A Prospective Observational Study of Physician Handoff for Intensive-Care-Unit-to-Ward Patient Transfers

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1 CLINICAL RESEARCH STUDY A Prospective Observational Study of Physician Handoff for Intensive-Care-Unit-to-Ward Patient Transfers Pin Li, MD, MSc, a Henry Thomas Stelfox, MD, PhD, b,c William Amin Ghali, MD, MPH a,c a Department of Medicine, b Department of Critical Care Medicine, and c Department of Community Health Sciences, University of Calgary, Alberta, Canada. ABSTRACT BACKGROUND: Poor physician handoff can be a major contributor to suboptimal care and medical errors occurring in the hospital. Physician handoffs for intensive care unit (ICU)-to-ward patient transfer may face more communication hurdles. However, few studies have focused on physician handoffs in patient transfers from the ICU to the inpatient ward. METHODS: We performed a hospitalized patient-based observational study in an urban, university-affiliated tertiary care center to assess physician handoff practices for ICU-to-ward patient transfer. One hundred twelve adult patients were enrolled. The stakeholders (sending physicians, receiving physicians, and patients/families) were interviewed to evaluate the quality of communication during these transfers. Data collected included the presence and effectiveness of communication, continuity of care, and overall satisfaction. RESULTS: During the initial stage of patient transfers, 15.6% of the consulted receiving physicians verbally communicated with sending physicians; 26% of receiving physicians received verbal communication from sending physicians when patient transfers occurred. Poor communication during patient transfer resulted in 13 medical errors and 2 patients being transiently lost to medical care. Overall, the levels of satisfaction with communication (scored on a 10-point scale) for sending physicians, receiving physicians, and patients were , , and , respectively. CONCLUSION: The overall levels of satisfaction with communication during ICU-to-ward patient transfer were reasonably high among the stakeholders. However, clear opportunities to improve the quality of physician communication exist in several areas, with potential benefits to quality of care and patient safety Elsevier Inc. All rights reserved. The American Journal of Medicine (2011) 124, KEYWORDS: Intensive care unit; Patient safety; Patient transfer; Physician communication Funding: None. Conflict of Interest: None. Authorship: All 3 authors contributed equally to conceiving and designing the study, and analyzing and interpreting the data. Dr Li contributed data collection and writing the manuscript. Dr Stelfox provided critical revision and assisted in statistical analysis of data. Dr Ghali provided critical revision and final approval of the manuscript. All 3 authors had access to data. Requests for reprints should be addressed to Pin Li, MD, MSc, Department of Medicine, University of Calgary, Health Sciences Center, 3330 Hospital Drive NW, 3330 Hospital Drive NW, Room 1404, Calgary, AB T2N 1N4, Canada. address: pli@ucalgary.ca The transfer of responsibility for patient care is a common practice in acute-care hospitals. 1 During transfers of patient care, crucial information on patient conditions, tests undertaken, and treatments received is transferred between providers so that general care plans can be continued by receiving physicians. Unfortunately, the practice of physician handoff is often suboptimal due to communication barriers 2-5 and is a major contributor to medical errors and adverse events Most research on physician handoffs for in-hospital patient transfers has focused on intra-specialty patient transfers, such as house staff end-of-service handoffs 10-12,15 or resident end-of-shift handoffs. 1,3,4,13,16 In contrast, few studies have addressed physician handoffs surrounding inter-specialty patient transfer. 2,17 The physician handoff for this type of patient transfer may face more communication hurdles due to cultural differences, work load challenges, and differences in clinical focus between specialties, and thus may lead to greater potential for medical errors and adverse events. 2,5, /$ -see front matter 2011 Elsevier Inc. All rights reserved. doi: /j.amjmed

