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Bloomhardt H, Schechter S, Fischer A, Schlosser Metitiri K, McCann T, McCarthy C, Rivera C, Lakhaney D. Communication Strategies for Transferring Medically Complex Children Out of Intensive Care. Clin Pediatr (Phila) 2024:99228231223098. [PMID: 38205734 DOI: 10.1177/00099228231223098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Affiliation(s)
- Hadley Bloomhardt
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA
- Boston Children's Hospital, Boston, MA, USA
| | - Sarah Schechter
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Morgan Stanley Children's Hospital, NewYork-Presbyterian, New York, NY, USA
| | - Avital Fischer
- Division of Pediatric Palliative Care, Maine Medical Center, Portland, ME, USA
| | - Katherine Schlosser Metitiri
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Morgan Stanley Children's Hospital, NewYork-Presbyterian, New York, NY, USA
| | - Teresa McCann
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Morgan Stanley Children's Hospital, NewYork-Presbyterian, New York, NY, USA
| | - Colleen McCarthy
- Morgan Stanley Children's Hospital, NewYork-Presbyterian, New York, NY, USA
| | - Cory Rivera
- Morgan Stanley Children's Hospital, NewYork-Presbyterian, New York, NY, USA
| | - Divya Lakhaney
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Morgan Stanley Children's Hospital, NewYork-Presbyterian, New York, NY, USA
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Cornell EG, Harris E, McCune E, Fukui E, Lyons PG, Rojas JC, Santhosh L. Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool. Diagnosis (Berl) 2023; 10:417-423. [PMID: 37598362 DOI: 10.1515/dx-2023-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 07/14/2023] [Indexed: 08/22/2023]
Abstract
OBJECTIVES The transition from the intensive care unit (ICU) to the medical ward is a high-risk period due to medical complexity, reduced patient monitoring, and diagnostic uncertainty. Standardized handoff practices reduce errors associated with transitions of care, but little work has been done to standardize the ICU to ward handoff. Further, tools that exist do not focus on preventing diagnostic error. Using Human-Centered Design methods we previously created a novel EHR-based ICU-ward handoff tool (ICU-PAUSE) that embeds a diagnostic pause at the time of transfer. This study aims to explore barriers and facilitators to implementing a diagnostic pause at the ICU-to-ward transition. METHODS This is a multi-center qualitative study of semi-structured interviews with intensivists from ten academic medical centers. Interviews were analyzed iteratively through a grounded theory approach. The Sittig-Singh sociotechnical model was used as a unifying conceptual framework. RESULTS Across the eight domains of the model, we identified major benefits and barriers to implementation. The embedded pause to address diagnostic uncertainty was recognized as a key benefit. Participants agreed that standardization of verbal and written handoff would decrease variation in communication. The main barriers fell within the domains of workflow, institutional culture, people, and assessment. CONCLUSIONS This study represents a novel application of the Sittig-Singh model in the assessment of a handoff tool. A unique feature of ICU-PAUSE is the explicit acknowledgement of diagnostic uncertainty, a practice that has been shown to reduce medical error and prevent premature closure. Results will be used to inform future multi-site implementation efforts.
