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ICU-PAUSE
8 Plays2 years ago
Transitions of care during a patient’s hospitalization are points of vulnerability with a high potential for harm. In this episode, we will discuss transitions of care from the ICU to the wards. We will explore the ICU-PAUSE framework and how it can be implemented to improve this critical process of care delivery in the ICU. Our guest is Dr. Lekshmi Santhosh, a practicing pulmonary critical care physician at UCSF Health. She is an Associate Professor of Medicine in the Divisions of Pulmonary/Critical Care Medicine & Hospital Medicine at the University of California San Francisco. Dr. Santosh is one of the creators and leaders of the ICU-PAUSE initiative.
Additional Resources
American Thoracic Society (ATS) ICU-PAUSE initiative. https://www.thoracic.org/professionals/education/ats-icu-pause-initiative.php
Creating the ICU-PAUSE Tool for Intensive Care Unit-Ward Transitions. L Santosh et al. ATS Scholar 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9341494/
Characterizing ICU-ward handoffs at three academic medical centres: process and perceptions. L Santosh, et al. BMJQS 2018. https://pubmed.ncbi.nlm.nih.gov/30636201/
Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study. A Starmer, et al. J Hosp Med 2023. https://pubmed.ncbi.nlm.nih.gov/36326255/
Books Mentioned in this Episode
In Shock. By Rana Awdish: bit.ly/441b0Cx
Every Deep Drawn Breath. By Wes Ely: bit.ly/3Aqt4IC
Mom Milestones. By Grace Farris: bit.ly/3ArT06z
Dare to Lead. By Brene Brown: bit.ly/3n3N54O
Quiet. By Susan Cain: bit.ly/3HcuHxk
The Credibility Code (Speech Skills). By Cara Hale Alter: bit.ly/40ErQE8
Recommended
Transcript
Podcast Introduction
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now, your host, Dr. Sergio Zanotti.
ICU to Ward Transition Challenges
00:00:32
Speaker
Transitions of care from the ICU to another area of service in the hospital presents a point of vulnerability for patients and is fraught with potential danger.
00:00:42
Speaker
A concept referred by some as the voltage drop is a serious patient safety issue.
00:00:47
Speaker
In today's episode of the podcast, we will discuss transitions of care, specifically from the ICU to the wards, through the lens of the ICU PAUSE framework.
00:00:56
Speaker
Our guest is Dr. Lakshmi Santoush, a practicing pulmonary critical care physician at UCSF Health.
00:01:02
Speaker
She's an associate professor of medicine in the divisions of pulmonary critical care medicine and hospital medicine at the University of California, San Francisco.
00:01:10
Speaker
Clinically, she attends in the medical ICU, the neuro ICU, and the internal medicine teaching wards, and has a clinic at the pulmonary outpatient faculty practice at UCSF Pernasus.
00:01:20
Speaker
She's the founder and medical director of the Multidisciplinary Long COVID Post-ICU Optimal Clinic at UCSF Health.
00:01:28
Speaker
It's a true pleasure to have her today on the podcast.
Focus on ICU PAUSE Framework
00:01:30
Speaker
Lakshmi, welcome to Critical Matters.
00:01:33
Speaker
Thank you so much for having me.
00:01:34
Speaker
I'm really excited to chat about this today.
00:01:36
Speaker
And we were talking before we started recording about how transitions of care from the ICU to medical services that we both attended on is really a potential dangerous time, but also an area that has not received a lot of attention, does not have a lot of evidence-based information.
00:01:54
Speaker
and guidance.
00:01:56
Speaker
And yet it's something that happens multiple times every day in hospitals all over the country and the world.
00:02:02
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So definitely a topic that I'm very happy that you have tackled with the ICU pause and excited to talk and learn more about it with you today.
00:02:11
Speaker
Thanks so much.
00:02:12
Speaker
That's exactly right.
00:02:13
Speaker
I think that as you described, most of our ICU patients are going to experience this transition of care, hopefully, when they recover and get stepped down to a transitional care unit, to a step down unit, to the acute care unit, or even to home.
00:02:28
Speaker
And though there's a lot of
00:02:31
Speaker
supporting evidence in the world of handoffs and handovers and transitions of care about day to night transition, right?
00:02:39
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The famous I-PASS framework by Dr. Amy Starmer and colleagues initially published in the New England Journal.
00:02:46
Speaker
That is a classic framework I-PASS that we all know and use
00:02:50
Speaker
from day to night transition.
00:02:52
Speaker
But our ICU patients and the ICU to ward transition, even though it's kind of dangerous, our patients are vulnerable, they're going from one to one nursing, A-line, central line, to maybe four to one nursing or six to one nursing or more, you know, Q2 hour vital signs or Q4 hour vital signs or more.
00:03:10
Speaker
New doctors, new APPs, new nurses,
00:03:13
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They're transitioning these healthcare teams.
00:03:15
Speaker
And sometimes in this transition, there's also this diagnostic uncertainty, right?
00:03:20
Speaker
Our patient with septic shock, they got better, but we never grew out an organism.
00:03:24
Speaker
Or a patient with altered mental status, encephalopathy, they're less altered now, and their head CT was negative, and it's kind of a mystery of what caused it.
00:03:33
Speaker
And so for all those reasons, I believe that that ICU to ward transition is one that bears...
00:03:39
Speaker
that needs close attention from us and that we can do better in communicating to make those patients safer.
00:03:46
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Absolutely.
00:03:46
Speaker
And I think you really highlight a very important point, which is as patients move from the ICU, the level of monitoring, the level of support that they receive drops drastically.
00:04:00
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And I always think that there's three buckets of patients I'm worried about when I show up to the hospital.
00:04:05
Speaker
One is the sickest patients in my ICU.
00:04:08
Speaker
Two is the patients who just left the ICU, right?
00:04:11
Speaker
And three is the patients who should be in my ICU, but are not there yet.
00:04:14
Speaker
Right.
00:04:15
Speaker
But we don't know where they are.
00:04:16
Speaker
That's exactly right.
00:04:17
Speaker
That's exactly right.
00:04:19
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I think that the known unknowns, right?
00:04:22
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The people where we're not exactly sure what's going on, they're getting sicker and we don't know why, are the ones that give you the creepy crawly feeling the most.
00:04:32
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The ones who are already vented on pressers, you know a little bit what you're dealing with.
