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Characterising ICU–ward handoffs at three academic medical centres: process and perceptions
  1. Lekshmi Santhosh1,
  2. Patrick G Lyons2,
  3. Juan C Rojas3,
  4. Thomas M Ciesielski4,
  5. Shire Beach1,
  6. Jeanne M Farnan5,
  7. Vineet Arora5
  1. 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of California San Francisco Medical Center at Parnassus, San Francisco, California, USA
  2. 2 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
  3. 3 Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
  4. 4 Department of Medicine, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
  5. 5 Department of Medicine, University of Chicago, Chicago, Illinois, USA
  1. Correspondence to Dr Lekshmi Santhosh, Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of California San Francisco Medical Center at Parnassus, San Francisco, CA 94117, USA; lekshmi.santhosh{at}ucsf.edu

Abstract

Background There is limited literature about physician handoffs between the intensive care unit (ICU) and the ward, and best practices have not been described. These patients are uniquely vulnerable given their medical complexity, diagnostic uncertainty and reduced monitoring intensity. We aimed to characterise the structure, perceptions and processes of ICU–ward handoffs across three teaching hospitals using multimodal methods: by identifying the handoff components involved in communication failures and describing common processes of patient transfer.

Methods We conducted a study at three academic medical centres using two methods to characterise the structure, perceptions and processes of ICU–ward transfers: (1) an anonymous resident survey characterising handoff communication during ICU–ward transfer, and (2) comparison of process maps to identify similarities and differences between ICU–ward transfer processes across the three hospitals.

Results Of the 295 internal medicine residents approached, 175 (59%) completed the survey. 87% of the respondents recalled at least one adverse event related to communication failure during ICU–ward transfer. 95% agreed that a well-structured handoff template would improve ICU–ward transfer. Rehabilitation needs, intravenous access/hardware and risk assessments for readmission to the ICU were the most frequently omitted or incorrectly communicated components of handoff notes. More than 60% of the respondents reported that notes omitted or miscommunicated pending results, active subspecialty consultants, nutrition and intravenous fluids, antibiotics, and healthcare decision-maker information at least twice per month. Despite variable process across the three sites, all process maps demonstrated flaws and potential for harm in critical steps of the ICU–ward transition.

Conclusion In this multisite study, despite significant process variation across sites, almost all resident physicians recalled an adverse event related to the ICU–ward handoff. Future work is needed to determine best practices for ICU–ward handoffs at academic medical centres.

  • graduate medical education
  • medical education
  • process mapping
  • transitions in care
  • chart review methodologies
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Footnotes

  • Twitter @LekshmiMD

  • Contributors All authors contributed to this work, including data collection, data analysis, manuscript drafting and manuscript revisions.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was granted institutional review board (IRB) exemption at site 1 and was approved by the IRBs at site 2 and site 3.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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