2 Li et al Physician Communication in Intensive-Care-Unit-to-Ward Patient Transfers 861 Patient transfers from intensive care units (ICU) to other inpatient wards may be particularly vulnerable in this regard, given the complexity of the medical conditions that characterize these transfers. 18,19 Furthermore, these patients are transferred from the ICU, where medical care is intensive and resources are rich, to environments where patients receive much less intensive monitoring and patient care. 18 We undertook this study to better understand the methods and quality of communication surrounding physician handoffs for ICU-to-ward patient transfers in an urban tertiary care center. METHODS CLINICAL SIGNIFICANCE Study Setting and Sample Foothills Medical Centre is the sole tertiary care center in Southern Alberta (population 1.8 million). Its 25-bed medical-surgical ICU serves as a regional referral center for trauma, neurosciences, thoracic surgery, and plastic surgery patients. This study was approved by the University of Calgary Conjoint Faculties Research Ethics Board. We enrolled consecutive patients, when investigators were available, who were 18 years of age or older and discharged alive from the medicalsurgical ICU at Foothills Medical Centre to other services within the hospital between March and July of Patients were excluded if they: were unable to provide consent and had no family member who could be approached for consent; were transferred from the ICU to another health care facility; or were discharged home from the ICU. Data Collection For each enrolled patient, a standardized survey querying perceptions of ICU-to-ward transfer was administered independently in person to the patient (or family if the patient was unable to complete), the ICU physician, and the receiving physician. We developed these surveys based on previously published studies about physician communications and the key steps for ICU-to-ward patient transfer in our institution. Data describing patient characteristics and processes of care were collected from the medical record and physician order entry system. Outcome Measures An ICU-to-ward patient transfer consisted of several steps, beginning with a consult request for patient transfer from the ICU service and finishing with the initial patient assessment by the receiving physician(s) following the patient s arrival on the ward. We developed separate survey instruments to obtain the perceptions of ICU-to-ward patient Only a small proportion of physicians performed verbal communication during patient transfers from intensive care unit to other in-hospital wards. Poor physician communication was a significant reason for medical errors and suboptimal patient follow-up during this type of patient transfer. Physician-patient/patient s family communication during this type of patient transfer also needs further improvement to facilitate the patient transfer. transfer from the perspective of ICU physicians, receiving physicians, and patients or their families. Specifically, we assessed the communication between ICU physicians and receiving physicians, quality of continuity of patient care and patient outcomes, the quality of physician-patient communication, and overall satisfaction of ICU-to-ward patient transfer among all 3 groups of stakeholders. Although not the primary focus of our study, we asked survey respondents to comment on medical errors and nearmiss events during these patient transfers as a secondary measure of continuity of care. A 10-point Likert scale was used to assess overall satisfaction with physician communication during ICU-toward patient transfer. Data Analysis The distribution of patient characteristics and survey results were summarized using simple descriptive statistics. We reported means or medians for continuous variables and proportions for categorical variables. Univariable comparisons employed the Student s t test for continuous variables and Fisher s exact test for categorical variables. Analysis was performed using Stata version 10.0 (StataCorp LP, College Station, Tex). RESULTS Study Population Characteristics During the 5-month study period, 112 patients were successfully recruited (44.6%). The main reason for eligible patient exclusion from participation in the study (patients in the nonstudy group) was patient transfer on nonstudy days when the investigators were not available. Table 1 summarizes the characteristics of the patients screened for the study. The demographic and clinical characteristics of patients in the study group, including ICU length of stay, proportion of transfers occurring at night/weekend shifts, were similar to those of eligible patients in the nonstudy group. The Figure summarizes the process of patient recruitment. The survey response rate from ICU physicians was 85.7% and from receiving physicians, 83.0%. Among the physicians who responded, 81% were residents. Fifty-five percent of surveys were conducted within 48 hours of patient transfer from the ICU to the ward, and 98% within 5 days. The median timing of survey occurred 2 days post patient transfers ((interquartile range 1-4 days). The median time between a patient being accepted for transfer by the

