Similar to the ED-to-inpatient transition, patients transferred from the ICU to the general ward face numerous obstacles, placing them at significant risk for diagnostic error. At this transition, patients with complex life-threatening problems transition from the care of a critical care medicine physician to a medical, surgical, or primary care physician. Furthermore, determining who is ready for ICU discharge is a daily cognitive challenge for critical care physicians. Standardized ICU discharge criteria are lacking, and the transition to a lower resourced setting with multiple clinician handoffs makes patients vulnerable to harm.55–57 Across academic medical centers, one survey57 showed that 87 percent of residents recalled at least one adverse event specifically related to communication failures in the ICU-to-ward transition.
ICU-Specific Contributors to Diagnostic Errors and Uncertainty
Due to the high complexity and acuity of patients, the ICU is a busy and distracting setting for both seasoned clinicians and learners alike.58 Despite the large volumes of physiologic data frequently available, the ICU context highlights the marked role of uncertainty in the diagnostic process.59
Dunlop and Schwartzstein suggest that the ICU context should be one where diagnostic uncertainty is clinically accepted and explicitly recognized, thereby countering some of the most common cognitive biases, such as anchoring, premature closure, and availability bias. The authors note that frontline ICU clinicians need a shared mental model to define what clinical uncertainty truly means.59
Just as in the ED, ICU clinicians grapple with high patient acuity, frequent task switching while processing large volumes of dynamic clinical information, and both cognitive failures and system-based failures, all of which can lead to diagnostic errors.60 Although substantial efforts have focused on improving communication during end-of-shift and end-of-service handoffs,61,62 the ICU-to-ward transition of care has been less studied.
ICU-to-Ward Handoff-Specific Contributors to Diagnostic Errors and Uncertainty
When transitioning from the ICU to the ward, the most critically ill patients in the hospital are often moved to a new care team from a resource-intensive environment to a less resource-intensive environment. Not surprisingly, at least 20 percent of patients discharged from the ICU experience an adverse event, with more than one-third of these adverse events deemed preventable.63 These adverse events are associated with ICU readmission, increased length of stay, and death but are not accurately predicted by ICU or ward physicians.63,64
Ineffective verbal and written handoffs have been estimated to lead to approximately 10 percent of adverse events in the ICU.65 However, few evidence-based approaches are available to structure written or verbal handoffs in the transition from the ICU to the ward despite it being a high-risk transition of care.
Santhosh, et al., conducted a study at three academic medical centers to evaluate the structure, perceptions, and processes of ICU-ward transfers.11,57 The authors found that despite significant process variation across sites, almost all resident physicians recalled an adverse event related to the ICU-ward handoff, and most of these adverse events were rooted in communication issues.57,66
In addition to communication between providers at the ICU-to-ward transition, communication between patients and providers is also an important facilitator for a successful ICU discharge.67 Patients and families valued summaries about the patient's stay in the ICU and information about the transfer to the ward.67,68 Patients and families also appreciated being actively engaged in the decision making regarding whether the patient was ready to transfer out of the ICU.67 Plotnikoff, et al., found that patients and families felt that consistent communication from the healthcare team helped facilitate a successful transition from an ICU to a hospital ward.69
Strategies To Mitigate Diagnostic Errors and Uncertainty at ICU-to-Ward Transitions
Stelfox, et al., conducted a scoping review to systematically review the literature reporting patient discharge from ICUs, identify facilitators and barriers to high-quality care, and describe tools developed to improve care.68 They found that ICU discharge is complex and a single universal tool is probably insufficient to address the challenges. However, the literature notes numerous elements to inform an ICU discharge strategy, including:
- Structures to facilitate patient discharge,
- Education programs to train providers,
- Risk stratification models to evaluate readiness for ICU discharge,
- Patient and family involvement in the ICU handoff process,
- Communication with the receiving team,
- Detailed medication reconciliation, and
- Deliberate tracking of postdischarge outcomes.
Plotnikoff, et al., found that the most common facilitator for a successful ICU discharge was the explicit education of patients and families regarding this process.69
While many ICU-to-ward transition tools focus on clinical criteria such as ICU readmissions, few focus explicitly on preventing diagnostic error. The ICU-PAUSE is one such tool that explicitly embeds a diagnostic pause with an acknowledgment and ranking of diagnostic uncertainty when clinicians communicate about a patient transitioning from the ICU to a ward.70,71
Further research should examine how diagnostic errors can be reduced with more widespread and standardized implementation of structured communication tools such as ICU-PAUSE. Once again, tools such as Calibrate Dx could also be useful for both individual clinicians and health systems alike to evaluate and calibrate diagnostic performance at the time of transitions of care.30
In conclusion, the ICU-to-ward transition is a high-risk time for diagnostic errors. Specific strategies such as educating providers and family on readiness for ICU discharge, explicitly embedding diagnostic pauses, and measuring post discharge diagnostic outcomes can mitigate diagnostic error at this transition.
