Transitions of medical care is a challenging task fraught with complex processes that can easily break down, resulting in morbidities or mortalities. Critically ill patients who are recovering from an ICU stay are at high risk for adverse events (AEs) during transfer of care from the ICU to the hospital ward. This is partly the result of the presence of underlying comorbidities, disease pathologies, multiple organ involvement in addition to the large amount of laboratory data, diagnostic information, and a list of active medications which needs to be handed off from one provider to the next (1). The transfer of responsibility between physicians has been proven to be a major contributor to the development of medical errors and AEs (2,3).
Although there are an abundance of literature pertaining to the long-term outcome of critically ill patients as it pertains to costs, in-hospital mortality, outcomes after rehospitalization following hospital discharge, after admission to the ICU, little is known about the frequency and nature of AEs occurring shortly after transition to the general hospital ward from the ICU and the potential interrelationship of ICU events to the development of AEs. For example, although the development of delirium in the ICU has been associated with long-term cognitive debility, little is known regarding to what extent, if any, ICU delirium contributes to morbidities such as patient falls following discharge to the general medical ward. As another example, it is unknown whether deconditioning developed during a several days stay for acute respiratory failure contributes to reintubation, pressure ulcer formation, or nosocomial pneumonia.
In this issue of Critical Care Medicine, Sauro et al (5) present an analysis of AE occurring after transition from the ICU to the hospital ward (5). Between 2014 and 2016, the data by Sauro et al (5) included patients from 10 Canadian ICUs who were transferred to a hospital ward. AEs were defined as “a negative event leading to patient harm that is caused by management rather than the underlying condition of the patient,” a definition adapted from the Institute of Medicine (6). Hospital charts were retrospectively reviewed, and the presence of an AE within the first 7 days of post-ICU care was identified by two independent clinicians. AEs were subcategorized into operative, medical procedure related, drug related, supportive care failure, diagnostic error, and anesthesia related.
The primary finding reported was that 18.6% of patients developed AE with the most common AE (40%) related to supportive care failures such as fluids and electrolyte abnormalities, falls, or pressure wounds. The majority of AEs reported in the study occurred within the first 3 days post-ICU transfer and 75% had clinical symptoms present, without permanent disability or death, which occurred in just 6% of instances. In addition, patients with an AE were more likely to be readmitted to the ICU, experience prolonged hospitalization, and die during that hospitalization. Sauro et al (5) found it difficult for care providers to predict, at the time of ICU discharge, whether an AE was likely to subsequently occur, with agreement between ICU and ward physicians of only 26%, despite an ICU patient having two or more comorbidities, a higher Acute Physiology and Chronic Health Evaluation (APACHE) II score at the time of ICU discharge, or a higher ICU occupancy at the time of ICU discharge being associated with an increased likelihood of an AE development.
In the United States, with one in five hospitalized Medicare patients experiencing an AE during their hospitalization (7), the Canadian data presented by Sauro et al (5) are not surprising. Critically ill patients are transferred from a resource laden environment of technology and personnel to one clearly less so. With the central line–associated bloodstream infection model establishing the goal of zero process defects emanating from care in the ICU (8), ideally, one should also seek to have zero defects occur following the transition from ICU to general ward. However, to the extent that the present study by Sauro et al (5) demonstrates ICU and floor caregivers are not particularly able to predict AEs, ICU readmissions, or post-ICU death; there do not appear to be ready opportunities for process improvement. Furthermore, to the extent, agreement between investigators regarding the potential preventability of AEs is poor, AEs are unlikely to make a scientifically acceptable performance measure without potentially penalizing centers for the AEs, which may have been unavoidable.
Patients who are sicker at the time of ICU discharge (APACHE II score) and have more comorbidities (Charlson Comorbidity Index) are more likely to develop AEs and suggest that additional efforts ought to be made to ensure proper care of these patients after ICU discharge. The preferential use of stepdown units for these patients might be one mechanism to ensure safe care after ICU discharge. However, there remain uncertainties which group of post-ICU patients should be admitted to stepdown and whether these admissions, when compared with the general wards, result in fewer AEs (9). Limited information is available to what extent patients may have encountered fewer AEs in stepdown units when compared with the general ward. One additional point Sauro et al (5) highlighted was the likelihood of AE increases with higher ICU bed occupancy on the day of discharge (5). ICU capacity and strain influence the decision to transfer a patient from the ICU to the ward (10,11). ICU capacities are fixed. Intensivists are often forced to transfer out some patients who might benefit from a longer ICU stay to accommodate patients with greater and more immediate needs.
The findings of Sauro et al (5) are consistent with those of the others. A variety of approaches and tools have been created to predict (and hopefully prevent) AEs during transition of care from the ICU to hospital wards. Hosein et al (12) conducted a systematic review of tools for predicting AE following discharge from the ICU and found all eight risk stratification tools that have been developed lacked clinical validity. Rojas et al (13) evaluated the accuracy of clinician’s ability to predict AE and readmission to the ICU and found an area under the curve of 0.70. Various handoff tools have been piloted and tried with varying success in preventing AE, at least in part because different clinicians interpret and analyze handoff data differently.
The study by Sauro et al (5) identifying AEs during transition from the ICU to the hospital wards is valuable to clinicians in raising awareness that AEs are difficult to classify, harder to reliably and consistently identify, and even more difficult to predict. It is alarming to realize that studies over the past 10 years have highlighted similar issues for which multiple strategies have been deployed with only limited success (12,14,15). Until such time as more rigorous systematic approaches for process intervention to limit AEs are possible, intensivists should be particularly engaged in assisting the orchestration of satisfactory floor care to sicker comorbid patients while making necessary disposition decisions for transfer during periods of high occupancy.
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