Background: Transitions of care from one service to another are a precarious time with risk of adverse events, medical errors, and clinician dissatisfaction. Every handoff involves transferring information and responsibility for a patient from one physician to another. The appropriateness of transfer is critical to safe patient care. The transfer process from an intensive care unit (ICU) to a general ward setting adds the challenges of increased acuity of illness, physical change in location, and transition to a limited resourced area. We sought to assess hospitalist physician’s and advance practiced provider’s (APP) perception of the transition of care process from the medical ICU to the ward at a large urban academic hospital to identify potential targets for improvement.
Methods: Setting: At our hospital, the medical ICU service is staffed by residents. When a patient is deemed appropriate for transfer by the ICU attending physician, the ICU resident will page a hospitalist triage physician. The triage physician will review the patient’s chart and page out the transfer to a receiving provider if deemed stable for transfer. The receiving physician or APP will then call the ICU resident for sign out. Survey: We created a quantitative and qualitative survey assessing 2 key components of ICU care transition –appropriateness for transfer and handoffs. The survey was distributed to attending physicians and APPs in the section of Hospital Medicine via a Redcap link. Responses were filed anonymously. Results were compiled with descriptive data analysis.
Results: The survey response rate was 62% (37 of 60 clinically active hospitalist physician and APPs). The majority (46%) of respondents had less than 3 years of clinical experience. All respondents agreed that the hospitalist triage physician should have input in accepting ICU transfers. The majority (42%) of respondents estimated that 5-10% of ICU transfer patients they encountered were unstable on transfer and a quarter thought that 10-20% of patients were unstable on transfer. If they encounter a perceived unstable patient on transfer, 92% of respondents would discuss the case with the ICU resident, but only 11% would discuss with the ICU attending. Regarding the perception of handoffs between ICU residents and hospitalist providers, 66% of respondents thought the medical ICU resident handoff notes were comprehensive, while there was a split between notes being concise and too wordy. 80% believed that verbal sign out was necessary and 51% thought that both teams should reconcile orders for patient care on transfer. Lastly, 46% said they frequently encountered problems with undocumented code status. Qualitative responses for recommendations to improve the ICU transition process included standardizing transfer readiness criteria for common ICU conditions and ensuring stability of patients prior to transfer.
Conclusions: The main concerns of hospitalist providers in the transition of care for ICU patients at a large academic medical center are the perception of patient stability and readiness for transfer. Handoffs appeared to be adequate with most providers preferring both written and verbal handoffs. Objective data on patient stability and ICU bounce backs is being collected. More work is needed to better define criteria for ICU transfer readiness.
