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Lost in Sign Out and Documentation

Michael E. Detsky, MD, MSc | April 1, 2016
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The Case

A 71-year-old man presented to the emergency department with chest pain. While being evaluated by the emergency physician, he suddenly went into cardiac arrest. He was successfully resuscitated and underwent emergent cardiac catheterization, which revealed multivessel coronary artery disease requiring placement of three stents. The patient was subsequently transferred to the coronary care unit (CCU) with respiratory failure requiring mechanical ventilation and acute kidney injury requiring hemodialysis. He had a prolonged CCU course and eventually needed tracheostomy placement due to inability to wean from the ventilator.

On hospital day 18, he underwent placement of a percutaneous endoscopic gastrostomy (PEG) tube for nutrition. The following day, an abdominal radiograph was performed to check tube placement prior to initiating feedings. The radiograph showed "free air under the diaphragm." The patient had no abdominal symptoms, and the CCU team discussed the case with a gastroenterologist who said that this finding was normal after PEG placement. The primary resident got a "curbside consult" from the on-call surgery resident who also felt that, given the absence of symptoms, the patient could simply be monitored. No official surgery consult was placed in the chart. Tube feeds were started later that day.

The patient was transferred to the ward on hospital day 20. Late that evening, the patient complained of left-sided abdominal pain. Labs showed a marked increase in his white blood cell count. A stat abdominal radiograph revealed a significant amount of air under the diaphragm. Only at that point did the ward team realize that the radiograph done 2 days earlier had also showed the same finding; this issue was not signed out to them when the patient was transferred out of the CCU. The surgery team was urgently re-consulted, and the patient was taken to the operating room. Exploratory laparotomy revealed a large gastric perforation at the PEG tube site and spillage of tube feeds into the peritoneum, with signs of acute peritonitis. Repair of the perforation was performed along with washout of the abdomen. The patient was transferred to the intensive care unit from the operating room in septic shock. Fortunately, he eventually recovered and was transferred to a long-term acute care facility on hospital day 30.

The case was reviewed in a multidisciplinary morbidity and mortality conference. Multiple errors were noted, including poor communication between teams and a lack of a standardized signout process for patients being transferred from the CCU to the ward. As a result of this case, a structured signout was designed and implemented with the expectation that both residents and attending physicians on the critical care team would directly sign out patients to the ward team.

The Commentary

Commentary by Michael E. Detsky, MD, MSc

This case highlights the challenges related to transferring patients from an intensive care unit (ICU) to a general ward. ICU transfers expose vulnerable patients to adverse events for several reasons. First, patients move from an area of high resource utilization and monitoring to an area of lower resource use and monitoring. Second, these transfers typically involve the transition of patients from one physician or team of health care providers to another physician or team. Patients leaving the ICU have generated a large body of clinical information. Communicating this information during an ICU transfer is challenging, and important details can be omitted, as in this case.

Efforts to improve ICU transfers are in their infancy, and at present there is no standard approach.(1) The fundamental objective of a safe ICU transfer is ensuring that appropriate and efficient communication takes place between the physician (or team) that was providing care to the physician (or team) that is assuming care. A recent literature review highlights a variety of barriers to effective ICU transfers and identified tools that have been used to improve this process of care.(2) The goal of an ICU transfer tool is to minimize adverse events associated with the transfer, like insufficient communication and medication errors (3), which can lead to low satisfaction from all stakeholders.(4)

One important tool may be the checklist. The use of checklists both in the critical care world (5) and other specialties (6) has improved patient outcomes, in part by ensuring that essential aspects of the transfer are not missed and that adequate communication takes place. A structured handoff bundle has been shown to prevent adverse events for pediatric inpatients, and similar principles can be used to develop a standard approach for ICU transfers.(7) Physicians who participate in ICU transfers have identified patient information that should be included in a transfer checklist for physician-to-physician communication (Table).(8) The importance of other factors associated with ICU transfers, such as ensuring ICU transfers take place during the day, has not shown to impact patient outcomes.(9)

In this case, the potential problem with the feeding tube was a surprise to the accepting team. Although it is true that free air under the diaphragm is reported in more than half of follow-up radiographs after insertion of a PEG tube (10), some of these cases do represent complications and clinical monitoring is essential to determine whether the free air has clinical significance. If the patient deteriorates, further investigations often include the use of imaging with contrast or laparotomy, depending on the patient's severity of illness. In this case, the patient developed clinical signs and symptoms of an intra-abdominal process on the day of transfer. The ward team recognized these clinical changes, yet they had no knowledge of the prior radiograph findings, nor does it seem they were aware of the timing of the PEG tube insertion. The potentially concerning radiographic findings and the date of the procedure should have been properly communicated from the cardiac care team to the ward team. It is unclear if knowledge of these facts would have expedited management.

