Dataset Information

Transfers from intensive care unit to hospital ward: a multicentre textual analysis of physician progress notes.

ABSTRACT:

Background

Little is known about documentation during transitions of patient care between clinical specialties. Therefore, we examined the focus, structure and purpose of physician progress notes for patients transferred from the intensive care unit (ICU) to hospital ward to identify opportunities to improve communication breaks.

Methods

This was a prospective cohort study in ten Canadian hospitals. We analyzed physician progress notes for consenting adult patients transferred from a medical-surgical ICU to hospital ward. The number, length, legibility and content of notes was counted and compared across care settings using mixed-effects linear regression models accounting for clustering within hospitals. Qualitative content analyses were conducted on a stratified random sample of 32 patients.

Results

A total of 447 patient medical records that included 7052 progress notes (mean 2.1 notes/patient/day 95% CI 1.9-2.3) were analyzed. Notes written by the ICU team were significantly longer than notes written by the ward team (mean lines of text 21 vs. 15, p?ConclusionsImportant gaps and variations in written documentation during transitions of patient care between ICU and hospital ward physicians are common, and include discrepancies in documentation of patient information.

SUBMITTER: Brown KN

PROVIDER: S-EPMC5787341 | biostudies-literature | 2018 Jan

REPOSITORIES: biostudies-literature

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Publications

Transfers from intensive care unit to hospital ward: a multicentre textual analysis of physician progress notes.

Brown Kyla N KN Leigh Jeanna Parsons JP Kamran Hasham H Bagshaw Sean M SM Fowler Rob A RA Dodek Peter M PM Turgeon Alexis F AF Forster Alan J AJ Lamontagne Francois F Soo Andrea A Stelfox Henry T HT

Critical care (London, England) 20180128 1

<h4>Background</h4>Little is known about documentation during transitions of patient care between clinical specialties. Therefore, we examined the focus, structure and purpose of physician progress notes for patients transferred from the intensive care unit (ICU) to hospital ward to identify opportunities to improve communication breaks.<h4>Methods</h4>This was a prospective cohort study in ten Canadian hospitals. We analyzed physician progress notes for consenting adult patients transferred fro ...[more]

PMID: 29374498

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Project description:PurposeTo systematically review and evaluate the effectiveness of interventions in order to improve the safety and efficiency of patient handover between intensive care unit (ICU) and general ward healthcare professionals at ICU discharge.MethodsPubMed, CINAHL, PsycINFO, EMBASE, Web of Science, and the Cochrane Library were searched for intervention studies with the aim to improve clinical handover between ICU and general ward healthcare professionals that had been published up to and including June 2013. The methods for article inclusion and data analysis were pre-specified and aligned with recommendations outlined in the PRISMA guideline. Two reviewers independently extracted data (study purpose, setting, population, method of sampling, sample size, intervention characteristics, outcome, and implementation activities) and assessed the quality of the included studies.ResultsFrom the 6,591 citations initially extracted from the six databases, we included 11 studies in this review. Of these, six (55 %) reported statistically significant effects. Effective interventions included liaison nurses to improve communication and coordination of care and forms to facilitate timely, complete and accurate handover information. Effective interventions resulted in improved continuity of care (e.g., reduced discharge delay) and in reduced adverse events. Inconsistent effects were observed for use of care, namely, reduction of length of stay versus increase of readmissions to higher care. No statistically significant effects were found in the reduction of mortality. The overall methodological quality of the 11 studies reviewed was relatively low, with an average score of 4.5 out of 11 points.ConclusionsThis review shows that liaison nurses and handover forms are promising interventions to improve the quality of patient handover between the ICU and general ward. More robust evidence is needed on the effectiveness of interventions aiming to improve ICU handover and supportive implementation strategies.