00:04:37
Speaker
but the ones who are deteriorating and you don't know why you have that diagnostic uncertainty or the ones that are deteriorating on the wards and about to come in, or as you mentioned, the ones that just left when you lie awake at night thinking, did I sign out everything?
00:04:52
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Did I do everything I could for that patient to prevent her readmission, to prevent ICU readmission?
00:04:57
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Those are the ones that keep you up at night.
00:04:59
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And hopefully our ICU pause framework helps communication around those sickest vulnerable patients.
00:05:05
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At that time where you might have that false reassurance, hey, they're off-pressors ready to go out, but actually they're still quite, quite sick.
Healthcare Equity and Standardization
00:05:13
Speaker
Now, before we dive into the Transitions of Care ICU to Ward, more specifically, one of the things that caught my eye when I was reading your work, Lakshmi, is that you've addressed already some of the patient safety issues, but you also mentioned in some of your publications healthcare equity issues, and that is something that
00:05:36
Speaker
a lot of us are talking about in multiple levels and COVID, I think, was a great illustrator of that problem.
00:05:42
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But I never thought about it in transitions of care.
00:05:44
Speaker
Could you explain that a little bit more?
00:05:47
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Absolutely.
00:05:49
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I think that this is such a key concept that we have a lot of literature that implicit bias, right, which is which is due to a lot of factors in our society, including structural racism,
00:06:03
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Implicit bias can creep into our documentation, into our notes, into the electronic health record when we have unstandardized communication.
00:06:12
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We've all seen in the chart verbiage like, you know, quote, difficult patient, difficult family, bounce back, frequent flying, all of those terms that are sort of a cognitive shorthand.
00:06:26
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but they actually are not patient-centered language.
00:06:28
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They're not patient-first language.
00:06:31
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And I wonder, I suspect, I hypothesize, and a lot of evidence shows that our patients of color, our patients who've had histories of structural racism and discrimination are, for example, in a recent JAMA study, more likely to have that behavioral alert flag in the EHR.
00:06:48
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Patients of color are much more likely to have flags talking about their, quote, behavior.
00:06:53
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And so one concept that we know is that standardization, standardized communication, doing things the same way every single time, right?
00:07:02
Speaker
The whole philosophy of the checklist, that not only helps with patient safety, but perhaps could also help with equity because you're following a structured template, you're following a structured checklist, and that leaves less of that room for that editorializing about the quote difficult family.
00:07:20
Speaker
or factors that might actually contain implicit bias and not patient-versed language.
00:07:25
Speaker
So have we proved it yet?
00:07:27
Speaker
No, but I hope that, and further aims in our study, hope to see whether using structured language, standardized templates, decrease the amount of that language that has implicit bias or language that's not very patient-centered.
00:07:43
Speaker
That is a great point.
00:07:44
Speaker
I think it's definitely something that I hope other people pay attention to.
00:07:48
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It was not something that was on my radar in this context, for sure.
00:07:52
Speaker
And I can see exactly what you're saying in terms of sometimes we read things that are atrocious and sometimes they're just funny.
00:07:59
Speaker
But again, by standardizing a process and making sure that what we are actually documenting is
00:08:07
Speaker
is helpful in making care better and is always the same, I think we can move the needle in that area as well.
00:08:16
Speaker
That is a hope.
00:08:16
Speaker
Thanks so much for your reflections.
00:08:19
Speaker
I mean, I think it's, this is when we talk about the triple aim of quality, safety, value, and patient care, increasingly and far too late, we are finally recognizing that equitable care for all, particularly equitable diagnosis for all, equitable treatment for all, is another key foundation of safe patient care.
00:08:40
Speaker
Absolutely.
00:08:41
Speaker
Absolutely.
00:08:42
Speaker
Well, let's go into a little bit more into the transitions of care from the ICU to the ward.
00:08:47
Speaker
As we were initiating the conversation, you did mention why this particular transition of care from the ICU to a medical or general surgical ward is a high-risk process or a high-risk position related to how we are moving from high-intensity monitoring to low-intensity monitoring, one-on-one nursing or one-to-two nursing to a higher ratio.
00:09:11
Speaker
There's also many patients that we are very preoccupied in the ICU with saving and making sure they get a ventilator and they get this and they get that, but we really don't know what caused all this sometimes, right?
00:09:23
Speaker
So diagnostic uncertainty is something that obviously sometimes travels with these patients.
00:09:28
Speaker
But as we explore this a little bit more, Lakshmi, could you tell me a little
Innovations in Transition Processes
00:09:32
Speaker
bit about the current state of ICU to ward transitions?
00:09:35
Speaker
I know that you have looked at this in some papers, but what's out there in the literature?
00:09:41
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It's a great question.
00:09:42
Speaker
So the interesting thing is that the ICU to ward transition, though, as you said, most of our ICU patients across the country are experiencing at least one of these transitions.
00:09:53
Speaker
It is so unstandardized.
00:09:54
Speaker
It is so heterogeneous.
00:09:56
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It is so variable between institutions and even within institutions.
00:10:01
Speaker
So your SICU might have a totally different process than your MICU.
00:10:05
Speaker
And definitely different institutions within the same city or different states, academic, non-academic,
00:10:11
Speaker
even though all the patients are having this similar progression of care when they graduate from intensive care to go to a step-down unit or the ward, this process is totally different.
00:10:23
Speaker
One of our papers that we had looked at that was published in the BMJ Quality and Safety a couple of years ago with my colleagues, Dr. Pat Lyons, Dr. JC Rojas, Dr. Vinnie Arora and others, wonderful team.
00:10:38
Speaker
really looked at actually physically drawing out what we call process maps to say let us actually identify and document the flow of how does a patient travel from the ic to the ward and how does the information travel right is there a bedside nurse talking to a charge nurse talking to another bedside nurse and what about physicians is there a flow physician is there a triage fellow is there an app who's in charge of flow
00:11:04
Speaker
And every single institution had a totally different process map for essentially the same concept, which is really interesting.
00:11:12
Speaker
The other thing that we found from that study in BMJ quality and safety was that nurses had much more structure to their communication.
00:11:21
Speaker
And I think, you know, we see that in a lot of contexts in healthcare where nurses have a lot of kind of protocolized checklists, standard work, standard ways of doing healthcare.