3 862 The American Journal of Medicine, Vol 124, No 9, September 2011 Table 1 Demographic and Clinical Characteristics of Patients Characteristics Study Group (n 112) Nonstudy Group* (n 1 39) P Value Age, mean (SD) 52.5 (19.5) 52.8 (18.1).900 Male sex, n (%) 71 (63.4) 86 (61.9).807 Primary admission diagnosis group, n (%) Cardiovascular 14 (12.5) 17 (12.2).943 Respiratory 39 (34.8) 44 (31.7).960 Gastrointestinal 13 (11.6) 15 (10.8).980 Endocrine, metabolic, poisoning 2 (1.8) 5 (3.6).389 Neurological 16 (14.3) 32 (23.0).081 Genitourinary 4 (3.6) 0 (0.0).024 Musculoskeletal 2 (1.8) 3 (2.2).822 Trauma 21 (18.8) 18 (12.9).199 Dermatological 0 (0.0) 1 (0.7).375 Missing diagnosis 2 (1.8) 4 (2.9).572 Admission APACHE II score, mean (SD) 16.6 (7.8) 15.6 (6.5).270 Transfer during night/weekend shift, n (%) 40 (35.7) 62 (44.6).150 Time from patient acceptance to transfer, 27.4 (30.0) 25.3 (33.1).603 hours: mean (SD) Services accepting transfer Surgical, n (%) 66 (58.9) 85 (61.2).748 Medical, n (%) 46 (41.1) 54 (38.8).748 ICU LOS, days, median (IQR) 4 (2-14) 6 (3-19).112 ICU readmission within 72 hours, n (%) 2 (1.8) 1 (0.7).425 Hospital LOS, days: median (IQR) 17 (10-41) 14 (9-29).355 In-hospital mortality, n (%) 4 (3.6) 6 (4.3).778 APACHE Acute Physiology and Chronic Health Evaluation; ED emergency department; ICU intensive care unit; IQR interquartile range; LOS length of stay; No number; SD standard deviation. *Nonstudy group consisted of eligible patients that were not recruited. A nighttime shift was defined as weekdays from5:00 PM to 8:00 AM. A weekend shift was defined as Friday 5:00 PM to Monday to 8:00 AM. The time interval between the patient being accepted by a receiving service and being transferred from the ICU to the ward. receiving physician and the patient leaving the ICU was 20 hours (interquartile range 5-44 hours). Assessment of Physician-Physician Communication Table 2 summarizes physicians, patients, and families accounts of the ICU transfer process. In 75% of the cases, the receiving physicians acted promptly after the requests of patient transfer were initiated by ICU physicians. However, only 16% of receiving physicians discussed their recommendations and decisions whether to accept transfer of care with the referring ICU physicians following assessment of the patient. In 5 cases (5.2%), the patient transfers were delayed due to unclear recommendations or orders by the receiving physicians. Conversely, only 26% of receiving physicians received a verbal update from the ICU physicians at the time of patient transfer (Table 2). Assessment of Continuity of Care Before patient transfer from the ICU, the orders in the computer database were updated by the ICU physicians in the majority of the cases (91%). A written discharge summary was available in patients charts for the receiving physicians to review in 61% of the cases. Only a small number of receiving physicians (12%) reported notification by ward staff on the patient s arrival. Five cases of medical errors associated with poor physician communication during patient transfers were identified by the receiving physicians (Table 3). An additional 8 medical errors were identified by other health care providers (Table 3). Medication errors were the most common error identified (n 9). No error was attributed for causing ICU readmission within 72 hours of patient transfer from ICU to the ward. After patients were transferred to the wards, the receiving physicians performed an initial patient assessment within 24 hours in 86% of the cases. However, 2 patients were transferred to the ward without the receiving physicians knowledge and were lost to medical care for more than 48 hours before being evaluated. Both patients did well clinically, but expressed dissatisfaction with the ICU-toward transfer process (satisfaction scores of 3 and 4 out of 10).

