Article Text
Abstract
Introduction The transfer of patients between hospitals, known as interhospital transfer (IHT), is associated with higher rates of mortality, longer lengths of stay and greater resource utilisation compared with admissions from the emergency department. To characterise the IHT process and identify key barriers and facilitators to IHT care, we examined the experiences of physician and advanced practice provider (APP) hospital medicine clinicians who care for IHT patients transferred to their facility.
Methods Qualitative descriptive study using semistructured interviews with adult medicine hospitalists from an academic acute care hospital that accepts approximately 4000 IHT patients annually. A combined inductive and deductive coding approach guided thematic analysis.
Results We interviewed 30 hospitalists with a mean of 5.7 years of experience. Two-thirds of interviewees were physicians and one-third were APPs.
They described IHTs as challenging when (1) exchanged information was incomplete, inaccurate, extraneous, and/or untimely, (2) uncertainty impacted care responsibilities and (3) healthcare team members and patients had differing care expectations. As a result, participants described patient safety issues such as delays in care and inappropriate triage of patients due to incomplete communication of clinical status changes.
Recommended improvement strategies include (1) dedicated individuals performing IHT tasks to improve consistency of information exchanged and relationships with transferring clinicians, (2) standardised scripts and documentation, (3) bidirectional communication, (4) interdisciplinary training and (5) shared understanding of care needs and expectations.
Conclusions Physicians and APP hospital medicine clinicians at an accepting hospital found information exchange, care responsibilities and expectation management challenging in IHT. In turn, hospitalists perceived a negative impact on IHT patient care and safety. Highly reliable and timely information transfer, standardisation of IHT processes and clear interdisciplinary communication may facilitate improved care for IHT patients.
- Transitions in care
- Health services research
- Patient safety
- Qualitative research
- Hospital medicine
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information. Deidentified interview transcripts, codebooks, deidentified field notes and consent forms are available from the corresponding author.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Interhospital transfers confer higher risk of mortality, longer lengths of stay and greater resource utilisation, with care coordination challenges likely contributing to these outcomes. This study characterises the experience of hospital medicine physicians and advanced practice providers at an accepting hospital to identify potential patient safety and care coordination targets to improve.
WHAT THIS STUDY ADDS
This study highlights the importance of streamlined information exchange and a cohesive clinical narrative to facilitate interhospital transfer (IHT) care continuity, clear identification of responsible IHT care teams to promote timely patient care and effective expectation management across clinicians and patients to improve IHT care delivery.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study identifies potential approaches for improving IHT care coordination, specifically: use of standardised scripts and documentation, use of dedicated IHT teams, interdisciplinary education about clinician responsibilities and managing clinical care expectations across all IHT parties.
Introduction
Each year, over one million patients in the United States of America are transferred between acute care hospitals in a process known as interhospital transfer (IHT).1–3 IHTs are often initiated for subspecialty management and/or procedures. Although patients can potentially benefit from IHT, transferred patients have higher risk of death, longer lengths of stay and increased resource utilisation compared with non-transferred patients.1–7 These differences are not completely explained by IHT patient severity of illness or comorbidities, suggesting that additional factors contribute.1–6
Similar to other areas of care transitions, poor communication, fragmented information exchange and non-standardised processes likely contribute to poor IHT patient outcomes.8–13 Prior studies have characterised barriers and facilitators to quality IHT care, but in-depth examination about how care coordination factors affect patient care as perceived by accepting hospital physicians and advanced practice providers (APPs, nurse practitioners or physician assistants), that is, the front-line clinicians that care for IHT patients at time of transfer, is needed.8 10 12–18
Our study details physician and APP experiences with IHTs and offers potential care coordination and organisational policy targets to advance quality and patient safety.