00:11:33
Speaker
And,
00:11:35
Speaker
physicians and advanced practice providers, we have somewhat resisted that standardization and that checklist to find a little bit more that the nursing world is a little bit ahead of us.
00:11:47
Speaker
And so we found that nursing communication was in general much more standard across institutions that usually pretty much always, if a patient's going out of the ICU, the ICU nurse is talking directly to the ward nurse who's gonna be accepting that patient.
00:12:02
Speaker
Or if your patient on the ward is getting really sick and going to the ICU, the ICU nurse, the ward nurse is talking to the ICU nurse.
00:12:09
Speaker
Whereas for physicians or advanced practice practitioners, it was a totally different web of game of telephone.
00:12:17
Speaker
You know, sometimes there were, you had to talk to bed control, you talk to a triage fellow, triage fellow talked to the ICU team, but not the ward team.
00:12:25
Speaker
And there was, like you said, this huge risk of that voltage drop.
00:12:29
Speaker
Yeah.
00:12:30
Speaker
And so when we thought about the ICU to ward transition and how to improve such a disparate, heterogeneous, variable process across different institutions, we really turned to a methodology of human-centered design or design thinking.
00:12:46
Speaker
And the whole concept of human-centered design or design thinking is
00:12:50
Speaker
how might we make this process, this flawed system, this, this imperfect process better, that's actually targeting the needs of the actual users, the actual clinicians, rather than designing something from the top down, a protocol to say, Hey, you do this, but how might we improve this process with the true clinical user at the heart of the matter?
00:13:12
Speaker
Awesome.
00:13:13
Speaker
So before we jump into, into that initiative itself, I did have a question and
00:13:20
Speaker
You did mention IPAS, and I think it's worth reemphasizing that this is different than IPAS, because I did mention to one of my colleagues, have you read about ICU POS?
00:13:31
Speaker
And he said, is this like IPAS?
00:13:34
Speaker
And really, they're both structures that are intended to improve communication, but they're really geared at different areas of our practice, right?
00:13:44
Speaker
That's exactly right.
00:13:45
Speaker
I have tremendous admiration, respect for iPass.
00:13:50
Speaker
And as a resident, I actually was really fortunate to tag along with one of my mentors in patient safety to a meeting of the iPass study group when they were visiting San Francisco for a PEDS meeting, which was really exciting and inspirational and innovative and got to meet
00:14:06
Speaker
some of the leaders and the original authors on the IPAS paper.
00:14:10
Speaker
I think IPAS has transformed the way we think about patient safety, transitions of care, and handoffs, absolutely.
00:14:18
Speaker
At the same time,
00:14:20
Speaker
I think that we know intensivists, intensive care unit clinicians know that it's quite difficult to boil down a complex evolving ICU patient into the IPAS framework to apply that to this transition.
00:14:37
Speaker
And so first, I definitely was experimenting with that.
00:14:40
Speaker
Can we add things to the iPass to make it not just a day-to-night and night-to-day tool, but actually to make it an ICU-to-ward tool?
00:14:50
Speaker
And I was finding in talking to users and listening to users who are clinicians, both hospitalists and intensivists, residents on both sides, et cetera, that that framework didn't neatly translate.
00:15:03
Speaker
It didn't neatly transfer.
00:15:05
Speaker
It wasn't
00:15:07
Speaker
100% applicable.
00:15:09
Speaker
And so this concept of ICU pause was really born by thinking about, again, how might we use some of those brilliant foundational principles of the IPAS work and how might we apply it?
Growth of ICU PAUSE Initiative
00:15:23
Speaker
So I definitely think that ICU pause is, like you said, like IPAS, a structural framework of
00:15:31
Speaker
to enable improved communication and patient safety to create, as they call it, a shared mental model, right?
00:15:38
Speaker
If everyone expects this type of communication in this format, just like you expect an ICU presentation, right?
00:15:45
Speaker
Perhaps you're a systems-based kind of guy or an organ-based kind of guy.
00:15:49
Speaker
I don't know.
00:15:49
Speaker
I haven't met with you in the ICU.
00:15:51
Speaker
But I think that when you tell your learners or you tell your APPs on day one,
00:15:56
Speaker
I like my plans organ system based or I like my plans problem based in the ICU.
00:16:01
Speaker
I think similar to that, if we all have a shared mental model of how we want this ICU to ward transition to look, both on the hospital medicine or surgical side and on the intensive care side, once we have that shared mental model, once we communicate in a structured way, you're really enabling safer patient care in a structured way and less things fall through the cracks.
00:16:21
Speaker
There is less of that voltage drop.
00:16:23
Speaker
Awesome.
00:16:24
Speaker
Let's talk about the ICU Paws Initiative.
00:16:27
Speaker
What is it?
00:16:30
Speaker
So this is so cool because it started as a fellowship passion project when I was a fellow.
00:16:37
Speaker
This was kind of one of my fellowship research projects that I was passionate about.
00:16:42
Speaker
And by a series of coincidences, you know, a faculty hospitalist mentor connected me with
00:16:51
Speaker
Dr. Vinny Arora, who said, you know, I have some residents who are interested in looking at this.
00:16:56
Speaker
And so myself, Dr. Lyons, Dr. Rojas, who are now all intensivists in different parts of the country at UCSF, OHSU, and Rush, we said, hey, we're kind of passionate about looking at this ICU to war transition and how to improve it.
00:17:11
Speaker
We're all at different institutions.
00:17:13
Speaker
How could we work together to improve this process?
00:17:15
Speaker
So it started off as a passion project where three fellows across the country who had never met before us in the pre-pandemic era wanted to work together just with this common shared passion about transitions of care from the ICU to the ward.
00:17:30
Speaker
And now in the last year or two, it's really taken on a life of its own because the American Thoracic Society, ATS, our professional society, really put forward this ICU PAUSE project
00:17:44
Speaker
to a national competitive grant by the Council of Medical Subspecialty Societies, CMSS, and the Moore Foundation.
00:17:52
Speaker
that really focused on diagnostic excellence.
00:17:54
Speaker
And so now ATS has really taken on the mission of ICU PAUSE and is saying that one of their core aims is to improve the ICU to ward transition really across the country.
00:18:07
Speaker
So it's really exciting.
00:18:08
Speaker
So what have we done now with the ICU PAUSE?
