Standardizing the Transmission of Medically Relevant Information for Outside Hospital Transfers to the Medical Intensive Care Unit (MICU): Understanding the Current State

From the 2019 HVPAA National Conference

Dr. Rabel Rameez (Cleveland Clinic Foundation), Dr. Francisco Marco Canosa (Cleveland Clinic Foundation), Ms. Mariel Nolan (Cleveland Clinic Foundation), Dr. Andrew Young (Cleveland Clinic Foundation), Dr. Samuel Wiles (Cleveland Clinic Foundation), Dr. Mani Latifi (Cleveland Clinic Foundation)

Background

Lack of efficient transmission of relevant clinical information during the ICU to ICU transfer process results in significant delays in care, increased costs (given the need to repeat unnecessary testing), lower diagnostic yield, prolonged ICU and hospital stays, and the potential for increases in patient morbidity and mortality.

Objective

The goal of our project was to understand the current process of outside hospital transfers to the MICU and quantify the percentage of clinically relevant information available for patients admitted to Cleveland Clinic Main Campus with diagnosis of sepsis from April 2018 to July 2018.

Methods

Data was collected via manual chart review of all patients admitted to the MICU from outside hospitals.  This included blood cultures, medication lists, code status, POA paper work, family information etc. Patients were excluded if the referring institution utilized EPIC as their electronic medical record, used the Care Everywhere platform for exchange of medical information between hospitals, or if the patient did not carry a diagnosis of sepsis. Surveys were administered to all residents in the internal medicine residency program to help identify issues with the current process.

Results

Our data collection showed that only about 35-40% of clinically relevant data points were available at the time of admission for patients carrying a diagnosis of sepsis.  Survey results demonstrated general dissatisfaction with the transfer process and the availability of clinically important information at the time of transfer.  Residents felt that they received the clinically relevant data necessary to treat their patients only 33% of the time. We also found that the process involving outside hospital transfers is incredibly complex.

Conclusions

Transitions of care are an extremely vulnerable time for patients, particularly those critically ill patients undergoing MICU to MICU transfers.  Data transfer is currently very poor and has the potential to result in delays in care, unnecessary testing, and potential morbidity and mortality.  Our study underscores the need for interventions to streamline this process. We propose the following:

  • Institute a checklist to be sent to referring institutions with expected information to be sent at the time of transfer to our facility
  • Standardize the critical care transport sheet to facilitate exchange of information from the referring to receiving facility
  • Standardize the nursing admission report to improve acquisition of clinically relevant data
  • Enhance MICU resident direct communication with outside hospital physicians by:
    • Including them in the nursing admission report process
    • Including them in the physician to physician discussion that occurs prior to accepting the patient

Clinical Implications

This QI project helps us underscore the complexity of out side hospital transfers particularly those between MICUs. It also highlights the paucity of relevant information that critically ill patients come with. This is an important area for future QI interventions to focus on.

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