Project description:BackgroundTransfers from one intensive care unit (ICU) to another ICU are associated with increased length of intensive care and hospital stay. Inter-hospital ICU transfers are carried out for three main reasons: clinical transfers, capacity transfers and repatriations. The aim of the study was to show that different ICU transfers differ in risk-adjusted mortality rate with repatriations having the least risk.ResultsObservational cohort study of adult patients transferred between Swedish ICUs during 3 years (2016-2018) with follow-up ending September 2019. Primary and secondary end-points were survival to 30 days and 180 days after discharge from the first ICU. Data from 75 ICUs in the Swedish Intensive Care Register, a nationwide intensive care register, were used for analysis (89% of all Swedish ICUs), covering local community hospitals, district general hospitals and tertiary care hospitals. We included adult patients (16 years or older) admitted to ICU and subsequently discharged by transfer to another ICU. Only the first admission was used. Exposure was discharge to any other ICU (ICU-to-ICU transfer), whether in the same or in another hospital. Transfers were grouped into three predefined categories: clinical transfer, capacity transfer, and repatriation. We identified 15,588 transfers among 112,860 admissions (14.8%) and analysed 11,176 after excluding 4112 repeat transfer of the same individual and 300 with missing risk adjustment. The majority were clinical transfers (62.7%), followed by repatriations (21.5%) and capacity transfers (15.8%). Unadjusted 30-day mortality was 25.0% among capacity transfers compared to 14.5% and 16.2% for clinical transfers and repatriations, respectively. Adjusted odds ratio (OR) for 30-day mortality were 1.25 (95% CI 1.06-1.49 p = 0.01) for capacity transfers and 1.17 (95% CI 1.02-1.36 p = 0.03) for clinical transfers using repatriation as reference. The differences remained 180 days post-discharge.ConclusionsThere was a large proportion of ICU-to-ICU transfers and an increased odds of dying for those transferred due to other reasons than repatriation.

Project description:BackgroundIncreasing numbers of intensive care units (ICUs) are adopting the practice of nighttime intensivist staffing despite the lack of experimental evidence of its effectiveness.MethodsWe conducted a 1-year randomized trial in an academic medical ICU of the effects of nighttime staffing with in-hospital intensivists (intervention) as compared with nighttime coverage by daytime intensivists who were available for consultation by telephone (control). We randomly assigned blocks of 7 consecutive nights to the intervention or the control strategy. The primary outcome was patients' length of stay in the ICU. Secondary outcomes were patients' length of stay in the hospital, ICU and in-hospital mortality, discharge disposition, and rates of readmission to the ICU. For length-of-stay outcomes, we performed time-to-event analyses, with data censored at the time of a patient's death or transfer to another ICU.ResultsA total of 1598 patients were included in the analyses. The median Acute Physiology and Chronic Health Evaluation (APACHE) III score (in which scores range from 0 to 299, with higher scores indicating more severe illness) was 67 (interquartile range, 47 to 91), the median length of stay in the ICU was 52.7 hours (interquartile range, 29.0 to 113.4), and mortality in the ICU was 18%. Patients who were admitted on intervention days were exposed to nighttime intensivists on more nights than were patients admitted on control days (median, 100% of nights [interquartile range, 67 to 100] vs. median, 0% [interquartile range, 0 to 33]; P<0.001). Nonetheless, intensivist staffing on the night of admission did not have a significant effect on the length of stay in the ICU (rate ratio for the time to ICU discharge, 0.98; 95% confidence interval [CI], 0.88 to 1.09; P=0.72), ICU mortality (relative risk, 1.07; 95% CI, 0.90 to 1.28), or any other end point. Analyses restricted to patients who were admitted at night showed similar results, as did sensitivity analyses that used different definitions of exposure and outcome.ConclusionsIn an academic medical ICU in the United States, nighttime in-hospital intensivist staffing did not improve patient outcomes. (Funded by University of Pennsylvania Health System and others; ClinicalTrials.gov number, NCT01434823.).