00:18:11
Speaker
So as I mentioned, we worked with residents and users of this ICU to ward transition process across multiple sites
00:18:20
Speaker
to put together this ICU PAUSE structured communication framework that we published at ATS Scholar last year, where each letter of ICU PAUSE actually stands for a specific item
00:18:32
Speaker
of what we need to know.
00:18:34
Speaker
What do clinicians need to know when they're communicating about a patient transferring out?
00:18:38
Speaker
And so using that structured framework for a written handoff embedded in the electronic health record, using this as basically a dot phrase or a note template every single time a patient goes out, is now something that we're rolling out across the country.
00:18:53
Speaker
So this started initially at Washington University of St.
00:18:57
Speaker
Louis,
00:18:57
Speaker
They were our pilot.
00:18:59
Speaker
They launched it back in September of 2019.
00:19:03
Speaker
And now, you know, as of today, April, 2023, we have over 30 sites
00:19:08
Speaker
across the country that are interested in implementing this at their sites.
00:19:13
Speaker
Other specialties, OB, the ER, even veterinary medicine, a colleague in veterinary medicine have approached us to say, could we modify this tool for our context as well?
00:19:23
Speaker
And so this concept of using a structured framework to communicate in a standardized way about patients transitioning from the ICU to the ward is really taking off nationwide.
00:19:35
Speaker
If you're listening in and you're thinking, that sounds pretty cool.
00:19:38
Speaker
How do I get this ICU pause to work at my institution?
00:19:41
Speaker
The ATS has a really cool website that they've launched.
00:19:45
Speaker
If you just go to your favorite search engine of choice and just put in ATS ICU pause,
00:19:51
Speaker
you'll get taken to a website that really talks to you about how do you get involved, who do you contact, we'll set up an informational interview, we have things like flyers, handouts, the dot phrase itself that you can embed into your EHR, a video to share with your faculty, with your clinical leads to help you implement this at your site, all for the low price of free 99.
00:20:17
Speaker
So, you know, at no cost to you.
00:20:19
Speaker
And so again, this is,
00:20:21
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The ATS really saying that we're excited about this too.
00:20:24
Speaker
We're excited about improving transitions of care.
00:20:26
Speaker
We're excited about talking about a diagnostic pause and diagnostic uncertainty and really discussing what we think the diagnosis is.
00:20:34
Speaker
And we're really thrilled and honored that this work is getting implemented and rolled out nationally.
00:20:43
Speaker
Absolutely.
00:20:44
Speaker
I agree.
00:20:44
Speaker
And just a couple of comments, and then I want to hear a little bit more about each component.
00:20:50
Speaker
But first, I understand that the Betty Moore Foundation is a foundation that has been really interested in critical care.
00:20:59
Speaker
Do I believe to a family member?
00:21:01
Speaker
These are the, I think, where the owners of Intel are one of those big soft companies.
00:21:05
Speaker
software companies who had septic shock and they've been really generous with critical care initiatives so it's great that you have now funding and through a grant to really scale this because that's that's the key right and um one of the things like me that i always try to remind the younger generation or two things i try to remind people is that first innovation is not always about technology
00:21:30
Speaker
It's just about finding a better way to do things that are important and that we do every day.
00:21:35
Speaker
And having a framework, a mental model that can be replicated and scaled that will improve transitions of care is for me like a perfect example of great innovation where you do it on paper or on the EMR, right?
00:21:47
Speaker
It's about the mental model that we'll talk about.
00:21:50
Speaker
And the
00:21:51
Speaker
That is so true.
00:21:52
Speaker
That is so true.
00:21:53
Speaker
Your reflection is so bright.
00:21:54
Speaker
I mean, first, just a brief moment, a brief aside to honor Gordon Moore, who recently passed away just a few weeks ago, who is a huge philanthropist, as you mentioned, co-founder of Intel.
00:22:11
Speaker
And the Gordon and Betty Moore Foundation has been instrumental in the field of healthcare, particularly in the field of diagnosis.
00:22:19
Speaker
So after his
00:22:20
Speaker
you know, incredible innovations and revolutionizing the field of, you know, of Intel and engineering, he really turned his,
00:22:30
Speaker
last couple of decades to thinking about making a dent in the philanthropic world in healthcare quality and specifically in diagnostic excellence among other things.
00:22:41
Speaker
And so what a generous person.
00:22:43
Speaker
The Moore Foundation has funded a lot of really innovative healthcare projects, like you mentioned, due to personal experiences.
00:22:49
Speaker
And I'm really indebted to the Moore Foundation for this funding, along with CMSS, Council of Medical Specialty Societies, and my former funding from the National Academy of Medicine as a diagnostic excellence scholar.
00:23:00
Speaker
Your second point is so important, which is that we often think when we're in the trenches, if we just designed a tech fix for this, it would all be better.
00:23:12
Speaker
But actually, culture change, changing communication, changing practice patterns are sometimes actually more difficult to change than technology.
00:23:22
Speaker
And yet, um,
00:23:24
Speaker
more cost effective.
00:23:25
Speaker
And so sometimes when you think about how might we improve this process and you really map out the components, there are some aspects for which we definitely need technology.
00:23:36
Speaker
And interestingly and paradoxically, there's some aspects where the lowest tech fix is an important one and it's actually a cultural change or communication change, which sometimes is even harder than technology to change.
00:23:50
Speaker
Absolutely.
00:23:51
Speaker
So let's take an ICU pause, deep dive.
Framework Elements Explained
00:23:54
Speaker
And why don't you just walk me through each one of obviously these letters represents an area that you need to address in this transfer of care note as you send somebody out of the ICU.
00:24:09
Speaker
Absolutely.
00:24:10
Speaker
So diving in.
00:24:11
Speaker
So each letter of ICU pause, it is a mnemonic and it shows up as a dot phrase so you don't have to memorize it.
00:24:17
Speaker
It'll show up in your EHR when you use this template.
00:24:21
Speaker
So I is kind of your chief complaint, chief concern.
00:24:24
Speaker
It's your ICU admission reason.
00:24:26
Speaker
So that's where you say if they were admitted for hypoxia, encephalopathy, that's right up front, the ICU admission reason.
00:24:33
Speaker
Your C is for code status, DPOA, designated power of attorney information, goals of care.