4 Li et al Physician Communication in Intensive-Care-Unit-to-Ward Patient Transfers 863 Total number of patients discharged from ICU (n = 339) Total number of patients deceased in ICU (n = 67) Total number of patients discharged alive from ICU (n = 272) Total number of patients discharge directly home or to other institutions (n = 21) Total number of patients discharged to hospital wards (n = 251) Total number of patients excluded due to discharged on non-study days (n = 137) Total number of eligible patients Interviewed (n = 114) Total number of patients declining participation in the study (n = 2) Total number of study subjects (n = 112) Total number of study subjects transferred to medical services (n = 46) Total number of study subjects transferred to surgical services (n = 66) Figure Study patient recruitment process. ICU intensive care unit. Assessment of Physician-Patient Communication Most of the ICU patients or their families were notified by ICU staff about the upcoming ICU-to-ward transfer (88%). In the majority of cases (78%), the receiving physicians introduced themselves to the patients and the families and explained their roles in patient care after patient transfer. However, only 32% of the patients indicated that they were given sufficient opportunity to discuss their transfer with their physician. Eighty-two percent of patient and family concerns were related to active medical problems and plans for future investigations and treatments. Stakeholder s Overall Impressions The mean satisfaction ratings among the 3 groups were consistently high ( among ICU physicians, among receiving physicians, and among patients and family members). However, satisfaction ratings for patients and family members demonstrated a wider distribution than the other 2 groups. Stakeholder s Recommendations Table 4 summarizes the recommendations about physician communication provided by physicians and patients/families who were interviewed. The most common recommendation provided by physicians pertained to the importance of timely and accurate completion of a patient transfer summary. The most common recommendation provided by patients and families was to ensure timely and accurate disclosure of patients conditions and treatment plans. DISCUSSION Relatively few existing studies have prospectively and extensively studied the quality of communication surrounding

5 864 The American Journal of Medicine, Vol 124, No 9, September 2011 Table 2 Physician, Patient, and Family Member Accounts of the ICU-to-Ward Patient Transfer ICU physicians Able to contact receiving physician(s) after requesting consult for ICU-toward patient transfer Opportunity to discuss recommendations and transfer opinion with the receiving physicians following consult Receiving physicians Received verbal handoff from ICU physician when patient transferred out of ICU Discharge summary available in the patient s chart during initial assessment Transfer orders and patient s medications updated by ICU physicians before transfer Patient s old medical record available on ward after the transfer Notified about patient s arrival on ward Patients and families A physician or nurse explained about the upcoming transfer to ward Sufficient opportunity to ask questions and expressed concerns Received satisfactory answers to questions/concerns about transfer* Introduced to receiving physician(s) before transfer Assessed by receiving physician(s) within 24 hours of transfer Yes n (%) No n (%) Unsure n (%) 72 (75) 9 (9) 15 (16) 15 (16) 51 (53) 30 (31) 25 (27) 65 (70) 3 (3) 57 (61) 15 (16) 21 (23) 85 (91) 6 (6) 2 (2) 38 (41) 25 (27) 30 (32) 11 (12) 76 (82) 6 (7) 99 (88) 12 (11) 1 (1) 36 (32) 76 (68) 0 (0) 26 (72) 10(28) 0(0) 87 (78) 22 (20) 3 (3) 96 (86) 2 (2) 14 (13) ICU intensive care unit. *Question evaluated by 36 patients who had an opportunity to ask relevant questions and express concerns. patient transfers from the ICU to the inpatient wards. Our study findings reveal that physicians and patients/families were, for the most part, generally satisfied with physician communication surrounding ICU-to-ward patient transfers. Our findings demonstrate that ICU staff typically notified and explained to patients and families that they were about to be transferred. We also found that the effort made by receiving physicians to initiate patient transfers also was generally satisfactory. However, we also did identify some deficiencies in key areas, including lack of interactive physician communication during the patient transfers, lack of a standardized physician handoff, and lack of an alarming mechanism to avoid ambiguity of physician responsibility towards patient care during this type of patient transfer. These deficits are notable both because they can produce a negative impact on patient care, and because they point to specific domains where targeted interventions could produce quality-of-care improvements. The most notable deficiency in the communications that we studied was the lack of face-to-face communication between physicians, both in initial stage of physician handoff and during patient transfers. Face-to-face communica-