Methods
Design and setting
This is a qualitative descriptive study of inpatient hospital medicine physician and APP experiences with IHTs at a Colorado quaternary care academic medical centre. The hospital receives 4000 IHTs annually from affiliated and non-affiliated facilities across the US Rocky Mountain and Southwest regions. Floor-level adult medicine patients comprise 44% of IHT patients.18 IHTs are managed by the health system’s call centre, which facilitates transfer request calls, clinician conversations and transfer logistics. Logistics include coordinating transport and monitoring bed capacity as these may create delays between transfer acceptance and patient arrival. Reporting follows the Consolidated Criteria for Reporting Qualitative Studies guidelines.19
Patient involvement
Given the scope of this study, patients and the public were not involved in the design, conduct, reporting or dissemination of this research.
Participants
A purposive convenience sampling strategy was used to recruit hospital medicine physicians and APPs who cared for IHT patients at the study site for at least 1 year.20–22 Participants in this study served in three possible roles during the IHT process (figure 1): (1) the accepting physician responsible for determining whether to accept a patient for transfer via a phone conversation with a transferring clinician, (2) the triage clinician, typically an APP or physician nocturnist, responsible for assigning IHT patients to medicine teams based on team capacity and key patient characteristics (eg, age) and (3) the admitting provider, a physician or APP, who cares for IHT patients on arrival. The accepting physician, who is also on a clinical service and changes daily, is expected to document the acceptance conversation in a transfer acceptance note in the electronic health record. Participants received general guidance on IHT roles at time of new hire onboarding and/or experiential learning on the job. We recruited participants via email and hospital medicine business meetings. We attempted to ensure representation across shifts (day, swing and night) and provider type (physician and APP).
Data collection
Interviews were conducted from September 2021 to December 2021 via secure video conference and lasted 1 hour. One interviewer (LM) with prior qualitative experience and no direct clinical role, facilitated all interviews while at least one team member (AY or CW, both with direct clinical roles) took field notes. All members of the interview team had pre-existing relationships with participants as members of the same division but were not in supervisory roles.
Semistructured interview guides (online supplemental appendices 1a,b) were used to explore physician and APP IHT care experiences as well as challenges and ideal approaches to successful IHT. The Agency for Healthcare Research and Quality (AHRQ) Care Coordination Measurement Framework (CCMF) (online supplemental file 2) and themes extracted from prior research informed interview guide development and data analysis.18 23 Specifically, the domains of Communication, Assessing Needs and Goals, and Negotiating Responsibility were used to examine care coordination.
Supplemental material
Supplemental material
Interviews were audio recorded, professionally transcribed and deidentified. Data were collected until theoretical data saturation was reached (ie, when additional data did not lead to new codes or emergent themes).24–26
Data analysis
Thematic analysis was used to interpret data obtained from transcribed interviews. Employing an a priori analytical framework as detailed above, three team members (AY, LM and CW) coreviewed a subset of transcripts (10%) and compiled a list of codes (ie, descriptors that capture interview ideas or concepts) into a codebook.18 23 A combined inductive and deductive approach was used; the inductive approach allowed for the discovery of new emerging themes and the deductive approach allowed for mapping to defined domains noted above.27 28 Approximately 20% of the transcripts were double-coded to ensure consistency across coders. Each transcript was coded in Atlas.ti (V.22, Berlin, Germany). An iterative process was used as the coders independently coded the remaining transcripts, meeting to establish consensus by identifying and resolving discrepancies in emerging themes through discussion and triangulation (AY, LM and CW). Reflexivity was accomplished by incorporating non-clinical (LM), physician (AY) and APP (CW) perspectives in interpreting themes. The senior author (CDJ) provided guidance as needed. The study team maintained a record of all analytical decisions and discussions. Member checking was conducted.
Results
Of 115 hospital medicine clinicians invited to participate, 30 (26%) completed interviews from September to December 2021. Participants reported working day shifts (n=24), swing shifts (n=24) and night shifts (n=10), with the option to select more than one shift type. 20 (67%) of the participants identified as female. Demographic data are displayed in table 1.
Our qualitative analyses identified three key domains of participant IHT experiences: (1) information exchange and communication during IHT, (2) responsibilities during IHT and (3) expectation management during IHT. Themes did not map directly to a single defined AHRQ CCMF domain, often overlapping two or three domains. Findings are summarised in figure 2, organised by study domain with text boxes representing identified challenges and potential improvement strategies within each domain. Additional representative quotes can be found in table 2 and online supplemental appendix 3.
