Article Text

Download PDFPDF

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

Statistics from Altmetric.com

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Background

The Joint Commission has identified communication failures during clinician handoffs as a major contributor to medical errors.1 Instruction about safe handoffs is a priority of the Accreditation Council for Graduate Medical Education (ACGME), which outlined specific mandates about the handoff process in their 2017 Common Programme Requirements.2 Although handoffs have been increasingly studied, most literature focuses on the change-of-shift handoffs3 4 or handoffs during hospitalist service changes.5 These studies documented the association between communication failures during handoffs and medical errors.6 7

To date, little work has examined communication when patients transfer from the intensive care unit (ICU) to the ward. In fact, a recent meta-analysis highlighted the lack of evidence for effective interventions to reduce handoff errors during the ICU to ward transition.8 One study found that nurses reviewing physician ICU transfer reports intercepted inaccurate communication.9 An observational single-centre study showed that poor communication during patient transfer resulted in medical errors, some of which led to patient harm and high-risk situations, such as patients being transiently ‘lost’ to medical care.10 A two-site Canadian study showed physician dissatisfaction with the current process of transferring patients from the ICU to the ward,11 but did not evaluate processes of care.

Only one study so far has exclusively analysed internal medicine resident physicians’ perceptions of ICU–ward transfers.12 In this single-centre, qualitative study, three of the authors identified frequent physician communication failures at ICU–ward transfer, including some near-misses and adverse patient events. These communication failures were thematically similar, typically involving missing information, unclear information and ambiguous responsibility for patients around the time of transfer.

Characterising the safety of ICU–ward transfers across teaching hospitals is important because this transition is one of the most vulnerable times for patients recovering from critical illness. These patients simultaneously experience an abrupt reduction in level of monitoring while frequently transitioning to a new team of clinicians. Currently, there are no best practices available for communication during ICU–ward transfers. Thus, we aimed to identify the handoff components involved in communication failures and to describe similarities and differences in the processes of patient transfer from the ICU to the ward across three teaching hospitals.

Methods

We conducted a multicentre study at three urban, academic, tertiary-care hospitals using two methods to characterise the structure and process of ICU–ward transfers. Specifically, we conducted (1) an anonymous resident survey characterising complexities of handoff communication during the ICU–ward transfer (structure) and (2) a comparison of process maps13 to identify similarities and differences between ICU–ward transfer processes across hospitals (process). The three sites were the University of Chicago, the University of California-San Francisco and the Washington University of St. Louis (sites 1, 2 and 3).

These sites were chosen for their geographical diversity and variety of ICU structures. The details of these sites are shown in table 1.

Table 1

Site characteristics and process map analysis

Structure

A cross-sectional, multi-institutional survey was developed by three of the authors, two of whom are content experts in the field of handoffs. Survey questions were developed according to prior literature,10 11 data from medical student observations of handoff errors14 and the authors’ expert opinions. The study was piloted among chief residents and graduating residents at site 1 in 2015. After pilot testing, no changes were made, and the survey was conducted at site 1. Following institutional review board approval at sites 2 and 3, the survey questions were rereviewed and edited for content and clarity before dissemination at these sites.

The survey was performed at three internal medicine residency programmes accredited by the ACGME and affiliated with the above-described hospitals. Internal medicine post-graduate year 2 (PGY2) and post-graduate year 3 (PGY3) resident physicians completed an anonymous, self-administered survey about ICU–ward handoffs. Surveys were conducted on paper at site 1 during the 2015–2016 academic year, and online at sites 2 and 3 between August 2017 and January 2018. PGY1 residents were excluded because they were rarely primarily responsible for ICU–ward transfer communication. Survey questions (online supplementary appendix 1) focused on adverse events and medical errors related to physician handoff communication between the ICU and ward teams, and the content included in ICU transfer notes.

Supplemental material

Online surveys were conducted in Qualtrics via a hyperlink emailed to eligible residents. Statistical analyses were performed using Stata V.15.1, with Fisher’s exact test and the Kruskal-Wallis test applied as appropriate. P values less than 0.05 were considered statistically significant.

Process map and clinical documentation review

Process maps13 were developed to depict the transfer of information during patient transfers from the ICU to the ward at each site. These maps were constructed by triangulating information from informal interviews with nurse managers, internal medicine residents, attending physicians, ICU fellows and administrative staff in bed control or the transfer centre. Interviews were conducted by the authors. Process maps were verified with clinical leaders (ICU directors and nurse managers).

