Handovers Among Staff Intensivists: A Study of Information Loss and Clinical Accuracy to Anticipate Events.

OBJECTIVES: Handovers are associated with medical errors, and our primary objective is to identify missed diagnosis and goals immediately after a shift handover. Our secondary objective is to assess clinicians' diagnostic accuracy in anticipating clinical events during the night shift. DESIGN: Single-center prospective observational cohort study. SETTING: Thirty-bed tertiary ICU in Sao Paulo, Brazil. PATIENTS: Three-hundred fifty-two patient encounters over 44 day-to-night handovers. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used a multimethods approach to measure transmission of information among staff physicians on diagnoses and goals for the night shift. We surveyed clinicians immediately after a handover and identified clinical events through chart abstractions and interviews with clinicians the next morning. Nighttime clinicians correctly identified 454 of 857 diagnoses (53%; 95% CI 50-56) and 123 of 304 goals (40%; 95% CI, 35-46). Daytime clinicians were more sensitive (65% vs 46%; p < 0.01) but less specific (82% vs 91%; p < 0.01) than nighttime clinicians in anticipating clinical events at night, resulting in similar accuracy (area under the receiver operating characteristic curve, 0.74 [95% CI, 0.68-0.79] vs 0.68 [95% CI 0.63-0.74]; p = 0.09). The positive predictive value of both daytime and nighttime clinicians was low (13% vs 17%; p = 0.2). Gaps in diagnosis and anticipation of events were more pronounced in neurologic diagnoses. CONCLUSIONS: Among staff intensivists, diagnoses and goals of treatment are either not conveyed or retained 50-60% of the cases immediately after a handover. Clinicians have limited ability to anticipate events, and the expectation that anticipatory guidance can inform handovers needs to be balanced against information overload. Handovers among staff intensivists showed more gaps in the identification of diagnostic uncertainty and for neurologic diagnoses, which could benefit from communication strategies such as cognitive checklists, prioritizing discussion of neurologic patients, and brief combined clinical examination at handover.

Nighttime cross-coverage is associated with decreased intensive care unit mortality. A single-center study.

RATIONALE: Cross-coverage is associated with medical errors caused by miscommunication during handoffs. However, no direct evidence links handoffs to outcomes, or explains the mechanisms leading to outcomes. Furthermore, the previous literature may overestimate the impact of handoffs because of hindsight bias. OBJECTIVES: To explore the effects of nighttime cross-coverage on mortality and decision making in critically ill patients. METHODS: Observational cohort of 629 consecutive critically ill admissions, admitted for at least 48 hours, and critical care fellows in an academic hospital. MEASUREMENTS AND MAIN RESULTS: Intensive care unit (ICU) mortality and nighttime decisions. Our exposure variable was cross-covering status of fellows. We observed a decrease in ICU mortality (odds ratio, 0.77 per 1 d; 0.60-0.99; P = 0.04), a higher number of nighttime decisions (19.3 vs. 10.4%; odds ratio, 2.02; 95% confidence interval [CI], 1.03-3.95; P = 0.04), an increase in fentanyl equivalents administered to patients at night (difference, +10.2 µg/h; 95% CI, +1.4 to +19.0; P = 0.02), and an increase in transfusions at night (difference, +465 ml; 95% CI, +98 to +832; P = 0.01) when fellows were cross-covering. CONCLUSIONS: In this single-center study exposure to cross-covering fellows was associated with a decrease in ICU mortality and with more nighttime decisions. Our findings contradict the dominant hypothesis that cross-coverage is associated with worse outcomes, and suggest that a "second look" by cross-covering fellows may mitigate cognitive errors. Future interventions to improve patient safety in ICUs should focus both on the quality of handoffs and on strategies to decrease cognitive errors.

Year in review 2011: Critical Care--Resource management.

Increasing complexity and costs are a fundamental problem in critical care medicine, leading researchers to study opportunities and threats to continue to provide high-quality care in a more efficient health system. Over the past decades, we have learned from industrial methods that quality improvement and resource management can help achieve these results. Last year, Critical Care published a number of papers that highlight key points of critical care resource management. Each of these is grouped into one of three broad categories, based on domains of quality: (a) outcomes, in which we review long-term outcome data with an emphasis on the aging population, strategies to help mitigate the psychological burden of critical care, adverse events, and the appropriate use of resources, such as prolonged mechanical ventilation and intensive care unit (ICU) beds; (b) processes of care, in which we review variability in the provision of critical care, owing to gender, insurance status, and delays in ICU admission; knowledge translation studies in critical care; goal-directed therapy for postoperative patients and decision-making in the ICU; and (c) structure, in which we review strategies to improve quality through changes in design and the structural limitations to provide care in resource-limited settings.

A handoff is not a telegram: an understanding of the patient is co-constructed.