Project description:BACKGROUND:Computerized physician order entry (CPOE) has grown since the early 1990s. While many systems serve adult patients, systems for pediatric and neonatal populations have lagged. Adapting adult CPOE systems for pediatric use may require significant modifications to address complexities associated with pediatric care such as daily weight changes and small medication doses. OBJECTIVE:This article aims to review the neonatal intensive care unit (NICU) CPOE literature to characterize trends in the introduction of this technology and to identify potential areas for further research. METHODS:Articles pertaining to NICU CPOE were identified in MEDLINE using MeSH terms "medical order entry systems," "drug therapy," "intensive care unit, neonatal," "infant, newborn," etc. Two physician reviewers evaluated each article for inclusion and exclusion criteria. Consensus judgments were used to classify the articles into five categories: medication safety, usability/alerts, clinical practice, clinical decision Support (CDS), and implementation. Articles addressing pediatric (nonneonatal) CPOE were included if they were applicable to the NICU setting. RESULTS:Sixty-nine articles were identified using MeSH search criteria. Twenty-two additional articles were identified by hand-searching bibliographies and 6 articles were added after the review process. Fifty-five articles met exclusion criteria, for a final set of 42 articles. Medication safety was the focus of 22 articles, followed by clinical practice (10), CDS (10), implementation (11), and usability/alerts (4). Several addressed more than one category. No study showed a decrease in medication safety post-CPOE implementation. Within clinical practice articles, CPOE implementation showed no effect on blood glucose levels or time to antibiotic administration but showed conflicting results on mortality rates. Implementation studies were largely descriptive of single-hospital experiences. CONCLUSION:CPOE implementation within the NICU has demonstrated improvement in medication safety, with the most consistent benefit involving a reduction in medication errors and wrong-time administration errors. Additional research is needed to understand the potential limitations of CPOE systems in neonatal intensive care and how CPOE affects mortality.

Project description:Importance:Professional guidelines have identified key communication skills for shared decision-making for critically ill patients, but it is unclear how intensivists interpret and implement them. Objective:To compare the self-evaluations of intensivists reviewing transcripts of their own simulated intensive care unit family meetings with the evaluations of trained expert colleagues. Design, Setting, and Participants:A posttrial web-based survey of intensivists was conducted between January and March 2019. Intensivists reviewed transcripts of simulated intensive care unit family meetings in which they participated in a previous trial from October 2016 to November 2017. In the follow-up survey, participants identified if and how they performed key elements of shared decision-making for an intensive care unit patient at high risk of death. Transcript texts that intensivists self-identified as examples of key communication skills recommended by their professional society's policy on shared decision-making were categorized. Main Outcomes and Measures:Comparison of the evaluations of 2 blinded nonparticipant intensivist colleagues with the self-reported responses of the intensivists. Results:Of 116 eligible intensivists, 76 (66%) completed the follow-up survey (mean [SD] respondent age was 43.1 [8.1] years; 72% were male). Sixty-one of 76 intensivists reported conveying prognosis; however, blinded colleagues who reviewed the deidentified transcripts were less likely to report that prognosis had been conveyed than intensivists reviewing their own transcripts (42 of 61; odds ratio, 0.10; 95% CI, 0.01-0.44; P < .001). When reviewing their own transcript, intensivists reported presenting many choices, with the most common choice being code status. They also provided a variety of recommendations, with the most common being to continue the current treatment plan. Thirty-three participants (43%) reported that they offered care focused on comfort, but blinded colleagues rated only 1 (4%) as explaining this option in a clear manner. Conclusions and Relevance:In this study, guidelines for shared decision-making and end of life care were interpreted by intensivists in disparate ways. In the absence of training or personalized feedback, self-assessment of communication skills may not be interpreted consistently.

Dataset Information

Transfers from intensive care unit to hospital ward: a multicentre textual analysis of physician progress notes.

Background

Methods

Results

Publications

Transfers from intensive care unit to hospital ward: a multicentre textual analysis of physician progress notes.

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