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Affiliation(s)
- Ella G Cornell
- University of California San Francisco, San Francisco, CA, USA
| | - Emily Harris
- Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Emma McCune
- University of California San Francisco, San Francisco, CA, USA
| | - Elle Fukui
- University of California San Francisco, San Francisco, CA, USA
| | - Patrick G Lyons
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Juan C Rojas
- Rush University Medical Center, Chicago, IL, USA
| | - Lekshmi Santhosh
- Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
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Ostermann M, Vincent JL. ICU without borders. Crit Care 2023; 27:186. [PMID: 37179324 PMCID: PMC10182543 DOI: 10.1186/s13054-023-04463-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
Critical illness is a continuum, but patient care is often fragmented. Value-based critical care focuses on the overall health of the patient, not on an episode of care. The "ICU without borders" model incorporates a concept where members of the critical care team are involved in the management of patients from the onset of critical illness until recovery and beyond. In this paper, we summarise the potential benefits and challenges to patients, families, staff and the wider healthcare system and list some essential requirements, including a tight governance framework, advanced technologies, investment and trust. We also argue that "ICU without borders" should be viewed as a bi-directional model, allowing extended visiting hours, giving patients and families direct access to experienced critical care staff and offering mutual aid when needed.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Foundation Hospital, NHS Foundation Trust, London, SE1 7EH, UK.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
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Mavragani A, Lyons PG, Harris E, McCune EK, Rojas JC, Santhosh L. Improving Communication in Intensive Care Unit to Ward Transitions: Protocol for Multisite National Implementation of the ICU-PAUSE Handoff Tool. JMIR Res Protoc 2023; 12:e40918. [PMID: 36745494 PMCID: PMC9941899 DOI: 10.2196/40918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 12/13/2022] [Accepted: 01/04/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The intensive care unit (ICU)-ward transfer poses a particularly high-risk period for patients. The period after transfer has been associated with adverse events and additional work for care teams related to miscommunication or omission of information. Standardized handoff processes have been found to reduce communication errors and adverse patient events in other clinical environments but are understudied at the ICU-ward interface. We previously developed an electronic ICU-ward transfer tool, ICU-PAUSE, which embeds the key elements and diagnostic reasoning to facilitate a safe transfer of care at ICU discharge. OBJECTIVE The aim of this study is to evaluate the implementation process of the ICU-PAUSE handoff tool across 10 academic medical centers, including the rate of adoption and acceptability, as perceived by clinical care teams. METHODS ICU-PAUSE will be implemented in the medical ICU across 10 academic hospitals, with each site customizing the tool to their institution's needs. Our mixed methods study will include a combination of a chart review, quantitative surveys, and qualitative interviews. After a 90-day implementation period, we will conduct a retrospective chart review to evaluate the rate of uptake of ICU-PAUSE. We will also conduct postimplementation surveys of providers to assess perceptions of the tool and its impact on the frequency of communication errors and adverse events during ICU-ward transfers. Lastly, we will conduct semistructured interviews of faculty stakeholders with subsequent thematic analysis with the goal of identifying benefits and barriers in implementing and using ICU-PAUSE. RESULTS ICU-PAUSE was piloted in the medical ICU at Barnes-Jewish Hospital, the teaching hospital of Washington University School of Medicine in St. Louis, in 2019. As of July 2022, implementation of ICU-PAUSE is ongoing at 6 of 10 participating sites. Our results will be published in 2023. CONCLUSIONS Our process of ICU-PAUSE implementation embeds each step of template design, uptake, and customization in the needs of users and key stakeholders. Here, we introduce our approach to evaluate its acceptability, usability, and impact on communication errors according to the tenets of sociotechnical theory. We anticipate that ICU-PAUSE will offer an effective handoff tool for the ICU-ward transition that can be generalized to other institutions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/40918.
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Affiliation(s)
| | - Patrick G Lyons
- Division of Pulmonary and Critical Care Medicine, John T Milliken Department of Medicine, Washington University School of Medicine in St. Louis, St Louis, MO, United States.,Healthcare Innovation Lab, BJC HealthCare, St Louis, MO, United States
| | - Emily Harris
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Emma K McCune
- School of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Juan C Rojas
- Department of Internal Medicine, Rush University, Chicago, IL, United States
| | - Lekshmi Santhosh
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
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Transitions of Patient Care: A Standardized Tool for Provider Handoff. J Nurse Pract 2023. [DOI: 10.1016/j.nurpra.2023.104544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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A Multiple Baseline Trial of an Electronic ICU Discharge Summary Tool for Improving Quality of Care. Crit Care Med 2022; 50:1566-1576. [PMID: 35972243 DOI: 10.1097/ccm.0000000000005638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Effective communication between clinicians is essential for seamless discharge of patients between care settings. Yet, discharge summaries are commonly not available and incomplete. We implemented and evaluated a structured electronic health record-embedded electronic discharge (eDischarge) summary tool for patients discharged from the ICU to a hospital ward. DESIGN Multiple baseline trial with randomized and staggered implementation. SETTING Adult medical-surgical ICUs at four acute care hospitals serving a single Canadian city. PATIENTS Health records of patients 18 years old or older, in the ICU 24 hours or longer, and discharged from the ICU to an in-hospital patient ward between February 12, 2018, and June 30, 2019. INTERVENTION A structured electronic note (ICU eDischarge tool) with predefined fields (e.g., diagnosis) embedded in the hospital-wide electronic health information system. MEASUREMENTS AND MAIN RESULTS We compared the percent of timely (available at discharge) and complete (included goals of care designation, diagnosis, list of active issues, active medications) discharge summaries pre and post implementation using mixed effects logistic regression models. After implementing the ICU eDischarge tool, there was an immediate and sustained increase in the proportion of patients discharged from ICU with timely and complete discharge summaries from 10.8% (preimplementation period) to 71.1% (postimplementation period) (adjusted odds ratio, 32.43; 95% CI, 18.22-57.73). No significant changes were observed in rapid response activation, cardiopulmonary arrest, death in hospital, ICU readmission, and hospital length of stay following ICU discharge. Preventable (60.1 vs 5.7 per 1,000 d; p = 0.023), but not nonpreventable (27.3 vs 40.2 per 1,000d; p = 0.54), adverse events decreased post implementation. Clinicians perceived the eDischarge tool to produce a higher quality discharge process. CONCLUSIONS Implementation of an electronic tool was associated with more timely and complete discharge summaries for patients discharged from the ICU to a hospital ward.
