Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now, your host, Dr. Sergio Zanotti.
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.
Speaker: A concept referred by some as the voltage drop is a serious patient safety issue.
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.
Speaker: Our guest is Dr. Lakshmi Santoush, a practicing pulmonary critical care physician at UCSF Health.
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.
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.
Speaker: She's the founder and medical director of the Multidisciplinary Long COVID Post-ICU Optimal Clinic at UCSF Health.
Speaker: It's a true pleasure to have her today on the podcast.
Speaker: Lakshmi, welcome to Critical Matters.
Speaker: Thank you so much for having me.
Speaker: I'm really excited to chat about this today.
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.
Speaker: and guidance.
Speaker: And yet it's something that happens multiple times every day in hospitals all over the country and the world.
Speaker: 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.
Speaker: Thanks so much.
Speaker: That's exactly right.
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.
Speaker: And though there's a lot of
Speaker: supporting evidence in the world of handoffs and handovers and transitions of care about day to night transition, right?
Speaker: The famous I-PASS framework by Dr. Amy Starmer and colleagues initially published in the New England Journal.
Speaker: That is a classic framework I-PASS that we all know and use
Speaker: from day to night transition.
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.
Speaker: New doctors, new APPs, new nurses,
Speaker: They're transitioning these healthcare teams.
Speaker: And sometimes in this transition, there's also this diagnostic uncertainty, right?
Speaker: Our patient with septic shock, they got better, but we never grew out an organism.
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.
Speaker: And so for all those reasons, I believe that that ICU to ward transition is one that bears...
Speaker: that needs close attention from us and that we can do better in communicating to make those patients safer.
Speaker: Absolutely.
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.
Speaker: And I always think that there's three buckets of patients I'm worried about when I show up to the hospital.
Speaker: One is the sickest patients in my ICU.
Speaker: Two is the patients who just left the ICU, right?
Speaker: And three is the patients who should be in my ICU, but are not there yet.
Speaker: Right.
Speaker: But we don't know where they are.
Speaker: That's exactly right.
Speaker: That's exactly right.
Speaker: I think that the known unknowns, right?
Speaker: 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.
Speaker: The ones who are already vented on pressers, you know a little bit what you're dealing with.
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?
Speaker: Did I do everything I could for that patient to prevent her readmission, to prevent ICU readmission?
Speaker: Those are the ones that keep you up at night.
Speaker: And hopefully our ICU pause framework helps communication around those sickest vulnerable patients.
Speaker: 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.
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
Speaker: a lot of us are talking about in multiple levels and COVID, I think, was a great illustrator of that problem.
Speaker: But I never thought about it in transitions of care.
Speaker: Could you explain that a little bit more?
Speaker: Absolutely.
Speaker: 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,
Speaker: Implicit bias can creep into our documentation, into our notes, into the electronic health record when we have unstandardized communication.
Speaker: 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.
Speaker: but they actually are not patient-centered language.
Speaker: They're not patient-first language.
Speaker: 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.
Speaker: Patients of color are much more likely to have flags talking about their, quote, behavior.
Speaker: And so one concept that we know is that standardization, standardized communication, doing things the same way every single time, right?
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.
Speaker: or factors that might actually contain implicit bias and not patient-versed language.
Speaker: So have we proved it yet?
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.
Speaker: That is a great point.
Speaker: I think it's definitely something that I hope other people pay attention to.
Speaker: It was not something that was on my radar in this context, for sure.
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.
Speaker: But again, by standardizing a process and making sure that what we are actually documenting is
Speaker: is helpful in making care better and is always the same, I think we can move the needle in that area as well.
Speaker: That is a hope.
Speaker: Thanks so much for your reflections.
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.
Speaker: Absolutely.
Speaker: Absolutely.
Speaker: Well, let's go into a little bit more into the transitions of care from the ICU to the ward.
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.
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?
Speaker: So diagnostic uncertainty is something that obviously sometimes travels with these patients.