The use of curbside consults may have also contributed to the delay in recognizing the misplaced feeding tube for a number of reasons. First, had the general surgery resident on call formally reviewed the case, the team may have recognized that the free air on under the diaphragm was a significant finding. Second, they would have provided some continuity of care around this specific issue. Third, the cardiac care team may have been inappropriately reassured that free air on the radiograph was not a possible sign of a complication, and this detail got lost in the transfer. A recent review found that management suggestions by curbside consultants were often different from those suggested in formal consultations.(11) This discrepancy is largely due to the perception of incomplete information provided during a curbside consult.(12) Despite the issues with curbside consultations, there may still be a role for them in certain circumstances. The use of antimicrobial stewardship to help de-escalate the use of antibiotics in the ICU is an example of how curbside consultations can improve the quality of care in this setting.(13)

In summarizing this case, a patient who was in the recovery phase of his critical illness experienced a life-threatening complication. There may have been a delay in the recognition of this complication because of a flawed transfer from a cardiac care unit to the general ward. The problem may have been compounded by the use of a curbside consultation, which provided the cardiology team with false reassurance and left behind no documentation. The patient required an emergent surgical procedure and further critical care services to rescue him from this complication. Though the patient survived to hospital discharge, his prognosis is relatively poor, with less than 5% of patients who experience prolonged mechanical ventilation being functionally independent at one year.(14) It is difficult to know the contribution the inadequate transfer and curbside consultation will play in the patient's future morbidity. There is no doubt, however, that if proper communication had taken place, all involved in this case would have been more comfortable that this patient received the best care possible. Based on projections of critical care use (15), ICU-to-ward transfers are expected to occur more frequently in the coming years. Optimizing these transfers must be a priority for health care systems to ensure high quality care for this vulnerable population.

Take-Home Points

  • Patients transferred from critical care units to general wards are at high risk to experience adverse events.
  • There is opportunity to enhance our understanding of the current pitfalls of ICU transfers. Future research should evaluate how this process of care can be improved.
  • The use of ICU transfer tools that incorporate best practices and are consistent with institutional culture can help mitigate this risk.
  • The use of curbside consults serve can serve a purpose, but must be used with caution. If the question of the consultant requires specific knowledge about a patient's history, formal consultation should be sought.

Michael E. Detsky, MD, MSc Department of Critical Care Mount Sinai Hospital/University Health Network Assistant Professor of Medicine Interdepartmental Division of Critical Care Medicine, University of Toronto Toronto, ON

Table. Information for Physician-to-Physician Communication to Include in an ICU Transfer.(8)

Active issues Presence of catheters, dates of insertion
Resuscitation status Medication changes
Primary diagnosis Route/type of nutrition
Past medical history Current intravenous fluid infusions
Name and contact of substitute decision maker Tracheostomy care (if applicable)
Antibiotic use/duration/discontinuation dates Date of extubation (if applicable)
Isolation status Suction requirements (if applicable)


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2. Stelfox HT, Lane D, Boyd JM, et al. A scoping review of patient discharge from intensive care: opportunities and tools to improve care. Chest. 2015;147:317-327. [go to PubMed]

3. Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011;306:840-847. [go to PubMed]

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5. Papadimos TJ, Hensley SJ, Duggan JM, et al. Implementation of the "FASTHUG" concept decreases the incidence of ventilator-associated pneumonia in a surgical intensive care unit. Patient Saf Surg. 2008;2:3. [go to PubMed]

6. de Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363:1928-1937. [go to PubMed]

7. Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310:2262-2270. [go to PubMed]

8. Detsky ME, Ailon J, Weinerman AS, Amaral AC, Bell CM. A two-site survey of clinicians to identify practices and preferences of intensive care unit transfers to general medical wards. J Crit Care. 2015;30:358-362. [go to PubMed]

9. Santamaria JD, Duke GJ, Pilcher DV, Cooper DJ, Moran J, Bellomo R; Discharge and Readmission Evaluation (DARE) Study. The timing of discharge from the intensive care unit and subsequent mortality. A prospective, multicenter study. Am J Respir Crit Care Med. 2015;191:1033-1039. [go to PubMed]

10. Wojtowycz MM, Arata JA Jr, Micklos TJ, Miller FJ Jr. CT findings after uncomplicated percutaneous gastrostomy. AJR Am J Roentgenol. 1988;151:307-309. [go to PubMed]

11. Burden M, Sarcone E, Keniston A, et al. Prospective comparison of curbside versus formal consultations. J Hosp Med. 2013;8:31-35. [go to PubMed]

12. Keating NL, Zaslavsky AM, Ayanian JZ. Physicians' experiences and beliefs regarding informal consultation. JAMA. 1998;280:900-904. [go to PubMed]

13. Katsios CM, Burry L, Nelson S, et al. An antimicrobial stewardship program improves antimicrobial treatment by culture site and the quality of antimicrobial prescribing in critically ill patients. Crit Care. 2012;16:R216. [go to PubMed]

14. Unroe M, Kahn JM, Carson SS, et al. One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation: a cohort study. Ann Intern Med. 2010;153:167-175. [go to PubMed]

15. Angus DC, Kelley MA, Schmitz RJ, et al. Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA. 2000;284:2762-2770. [go to PubMed]

This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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