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Correia PC, Gomes de Macedo P, Santos JFG, Moreira Júnior JR, de Oliveira C, Malbouisson LMS. Impact of customised ICU handover protocol on the quality of ICU discharge reports. BMJ Open Qual 2022; 11:bmjoq-2021-001647. [PMID: 35977742 PMCID: PMC9389091 DOI: 10.1136/bmjoq-2021-001647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 06/30/2022] [Indexed: 11/10/2022] Open
Abstract
Background The aim of this investigation was to evaluate the impact of implementing a handover protocol, based on a standardised mnemonic tool specific for a cardiovascular intensive care unit (ICU), on the quality of information transferred during ICU discharge. Methods In this prospective pre–post study, we evaluated the implementation of an ICU discharge handover protocol in 168 patients who underwent coronary artery bypass graft surgery. The primary outcome was the quality of the information. In the preintervention phase, 84 ICU standard discharge reports were evaluated. During the intervention period, a new handover protocol which included a written discharge report based on the I-PASS (illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver) mnemonic tool was implemented. After the intervention, 84 new reports were assessed. The reports were evaluated by the ward physicians and by an external independent examiner using a standardised questionnaire. ICU discharge time and postoperative length of stay were also analysed. Results The overall quality of the reports was evaluated as ‘completely understood’ by the ward physicians in 17 patients (21%) in the preintervention phase compared with 45 patients (54.9%) in the postintervention phase (p<0.001). The independent examiner classified one report (1.2% of the total number) as ‘excellent’ in the preintervention phase and 30 (35.7%) in the postintervention phase (p<0.001). After protocol implementation, patients were released from the ICU 58 min later (p<0.001). There was no difference in the length of postoperative hospital stay. Conclusion Implementation of a customised handover protocol when discharging patients from the ICU was associated with improvement in the quality of the information transferred but also with ICU discharge occurring at a later time of day.
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Affiliation(s)
- Paulo César Correia
- Anestesiologia, Ciências Cirúrgicas e Medicina Perioperatória, Universidade de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
- Santa Casa BH, Belo Horizonte, Minas Gerais, Brazil
| | | | | | | | | | - Luiz Marcelo Sá Malbouisson
- Anestesiologia, Ciências Cirúrgicas e Medicina Perioperatória, Universidade de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
- Universidade de Sao Paulo Hospital das Clinicas, Sao Paulo, São Paulo, Brazil
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Leven EA, Luo Y, Nguyen VT, Pourmand K. Enhanced Communication for Interhospital Transfers Increases Preparedness in an Academic Tertiary Care Center. Appl Clin Inform 2022; 13:811-819. [PMID: 36044918 PMCID: PMC9433165 DOI: 10.1055/s-0042-1756371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 07/21/2022] [Indexed: 11/02/2022] Open
Abstract
OBJECTIVES This quality improvement project sought to enhance clinical information sharing for interhospital transfers to an inpatient hepatology service comprised of internal medicine resident frontline providers (housestaff) with the specific aims of making housestaff aware of 100% of incoming transfers and providing timely access to clinical summaries. INTERVENTIONS In February 2020, an email notification system to senior medicine residents responsible for patient triage shared planned arrival time for patients pending transfer. In July 2020, a clinical data repository ("Transfer Log") updated daily by accepting providers (attending physicians and subspecialty fellows) became available to senior medicine residents responsible for triage. METHODS Likert scale surveys were administered to housestaff before email intervention (pre) and after transfer log intervention (post). The time from patient arrival to team assignment (TTA) in the electronic medical record was used as a proxy for time to patient assessment and was measured pre- and postinterventions; >2 hours to TTA was considered an extreme delay. RESULTS Housestaff reported frequency of access to clinical information as follows: preinterventions 4/31 (13%) sometimes/very often and 27/31 (87%) never/rarely; postinterventions 11/26 (42%) sometimes/very often and 15/26 (58%) never/rarely (p = 0.02). Preinterventions 12/39 (31%) felt "not at all prepared" versus 27/39 (69%) "somewhat" or "adequately"; postinterventions 2/24 (8%) felt "not at all prepared" versus 22/24 (92%) somewhat/adequately prepared (p = 0.06). There was a significant difference in mean TTA between pre- and posttransfer log groups (62 vs. 40 minutes, p = 0.01) and a significant reduction in patients with extreme delays in TTA post-email (18/180 pre-email vs. 7/174 post-email, p = 0.04). CONCLUSION Early notification and increased access to clinical information were associated with better sense of preparedness for admitting housestaff, reduction in TTA, and reduced frequency of extreme delays in team assignment.