Process maps were analysed to compare and contrast team member roles during handoff, transitions of professional responsibility and physical transfers of patients. Finally, we analysed clinical transfer documentation (transfer notes and note templates) at each site.15

Results

Structure

Of 295 residents approached, 175 (59%) completed the survey. The response rates were 84% (61/73) at site 1, 55% (68/123) at site 2 and 46% (46/99) at site 3 (p<0.001). Table 1 presents the complete survey responses by site.

According to survey respondents, rehabilitation needs, intravenous access and other indwelling hardware, and risk for readmission to the ICU were the most frequently omitted or incorrectly communicated components of handoff notes (figure 1). More than 60% of the respondents reported that at least twice per month, notes omitted or miscommunicated pending results, active subspecialty consultants, nutrition and intravenous fluids, antibiotics and healthcare decision-maker information. Over 40% of the respondents recalled adverse outcomes, including missed critical results, medication errors and ICU readmissions related to incorrect or missing information (figure 1).

Figure 1

(A) Residents reporting handoff errors or omissions twice or more per month. (B) Residents reporting awareness of adverse outcomes as a result of poor ICU–ward handoff. (C) Estimated average time spent, per patient, repeating previously completed patient care tasks as a result of insufficient handoff quality. ICU, intensive care unit; OT, occupational therapy; PT, physical therapy; VTE, venous thromboembolism.

Moreover, transfer note items at risk for omission or miscommunication differed significantly between institutions (p<0.05 for outstanding studies and fluids; p<0.01 for goals of care, ICU readmission risk, oxygen requirements and pain needs; p<0.001 for active consultants, access and hardware, physical or occupational therapy assessments, diet, venous thromboembolism prophylaxis, and information regarding family updates).

In total, 87% of the respondents recalled an adverse event related to communication failure from the ICU to the ward, with each institution reporting identical rates of recalling at least one adverse event (p=1.0). However, the relative frequencies of most potential adverse outcomes were not significantly different between institutions (p>0.09) for all outcomes except upset families and rapid response activations. The significant institutional differences in rapid response activation rates were thought to be related to poor handoff communication (p<0.001).

Survey respondents reported engaging in ‘re-work’: that is, recovering or repeating previously completed patient care tasks to compensate for suboptimal handoff communication.16 Over 80% of the respondents recalled spending 30 min or more per patient to recover information due to handoff communication failures (figure 1). Respondents from site 2, which employs the ‘open ICU’ system, reported significantly less time on these activities than other sites (p<0.001). Almost 70% of respondents reported calling the ICU for clarifying information after transfer, with site 2 respondents calling most frequently (p<0.05). Finally, 95% of the respondents strongly or somewhat agreed that a well-structured handoff template would improve communication at the ICU–ward transfer.

Process map and clinical documentation review

Process maps are shown in figure 2. Site 2 has an ‘open-ICU’ structure, where a patient’s primary ward-based service manages the majority of patient care in the ICU, while the ICU team manages mechanical ventilation, sedation and placement of central lines. Therefore, the processes for the ICU–ward transfer varied greatly between site 2 and the other sites.

Figure 2

The left side of the figure refers to communication happening while the patient is in the MICU; the right side of the figure refers to communication happening while the patient is on the ward. The dotted lines refer to the optional ‘as-needed’ communication between providers. The solid lines refer to mandatory communication between providers. Lines with double arrows indicate bidirectional flow ofcommunication. Lines with single arrows indicate unidirectional flow of communication. Trainee roles (residents and fellows) are indicated by black boxes with white texts and nursing roles (ward and ICU) are indicated by light-grey boxes with black text. EMR, electronic medical record; ICU, intensive care unit; MICU, medical intensive care unit; RN, registered nurse.

Table 2 highlights the main differences in required communication between the ICU and ward teams across sites. Direct verbal communication between the ICU nurse and the receiving ward nurse was required at all sites, although physician-to-physician communication varied between sites.

Table 2

Survey responses by residency programme

Process maps revealed explicit differences related to timing of transfer of professional responsibility in relation to the patient’s location in the ICU or ward. At site 3, physician responsibility transferred when the patient physically moved to the ward. In contrast, at site 1, ICU physician responsibility for the patient sometimes continued after the patient had physically moved to the ward if the receiving primary team had ‘capped’ or during times of cross-coverage. At site 2, primary teams and ICU teams shared responsibility until the patient physically left the ICU.

