Relevant and essential info such as resuscitation wishes are not contained and the layout is packed and essentials not stressed enough or visible (S17) Some participants did think positively about the document but had concerns about whether it would be completed properly.
Should work when filled out correctly and used efficiently (S29)

| Suggestions for improvement
Participants proposed changes to the pilot document such as relooking at layout, being concise, adding more information, patient involvement in completing document and computerisation. There was a resounding call for a computerised rather than paper-based version. Staff argued that computerising this document would reduce errors due to illegible handwriting, less time would be spent writing down information, and it would enable the document to be sent swiftly in emergency situations.
It would be easier and quicker to use if the document was computerised and handwriting can be difficult to read and takes longer (S23) Many participants wanted a one-page summary document with person-centred information to accompany an existing transfer document. It was suggested that the summary document could be populated in advance within the residential care service.
Maybe a summary, person-centred sheet that is pre-filled (S11) Changes in the layout were suggested for effective use. These in-

| DISCUSS ION
This study aimed to identify residential care participants' (nurses and health care assistants) perceptions of their current resident transfer document (pre-pilot) and to identify participants' (residential care and acute care staff) perceptions of the feasibility and usability of the pilot transfer document and its applicability to the care facility. Definitions of pilot studies include focusing on acceptability and feasibility issues of a tool being piloted (Spurlock, 2018). The findings of this study reinforce the literature emphasising that a standardised and consistent layout is an important determining factor in the provision of relevant up-to-date information on the resident being transferred (Arendts et al., 2013;McCloskey, 2011;Robinson et al., 2012). The use of a standardised national transfer document is important in providing coordination and continuity of health care for older people being transferred, especially as older people often have comorbidities requiring complex care management.
It is acknowledged that there were differences in the pre-and post-pilot groups, in that the pre-pilot sample was drawn from residential care sites only and comprised many nurses, whereas the post-pilot sample comprised both residential care participants Although most transfer documents were reported as the traditional paper and pen version, electronic versions of transfer documents were identified (Campbell et al., 2017). In tune with Yu et al., (2006), participants in this study favoured a computerised document and recommended some pre-population of data where appropriate, to save time and promote person-centred care. Like previous research (Murray & Laditka, 2010;Zamora et al., 2012), this study finds that an electronic transfer document is perceived as a means of reducing errors when transferring residents. Furthermore, it would provide comprehensive and accurate information.
This study highlights the need to promote a culture that supports both effective and person-centred documentation and recognises the importance of allocating time to document. In response to the findings of this study, amendments and changes to the document were made as outlined previously.

| Limitations and recommendations
The sites in this study represented a good geographical spread of rural and urban areas although located within one county. While the pilot sample provided a valuable perspective on person-centred transfer, it is acknowledged that older people and their families are absent at this stage of the research project. A limitation of this study was the low response rate for post-pilot questionnaires (11%). It is unclear, and there is no evidence to suggest that this may be due to high workloads and limited time among staff or lack of awareness of study. The results of the pilot provided valuable information to inform the development of the final document. The views of various health and social care staff were represented in the pilot and in the final post-pilot consultation along with key stakeholders involved in the delivery, planning and design of services for older people. The older person's perspective was included in the final consultation process through the involvement of advocates. The final document will now be available electronically, a welcomed support from governing health bodies, thereby increasing accessibility and accessibility. Future research to implement the transfer document will use a public and patient involvement (PPI) approach, which will enable older people to become involved with research within residential and acute care settings.

| CON CLUS ION
This paper describes the results of a pilot study that combined with a consultative process resulted in an evidence-based consensus document that may provide relevant and appropriate personcentred information on transfer between residential and acute care.
Incorporating a consultative process has the potential to develop user-friendly and comprehensive documents. The methodology used facilitated the inclusion of all stakeholders. Employing an electronic document offers quick and efficient access to patient's details and valuable information.

ACK N OWLED G EM ENTS
The authors would like to acknowledge thanks to all the residential care staff and staff within the acute care services for completing the pre-and post-questionnaires and their cooperation throughout the whole process.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared with the authors.