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Affiliation(s)
- Emily A. Leven
- Department of Medicine, Mount Sinai Hospital, New York, New York, United States
| | - Yuying Luo
- Division of Gastroenterology, Department of Medicine, Mount Sinai Hospital, New York, New York, United States
| | - Vinh-Tung Nguyen
- Division of Hospital Medicine, Department of Medicine, Mount Sinai Hospital, New York, New York, United States
| | - Kamron Pourmand
- Division of Liver Diseases, Recanati/Miller Transplantation Institute, Mount Sinai Hospital, New York, New York, United States
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Casanova NL, LeClair AM, Xiao V, Mullikin KR, Lemon SC, Freund KM, Haas JS, Freedman RA, Battaglia TA. Development of a workflow process mapping protocol to inform the implementation of regional patient navigation programs in breast oncology. Cancer 2022; 128 Suppl 13:2649-2658. [PMID: 35699611 PMCID: PMC9201987 DOI: 10.1002/cncr.33944] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 08/06/2021] [Accepted: 08/20/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Implementing city-wide patient navigation processes that support patients across the continuum of cancer care is impeded by a lack of standardized tools to integrate workflows and reduce gaps in care. The authors present an actionable workflow process mapping protocol for navigation process planning and improvement based on methods developed for the Translating Research Into Practice study. METHODS Key stakeholders at each study site were identified through existing community partnerships, and data on each site's navigation processes were collected using mixed methods through a series of team meetings. The authors used Health Quality Ontario's Quality Improvement Guide, service design principles, and key stakeholder input to map the collected data onto a template structured according to the case-management model. RESULTS Data collection and process mapping exercises resulted in a 10-step protocol that includes: 1) workflow mapping procedures to guide data collection on the series of activities performed by health care personnel that comprise a patient's navigation experience, 2) a site survey to assess program characteristics, 3) a semistructured interview guide to assess care coordination workflows, 4) a site-level swim lane workflow process mapping template, and 5) a regional high-level process mapping template to aggregate data from multiple site-level process maps. CONCLUSIONS This iterative, participatory approach to data collection and process mapping can be used by improvement teams to streamline care coordination, ultimately improving the design and delivery of an evidence-based navigation model that spans multiple treatment modalities and multiple health systems in a metropolitan area. This protocol is presented as an actionable toolkit so the work may be replicated to support other quality-improvement initiatives and efforts to design truly patient-centered breast cancer treatment experiences. LAY SUMMARY Evidence-based patient navigation in breast cancer care requires the integration of services through each phase of cancer treatment. The Translating Research Into Practice study aims to implement patient navigation for patients with breast cancer who are at risk for delays and are seeking care across 6 health systems in Boston, Massachusetts. The authors designed a 10-step protocol outlining procedures and tools that support a systematic assessment for health systems that want to implement breast cancer patient navigation services for patients who are at risk for treatment delays.
