Background: Previous studies demonstrate patient readmissions to the Medical Intensive Care unit (MICU) from the ward are potentially associated with worse outcomes due to breakdowns in communication during ICU-ward transfer. Though previous work highlights the importance of shared mental models (whether clinicians have a mutual understanding) during handoffs, no studies examined the prevalence of a shared mental model during ICU-ward transfer.
Methods: Data was collected from ICU teams prior to the day of transfer, and ward data was collected the day of transfer. Ward and ICU clinicians (Physicians/Nurses) were asked the same question, “In your judgement, what do you think would be the single most important component of this patient’s care on the wards?” and provided a free-text response. All clinicians were also asked to rate the probability of the patient’s readmission to the MICU within 48 hours on a 10-point scale. We calculated the difference between the highest score given by the ICU and ward clinician. Three coders agreed on a standard coding data scheme (figure), which was applied by an individual coder. Chi-square tests, Spearman Rank Correlation Coefficient, and ANOVA were used for statistical analyses.
Results: For 199 unique patients transferred from ICU to ward, a total of 464 ICU and 212 ward clinicians responded, with at least one ward provider and one ICU provider represented. Complete data was available for 115 unique patient cases where both intra-team and inter-team agreements were determined. For 46.9% of patients, there was no inter-team agreement on the most important component of patient care (9.6% full, 43.5% partial). Intra-team agreement among ICU clinicians at time of transfer was better: 20.9% complete, 22.6% strong, 18.3% weak, and 38.3% no intra-team MICU agreement. There was a significant positive correlation between inter-team and intra-team agreement (⍴=0.3082, p=0.008). There was a positive association between the level of inter-team agreement measured qualitatively and the numeric difference of rated likelihood of readmission between ICU and ward clinicians (F=3.12, p=0.0470).
Conclusions: For nearly half of patients, there was no agreement between ICU and ward clinicians on the most important component of patient care. The degree of inter-team agreement between ICU and ward clinician was positively correlated with degree of intra-team agreement among ICU clinicians. Better qualitative agreement between ICU-ward clinicians about the most important piece of patient information was associated with greater quantitative agreement between ICU and ward clinician on the numeric prognostication of how likely a patient is to return to the ICU. Future investigations should seek to understand if improved inter-team agreement is associated with improved patient outcomes.
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