Supplemental material
Domain 1: information exchange and communication in IHT
Challenges in information exchange were frequently cited as barriers to providing comprehensive and timely patient care. Communication structure changes were presented as solutions.
Theme 1.1: information fragmentation
Interviewees shared having to piece together information from various sources to construct an organised clinical narrative. Sources of information include prior chart documentation within the accepting hospital EHR, health information exchange platforms, the transfer acceptance note (documented by the accepting physician) and paper records. Patients and/or care partners also served as additional information sources.
I'll first look at the [transfer acceptance] note and then see if this patient has been here before. Then I will check CareEverywhere® to see if there’s any information there… and then I'll look for a packet of records. Then once I look through all that information, I will go and talk to the patient. Interview 17, Physician
When key study results were not accessible, that is, data were not sent or difficult to find, admitters repeated diagnostic tests, delaying care and generating system waste.
[With IHTs], you're having to slowly put the pieces together and figure out what’s going on, why they were transferred, and how you can best you know get the ball rolling on what it is that they actually need… sometimes I feel like a lot is missing or falls through the cracks, and I end up duplicating workups just because information is lost. There’s time that’s lost too…I feel like you're playing a lot of catch up unnecessarily. Interview 27, APP
Potential improvement strategies
Several participants identified a discharge or interim summary as one strategy to address information fragmentation and narrative discontinuity. They described several key elements in an ideal discharge summary: transfer reason, summary of the transferring hospital course, list of procedures, a medication list, physical exam and vital signs prior to transfer, consultant notes or recommendations, and key laboratory and/or imaging information.
I like a discharge summary … [with] a good kind of overview of the days leading up to the transfer. And then all relevant imaging, most recent consult note, and … records of medications being administered. Interviewee 24, APP
Theme 1.2: information exchanged is missing, inaccurate, untimely and/or extraneous
Participants across different roles described that the information they received about IHT patients was often incomplete, inaccurate, untimely and/or extraneous.
For accepting physicians, many described having an incomplete picture of the IHT patient. They often had to prompt for information such as vital signs or the patient’s clinical course to help them determine acuity level and whether a transfer would be beneficial.
…sometimes it’s really just guesswork… trying to figure out and taking the information from another provider and trying to piece that together to figure out what the patient’s [going to] look like when they get here… Interview 20, Physician
Many admitting clinicians described that the information at the time of admission was variable in accuracy, content and pertinence. They attributed these discrepancies to missing or inaccurate information exchange during the acceptance call and/or clinical status changes that were not reported to the accepting hospital before the IHT patient’s arrival. Additionally, relevant clinical information was often described as buried within extraneous data (eg, nursing assessments) and tedious to extract.
Even when it’s not haphazard, even when it happens exactly the way it’s supposed to, there are a lot of transfers of responsibility for receipt of information and transfer of information. And each one of those creates the opportunity for information attrition or error. And you have to go no farther than to play the game of telephone to see how that can happen. Interview 7, Physician
Potential improvement strategies
Participants suggested instituting a dedicated individual at the accepting hospital to field transfer acceptance calls to improve consistency and completeness of information exchange. In addition to a templated acceptance note, dedicated scripts and formal training were highlighted as approaches to standardise what information elements are communicated.
Having a dedicated person receiving those calls and [who] has the time to run through things, and maybe even having dedicated scripts for certain clinical conditions would be great, just so that everybody does it the same way. Interview 27, APP
Lastly, bidirectional communication between transferring and accepting clinicians was described as an approach to mitigate information loss.
…if somebody shows up and you're missing information or they're different than clinically anticipated, there should be a method for reaching back out to the provider at the outside hospital. Interview 8, Physician
Domain 2: responsibilities during IHT
When discussing IHT care workflow, participants identified uncertainty driving challenges with IHT care responsibilities.
Theme 2.1: pressures on clinicians at time of IHT acceptance
For accepting physicians, they frequently experienced unease with the transfer decision-making process. They described making a consequential decision for a patient they had not personally evaluated based on potentially incomplete information from a transferring clinician with whom they had no prior working relationship.