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Affiliation(s)
- Nicole L Casanova
- University of Washington School of Public Health, 1959 NE Pacific St., Seattle, WA, United States of America
| | - Amy M LeClair
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center,800 Washington Street., Boston, MA, United States of America
| | - Victoria Xiao
- Boston Medical Center, 801 Massachusetts Ave., Boston, MA, United States of America
| | - Katelyn R Mullikin
- Boston Medical Center, 801 Massachusetts Ave., Boston, MA, United States of America
| | - Stephenie C Lemon
- University of Massachusetts Medical School, 368 Plantation St., Worcester MA, United States of America
| | - Karen M Freund
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center,800 Washington Street., Boston, MA, United States of America
| | - Jennifer S Haas
- Massachusetts General Hospital, 100 Cambridge St., Suite 1600, Boston, MA, United States of America
| | - Rachel A Freedman
- Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA, United States of America
| | - Tracy A Battaglia
- Boston Medical Center, 801 Massachusetts Ave., Boston, MA, United States of America,Boston University School of Medicine, 801 Massachusetts Ave., Boston, MA, United States of America
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Cocreating the ICU-PAUSE Tool for Intensive Care Unit–Ward Transitions. ATS Sch 2022; 3:312-323. [PMID: 35924191 PMCID: PMC9341494 DOI: 10.34197/ats-scholar.2021-0135in] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/18/2022] [Indexed: 11/23/2022] Open
Abstract
Background Intensive care unit (ICU)–ward patient transfers are inherently high risk, and clinician miscommunication has been linked to adverse events and negative outcomes. Despite these risks, few educational tools exist to improve resident handoff communication at ICU–ward transfer. Objective We used human-centered design (HCD) methods to cocreate a novel electronic health record ICU–ward transfer tool alongside Internal Medicine residents at three academic hospitals. Methods We conducted HCD workshops at each hospital, performing process mapping, brainstorming, and rapid prototyping. We performed thematic analysis on verbatim-transcribed workshop audio recordings to inform development and adaptation of the final resident prototype into the ICU-PAUSE tool. Results ICU-PAUSE focuses on reasons for ICU admission and problem-based ICU course (I); Code status, goals of care, and family contacts (C); a diagnostic pause acknowledging Uncertainty (U); Pending tests (P); Active consultants (A); high-risk medications, including medications to be Unprescribed (U); Summary of problems and to-dos (S); and a current physical Exam (E). Conclusion We used HCD to cocreate a novel, more user-friendly electronic ICU–ward transfer tool, ICU-PAUSE, alongside Internal Medicine trainees. Future steps will involve formal usability testing, evidence-driven implementation, and clinical evaluation of ICU-PAUSE across multiple hospitals.
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El-Kareh R, Sittig DF. Enhancing Diagnosis Through Technology: Decision Support, Artificial Intelligence, and Beyond. Crit Care Clin 2022; 38:129-139. [PMID: 34794627 PMCID: PMC8608279 DOI: 10.1016/j.ccc.2021.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Patient care in intensive care environments is complex, time-sensitive, and data-rich, factors that make these settings particularly well-suited to clinical decision support (CDS). A wide range of CDS interventions have been used in intensive care unit environments. The field needs well-designed studies to identify the most effective CDS approaches. Evolving artificial intelligence and machine learning models may reduce information-overload and enable teams to take better advantage of the large volume of patient data available to them. It is vital to effectively integrate new CDS into clinical workflows and to align closely with the cognitive processes of frontline clinicians.
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Affiliation(s)
- Robert El-Kareh
- University of California, San Diego, 9500 Gilman Drive, #0881 La Jolla, CA 92093-0881, USA.
| | - Dean F Sittig
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, UT-Memorial Hermann Center for Healthcare Quality & Safety, Houston, TX 77030, USA. https://twitter.com/DeanSittig
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Information handoffs in critical care and their implications for information quality: A socio-technical network approach. J Biomed Inform 2021; 122:103914. [PMID: 34509637 DOI: 10.1016/j.jbi.2021.103914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/13/2021] [Accepted: 09/04/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The design of health ICTs, as well as human factors, have been shown to influence patient information quality. The aim of this study was to understand how patterns of interaction between these factors influence information quality aspects in a critical care environment. METHOD We conducted an ethnographic study of socio-technical information handoffs in a critical care unit. Data collection methods included non-participant observations and semi-structured interviews. Methodological principles from network analysis (SNA, VNA) were used to develop visual network diagrams, as well as to analyze the composition of the information network and its influence on patient information quality. RESULTS The network patterns that emerged uncover that human actors have many information processing and dissemination roles at the critical care unit. However, ICTs play key network roles, acting as information intermediaries and gatekeepers. We further identify three types of information handoffs in the critical care environment - human-human, human-ICT and ICT-human. On the one hand, we find that human-human and ICT-human handoffs influence contextual and intrinsic aspects of patient information, such as information completeness and accuracy. On the other hand, human-ICT handoffs influence information accessibility and representational quality, such as consistency and interpretability. DISCUSSION The results suggest that standardizing change of shift handoff communication may not be sufficient to prevent information decay in complex care trajectories. In particular, we argue that ensuring information consistency and interpretability across disciplines and professions is as important as ensuring information completeness and accuracy during change of shift handoffs. ICT and workflow design opportunities are discussed as means to address overlapping or conflicting information needs across disciplines and professions, increase information consistency, and reduce information redundancy across the network.