00:24:40
Speaker
And the important thing is that a lot of times, many EHRs like Epic, Cerner, the VA, they'll have your code status on a banner in a high value location in the EHR, readily located where it says full code, DNR, DNI.
00:24:55
Speaker
But the C in code status, we really wanted to put that up front because people felt like that was really important
00:25:01
Speaker
Just like the nurses do when they're communicating to include that code status really early in the conversation, rather than saving it for the end where we traditionally put it in the plan.
00:25:12
Speaker
And not only the code status, but also putting in the designated power of attorney or the surrogate's information up front.
00:25:19
Speaker
So C is for code status, but it also includes, you know, you write C code status, you write full code, patient's daughter, Mary, is the power of attorney, and this is her phone number.
00:25:30
Speaker
Because oftentimes that stuff is really buried.
00:25:32
Speaker
You have to look in multiple places in the chart.
00:25:34
Speaker
So we wanted to put that phone number, family contact information, code status right up front.
00:25:39
Speaker
U is this really interesting thing.
00:25:41
Speaker
U stands for uncertainty measure or diagnostic pause.
00:25:46
Speaker
And what that refers to is really that concept of when we explicitly say, what are we thinking is the most likely diagnosis or what is the working diagnosis at the time of transfer and how certain or confident are we in that diagnosis?
00:26:01
Speaker
In some cases, it's going to be easy, right?
00:26:03
Speaker
The working diagnosis at the time of transfer was COVID pneumonia.
00:26:07
Speaker
Straightforward, we diagnose them with COVID, they're better.
00:26:10
Speaker
But sometimes it's those situations where there's uncertainty diagnostically, as we mentioned, that septic shock, but we never got a bug, that altered mental status, but we don't know why.
00:26:20
Speaker
And so this is an opportunity, this diagnostic pause is an opportunity for you to say, my working diagnosis is this, and, you know,
00:26:29
Speaker
This is a slam dunk open and shut case of COVID pneumonia or MRSA pneumonia or Pseudomonas UTI.
00:26:36
Speaker
Or this is a complicated case.
00:26:38
Speaker
You know, this is a case where there's a little bit of uncertainty.
00:26:41
Speaker
And research shows that explicitly discussing diagnostic uncertainty or embedding a diagnostic pause can actually reduce the risk of diagnostic errors.
00:26:51
Speaker
So that's the U for uncertainty.
00:26:53
Speaker
The P is for pending tests at the time of transfer.
00:26:56
Speaker
So our prior work really showed that pending tests, right?
00:26:59
Speaker
That cytology that's still cooking, the ANA, ANCA's that are still cooking in the lab.
00:27:04
Speaker
Prior tests are often lost either at hospital discharge or between other care transitions like ICU to ward.
00:27:11
Speaker
And often the new team doesn't really know what's cooking and pending to follow up on.
00:27:16
Speaker
So you're calling out explicitly P for pending tests.
00:27:19
Speaker
A is for the active consultants.
00:27:21
Speaker
Who's still following?
00:27:22
Speaker
So is ID following?
00:27:24
Speaker
Is PT, OT following?
00:27:26
Speaker
What about wound care?
00:27:27
Speaker
It's just a chance for you to say, hey, hospitalist or hey, surgeon, you know, ID, PT, and OT still need to follow this patient.
00:27:35
Speaker
So everyone's on the same page, shared mental model, A for active consultants.
00:27:39
Speaker
The second U is for unprescribing, quote.
00:27:42
Speaker
And what that means is it's basically just a way of calling out the high-risk medications.
00:27:48
Speaker
Um,
00:27:49
Speaker
Many of us have EHRs where it will import a giant med list that is often still contains outdated things.
00:27:56
Speaker
It still might say norepinephrine.
00:27:58
Speaker
It still might say purple fall.
00:27:59
Speaker
It might auto import like 10 saline flushes for no clear reason.
00:28:03
Speaker
We've all seen that before.
00:28:04
Speaker
Right.
00:28:05
Speaker
And your eyes, the listener, right, the hospitalist, the resident or the APP, your eyes glaze over when you see that giant med list and you think, ah, I'll figure it out later what they really need.
00:28:15
Speaker
This U is really about calling out the high-risk meds to say, hey, we actually held the home beta blocker because they were septic, but you should think about restarting it.
00:28:25
Speaker
We held the home anticoag because we were there bleeding, but you should restart that.
00:28:31
Speaker
or we started new antibiotics and we anticipate they're gonna end in 10 days.
00:28:36
Speaker
And so you can, anyone can look up that giant med list, but this you just means it's an opportunity for you to call out those high-risk medications.
00:28:44
Speaker
And we call that unprescribing for you.
00:28:47
Speaker
The S is the traditional summary of the problems and to-dos.
00:28:51
Speaker
So the S is where you usually see in a transfer note or a discharge summary, you know, the problem-based to-dos.
00:28:57
Speaker
So problem number one,
00:29:00
Speaker
Acute kidney injury, they were on dialysis, they got better.
00:29:03
Speaker
The main to-do for you is to follow up, you know, follow up the daily BMP.
00:29:09
Speaker
Or, you know, the new problem is respiratory failure, hypoxemic respiratory failure now improved.
00:29:17
Speaker
CTPE was negative.
00:29:18
Speaker
The main to-do for you to do is to follow up an outpatient CT in six months because there was a nodule that was C. So that's your S for summary and to-do's.
00:29:28
Speaker
And E is your pertinent physical exam at the time of transfer.
00:29:33
Speaker
So it's again, calling out your pertinent physical exam to say, hey, they're leaving with this line in place.
00:29:38
Speaker
They still have a pick line in place.
00:29:41
Speaker
They still have a Foley in place.
00:29:43
Speaker
This was their mental status at the time of transfer, which is still not perfect.
00:29:47
Speaker
This is their abdominal exam at the time of transfer.
00:29:49
Speaker
So pertinent physical exam with calling out the important things.
00:29:53
Speaker
And different health systems, depending on your health system, might use this tool differently.
00:29:58
Speaker
Because as you see, it contains billable elements.
00:30:03
Speaker
It has medical decision making.
00:30:05
Speaker
It has to-dos.
00:30:06
Speaker
It has a pertinent physical exam.
00:30:08
Speaker
You're analyzing things.
00:30:09
Speaker
And so many of us in critical care, we're using time-based billing anyways.