In [transfer acceptance] calls, you feel so responsible, but also so vulnerable, because you're so reliant on what this other person is telling you and then you're having to make important clinical decisions. Interview 18, Physician
Potential downstream impacts on admitting colleagues’ workflows due to care needs mismatch increased pressure on accepting providers to make appropriate acceptance decisions.
I [felt I] set one of my colleagues up [for] a busy admitting night—you can imagine if you get someone that you have to do an acute transfer to the ICU [intensive care unit] or is not billed as [expected] and comes with tons of records, there are other patients that are missing out on the care they need. It’s not the greatest professional experience. Interview 21, Physician
Potential improvement strategies
Similar to domain 1, theme 1, a dedicated team to field transfer calls was suggested to establish relationships with transferring clinicians and increase confidence in information exchange.
Theme 2.2: uncertainty around who is responsible for IHT patients on arrival
For triage clinicians, who assign IHT patients to teams after their arrival, they often were responsible for identifying the admitting service even for patients who were not accepted to a medicine service.
I've had a number of times where I get called by nurses… saying 'this person is here, who’s going to be admitting them?' And after a lot of digging, they're not even a hospital medicine patient. [Other] services, even though they've accepted the patient for transfer, have not documented. Sometimes [I go] through … Epic trying to find the encounters and [call center] calls and … have to Google who was the doctor involved in the calls to figure out [their] specialty. Interview 9, APP
Additionally, many participants pointed to the absence of a clear admitting team for IHT patients at the time of arrival as a safety concern and source of professional stress. This uncertainty regarding the responsible admitting team could result in communication breakdowns, delayed clinician evaluation and potential patient safety compromise, which was most apparent when IHT patients clinically deteriorated on arrival. Participants attributed the uncertainty to incomplete documentation of acceptance conversations by other services and lack of a list of anticipated IHTs for front-line clinicians.
The scary thing is that [something] bad can happen …and the nurses don't know what provider is caring for the patient and then you're contacted…. They're just calling people because they don't know who to call. It’s one of the biggest problems: there’s potentially a window where no care team is aware that the patient is physically there and that they're responsible for them. Interview 14, Physician
Potential improvement strategies
Suggestions included (1) a dedicated admitting team responsible for IHT patients and (2) organisational policies that require documentation of a standardised acceptance note across all services to aid in timely team identification.
I think just clear identification of who’s the person that’s responsible for the patient upon arrival and then a check in process would make things safer. Interview 1, Physician
Domain 3: expectation management during IHT
Interviewees described that the way IHT care is currently delivered creates constraints that make meeting nursing, patient and system expectations challenging.
Theme 3.1: nursing expectations of hospital medicine clinicians
Many triage and admitting team participants shared that nurses expected them to be aware of IHT patients prior to their arrival and prepared to initiate a care plan. However, because the accepting provider who takes the phone call from the transferring hospital is frequently not the triage clinician or the admitting provider, care plans are not pre-established at the time of IHT patient arrival.
[The nurses] expect me to know about the patient, know what’s going on, and who’s going to take them. I think that there’s like a huge disconnect in the realization that I don't know the patient has hit the floor until they informed me the patient is on the floor. Interview 26, APP
Potential improvement strategies
Education about workflows may aid in more realistic interdisciplinary expectations and reduce tensions between nursing and clinicians.
I wish they understood our workflow a little bit better; it can be really distracting when a nurse says multiple times ‘can I get orders?’ and I don't know anything about this patient… I can't put in a Lovenox order without knowing that they're not [having] a GI bleed. Interview 2, Physician
Theme 3.2: patient expectations of care at the accepting hospital
Several interviewees reported that IHT patients expected their care to be seamlessly continued on transfer but were disappointed when their hospital stay following transfer did not unfold as expected.
I would say there’s often a discrepancy between a patient’s expectation and what might happen once they're [transferred]. For example, they don't get the procedure that they were promised, so they're understandably frustrated. Interview 9, APP
When subspecialty teams decided not to pursue procedures or studies for which the patient was originally transferred—a decision that may not have been feasible until an in-person evaluation was completed—participants described navigating difficult conversations with patients and their care partners.