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Abstract
OBJECTIVES To examine adverse events and associated factors and outcomes during transition from ICU to hospital ward (after ICU discharge). DESIGN Multicenter cohort study. SETTING Ten adult medical-surgical Canadian ICUs. PATIENTS Patients were those admitted to one of the 10 ICUs from July 2014 to January 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two ICU physicians independently reviewed progress and consultation notes documented in the medical record within 7 days of patient's ICU discharge date to identify and classify adverse events. The adverse event data were linked to patient characteristics and ICU and ward physician surveys collected during the larger prospective cohort study. Analyses were conducted using multivariable logistic regression. Of the 451 patients included in the study, 84 (19%) experienced an adverse event, the majority (62%) within 3 days of transfer from ICU to hospital ward. Most adverse events resulted only in symptoms (77%) and 36% were judged to be preventable. Patients with adverse events were more likely to be readmitted to the ICU (odds ratio, 5.5; 95% CI, 2.4-13.0), have a longer hospital stay (mean difference, 16.1 d; 95% CI, 8.4-23.7) or die in hospital (odds ratio, 4.6; 95% CI, 1.8-11.8) than those without an adverse event. ICU and ward physician predictions at the time of ICU discharge had low sensitivity and specificity for predicting adverse events, ICU readmissions, and hospital death. CONCLUSIONS Adverse events are common after ICU discharge to hospital ward and are associated with ICU readmission, increased hospital length of stay and death and are not predicted by ICU or ward physicians.
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Parsons Leigh J, Brundin-Mather R, Whalen-Browne L, Kashyap D, Sauro K, Soo A, Petersen J, Taljaard M, Stelfox HT. Effectiveness of an Electronic Communication Tool on Transitions in Care From the Intensive Care Unit: Protocol for a Cluster-Specific Pre-Post Trial. JMIR Res Protoc 2021; 10:e18675. [PMID: 33416509 PMCID: PMC7822720 DOI: 10.2196/18675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Transitions in care are vulnerable periods in health care that can expose patients to preventable errors due to incomplete or delayed communication between health care providers. Transitioning critically ill patients from intensive care units (ICUs) to other patient care units (PCUs) is particularly risky, due to the high acuity of the patients and the diversity of health care providers involved in their care. Instituting structured documentation to standardize written communication between health care providers during transitions has been identified as a promising means to reduce communication breakdowns. We developed an evidence-informed, computer-enabled, ICU-specific structured tool-an electronic transfer (e-transfer) tool-to facilitate and standardize the composition of written transfer summaries in the ICUs of one Canadian city. The tool consisted of 10 primary sections with a user interface combination of structured, automated, and free-text fields. OBJECTIVE Our overarching goal is to evaluate whether implementation of our e-transfer tool will improve the completeness and timeliness of transfer summaries and streamline communications between health care providers during high-risk transitions. METHODS This study is a cluster-specific pre-post trial, with randomized and staggered implementation of the e-transfer tool in four hospitals in Calgary, Alberta. Hospitals (ie, clusters) were allocated randomly to cross over every 2 months from control (ie, dictation only) to intervention (ie, e-transfer tool). Implementation at each site was facilitated with user education, point-of-care support, and audit and feedback. We will compare transfer summaries randomly sampled over 6 months postimplementation to summaries randomly sampled over 6 months preimplementation. The primary outcome will be a binary composite measure of the timeliness and completeness of transfer summaries. Secondary measures will include overall completeness, timeliness, and provider ratings of transfer summaries; hospital and ICU lengths of stay; and post-ICU patient outcomes, including ICU readmission, adverse events, cardiac arrest, rapid response team activation, and mortality. We will use descriptive statistics (ie, medians and means) to describe demographic characteristics. The primary outcome will be compared within each hospital pre- and postimplementation using separate logistic regression models for each hospital, with adjustment for patient characteristics. RESULTS Participating hospitals were cluster randomized to the intervention between July 2018 and January 2019. Preliminary extraction of ICU patient admission lists was completed in September 2019. We anticipate that evaluation data collection will be completed by early 2021, with first results ready for publication in spring or summer 2021. CONCLUSIONS This study will report the impact of implementing an evidence-informed, computer-enabled, ICU-specific structured transfer tool on communication and preventable medical errors among patients transferred from the ICU to other hospital care units. TRIAL REGISTRATION ClinicalTrials.gov NCT03590002; https://www.clinicaltrials.gov/ct2/show/NCT03590002. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/18675.