While ICU–ward handoff documentation was variable, no site used a standard communication template to support ICU–ward transfer. At site 2, ICU–ward transfer did not involve a dedicated transfer note. The ICU team independently wrote an ICU admission note, and both ICU and primary teams wrote daily progress notes. In contrast, both sites 2 and site 3 used transfer notes routinely (online supplementary appendix 2). Site 1’s notes had a short free-form narrative description of ICU events, followed by checkboxes indicating future clinical needs and tasks to follow up. Site 3’s transfer note content was left to the writer’s discretion, but typically involved problem-based clinical summaries and rarely itemised individual follow-up tasks explicitly, although some were embedded in the narrative description for each problem.

Conclusions

In summary, all three sites’ process maps had different flaws and potential areas for harm. For example, at site 2, the lack of standardised communication between the ICU and primary teams is a failure-prone process. At site 1, the continuation of responsibility of the ICU team for patients already discharged from the ICU on the medical wards is a source of potential error. At site 3, the additional role of the fellow and the required transfer notes are positive safeguards for patient safety, but the content of transfer notes was left to the authors’ discretion. This invites process variability that may lead to incomplete transfer communication.

This is the first study to elaborate on process-related and safety-related perceptions of ICU–ward handoffs across multiple academic medical centres. In this three-site study, almost all resident physicians recalled at least one adverse event related to ICU–ward handoff communication failure. Additionally, most respondents described frequent written handoff errors, miscommunication-related adverse patient events and time wasted repeating previously completed patient care tasks. These results suggest that respondents at all institutions perceived ICU–ward handoffs as an area of high vulnerability and potential for errors. Notably, these perceptions were common despite high rates of ‘re-working’ previously completed patient care tasks to recover lost or miscommunicated information. It is possible that in the absence of this repeated work, perceptions of handoff-related adverse events and near-misses could be even more alarming. The significant institutional differences in rapid response activation rates were thought to be related to poor handoff communication, which may stem from institution-dependent rapid response activation protocols.

Process maps and analysis of transfer documentation highlighted complex and variable webs of communication, potential areas of redundant communication and possible gaps in communication where medical errors may arise. The differences in the flow of information across sites can be attributable to several factors. ‘Open’ ICUs, for example, may promote longitudinal patient care experiences by one primary team, while ‘closed’ ICUs concentrate management of critically ill patients among a group of providers tasked solely to the ICU; such distinctions likely influence communication pathways at these different hospitals. There may also be variability in residency education regarding transitions of care and quality improvement. Finally, physician staffing may affect communication processes, as seen at site 3, where the presence of a critical care fellow around the clock permits high utilisation of a ‘just-in-time’ patient evaluation prior to transfer. These factors could also contribute to the institutional differences in handoff components at risk for miscommunication.

Most residents agreed that a well-structured standardised handoff template would be beneficial. This finding mirrors results from a 360-degree study of ICU handoffs,17 which recommended a standardised face-to-face physician handover, and from the landmark Illness Severity-Patient Summary-Action List-Situation Awareness-Synthesis by Receiver (I-PASS trial), which demonstrated fewer medical errors and preventable adverse events with a structured handoff programme18 for paediatric residents at shift change. Efforts to standardise ICU–ward handoffs may prove beneficial in the future and merit further study, and employing a comparative failure mode and effects analysis to more rigorously compare the processes and sources of errors might enhance standardisation efforts. Moreover, as the quality improvement/implementation science literature in both paediatrics and adult medicine has shown, it can take several months for a structured handoff protocol to be widely implemented and disseminated.16 19

Limitations of our study include the low survey response rates at two sites; this affects the validity of our results and threatens our conclusions, especially given potential response bias and hindsight bias. Our results may not be generalisable to other training programmes, non-academic institutions, or to specialty ICUs or ICUs with different case mixes or patient populations. Additionally, we only surveyed internal medicine residents; trainees in other specialties or subspecialties, attending physicians and advanced care practitioners may report different experiences. Finally, there is no evidence for direct causality connecting poor handoffs to adverse events.

In conclusion, academic centres have highly variable communication practices during patient transfers from the ICU to ward, yet residents overwhelmingly perceive these handoffs to be a period of patient vulnerability. This study elucidates the structure and process of ICU–ward transitions across three academic medical centres, providing foundational literature for future quality improvement and medical education work targeting the ICU–ward handoff process. Further research to establish best practices for ICU–ward handoffs at academic medical centres is needed.

References

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.