The worst is when a patient is transferred to your service to receive specialty care of a consultant, and then the consultant does not agree that the patient required transfer and does not want to provide the course of treatment that was the reason for the transfer. And now, you're the one who has to talk to the patient about this expectation that [what] they were transferred five hours, across state lines… for is not something that is actually going to be provided for them. Interview 7, Physician
Potential improvement strategies
Recommendations included improved coordination between transferring clinicians, accepting clinicians and consulting teams to facilitate consistent messaging to patients and their care partners.
I think there could be better coordination between services—between the accepting clinicians, the [consulting] teams, and the transferring facility. Interview 14, Physician
Opportunities to increase sense-making for patients could include explanations directly from the specialty team regarding the rationale for not offering a treatment or procedure after transfer.
Theme 3.3: unrealistic expectations of what can be achieved on a floor-level unit
Triage and admitting clinicians described that when IHT patients arrive clinically unstable, inpatient floor-level units have difficulty managing emergent situations. Unlike the emergency department or the intensive care unit (ICU), floor-level units do not have the level of staffing or resources to address a decompensating IHT patient who has just arrived. Additionally, system structures make obtaining STAT workup challenging on a floor unit.
[A patient] decompensated on the way to the hospital and [was] taken up to the floor. I spent six hours trying to get this patient upgraded to the appropriate level of care. [She] probably should have gone straight to the ED or straight to the ICU, but because she was accepted as floor [status], EMS [emergency medical services] just took her there. She just got dumped on the floor, and then it was hard to get anything done for her in a timely manner because we don't have quite the same resources [as] the ICU or in the emergency department. Interview 11, APP
Potential improvement strategies
Proposed solutions were (1) timely updates of the patient’s clinical status and/or medication changes that could alter the level of care required on arrival and (2) increased agency for emergency medical service (EMS) to deviate from the original transfer plan destination if patients deteriorate.
[In an] ideal world, if the patient started crumping in the ambulance, EMS can call [the call center] and say, “This patient can't come to the floor, they need to go to step down or they need to go to the ER. Interview 16, APP
Discussion
Our qualitative study of hospital medicine physicians and APPs at an academic medical centre found challenges in IHT information exchange, care team responsibilities and expectation management. To streamline IHT care, participants proposed designating specific individuals to manage both IHT transfer acceptance calls and IHT patient admissions. This approach would facilitate enhanced communication and build stronger relationships between transferring and accepting clinicians, ultimately optimising care continuity. Moreover, dedicated IHT admission teams would allow nurses to easily identify the responsible primary team. Interviewees also suggested standardised transfer acceptance scripts, transfer summary elements and documentation policies as additional means to improve information exchange. Lastly, the findings from our study suggest that bidirectional communication and interdisciplinary training may enable shared mental models of clinical acuity and expectations of care. By incorporating these strategies, IHT care could move closer to an ideal care delivery model.
While prior studies have revealed concerns about fragmented IHT information and inconsistent handover practices, our research highlights a larger issue: the lack of a cohesive clinical narrative readily available in a central location.8 10 12 13 29 30 Currently, clinicians must review multiple data sources to understand an IHT patient’s medical history, the prior hospital course and anticipated plan of care. Some of these sources may contain missing, inaccurate and/or extraneous information, hindering synthesis of pertinent clinical information. Employing dedicated IHT teams who follow standardised scripts and receive formal training focused on IHT process nuances was identified as an avenue to improve consistency of information quality and completeness and has been shown to be effective in at least one healthcare system.31 Additionally, participants suggested the use of discharge summaries with specified elements to further facilitate organisation of relevant clinical information into one source.
