To the Editor:
Although inpatient handoffs absorb added accommodating vulnerability (1–5), little is accepted about physician advice back patients alteration from an accelerated affliction assemblage (ICU) to a medical ward. This is a potentially high-risk alteration because of the complication of accommodating problems and the brusque abridgement in accommodating monitoring. The few studies in this breadth accept been bedfast to nursing cross-checks of alteration letters (6) or were bound by some patients accepting no handoff at the time of alteration (7, 8).
The bound absolute abstruse highlights cogent abeyant pitfalls aural the alteration process, decidedly with attention to advice errors or altogether absent communication. To date, no abstraction alone describes citizen perceptions of ICU–ward handoffs and how these handoffs ability affect care. Because association accommodate the majority of analytical affliction aural bookish hospitals, and because handoff behaviors abstruse in abode may admission approaching convenance patterns, it is decidedly important to accept abode administrator handoff advice and perceptions of these transfers.
In this study, we aimed to call citizen handoff communications during ICU–ward alteration and to analyze near-miss and adverse accommodating contest associated with ambiguity accompanying to these handoffs. Some of these after-effects accept ahead been appear in the anatomy of an abstruse (9).
Methods
From October 2013 to January 2014, we arrive all centralized anesthetic citizen physicians commutual inpatient rotations in accepted medicine, oncology, or cardiology at one 500-bed bookish tertiary affliction hospital (the University of Chicago Medical Center) to participate in structured interviews. Consenting association were abreast interviewed application the analytical adventure abode to arm-twist near-miss and adverse contest accompanying to abortive handoffs of patients appointment from the ICU. The analytical adventure abode is a accurate and reliable qualitative assay adjustment in which anecdotal letters are systematically accumulated to actualize a absolute description of a agreeable area (10).
Interviews were audio recorded, anonymized, and transcribed for analysis. A affiliate of the assay aggregation coded transcripts application the connected allusive method, with no a priori hypotheses, to accomplish antecedent categories. A additional affiliate of the assay aggregation apart advised 15% of the transcripts to ensure coder acceding and reliability. Capacity were discussed with residents, and categories were accepted with their assent. Accommodating outcomes articular in anecdotal examples were evaluated to analyze analytical events. The abstraction acceding was accustomed by the University of Chicago Institutional Review Board (IRB #13-0653).
Results
In total, 68 association were emailed about the abstraction and 29 bidding absorption in participating. All 29 of these association completed interviews, abandoning 250 ICU transfers over the advance of 92 weeks of inpatient account (2.7 transfers per week). Association appear an boilerplate of 8 account (±3) per accommodating per handoff.
Of the 29 association interviewed, 19 (66%) appear a absolute of 27 adverse or near-miss accommodating contest consistent from advice failures during ICU–ward handoff (Table 1). Four contest complex afterlife or actual blackmail to activity (e.g., evolving respiratory failure), and accession six were advised potentially life-threatening near-misses (e.g., alive broadcast intravascular agglomeration not mentioned in accounting or exact handoffs). The actual 17 near-miss contest were advised aerial accident for adjournment or absolute nonfatal accommodating harm.
Table 1. Categories of adverse contest and near-misses
During analysis, three above domains of advice abortion emerged (Table 2): missing advice (16, 59%), incorrect advice (10, 37%), and cryptic albatross for the accommodating peri-handoff (one, 4%). There was 100% coder acceding with attention to these themes. A adumbrative anecdotal animadversion for the area of “unclear alteration of responsibility” in a handoff for a accommodating appointment from an ICU was declared by one resident: “I was told [during handoff that a appointment patient] was stable, and again she had a cardiac arrest afore I met her…. I don’t accept the [covering resident] came over to see the patient” during deterioration, admitting not yet accepting completed handoff.
Table 2. Domains of advice abortion articular at accelerated affliction unit–ward handoff
Discussion
In this aboriginal abstraction of citizen perceptions of ICU–ward transfers, we begin common advice failures accompanying to near-miss or adverse accommodating events. Advice failures fell into three above domains: missing information, cryptic information, and cryptic albatross for patients about the time of transfer. This is a anatomy that can be acclimated to advance handoffs, as interventions are advised to abode these issues.
Our abstraction was bound by ascertainment at a distinct bookish medical center, which may anticipate generalizability to added institutions. In addition, our account amount of 43% exposes our after-effects to acknowledgment bias, and the attendant attributes of our interviews may accept resulted in anamnesis bias; in particular, capacity apropos advice modalities and handoff continuance were calm in aggregate, rather than at the akin of anniversary transfer, and appropriately may be decidedly accessible to anamnesis bias. However, these biases may be beneath pertinent to the bearing of accordant capacity than to survey-based epidemiologic data. Finally, we did not validate the accommodating outcomes that were appear aural our interviews.
Residency programs and bookish institutions should assignment calm to accumulate this process. Approaching assignment to advance these handoffs aims to absorb these capacity and includes action acclimation (11) with template-based alteration addendum and handoff scripts, academic educational initiatives, and alive captivation of nurses, patients, or ancestors associates in these handoffs. In addition, accident stratification of appointment patients, based on cold physiologic criteria, provider intuition, or both, could be acclimated to highlight a subset of patients who may account added from these accelerated interventions. Further assay is acceptable to affirm our allegation beyond added settings and to appraise interventions that could admission these outcomes.
Author Contributions: Abstraction abstraction and design: all authors; interviews and accretion of data: P.G.L.; assay and estimation of data: P.G.L. and J.M.F.; aboriginal drafting of the manuscript: P.G.L.; analytical afterlight of the arrangement for important bookish content: all authors; statistical analysis: P.G.L.; acquired funding: V.M.A.; administrative, technical, and actual support: V.M.A.; abstraction supervision: V.M.A. and J.M.F.; abstracts admission and responsibility: P.G.L. and J.M.F. had abounding admission to all the abstracts in the abstraction and booty albatross for the candor of the abstracts and the accurateness of the abstracts analysis.
Preliminary versions of these abstracts were presented as a affiche altercation at the 2015 affair of the American Thoracic Society (May 17, 2015; Denver, Colorado).
Author disclosures are accessible with the argument of this letter at www.atsjournals.org.
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