Background: Transfers from the ICU to the medical ward pose a number of unique risks to patients recovering from critical illness. Several studies have identified communication breakdown among physicians and nurses at the time of transfer as a key vulnerability. This dilemma is particularly challenging in the context of tertiary institutions with high levels of patient acuity and complexity. Unfortunately, no studies are available to provide guidance as to the optimal transfer mechanism in this setting. 

Purpose: To describe an innovative reorganization of the transfer process at Wake Forest Baptist Health. Our aim was to collaboratively involve transferring physicians, nurse managers, and hospital bed logistics personnel in a proactive multi-disciplinary daily handoff process. 

Description: Wake Forest Baptist Health is an 885 bed tertiary teaching institution with a 34 bed capacity medical ICU. Previously, patients were transferred from the ICU to either a resident service or an academic hospitalist service as ward beds became available. This method of patient transfer required handoffs around the clock, including a significant number of overnight transfers when there were limited physician, nursing, and logistical resources available. We reorganized our transfer process in an effort to improve patient safety, optimize handoff communication, and expedite ICU to floor throughput. We eliminated ICU transfers to the resident services except in cases to maintain pre-existing continuity of care. Each morning, one hospitalist met with the ICU triage physician and designated nursing leadership as well as bed logistics personnel.  All patients anticipated to transfer from the ICU within the next 24 hours were discussed. During this meeting, the ICU physician provided a brief patient handoff to the accepting hospitalist. Subsequently, that hospitalist reviewed the EMR and examined these patients prior to transfer. Thus, the number of patients requiring transfer of care during the overnight hours decreased substantially. Additionally, both the ICU physician and the accepting hospitalist provided written documentation utilizing a standardized transfer note template in order to highlight important details for safe transition of care.

Conclusions: After a successful pilot of the described transfer process, we have performed a full-scale implementation. Specific metrics and outcomes to directly assess the impact of the above changes are under development. We anticipate reduced length of stay secondary to decreased delays in time to transfer and more concise handoffs, reduced rates of ICU readmission, and improved patient satisfaction. Furthermore, residency program feedback regarding the educational impact of these changes has been positive. Additional study is necessary to quantitatively assess the impact of our reorganized transfer process.