This study expands our understanding of the impact of uncertainty on IHT care responsibilities. Prior work has highlighted the frustration and stress transferring clinicians experience due to the uncertainties in finding an accepting hospital for IHT patients.8 Our participants provided an alternative viewpoint, revealing the pressure and stress associated with decision-making when accepting IHT patients. They described the pressure and stress stemming from (1) making important clinical decisions with potentially incomplete clinical information and (2) the possible consequences for patients and admitting clinicians downstream if they made an inappropriate decision. Developing relationships with transferring clinicians could address some of these stressors. Additionally, our work further validates the importance of clear identification of which clinicians are responsible for IHT patients at time of arrival to accepting hospitals.18 29 As described in research examining safety threats related to IHT of patients with non-traumatic intracranial haemorrhage, ambiguity in roles and responsibilities can lead to diffusion of accountability and increase the risk of medical errors.29 Establishing organisational policies to facilitate timely admitting team identification could mitigate communication breakdowns and potential delays in patient care.
Our work offers new insights into the dynamics between nurses and admitting clinicians as well as the relationships between patients and admitting clinicians. In prior work, nurses described feeling powerless to deliver timely and appropriate care for IHT patients while awaiting the admitting teams’ assessment and orders.18 Clinicians in this study also described feeling ineffective when IHT patients arrived for procedures that subspecialists did not ultimately pursue, leaving them caught in the middle. Additionally, clinicians described the tension to provide a timely and safe care plan while synthesising a clinical narrative for a patient that they had no awareness of prior to arrival. Mueller et al previously described a lack of shared understanding of the goals for transfer between various individuals involved in the IHT process; our work highlights the stress that clinicians sustain and the frustration that patients experience due to the discordance between the ideal and the current reality of IHT care.13 Our findings confirm that patients often assume that clinical information is seamlessly communicated between clinicians and expand on the consequences of disappointment and dissatisfaction when this expectation is not met.
Lastly, our research adds to existing literature regarding inappropriate IHT triage in the context of changing clinical acuity. The assumption that IHT patients remain clinically static from acceptance to arrival can lead to unexpected and potentially dangerous clinical decompensations enroute or on arrival at the accepting hospital. Participants described unanticipated IHT patient decompensations as particularly stressful because floor-level clinicians, nurses and units are not properly resourced to manage emergent situations for unfamiliar patients. This underscores the need for more flexible systems that can account for the possibility of unforeseen clinical changes and ensure proper resource allocation to prevent chaotic and unsafe situations.
Our study findings must be interpreted within the design limitations. This study was conducted at a single site, which limits generalisability given that IHT processes vary between hospitals and systems.2 10 However, given the consistency of our findings with prior work that have used both quantitative and qualitative methods, we believe that the broad themes in this study are likely similar at other large academic centres. Additionally, we sampled a large quaternary hospital that manages a high volume of IHTs.1 Second, our study may have been subject to selection bias with clinicians self-selecting to participate in order to discuss negative experiences, especially since they were familiar with the research team. We attempted to mitigate this by asking about both ideal and challenging IHT experiences. Lastly, we also acknowledge that there are other key informants involved in the IHT process that were excluded in our study, such as transferring clinicians and other clinical services (ie, ICU, surgery, etc) but opted to focus on accepting facility clinicians within general medicine given the scope of this study.
In summary, this study highlights the complexity of the IHT process and characterises challenges physicians and APPs at an accepting hospital experience with information exchange, care responsibilities and expectation management during IHT. Creating standardised transfer acceptance scripts with tailored training, having dedicated IHT personnel for acceptance calls and admissions and managing interdisciplinary expectations may alleviate some of the challenges in IHTs. Findings from this study offer several potential policy and care coordination targets to make IHT care safer and more streamlined for both patients and clinicians alike.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information. Deidentified interview transcripts, codebooks, deidentified field notes and consent forms are available from the corresponding author.
Ethics statements
Patient consent for publication
Ethics approval
The Colorado Multiple Institutional Review Board deemed this study exempt (21-3846). Participants provided verbal informed consent prior to the start of each interview.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
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Contributors AY initiated the collaborative project and is the guarantor. AY, LM and CW co-created the data collection tools, performed data collection, created the analysis plan and analysed the data. CDJ provided oversight and guidance over all aspects of the study. AY, LM, CW, JMN, SM, BDH, MO and CDJ drafted and revised the manuscript.
Funding This work was supported by the University of Colorado Division of Hospital Medicine’s Small Grant Program.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.