6 Li et al Physician Communication in Intensive-Care-Unit-to-Ward Patient Transfers 865 Table 3 Transfer Medical Errors Reported During ICU-to-Ward Patient Medical errors reported by receiving physicians Inappropriate medications or doses given 3 Important medications erroneously stopped 1 Acute medical conditions not recognized 1 Medical errors reported by other health care providers* ICU-specific investigations or treatments 3 given Inappropriate medications or doses given 2 Patient monitor or nursing care not applied 2 due to poor communication TPN order delayed due to 1 failure to reactivate the order Total medical error events reported 13 Number ICU intensive care unit; TPN total parenteral nutrition. *The medical errors detected by other health care providers were obtained by interviewing rapid response team members and ward nurses and chart reviewing. These events were in addition to the events detected by physicians. tion has been proven to be the most effective method of handoff to decrease errors in other industries, including nuclear power, 20 aviation, 21 and space travel, 22 as well as in health care. 23,24 Many organizations have implemented specific recommendations about effective communication among health care providers Many strategies and recommendations have been established in order to facilitate interactive physician handoff. 4,7,28-32 Despite these recommendations and the supporting evidence, this type of communication was not commonly used by the physicians that we studied. This deficit certainly has a negative impact on patient care because all the delays of patient transfers and most medical errors identified in our study could be potentially avoided by enhancing interactive physician communication during patient transfer. It is noted that 35.7% of patient transfers in our study took place during night and weekend shifts. These are periods characterized by more onerous physician cross-coverage duties and reduced numbers of residents in academic centers. 33 Clearly, these factors constitute an additional challenge to effective physician handoffs. It has been reported that patients discharged from the ICU during night shifts suffer more adverse events, greater probability of readmission, and higher mortality. 34,35 Thus, developing and implementing a simple and standardized physician handoff protocol for the ICU-to-ward transfer appears to be necessary for facilitating physician communication and a smooth patient transfer, particularly when these transfers are to occur after hours. Another important focus of respondents in our study was on the importance of transfer summaries. It has been suggested in many studies that a standardized handoff template that prompts both verbal communication and a structured written document is the best way to avoid communication failures during transition of responsibility. 1,7,15,22,30-32,36-38 It is even more important in our institution where there was often a lack of verbal communication between services during patient transfer. In our study, we discovered that nonsurgical services rely heavily on transfer summaries for the initial phase of post-transfer patient care. Therefore, it is not surprising that the accuracy and conciseness of such transfer summaries are considered to be of great importance by our study s respondents (Table 4). According to our study findings, important information that was often missing in handoff documents included pending investigations (especially those that could not easily be determined through the hospital s main information system), recommendations arising from specialist consultations, and changes of important medications. However, there is little Table 4 Recommendations to Improve Physician Communication in ICU-to-Ward Patient Transfer Recommendations made by physicians Concise, accurate, and up-to-date ICU discharge summaries focused on key issues of patients ICU discharge summaries completed before patient transfer Face-to-face communication between ICU physicians and receiving physicians Receiving physicians notified about patient s arrival on the ward The patient s medications and orders updated by ICU physicians and confirmed by receiving physicians before patient transfer Clear documentation of acceptance of patient transfer of care by receiving physicians Using rapid response teams as a redundant system during transfer from the ICU Recommendations made by patients or families Inform patient and family about current medical conditions and future plans before the transfer Provide earlier notification to patients and family members about the upcoming ICU discharge Allow family members to accompany patients during the transfer ICU staff follow-up on the ward following transfer to ensure continuity of care Number* ICU intensive care unit. *Number indicates the number of times that a recommendation was made by interviewees