00:30:13
Speaker
And so this is a billable note if you want to use this as your progress note for the day.
00:30:17
Speaker
Depending on your context, some people might be using this as a
00:30:21
Speaker
progress note and billing directly on that.
00:30:24
Speaker
Some people might be using this as a separate standalone transfer note.
00:30:28
Speaker
Either way it works.
00:30:31
Speaker
And so just to summarize briefly, taking it from the top for ICPause, I admission reason, C code status, U uncertainty or diagnostic pause,
00:30:40
Speaker
P, pending tests, A, active consults, U, unprescribing, which basically means calling out the meds, high risk.
00:30:47
Speaker
S is your summary, and E is your pertinent physical exam.
00:30:50
Speaker
And that is what this letter stands for.
00:30:53
Speaker
And again, if that's a mouthful, if it's hard to remember, that's why we have it as a visual embedded tool in your EHR.
00:30:59
Speaker
And you can go to the ATS website or to our paper at ATS Scholar to read more about it.
00:31:05
Speaker
And we'll definitely include all the links.
00:31:07
Speaker
I was looking at the ATS link.
00:31:10
Speaker
I was preparing for the podcast and you have videos.
00:31:14
Speaker
You can download the EMR dot phrase.
00:31:20
Speaker
There's examples.
00:31:21
Speaker
I mean, there's a lot of great stuff that I think would make it.
00:31:24
Speaker
very intuitive for people to try to take that and start doing it.
00:31:29
Speaker
I believe that the heavy lifting is changing the culture, like you said.
00:31:33
Speaker
But clearly, there's a lot of elements that are very, very powerful here.
00:31:38
Speaker
I think that if you always did it the same way, you would get better and better at it.
00:31:41
Speaker
And I can also see how in many practices,
00:31:46
Speaker
You call somebody who's the admitting hospitals, maybe they send it to another team and you don't always have that opportunity to have that one-on-one real-time conversation.
00:31:55
Speaker
So I believe that by having a structure that can almost work like a flipped classroom, right?
00:32:01
Speaker
If I were to read this from a patient, even though I had questions, if I were to call you after having all this information, my questions would probably be much more directed and much more valuable in terms of really understanding what needs to be done for that patient.
00:32:14
Speaker
And ultimately,
00:32:15
Speaker
being truly patient center right and it's about the patient and and nothing more more than that so i really think it it's fascinating you did mention the emr and basically that's just a dot phrase that you have at the at the resources that you can just copy and paste into one of your own notes and any of the emrs and it kind of works is that how how we should apply it
00:32:36
Speaker
That's exactly right.
00:32:37
Speaker
So we, as you mentioned, have kind of posted this full implementation toolkit, courtesy of the ATS, CMSS, and the Moore Foundation have created this implementation toolkit that you can, you know, use all these ingredients to put into your own institution.
00:32:54
Speaker
And so the dot phrase is, of course, kind of an easy, seamless way to do that.
00:32:59
Speaker
And some institutions, they don't like that.
00:33:01
Speaker
They don't like a dot phrase that you plop in.
00:33:03
Speaker
They'd prefer that you go through the standard process to make a structured note template and that you provide the dot phrase so they program it to a note template.
00:33:11
Speaker
That works great too.
00:33:12
Speaker
And so you can really go about it either way.
00:33:15
Speaker
And again,
00:33:16
Speaker
I appreciate your mentioning that it seems pretty user-friendly and easy to use.
00:33:21
Speaker
And you're exactly right that our goal was to make implementation as low of a lift as possible and give you all these toolkit materials, like the flyers, the posters, the video, the physical dot phrase, so that all you have to do, which is easier said than done, is get buy-in from your community, your hospitals, to say, hey, if you're interested in this, I have it ready to go on a platter to implement
00:33:44
Speaker
at our institutions.
00:33:45
Speaker
I think one of the cool things that I've seen that I've been pleasantly surprised and heartened to see when I do post implementation interviews is how it hasn't been a big lift for medical centers.
00:33:58
Speaker
Again,
00:33:59
Speaker
We're not saying we need you to do this whole new way of preparing for central lines and grab new equipment and new workflows and new protocols.
00:34:08
Speaker
It's really about changing the way we communicate, changing the way to document and culture change around that.
00:34:14
Speaker
But it's not, you know, it doesn't cost much.
00:34:18
Speaker
It standardizes the care, improves the care.
00:34:20
Speaker
And we've received feedback from the sites that have already implemented that.
00:34:24
Speaker
People are spending less time doing exactly as you said, they're doing less rework.
00:34:29
Speaker
Previously, when you got that ICU transfer, your face would fall when you say, oh, I'm getting an ICU transfer as a hospitalist.
00:34:36
Speaker
Now you have a one note place to look where all the key items are there.
00:34:42
Speaker
So there's a lot less rework that has to be done.
00:34:44
Speaker
The other thing that people appreciate is the diagnostic pause.
00:34:48
Speaker
As you know, there's kind of this, when we talk about ICU presentations or even ward presentations, there's almost a gradual slow death that we're witnessing of the assessment sentence, right?
00:35:00
Speaker
Oftentimes trainees or APPs or faculty will launch straight into the to-dos, but not actually say the assessment sentence of what do I think is actually going on with this patient?
00:35:11
Speaker
And so that you, the uncertainty, the diagnostic pause is a point for us to take a deep breath and say, hey,
00:35:17
Speaker
These are the to-dos, and I think the main process going on here is COVID pneumonia.
00:35:23
Speaker
I think the main process going on here is altered mental status that I think is due to delirium, but I'm not quite sure, and actually kind of re-anchoring us back in that valuable assessment sentence to provide safer, more effective patient care.
00:35:39
Speaker
So it's a really cool concept that's a relatively low lift,
00:35:44
Speaker
that the sites that have implemented have found it really useful, pragmatic, and not a lot of extra work.
Encouragement and Implementation Tips
00:35:50
Speaker
You talked about implicit bias at the beginning, and I think another bias that is pervasive in medicine is anchoring bias.
00:35:57
Speaker
And I think this is a great tool to unanchor ourselves from maybe the wrong diagnosis, right?
00:36:02
Speaker
I mean, whatever somebody labels a patient in the ED used to stick with that patient until the day they leave the hospital.
