Q&A: Initiative aims to improve care during ICU-to-hospital transition

When a patient is discharged from the ICU and transferred to a hospital ward, there is an increased risk for diagnostic uncertainty and lack of communication among care teams, according to a press release from the American Thoracic Society.

In response to these identified risks, ATS has launched the ICU Pause Initiative to bring attention to patient safety and equity in diagnosis during this critical transition period.

Healio spoke with Lekshmi Santhosh, MD, ATS member and associate professor of pulmonary/critical care medicine at University of California, San Francisco, to learn more about the initiative, risks associated with transitioning patients from the ICU and goals for the program.

Healio: What inspired the launching of the ATS ICU Pause Initiative?

Santhosh: Ever since my residency, I have always been interested in the overlap between patient safety, quality improvement and medical education. I have a passion for continuous process improvement, and I’m always thinking about ways to improve education and clinical care. I have observed through my clinical practice — and the literature supports — that transition out of the ICU is a high-risk and unstandardized time, both within the same hospital and across hospitals. I remember vividly from residency an experience where we rescued a patient from the brink of death, were delighted to transfer him to the floor and then just days later he was back in the ICU. I remember thinking to myself, how could we have communicated better that there were some aspects of his clinical status that improved? However, there were also some aspects of his clinical status that we did not fully understand why they improved.

During the research portion of my fellowship and ever since then, I have conducted research on the ICU-to-ward transition and thought about how to better standardize this process. For instance, we all use the I-PASS mnemonic — which stands for illness severity, patient summary, action list, situation awareness and synthesis by receiver — developed by Amy Starmer, MD, director of primary care quality improvement at Boston’s Children’s Hospital, for our day-to-night and night-to-day transitions. This inspired me to think about how to develop a structured tool to standardize information to help make the high-risk ICU-to-ward transition even safer. The ICU-PAUSE was cocreated by residents at multiple hospitals through the human-centered design process to really focus on the key elements that are most likely to be missed in the ICU-to-ward transition.

Healio: The ATS ICU Pause Initiative website says that transitioning ICU patients to a hospital ward is a “high-risk time.” What makes this situation high risk and what are some known issues surrounding this transfer of care?

Santhosh: There is a large body of literature noting that transitions of care in general are high-risk times, and the ICU-to-ward transition is no different. When patients transfer from the ICU to the ward, they experience a reduction in clinical monitoring, a change in their clinical care team and often both diagnostic and prognostic uncertainty. Therefore, communication around this care transition is extremely important, yet is often overlooked.

Healio: The tool also aims to improve equity. How does implicit bias potentially play a role during this transition?

Santhosh: When communication is done in a standardized structured way, the same way every single time, our hope is that it reduces bias as well. We know from the literature of Gracie Himmelstein, MD, of the office of population research at Princeton University, and others that stigmatizing language is sadly present in many notes. Unstructured notes may be more likely to carry stigmatizing language. Our hope is that structured communication tools help providers focus on the most clinically important information and avoid stigmatizing language.

Healio: What is the ICU Pause tool? How will it impact both the clinician and the patient?

Santhosh: The ICU-PAUSE is a structured transfer note tool that focuses on making explicit certain high-yield aspects of a patient’s care that are important to communicate explicitly during the ICU-to-ward transition, including:

• I: the reason for ICU admission;
• C: code status;
• U: uncertainty measure/diagnostic pause;
• P: pending tests on transfer;
• A: active consultants;
• U: unprescribing high-risk meds;
• S: summary of major problems; and
• E: pertinent physical exam.

Each letter in the ICU-PAUSE mnemonic corresponds to one of these key items that are frequently lost in the handoff. Moreover, there is an explicit diagnostic pause where providers can name explicitly the working diagnosis and share if they have high/low/medium diagnostic uncertainty. The ICU-PAUSE provides a structured way of communicating key information without adding excessive work and actually saves clinicians from repeating work when they accept an ICU transfer. It will impact the patients positively as ICU clinicians and ward clinicians will have a shared mental model of the key aspects of their ICU course and a key understanding of their working diagnosis and diagnostic uncertainty.

Healio: Six sites have implemented the tool. Do you have any plans for studying the tool’s impact on care at these sites?

Santhosh: We are in the process of studying the tool’s impact using both pre- and post-implementation structured interviews, as well as analysis of ICU-PAUSE transfer summaries and other quality improvement metrics. Our study protocol was recently published in JMIR Research Protocols.

Healio: What are the overall goals of the initiative? Do you hope to expand to other sites?

Santhosh: The overall goals of the initiative are to improve ICU and hospital medicine clinicians’ awareness of the importance of the ICU-to-ward transition and to provide a standardized framework via the ICU-PAUSE to standardize communication at this high-risk transition.

If your hospital is interested in adopting ICU-PAUSE, please contact Lauren Lynch, senior director of professional development and training at ATS, and me to get your institution started. We will provide instructional materials with a video, posters/handouts, sample EHR dot phrases and access to other institutions who have already implemented ICU-PAUSE. Other subspecialties such as emergency medicine and OB/GYN are also thinking about how they can modify ICU-PAUSE to their own subspecialty contexts. Ultimately, our hope is that the ICU-PAUSE tool will improve patient safety, clinician communication, trainee education and awareness of implicit bias.

For more information:

Lekshmi Santhosh, MD, can be reached at lekshmi.santhosh@ucsf.edu.

Lauren Lynch can be reached at llynch@thoracic.org.

References:

• The American Thoracic Society wants to improve safety and equity at the time of ICU discharge. https://www.newswise.com/articles/the-american-thoracic-society-wants-to-improve-patient-safety-and-equity-at-the-time-of-icu-discharge?sc=dwhr&xy=10013298. Published Feb. 8, 2023. Accessed Feb. 9, 2023.
• ATS ICU-PAUSE Initiative. https://www.thoracic.org/professionals/education/ats-icu-pause-initiative.php. Accessed Feb. 14, 2023.
• Fukui EM, et al. JMIR Res Protoc. 2023;doi:10.2196/40918.
• Himmelstein G, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2021.44967.
• Santhosh L, et al. ATS Sch. 2022;doi:10.34197/ats-scholar.2021-0135IN.
• Starmer AJ, et al. Pediatrics. 2012;doi:10.1542/peds.2011-2966.