Date of Paper/Work


Type of Paper/Work

Doctor of Nursing Practice Project

Degree Name

Doctor of Nursing Practice



First Advisor

Gay Varecka


Doctor of Nursing Practice


Background: Information gaps for geriatric residents of extended care facilities transferred to the emergency department are prevalent, increasing the risk of adverse health events. Poor communication during care transitions is the leading cause of medical errors in healthcare systems, accounting for 50% of all communication errors in health care and 80% of severe medical errors (Britton et al., 2017, Joint Commission, 2017, Li et al., 2017, Rosenthal et al., 2018).

Purpose: The purpose of this quality improvement pilot project is to implement a standardized acute care transfer packet to increase the amount of essential patient health information shared with emergency room providers during a transition of care from an assisted living facility.

Methods: The quality improvement team implemented a standardized acute care transfer packet in an assisted living facility. Pre-and post-implementation data assessed average amount of essential patient health information shared during each transfer, a post-transfer debriefing survey, post-implementation staff satisfaction surveys, and qualitative interviews with assisted living and local emergency room staff. The standardized packet included 14 health information data points deemed essential for a safe care transition.

Results: Of then two patients transferred during the implementation period, there was an increase in the amount of essential patient health information shared, from an average of 8.4 data points in the pre-implementation period, to 14 in the post-implementation period.

Conclusion: Implementation of a standardized acute care transfer packet increases the amount of patient information shared during a transition of care between medical providers. This transfer strategy can successfully be utilized in assisted living settings. Qualitative interviews revealed four care transition themes including time, staffing levels, technology, and bidirectional communication. Post-implementation satisfaction surveys revealed a positive experience with the new transfer process.

Available for download on Saturday, December 31, 2022