00:36:08
Speaker
And I think that pausing and reflecting is something we should be doing not only with our patients, but probably more often with our own lives.
00:36:16
Speaker
So I think it's a great tool.
00:36:17
Speaker
I love it.
00:36:17
Speaker
Yep.
00:36:18
Speaker
Thank you, that's exactly right.
00:36:20
Speaker
I think anchoring bias is one of the most common cognitive biases that affect care transitions, right?
00:36:27
Speaker
Whether it's ED to wards or ED to ICU, as you mentioned, ICU to ward, and even inpatient to outpatient.
00:36:34
Speaker
So taking that moment for a diagnostic pause at any of those transitions is really valuable.
00:36:41
Speaker
We will have a piece coming out shortly with the AHRQ that really talks about diagnosis at all these care transitions.
00:36:50
Speaker
But of course, being an intensivist and hospitalist, the ICU to ward transition is my passion.
00:36:57
Speaker
I think Herb Spencer was the one who said that the aim of education is not knowledge by action.
00:37:03
Speaker
So let's talk about a call to action for our listeners in terms of improving the transitions of care.
00:37:08
Speaker
And you did mention a lot of these things again, but if I'm an intensivist, a physician, an APP in a community hospital, and I want to improve how we send patients out of the ICU, what would you recommend?
00:37:22
Speaker
This is a great question.
00:37:24
Speaker
And I should have said earlier, you know, I'm a clinician.
00:37:27
Speaker
I'm not a big clinician.
00:37:29
Speaker
R01 grant funded research.
00:37:31
Speaker
I'm a clinician with a passion.
00:37:33
Speaker
I'm an educator.
00:37:35
Speaker
And this is really a passion project.
00:37:37
Speaker
I really believe that if you, like me, felt bothered that, ah, this process is suboptimal, we could be doing this better.
00:37:46
Speaker
I worry about my patients that I've sent out and could I have done it better?
00:37:48
Speaker
Could I have prevented ICU readmissions?
00:37:51
Speaker
I might ask you first to think about, A, what is my current process at my institution?
00:37:57
Speaker
We made that process map in our first paper, looking at the three different institutions process maps.
00:38:03
Speaker
And it was eye opening just to see the, to localize the legion, to see where are those opportunities for the voltage drop.
00:38:11
Speaker
So I think first things first is think about what is the current process at your institution.
00:38:18
Speaker
The second thing to do if you want to make a change, if you want to do culture change, it seems intimidating.
00:38:24
Speaker
If you're, you know, on the boots on the ground, boots on the ground clinician who wants to change this process is thinking about getting other team members, getting other stakeholders who would share your passion.
00:38:36
Speaker
I think aligning this mission with existing incentives or quality improvement projects that your institution is doing is really helpful.
00:38:46
Speaker
After ATS put out this call for ICU pause, a number of institutions approached us saying,
00:38:52
Speaker
We want to implement because we notice that we're having an issue with ICU readmissions, or we notice that we're having an issue with, you know, hospitalists complaining that their sign out is not good, or we notice that our documentation isn't bare and it's essentially useless because people are cutting and pasting for days.
00:39:10
Speaker
So find the thorn in your side, the thing that bothers you most, and the thing that you think will resonate with the rest of your team and say, hey, hey, team, hey, y'all.
00:39:21
Speaker
You know, we've been talking about how documentation, these ICU transfer notes are so pointless because it's basically a copy forward of the progress net.
00:39:29
Speaker
Or we've been talking about our ICU readmissions.
00:39:31
Speaker
We've been talking about how our hospitalist medicine service is very dissatisfied with our transfers.
00:39:36
Speaker
Like you mentioned, we've been talking about how many times there's multiple handoffs and you don't even know who to call.
00:39:43
Speaker
You don't know who's accepting the patient because the next day it might be a totally brand new team than the one you signed out to.
00:39:48
Speaker
So try to align your interest with existing priorities or existing pain points.
00:39:53
Speaker
And then, you know, point to resources like the ATS ICU pause to say, hey, if we want to make a change, this implementation toolkit is ready to go.
00:40:03
Speaker
It's nationally used.
00:40:04
Speaker
It's standardized.
00:40:05
Speaker
It's all there.
00:40:07
Speaker
And it's a relatively low lift, low cost, and lots of sites are doing it.
00:40:12
Speaker
We also will have an in-person meetup at ATS for those of you who are going to ATS.
00:40:18
Speaker
So ATS is hosting an ICU pause sort of
00:40:23
Speaker
Ask Me Anything session on the Monday, May 22nd at 1030 a.m.
00:40:27
Speaker
in D.C.
00:40:28
Speaker
as well.
00:40:29
Speaker
And all the sites are going to get together.
00:40:31
Speaker
People who are interested should come by.
00:40:33
Speaker
There'll be some free swag about the ATS ICU pause.
00:40:38
Speaker
And so it's just an opportunity to get to meet people who've already implemented or who are in the implementation journey.
00:40:43
Speaker
So it's really exciting times.
00:40:45
Speaker
Perfect.
00:40:46
Speaker
So Lakshmi, thank you so much for sharing this very important initiative and your work.
00:40:52
Speaker
We'd like to close the podcast with a couple of questions that are unrelated to the clinical topic.
00:40:57
Speaker
Would that be okay?
00:40:59
Speaker
I love it.
Influences and Personal Connection
00:41:00
Speaker
I mean, we are more than just our jobs.
00:41:03
Speaker
And I think that's really important that we discuss kind of our whole our whole lives.
00:41:07
Speaker
Absolutely.
00:41:08
Speaker
So the first question relates to books.
00:41:11
Speaker
What book or books have influenced you the most or what books have you gifted to others to others more often?
00:41:20
Speaker
I love this question so much.
00:41:22
Speaker
It's almost like you read my mind that I love to, I love to give giving is kind of one of my love language, love languages.
00:41:30
Speaker
And I love to give gifts and books are one of the best gifts that you can give people.
00:41:35
Speaker
I think that there's a couple of books that I've seen in my rotation that I give time and time again to my ICU community, to trainees, especially I am a frequent gift giver of two of my favorite, um,
00:41:50
Speaker
ICU intensive authors books, which is In Shock by Dr. Rana Oddish and Every Deep Drawn Breath by Dr. Wes Ely.
