A Multiple Baseline Trial of an Electronic ICU Discharge Summary Tool for Improving Quality of Care*

Abstract

Objective: Effective communication between clinicians is essential for seamless discharge of patients between care settings. Yet, discharge summaries are commonly not available and incomplete. We implemented and evaluated a structured electronic health record–embedded electronic discharge (eDischarge) summary tool for patients discharged from the ICU to a hospital ward. DESIGN: Multiple baseline trial with randomized and staggered implementation. SETTING: Adult medical-surgical ICUs at four acute care hospitals serving a single Canadian city. PATIENTS: Health records of patients 18 years old or older, in the ICU 24 hours or longer, and discharged from the ICU to an in-hospital patient ward between February 12, 2018, and June 30, 2019. INTERVENTION: A structured electronic note (ICU eDischarge tool) with predefined fields (e.g., diagnosis) embedded in the hospital-wide electronic health information system. MEASUREMENTS AND MAIN RESULTS: We compared the percent of timely (available at discharge) and complete (included goals of care designation, diagnosis, list of active issues, active medications) discharge summaries pre and post implementation using mixed effects logistic regression models. After implementing the ICU eDischarge tool, there was an immediate and sustained increase in the proportion of patients discharged from ICU with timely and complete discharge summaries from 10.8% (preimplementation period) to 71.1% (postimplementation period) (adjusted odds ratio, 32.43; 95% CI, 18.22–57.73). No significant changes were observed in rapid response activation, cardiopulmonary arrest, death in hospital, ICU readmission, and hospital length of stay following ICU discharge. Preventable (60.1 vs 5.7 per 1,000 d; p = 0.023), but not nonpreventable (27.3 vs 40.2 per 1,000d; p = 0.54), adverse events decreased post implementation. Clinicians perceived the eDischarge tool to produce a higher quality discharge process. CONCLUSIONS: Implementation of an electronic tool was associated with more timely and complete discharge summaries for patients discharged from the ICU to a hospital ward.

Validating the Physician Documentation Quality Instrument for Intensive Care Unit–Ward Transfer Notes

“…For instance, the structured illness severity, patient summary, action list, situational awareness, and synthesis by receiver (or, I-PASS) program has been associated with reductions in medical errors and in preventable adverse events when implemented in pediatric settings ( 16 , 17 ). In critical care settings, implementation of a standardized electronic handoff tool led to earlier and more detailed completion of ICU transfer notes in patient charts ( 14 ).…”

Communication Strategies and Patient Care Transitions in the Early ICU Aftercare Period*

“…In this issue of Critical Care Medicine , Stelfox et al (4) investigate the crucially important step of timely and effective physician-to-physician ICU discharge handoff documentation to communicate clinical priorities for patients entering the early ICU aftercare period. Their intervention of an EHR-enabled structured ICU discharge note replaced a free-form dictation approach in four participating hospitals in Calgary, AB, Canada.…”

“…During times of fasting, such as in critical illness, muscle is catabolized into its constitutive amino acids and serves as the primary source of serum phenylalanine, which is understood to be a marker of whole body proteolysis (1). There is evidence that "chronically" elevated levels of serum phenylalanine are cardiotoxic, leading to the development of coronary artery disease, increased heart failure hospitalizations, and even cardiac fibrosis (2)(3)(4)(5). However, the association between "acute" elevations in phenylalanine and an increased risk of mortality in critically ill patients admitted to the cardiac ICU (CICU) has only recently been studied.…”

“…The secondary measures presented by Stelfox et al (4) examine the prevalence of adverse events during the early ICU aftercare period with the premise that timely access to comprehensive handoff documentation could curtail preventable adverse events (e.g., falls, hospital-acquired infections, drug-related adverse events) (4, 5). The lack of significance attributed to the eDischarge tool adoption is not surprising, given that fall prevention, hospital-acquired infections, and medication safety each represent examples of matured patient safety priorities with multilevel multidisciplinary interventions in place in most, if not all, hospital settings.…”

“…The need for effective communication via handoff documentation for patient care transitions during acute hospitalization is indisputable (2, 3). Structured ICU discharge documentation strategies are maturing by leveraging features within EHRs to temper delayed and incomplete records (4, 7, 9). Attention to the ICU discharge transition handoff is particularly relevant and understudied despite persistent characterizations of higher rates of adverse events relative to other periods of hospitalization (1, 5).…”