7 866 The American Journal of Medicine, Vol 124, No 9, September 2011 published information on the ideal content for written handoff documents to support patient transfers from the ICU. A standard ICU transfer-specific summary developed within an electronic medical records system could potentially facilitate the ICU-to-ward transfer. However, the electronic medical records system in our hospital has not yet been used for this purpose. More studies need to be done in these domains to determine the essential information that needs to be relayed, and to develop an ICU transfer-specific summary to adopt the culture-specific needs by receiving services. Ambiguous responsibility of patient care during patient transfer also has been a cause of suboptimal patient care in many cases. 2,14,17,24,38 In our study, it resulted in at least 2 lost patients due to ambiguous responsibility during transition of patient care. Because only 11.8% of the receiving physicians were notified directly of patient arrival from the destination unit, and verbal communication between ICU physicians and receiving physicians occurred in only 26.9% of the cases, it is clear that there is ambiguity around the timing of assuming responsibility for care, and the actions that are required in assuming that care. These phenomena introduce risks to patients. Therefore, an alarming mechanism/back-up system is urgently needed to avoid such ambiguity and to ensure continuity of patient care. The need of such a system is more pressing at present due to the employment of new 24-work-hour limits for resident trainees and associated increases in the numbers of physician handoffs that occur each day. 1,16,39 Our stakeholders suggested that a communication method of paging receiving physicians taking over patient care by the ICU outreach team or unit clerk at the patient s destination unit can serve as a notification mechanism. Such a system will, of course, require cautious system-level implementation and associated evaluation. In addition, our study highlights the potential link between poor communication and low patient satisfaction during ICU-to-ward patient transfers. The major contributor to low patient/family satisfaction appears to be their lack of knowledge about medical conditions and the treatment plan post-transfer due to poor communication between both ICU and receiving physicians and the patient/family stakeholders. This appeared to cause significant anxiety and stress in the patients and families who felt uninformed in our study. Relocation stress has been recognized as a phenomenon in patients discharged from ICUs. 40,41 It has been suggested to have negative psychological and physiological impacts on critically ill patients, and indeed, such impacts can potentially be reduced by better explanation and education provided by medical staff. 40,41 Furthermore, according to Reason s Swiss cheese model, patient and family involvement in pretransfer communications may add one more line of defense for avoiding medical errors. 42,43 Improving physician-patient communication is likely to facilitate ICU-toward transfers and help to maintain quality of care during this vulnerable transition period. Our study has limitations. First, the majority of the outcomes measured in our study are subjective assessments. These can be influenced by multiple factors, such as patient satisfaction in overall quality of care received, and are prone to recall bias. To strengthen the inferences that we can make from our study, we have complemented our subjective measurements with some objective measures, including readmission rates, medical errors, and lost patients. In addition, we conducted most of our surveys within 5 days of ICU-to-ward patient transfer to optimize recall of events and sentiments surrounding discharge. A second limitation lies in the fact that we developed our survey questions based on previous literature in this area and expert opinion on dimensions that needed to be assessed. Therefore, it is possible that we failed to include some important questions addressing issues relating to these complex patient transfers. In order to capture any potential important elements of physician handoff, we asked the participants for their comments and recommendations about patient transfers from the ICU in every survey. Finally, our study is a single-center study. Therefore, it is possible that the results may not apply to other institutions. However, the communication challenges presented in this paper are likely common in other health systems globally, and the insights derived are of potential value to assist these systems to improve physician communications surrounding these types of patient transfers. Despite these limitations, our study has shed light on the current status of physician handoff in ICU-to-ward patient transfer in a tertiary care center. Based on our findings, a few concrete recommendations can be stated: Institutions need to develop standardized physician handoff protocols, with both verbal and written components; A back-up system also is necessary to ensure continuity of patient care and patient safety during this process. An example of such a system is verbal communication or notification to receiving physicians from ward clerks at the moment when transferred patients arrive in the destination ward; and There is a need to emphasize physician-to-patient/family communications as a vital component of transfer care. Future studies in designing and testing such standardized physician handoff protocols; determining the key contents of transfer summaries; and assessing the efficacy of a back-up system for ICU-to-ward patient transfer, will be urgently needed for promoting a seamless and safe patient transfer. ACKNOWLEDGMENT We thank Alan Delosangeles (Department of Critical Care Medicine) for assistance with data acquisition. References 1. Horwitz LI, Krumholz HM, Green ML, Huot SJ. Transfers of patient care between house staff on internal medicine wards: a national survey. Arch Intern Med. 2006;166: Apker J, Mallak LA, Gibson SC. 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