00:41:59
Speaker
Both of these books, I feel like are just mandatory reading for anyone who practices intensive care medicine,
00:42:06
Speaker
Whether you're a practicing clinician, a trainee, or anyone in between, these books changed my life.
00:42:13
Speaker
They changed how I practice critical care.
00:42:15
Speaker
And the people who wrote them, Dr. Rana Adish, Dr. Wes Ely, are just the best humans and beautiful writers and have such important stories to tell.
00:42:25
Speaker
And so I've given those books out a lot to friends and colleagues.
00:42:30
Speaker
Other books that I frequently gifted, so there's this new book, newish book out called Mom Milestones by Dr. Grace Ferris.
00:42:39
Speaker
And she basically is a really talented writer and artist.
00:42:45
Speaker
And the whole book is essentially a graphic novel or a comic talking about what does it mean to be a mom in medicine or be a mom in general in these times.
00:42:55
Speaker
And it's a book that will make you laugh, make you cry and make you feel seen.
00:42:59
Speaker
for any moms in medicine, especially.
00:43:02
Speaker
I'm a huge fan of also Brene Brown's book, Dare to Lead, just a classic leadership book, a book about thinking, a book about vulnerability, a book about how we can be better leaders.
00:43:15
Speaker
And then I also love...
00:43:18
Speaker
for many people that I work with, the book Quiet, which is a book about the power of introverts in a loud extroverted world.
00:43:27
Speaker
And I will say I'm not an introvert, but I'm married to one and I learned a lot about introverts in
00:43:33
Speaker
in reading that book and I give that book out a lot.
00:43:36
Speaker
And then the last book I'd say I recommend is actually really interesting.
00:43:40
Speaker
It's called Speech Skills by Kara Alter, who's kind of a leadership coach or public speaking coach who gave a class at UCSF once and it just blew my mind of how we can all learn how to communicate more effectively.
00:43:54
Speaker
So I give that book out a lot as well.
00:43:56
Speaker
So I love to give books as gifts and there's so many
00:43:59
Speaker
There's even more, you know, we didn't even get into the fiction category.
00:44:02
Speaker
So more for another day.
00:44:03
Speaker
Next time.
00:44:04
Speaker
And I think that obviously I asked this because in a selfish reason, I want to hear about great books.
00:44:11
Speaker
Some of these I've had the chance to read and agree.
00:44:14
Speaker
There's a couple that I have not read that immediately caught my attention.
00:44:19
Speaker
One is mom milestones as a husband, a father, and trying to be a better person.
00:44:26
Speaker
colleague to my female intensivist colleagues, I think that I definitely have to take a look at that and share it with some of my colleagues.
00:44:34
Speaker
And then the other one that really caught my attention because I never heard about it is speech skills that I definitely will look at it.
00:44:40
Speaker
But the other ones I've read and they are phenomenal.
00:44:42
Speaker
I agree.
00:44:43
Speaker
These are
00:44:43
Speaker
Great, great reads, and they'll all be linked in the show notes for those of our listeners who are interested in expanding their horizons there.
00:44:51
Speaker
Thank you for that list.
00:44:54
Speaker
The second question relates to something you believe to be true in medicine or life that most other people don't believe or don't act as they believe.
00:45:04
Speaker
This is such a hard question.
00:45:07
Speaker
I think it's almost like what's kind of a quick tip for life?
00:45:11
Speaker
I think that it sounds...
00:45:13
Speaker
It sounds maybe cheesy or really basic, but it's true.
00:45:16
Speaker
It's just know people's names, you know, know, know everyone's names that you encounter, whether it's your trainee, whether it's your team pharmacist, whether it's your respiratory therapist, whether it's your, you know, the janitor at your kid's school.
00:45:36
Speaker
I think that when you use people's names, it's incredibly powerful.
00:45:41
Speaker
It's showing that again, you see them as a human, as a person beyond their role, beyond their job, beyond their function that you expect them to play in your society.
00:45:53
Speaker
And that, you know, this is a valued member of your team.
00:45:56
Speaker
This is a valued member of your community and that you know their name and that you use their name and that you see them as a real human.
00:46:03
Speaker
So,
00:46:04
Speaker
I just, I think people's names also have a special kind of always have a special history, have a special story, have a family, a tale behind them.
00:46:13
Speaker
So I would just make a plug to getting to know names of people you encounter in your teams.
00:46:19
Speaker
You know, the person who you get your daily cappuccino from getting to know their names will just enrich your life.
00:46:25
Speaker
I think it's a great, great tip and definitely something worth investing in, right?
00:46:31
Speaker
Because like you said, nothing says I see you more than being surprised that somebody knows your name.
00:46:37
Speaker
And especially when you don't expect it for whatever reason.
00:46:39
Speaker
So I think it's a great, great answer.
00:46:43
Speaker
And the last question is for closing.
00:46:46
Speaker
What would you want every intensivist to know?
00:46:48
Speaker
It could be a quote or a fact as we close the podcast.
00:47:01
Speaker
This is such a good question too.
00:47:03
Speaker
What would I want every intensivist to know?
00:47:07
Speaker
I think I would have to close by saying thank you.
00:47:11
Speaker
I want every intensivist to know that these last couple of years have been so incredibly challenging with COVID, huge workforce shortages, burnout, misinformation, mistrust of healthcare workers.
00:47:28
Speaker
And just to say thank you that that
00:47:31
Speaker
You are all doing an amazing job.
00:47:33
Speaker
You are enough.
00:47:34
Speaker
You are wonderful.
00:47:35
Speaker
You are effective.
00:47:36
Speaker
You are helping people.
00:47:38
Speaker
And just wanted whoever's listening to know that, that I thank you.
00:47:42
Speaker
I think that's a perfect place to stop, Lakshmi.
00:47:45
Speaker
Thank you so much for what you're doing and for taking the time to talk with us today.
00:47:50
Speaker
I definitely look forward to seeing you in person and having you back on the podcast.
00:47:56
Speaker
Thank you so much, Sergio.
00:47:58
Speaker
It was great to be here with you and looking forward to meeting you in real life soon.
00:48:03
Speaker
Thanks.
00:48:04
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:48:07
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
00:48:13
Speaker
Sounds transforming the way critical care is provided in hospitals across the country.
00:48:18
Speaker
To learn more, visit www.soundphysicians.com.