Improving Communication in Intensive Care Unit to Ward Transitions: Protocol for Multisite National Implementation of the ICU-PAUSE Handoff Tool.

BACKGROUND: The intensive care unit (ICU)-ward transfer poses a particularly high-risk period for patients. The period after transfer has been associated with adverse events and additional work for care teams related to miscommunication or omission of information. Standardized handoff processes have been found to reduce communication errors and adverse patient events in other clinical environments but are understudied at the ICU-ward interface. We previously developed an electronic ICU-ward transfer tool, ICU-PAUSE, which embeds the key elements and diagnostic reasoning to facilitate a safe transfer of care at ICU discharge. OBJECTIVE: The aim of this study is to evaluate the implementation process of the ICU-PAUSE handoff tool across 10 academic medical centers, including the rate of adoption and acceptability, as perceived by clinical care teams. METHODS: ICU-PAUSE will be implemented in the medical ICU across 10 academic hospitals, with each site customizing the tool to their institution's needs. Our mixed methods study will include a combination of a chart review, quantitative surveys, and qualitative interviews. After a 90-day implementation period, we will conduct a retrospective chart review to evaluate the rate of uptake of ICU-PAUSE. We will also conduct postimplementation surveys of providers to assess perceptions of the tool and its impact on the frequency of communication errors and adverse events during ICU-ward transfers. Lastly, we will conduct semistructured interviews of faculty stakeholders with subsequent thematic analysis with the goal of identifying benefits and barriers in implementing and using ICU-PAUSE. RESULTS: ICU-PAUSE was piloted in the medical ICU at Barnes-Jewish Hospital, the teaching hospital of Washington University School of Medicine in St. Louis, in 2019. As of July 2022, implementation of ICU-PAUSE is ongoing at 6 of 10 participating sites. Our results will be published in 2023. CONCLUSIONS: Our process of ICU-PAUSE implementation embeds each step of template design, uptake, and customization in the needs of users and key stakeholders. Here, we introduce our approach to evaluate its acceptability, usability, and impact on communication errors according to the tenets of sociotechnical theory. We anticipate that ICU-PAUSE will offer an effective handoff tool for the ICU-ward transition that can be generalized to other institutions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40918.

Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool.

OBJECTIVES: The transition from the intensive care unit (ICU) to the medical ward is a high-risk period due to medical complexity, reduced patient monitoring, and diagnostic uncertainty. Standardized handoff practices reduce errors associated with transitions of care, but little work has been done to standardize the ICU to ward handoff. Further, tools that exist do not focus on preventing diagnostic error. Using Human-Centered Design methods we previously created a novel EHR-based ICU-ward handoff tool (ICU-PAUSE) that embeds a diagnostic pause at the time of transfer. This study aims to explore barriers and facilitators to implementing a diagnostic pause at the ICU-to-ward transition. METHODS: This is a multi-center qualitative study of semi-structured interviews with intensivists from ten academic medical centers. Interviews were analyzed iteratively through a grounded theory approach. The Sittig-Singh sociotechnical model was used as a unifying conceptual framework. RESULTS: Across the eight domains of the model, we identified major benefits and barriers to implementation. The embedded pause to address diagnostic uncertainty was recognized as a key benefit. Participants agreed that standardization of verbal and written handoff would decrease variation in communication. The main barriers fell within the domains of workflow, institutional culture, people, and assessment. CONCLUSIONS: This study represents a novel application of the Sittig-Singh model in the assessment of a handoff tool. A unique feature of ICU-PAUSE is the explicit acknowledgement of diagnostic uncertainty, a practice that has been shown to reduce medical error and prevent premature closure. Results will be used to inform future multi-site implementation efforts.

Author Correction: Elevated faecal 12,13-diHOME concentration in neonates at high risk for asthma is produced by gut bacteria and impedes immune tolerance.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Elevated faecal 12,13-diHOME concentration in neonates at high risk for asthma is produced by gut bacteria and impedes immune tolerance.

Neonates at risk of childhood atopy and asthma exhibit perturbation of the gut microbiome, metabolic dysfunction and increased concentrations of 12,13-diHOME in their faeces. However, the mechanism, source and contribution of this lipid to allergic inflammation remain unknown. Here, we show that intra-abdominal treatment of mice with 12,13-diHOME increased pulmonary inflammation and decreased the number of regulatory T (Treg) cells in the lungs. Treatment of human dendritic cells with 12,13-diHOME altered expression of PPARγ-regulated genes and reduced anti-inflammatory cytokine secretion and the number of Treg cells in vitro. Shotgun metagenomic sequencing of neonatal faeces indicated that bacterial epoxide hydrolase (EH) genes are more abundant in the gut microbiome of neonates who develop atopy and/or asthma during childhood. Three of these bacterial EH genes (3EH) specifically produce 12,13-diHOME, and treatment of mice with bacterial strains expressing 3EH caused a decrease in the number of lung Treg cells in an allergen challenge model. In two small birth cohorts, an increase in the copy number of 3EH or the concentration of 12,13-diHOME in the faeces of neonates was found to be associated with an increased probability of developing atopy, eczema or asthma during childhood. Our data indicate that elevated 12,13-diHOME concentrations impede immune tolerance and may be produced by bacterial EHs in the neonatal gut, offering a mechanistic link between perturbation of the gut microbiome during early life and atopy and asthma during childhood.