Background Deficient transfer letters are widely recognised as a significant cause of increased risk.¹ Following a coroner’s enquiry which cited a suboptimal transfer letter as a factor in delayed medical intervention, the Hillingdon Hospital Paediatric department introduced a standardised template and a powerful quality improvement project began.

Methods A template was devised using APLS² and CATS³ documents to identify gold standards. A retrospective audit was carried out, comparing 20 letters pre with 20 post template introduction. 29 key content points were compared. It included a range of trainee doctors filling in the forms and a range of different reasons, from PICU transfers to tertiary acute transfer for ongoing investigation. A telephone survey was then carried out to explore varying practice in 12 London Paediatric units.

Results Prior to introduction of template; only 12 of the 29 key information times were present over 75% of the time. With the template introduction; all 29 areas were identified over 75% of forms.

The template has resulted in significant improvement in sharing patient information across a number of areas, from patient demographics to current treatment. Examples include a 20% increase in communicating current medications which is a significant improvement (p < 0.05), and a 50% improvement in recording current working weight. Before the use of a template, 0/20 letters sampled provided information on allergy and immunisation, whereas letters using the template were over 90% compliant in these criteria.

Phone surveys of other London Paediatric units found only one of eight has a transfer template. It was reported transfer documentation was rushed, time-pressured and rarely involved consultant input.

Conclusion Using a concise template significantly improves the content of paediatric transfer letters. This simple intervention should in turn improve continuity of care and patient safety. The inclusion of a ‘status at transfer’ prompt improves governance regarding documentation of deteriorations during transit. The pathway within which each letter is approved and signed off by an attending consultant has also greatly increased senior input into these important communication documents.

Given the standard practice amongst London Hospitals being no formal template; we propose that a standardised template could be rolled out to all London Hospitals and beyond, to improve the handover of patients between hospitals.

References

1. Delegation and referral. London: GMC, 2013

2. Samuels M, Wieteska S. Advance paediatric life support: the practical approach. 5th edn. Chichester: Wiley-Blackwell, 2011:261

3. Children’s Acute Transfer Team. Referral Form. http://site.cats.nhs.uk/wp-content/uploads/2012/08/Referrer_prompt_-sheet.pdf accessed 03/12/14