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Quality improvement report
Improving end-of-rotation transitions of care among ICU patients
  1. Joshua Lee Denson1,2,
  2. Julie Knoeckel3,4,
  3. Sara Kjerengtroen2,
  4. Rachel Johnson5,
  5. Bryan McNair5,
  6. Olivia Thornton6,
  7. Ivor S Douglas2,7,
  8. Michael E Wechsler2,8,
  9. Robert E Burke9,10
  1. 1 Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
  2. 2 Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
  3. 3 Medicine, Denver Health Medical Center, Denver, CO, United States
  4. 4 Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
  5. 5 Department of Biostatistics and Informatics, School of Public Health, University of Colorado, Aurora, Colorado, USA
  6. 6 University of Colorado Health, Aurora, Colorado, USA
  7. 7 Pulmonary and Critical Care Medicine, Denver Health Medical Center, Denver, Colorado, USA
  8. 8 Pulmonary and Critical Care Medicine, National Jewish Health, Denver, Colorado, USA
  9. 9 Section of Hospital Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
  10. 10 Center for Health Equity Research and Promotion (CHERP), Corporal Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Joshua Lee Denson, Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA 70112-2632, USA; Jdenson{at}tulane.edu

Abstract

Background Hospitalised patients whose inpatient teams rotate off service experience increased mortality related to end-of-rotation care transitions, yet standardised handoff practices are lacking.

Objective Develop and implement a multidisciplinary patient-centred handoff intervention to improve outcomes for patients who are critically ill during end-of-rotation transitions.

Design, setting and participants Single-centre, controlled pilot study of medical intensive care unit (ICU) patients whose resident team was undergoing end-of-rotation transition at a university hospital from June 2017 to February 2018.

Intervention A 4-item intervention was implemented over two study periods. Intervention 1 included: (1) in-person bedside handoff between teams rotating off and on service, (2) handoff checklist, (3) nursing involvement in handoff, and (4) 30 min education session. Intervention 2 included the additional option to conduct bedside handoff via videoconferencing.

Main outcome measures Implementation was measured by repeated clinician surveys and direct observation. Patient outcomes included length of stay (LOS; ICU and hospital) and mortality (ICU, hospital and 30 days). Clinician perceptions were modelled over time using per cent positive responses in logistic regression. Patient outcomes were compared with matched control ‘transition’ patients from 1 year prior to implementation of the intervention.

Results Among 270 transition patients, 46.3% were female with a mean age of 55.9 years. Mechanical ventilation (64.1%) and in-hospital death (27.6%) rates were prevalent. Despite high implementation rates—handoff participation (93.8%), checklist utilisation (75.0%), videoconferencing (62.5%), nursing involvement (75.0%)—the intervention did not significantly improve LOS or mortality. Multidisciplinary survey data revealed significant improvement in acceptability by nursing staff, while satisfaction significantly declined for resident physicians.

Conclusions In this controlled pilot study, a structured ICU end-of-rotation care transition strategy was feasible to implement with high fidelity. While mortality and LOS were not affected in a pilot study with limited power, the pragmatic strategy of this intervention holds promise for future trials.

  • hand-off
  • transitions in care
  • patient safety
  • critical care
  • checklists

https://doi.org/10.1136/bmjqs-2019-009867

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    Footnotes

    • Twitter @jdensonMD, @com543, @BBurkeMD

    • Presented at Portions of these data were presented at the 2018 & 2019 International Conferences of the American Thoracic Society.

    • Funding This project was supported by grant funding from the UCH Clinical Effectiveness and Patient Safety Small Grants Program (#63500549) and the NIH/NCRR Colorado CTSI Grant Number UL1 RR025780.

    • Disclaimer The contents of this study are the authors’ sole responsibility and do not necessarily represent official NIH views.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval This study was reviewed and approved by the Institutional Review Board (protocol number 17-1762).

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

    • Data availability statement Data are available upon reasonable request.