Published in the April 2016 issue of Today’s Hospitalist
IN THE GROWING BODY of research devoted to building better care transitions, one transition has pretty much been neglected: how to safely hand off general medical patients from the ICU to the ward. According to Joseph Cristiano, MD, an assistant professor of internal medicine at Wake Forest Baptist Medical Center in Winston-Salem, N.C., the research that is available has been done outside the U.S. and has targeted handoffs to residents.
Why such a lack of evidence? For one, says Dr. Cristiano, ICUs come in so many models—closed, open, semi-closed—that results in one don’t necessarily apply to others. Plus, the ICU-to-ward handoff “is a multifaceted, multidisciplinary transition with many operational components that go way beyond the physician’s role.”
Then there’s this problem: Researchers have yet to agree on the right endpoint to measure for such transfers.
“Now, a much larger number of our ICU transfers are going out between 2 p.m. and 7 p.m.”
“We all recognize that this is a very fragile transition of care,” he notes. “But how do you measure success in terms of better safety or quality, or the lack thereof?”
Dr. Cristiano does say that one big finding in the literature can provide an approximate endpoint: Poorer outcomes—including higher mortality and more frequent readmissions to the ICU—are associated with transfers that take place at night.
That message resonated in his own shop, he notes, because “we were seeing a large number of transfers out of the ICU between 7 p.m. and midnight.” In addition, a survey of both the intensivists at his center (Wake Forest’s medical ICU is closed) and ward doctors identified the lack of an interactive handoff and of standardized written transfer documentation as big deficiencies.
As a result, Dr. Cristiano and his colleagues decided to renovate the ICU-to-ward transfer process in April 2014. While he is still trying to figure out how to extract outcomes data on the reorganized process from his system’s EHR, he can report these results: “Now, a much larger number of our transfers are going out between 2 p.m. and 7 p.m.,” he says. “The night hospitalist doesn’t even need to see those patients now.”
A dedicated transfer hospitalist
In reengineering the transition of patients from the medical ICU to the wards, Dr. Cristiano says his team was able to build on one step already in place: Every morning in the ICU, the intensive care attending and fellow would go room to room and identify patients they thought were ready to be transferred out.
Previously, the ICU team did not anticipate transfers systematically. “The process would begin only at the time the patient was ready,” Dr. Cristiano says. “There wasn’t much planning that took place.”
ICU attendings, for instance, didn’t pass along their list of patients deemed ready to be transferred. That was one of the first things to be changed in the reorganization. According to Dr. Cristiano, that list is now disseminated to both bed logistics (to get a jump on finding beds for transferred patients) and to the hospitalist group.
Another innovation: Instead of assigning a transferring patient to whichever resident team or rounding hospitalist was available, only one hospitalist per day now takes charge of all patients being transferred that day from the ICU. That move “decreases fragmentation and centralizes communication,” says Dr. Cristiano. Once that hospitalist receives the list of potential transfers, he or she goes to the ICU to not only get a verbal handoff of patients from the attending, but also to assess those patients’ stability.
“Patients are now being evaluated by the hospitalist sometimes even before leaving the ICU, negating in some cases the need to transfer them back,” says Dr. Cristiano.
The hospitalist assigned to the ICU transfers also talks to patients and their families. “That puts a lot of them at ease,” he explains, “and it allows us to pre-emptively address any patient satisfaction issues that patients or families may have.”
For the hospitalist assigned to ICU transfers, “it’s almost like rounding on these patients in the ICU,” he notes, a task that takes up about half that hospitalist’s time. (The rest of his or her day is devoted to admissions, particularly transfers from other hospitals.) An individual hospitalist typically fills that position for a week at a time, and patients successfully transferred out of the ICU are then assigned the next day to a rounding hospitalist.
Cutting residents out of ICU transfers
Another change that was part of the reorganization: Patients being transferred out of the ICU used to be assigned to either a teaching service or to the hospitalist service. Now, the residents have been cut out of that transition completely with few exceptions.
One rationale for that change is educational. “There’s a fairly strong consensus among the residents and residency program leaders that having residents take care of patients following an ICU course is not as educationally valuable as the patients that residents admit themselves from the beginning,” says Dr. Cristiano. “It’s better for residents to be involved in a patient’s care from admission to the end of the hospitalization.”
Then there’s the fact that the residents are geographically based. When patients transferring out of the ICU used to be assigned to a specific teaching team, they often had to wait for a bed to open up in that unit. “That meant,” says Dr. Cristiano, “that a lot of patients spent time waiting in the ICU when there was potentially a vacant bed elsewhere.”
While individual rounding hospitalists are geographically based, the hospitalist group as a whole is not. “Hospitalists can expand to any unit in the hospital,” he says, “so not assigning patients to teaching teams with corresponding units makes transfers much more flexible from the standpoint of bed logistics. Anecdotally, one reason we were able to move the timeframe for transfers up earlier in the day was because of that flexibility.”
Standardizing transfer notes
According to Dr. Cristiano, another hospitalist at Wake Forest—Daniel Beekman, MD—launched another innovation around the same time as ICU transfers were being reorganized: introducing a standardized transfer note template.
“That was a separate innovation that we weren’t involved in,” Dr. Cristiano points out. “But it turns out that better written documentation is a fundamental element in a successful transfer.”
The standardized template, he explains, doesn’t try to provide a more detailed script of all the clinical data related to the hospitalization. Instead, “it puts more emphasis on what needs to happen going forward for the patient within the next 24 to 48 hours.”
This highlights key items that accepting hospitalists will need to address once the patient is on the floor. The new template also stresses disposition, which “a lot of times, we don’t know,” Dr. Cristiano says. “But we may have already identified particular issues, like the patient is going to need some durable medical equipment.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.