Lost in transit

Even when errors didn't occur, communication patterns appeared less than ideal.

Pin Li, MD, knows well how rare it is for hospitalists and intensive care unit (ICU) physicians to collaborate on the care of patients transferred between their services. He recently conducted a study at his hospital, Foothills Medical Centre in Alberta, Canada, to assess the quality of ICU-to-ward transfers.

Several issues with communication between physicians were identified. For example, two of the 112 patients studied were “lost”—as in, no physician was taking responsibility for their care—for more than 48 hours. Not surprisingly, those patients reported dissatisfaction with their transfers. The study also found 13 medical errors associated with transfer communication problems.

Even when errors didn't occur, the communication patterns appeared less than ideal. Only about 16% of ward physicians communicated with the ICU about impending transfers and only a quarter of them got any kind of verbal communication from the ICU when the transfer was happening.

Dr. Li, who is a clinical assistant professor of medicine at the University of Calgary, recently spoke with ACP Hospitalist about his research and his ideas for improving ICU transfers.

Q: Why study this issue?

A: I'm a clinician doing mostly patient care. During daily practice, I see so many problems with this process, putting at risk patient care and patient safety. Most studies we found studied patient transfers and handoffs within the same department. When inter-department patient transfers occur, especially in very busy departments, like the ICU, there's one more layer of barriers. However, the practice of physician handover and patient care in this area is understudied.

Q: What do you see as the biggest issues uncovered by your study?

A: We were happy to see that in the majority of cases, there is some form of communication between the ICU service and the receiving services, but we certainly also noticed lots of gaps that we can fill to improve patient safety and care, in personal practice as well as on an institutional level. For example, there are no standardized transfer protocols for the physicians when they transfer patients from one service to another in our institution. This is a potential area to improve. For example, there have been numerous studies in nursing care, suggesting that standardized patient transfer protocols have been used in lots of centers in North America and improved the quality of handovers and patient care.

Q: Should these protocols involve face-to-face communication?

A: Absolutely. There are lots of studies in other industries as well as in health care showing that interactive communication, either in person or by phone, is the best and most effective way to relay information to avoid miscommunication and cut down the rate of errors. But unfortunately it's not common practice in physician handover during inter-department patient transfer in our institution, and I believe it may not be a common practice among the centers across North America, based on the available evidence.

Q: How can hospitals prevent “lost” patients?

A: We need to have a backup system as a part of physician handover protocol to catch those patients and prevent them from falling between the cracks. It can be as simple as asking the unit that receives the patient to notify the receiving physician after the patient arrives on the unit. But, again, I believe that what we need to have is a clear, straightforward, concise protocol to help to guide the health care providers when we transfer patients.

Q: What should be in such a protocol?

A: When patients are transferred between departments, it involves lots of steps. In each step there is vital information about patient care to be delivered. For example, to initiate an ICU-ward patient transfer in our institution, the ICU physician will consult the service where they think the patient should go, and the receiving service physicians will come to assess the patient and then make a decision about taking over patient care based on their assessment. Some information critical for making such decisions and for patient care down the road cannot be obtained without communicating with the ICU physician directly.

Q: Are electronic health records helpful?

A: Electronic health record systems have been gaining popularity in health care. But, to my knowledge, only a few studies have been published to address this question. We are actually conducting a review looking for any potential roles of electronic record systems in patient transfer. Certainly, we think they will play an important role in terms of improving communication and decreasing miscommunication-induced medical errors, if they are developed or modified properly to serve this purpose. I think that's a potential area for future study.