Hospital handoffs are believed to be a key locus of communication breakdown that can endanger patient safety and undermine quality of care. Substantial new efforts to better understand handoffs and to improve handoff practices are under way. Many such efforts appear to be seriously hampered, however, by an underlying presumption that the essential function of a handoff is one-way information transmission. Here, we examine social science literature that supports a richer framing of handoff conversations, one that characterizes them as co-constructions of an understanding of the patient.

The effects of acute care hospitalization on health and cost trajectories for nursing home residents: A matched cohort study.

Thirty five percent to sixty seven percent of admissions to acute care hospitals from nursing homes are potentially preventable. Limited data exist regarding clinical and cost trajectories post an acute care hospitalization. To describe clinical impact and post-hospitalization costs associated with acute care admissions for nursing home residents. Analysis of population-based data. The 65,996 nursing home residents from a total of 645 nursing homes. Clinical outcomes assessed with the Changes in Health, End-stage disease and Symptoms and Signs (CHESS) scores, and monthly costs. Post-index date, hospitalized residents worsened their clinical conditions, with increases in CHESS scores (CHESS 3 + 24.5% vs 7.6%, SD 0.46), more limitations in activities of daily living (ADL) (86.1% vs 76.0%, SD 0.23), more prescriptions (+1.64 95% CI 1.43-1.86, P < .001), falls (30.9% vs 18.1%, SD 0.16), pressure ulcers (16.4% vs 8.6%, SD 0.37), and bowel incontinence (47.3% vs 39.3%, SD 0.35). Acute care hospitalizations for nursing home residents had a significant impact on their clinical and cost trajectories upon return to the nursing home. Investments in preventive strategies at the nursing home level, and to mitigate functional decline of hospitalized frail elderly residents may lead to improved quality of care and reduced costs for this population. Pre-hospitalization costs were not different between the hospitalized and control groups but showed an immediate increase post-hospitalization (CAD 1882.60 per month, P < .001).

Performance Measure Development, Use, and Measurement of Effectiveness Using the Guideline on Mechanical Ventilation in Acute Respiratory Distress Syndrome. An Official American Thoracic Society Workshop Report.

Guideline implementation tools are designed to improve uptake of guideline recommendations in clinical settings but do not uniformly accompany the clinical practice guideline documents. Performance measures are a type of guideline implementation tool with the potential to catalyze behavior change and greater adherence to clinical practice guidelines. However, many performance measures suffer from serious flaws in their design and application, prompting the American Thoracic Society (ATS) to define its own performance measure development standards in a previous workshop in 2012. This report summarizes the proceedings of a follow-up workshop convened to advance the ATS's work in performance measure development and guideline implementation. To illustrate the application of the ATS's performance measure development framework, we used the example of a low-tidal volume ventilation performance measure created de novo from the 2017 ATS/European Society of Intensive Care Medicine/Society of Critical Care Medicine mechanical ventilation in acute respiratory distress syndrome clinical practice guideline. We include a detailed explanation of the rationale for the specifications chosen, identification of areas in need of further validity testing, and a preliminary strategy for pilot testing of the performance measure. Pending additional resources and broader performance measure expertise, issuing "preliminary performance measures" and their specifications alongside an ATS clinical practice guideline offers a first step to further the ATS's guideline implementation agenda. We recommend selectively proceeding with full performance measure development for those measures with positive early user feedback and the greatest potential impact in accordance with ATS leadership guidance.

Use of the sequential organ failure assessment score as a severity score.

OBJECTIVE: To evaluate whether the SOFA score can be used to develop a model to predict intensive care unit (ICU) mortality in different countries. DESIGN AND SETTING: Analysis of a prospectively collected database. Patients with ICU stay longer than 2 days were studied to develop a mortality prediction model based on measurements of organ dysfunction. PATIENTS: 748 patients from six countries. MEASUREMENTS AND RESULTS: Two logistic regression models were constructed, one based on the SOFA maximum (SOFA Max model) and the other on variables identified by multivariate regression (SOFA Max-infection model). The H and C statistics had a p value above 0.05 for both models, but the D statistics showed a poor performance on the SOFA Max model when stratified for the presence of infection. Subsequent analysis was performed with SOFA Max-infection model. The area under the curve was 0.853. There were no statistically significant differences in observed and predicted mortalities except for one country which had a higher than predicted ICU mortality both in the overall population (28.3 vs. 19.1%) and in the noninfected patients (21.4 vs. 12.6%). CONCLUSIONS: The SOFA Max adjusted for age and the presence of infection can predict mortality in this population, but in one country the ICU mortality was higher than expected. Our data do not allow us to determine the reasons behind these differences, and further studies to detect differences in mortality between countries and to elucidate the basis for these differences should be encouraged.