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Affiliation(s)
- Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada.,Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Rebecca Brundin-Mather
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Liam Whalen-Browne
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Devika Kashyap
- Critical Care Medicine, Alberta Health Services, Calgary, AB, Canada
| | - Khara Sauro
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada.,Arnie Charbonneau Cancer Institute, Health Research Innovation Centre, University of Calgary, Calgary, AB, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Critical Care Medicine, Alberta Health Services, Calgary, AB, Canada
| | - Jennie Petersen
- Faculty of Applied Health Sciences, Brock University, St Catharines, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Critical Care Medicine, Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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On Baseball, Counterfactuals, and Measuring Care Delivery Performance at the Emergency Department-Intensive Care Unit Interface. Ann Am Thorac Soc 2020; 17:1532-1534. [PMID: 33258671 PMCID: PMC7706602 DOI: 10.1513/annalsats.202008-951ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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16
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Mueller JT, Poterack KA, O'Connor KC. Patient Safety and Resident Schedules without 24-Hour Shifts. N Engl J Med 2020; 383:1286-1287. [PMID: 32966728 DOI: 10.1056/nejmc2025843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Bodley T, Rassos J, Mansoor W, Bell CM, Detsky ME. Improving Transitions of Care between the Intensive Care Unit and General Internal Medicine Ward. A Demonstration Study. ATS Sch 2020; 1:288-300. [PMID: 33870295 PMCID: PMC8043311 DOI: 10.34197/ats-scholar.2019-0023oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 06/15/2020] [Indexed: 12/22/2022] Open
Abstract
Background: In-hospital transfers such as from the intensive care unit (ICU) to the general internal medicine (GIM) ward place patients at risk of adverse events. A structured handover tool may improve transitions from the ICU to the GIM ward. Objective: To develop, implement, and evaluate a customized user-designed transfer tool to improve transitions from the ICU to the GIM ward. Methods: This was a pre-post intervention study at a tertiary academic hospital. We developed and implemented a user-designed, structured, handwritten ICU-to-GIM transfer tool. The tool included active medical issues, functional status, medications and medication changes, consulting services, code status, and emergency contact information. Transfer tool users included GIM physicians, ICU physicians, and critical care rapid response team nurses. An implementation audit and mixed qualitative and quantitative analysis of pre-post survey responses was used to evaluate clinician satisfaction and the perceived quality of patient transfers. Results: The pre-post survey response rate was 51.8% (99/191). Respondents included GIM residents (58.5%), ICU rapid response team physicians and nurses (24.2%), and GIM attending physicians (17.2%). Less than half of clinicians (48.8%) reported that the preintervention transfer process was adequate. Clinicians who used the transfer tool reported that the transfer process was improved (93.3% vs. 48.8%, P = 0.03). Clinician-reported understanding of medication changes in the ICU increased (69.2% vs. 29.1%, P = 0.004), as did their ability to plan for a safe hospital discharge (69.2% vs. 31.0%, P = 0.01). However, only 64.2% of audited transfers used the tool. Frequently omitted sections included home medications (missing in 83.4% of audits), new medications (33.3%), and secondary diagnosis (33.3%). Thematic analysis of free-text responses identified areas for improvement including clarifying the course of ICU events and enhancing tool usability. Conclusion: A user-designed, structured, handwritten transfer tool may improve the perceived quality of patient transfers from the ICU to the GIM wards.
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Affiliation(s)
- Thomas Bodley
- Interdepartmental Division of Critical Care and
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | - James Rassos
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | - Wasim Mansoor
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | - Chaim M. Bell
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
- Division of General Internal Medicine, Sinai Health System and University Health Network, Toronto, Ontario, Canada
| | - Michael E. Detsky
- Interdepartmental Division of Critical Care and
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
- Division of General Internal Medicine, Sinai Health System and University Health Network, Toronto, Ontario, Canada
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