Speaker: But as we explore this a little bit more, Lakshmi, could you tell me a little bit about the current state of ICU to ward transitions?
Speaker: I know that you have looked at this in some papers, but what's out there in the literature?
Speaker: It's a great question.
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.
Speaker: It is so unstandardized.
Speaker: It is so heterogeneous.
Speaker: It is so variable between institutions and even within institutions.
Speaker: So your SICU might have a totally different process than your MICU.
Speaker: And definitely different institutions within the same city or different states, academic, non-academic,
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.
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.
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
Speaker: And every single institution had a totally different process map for essentially the same concept, which is really interesting.
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.
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.
Speaker: And,
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.
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.
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.
Speaker: Whereas for physicians or advanced practice practitioners, it was a totally different web of game of telephone.
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.
Speaker: And there was, like you said, this huge risk of that voltage drop.
Speaker: Yeah.
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.
Speaker: And the whole concept of human-centered design or design thinking is
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?
Speaker: Awesome.
Speaker: So before we jump into, into that initiative itself, I did have a question and
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?
Speaker: And he said, is this like IPAS?
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?
Speaker: That's exactly right.
Speaker: I have tremendous admiration, respect for iPass.
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
Speaker: some of the leaders and the original authors on the IPAS paper.
Speaker: I think IPAS has transformed the way we think about patient safety, transitions of care, and handoffs, absolutely.
Speaker: At the same time,
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.
Speaker: And so first, I definitely was experimenting with that.
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?
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.
Speaker: It didn't neatly transfer.
Speaker: It wasn't
Speaker: 100% applicable.
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?
Speaker: So I definitely think that ICU pause is, like you said, like IPAS, a structural framework of
Speaker: to enable improved communication and patient safety to create, as they call it, a shared mental model, right?
Speaker: If everyone expects this type of communication in this format, just like you expect an ICU presentation, right?
Speaker: Perhaps you're a systems-based kind of guy or an organ-based kind of guy.
Speaker: I don't know.
Speaker: I haven't met with you in the ICU.
Speaker: But I think that when you tell your learners or you tell your APPs on day one,
Speaker: I like my plans organ system based or I like my plans problem based in the ICU.
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.
Speaker: There is less of that voltage drop.
Speaker: Awesome.
Speaker: Let's talk about the ICU Paws Initiative.
Speaker: What is it?
Speaker: So this is so cool because it started as a fellowship passion project when I was a fellow.
Speaker: This was kind of one of my fellowship research projects that I was passionate about.
Speaker: And by a series of coincidences, you know, a faculty hospitalist mentor connected me with
Speaker: Dr. Vinny Arora, who said, you know, I have some residents who are interested in looking at this.
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.
Speaker: We're all at different institutions.
Speaker: How could we work together to improve this process?
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.
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
Speaker: to a national competitive grant by the Council of Medical Subspecialty Societies, CMSS, and the Moore Foundation.
Speaker: that really focused on diagnostic excellence.
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.
Speaker: So it's really exciting.
Speaker: So what have we done now with the ICU PAUSE?
Speaker: So as I mentioned, we worked with residents and users of this ICU to ward transition process across multiple sites
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
Speaker: of what we need to know.
Speaker: What do clinicians need to know when they're communicating about a patient transferring out?
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.
Speaker: So this started initially at Washington University of St.
Speaker: Louis,
Speaker: They were our pilot.
Speaker: They launched it back in September of 2019.
Speaker: And now, you know, as of today, April, 2023, we have over 30 sites
Speaker: across the country that are interested in implementing this at their sites.
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?
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.
Speaker: If you're listening in and you're thinking, that sounds pretty cool.
Speaker: How do I get this ICU pause to work at my institution?
Speaker: The ATS has a really cool website that they've launched.
Speaker: If you just go to your favorite search engine of choice and just put in ATS ICU pause,
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.
Speaker: So, you know, at no cost to you.
Speaker: And so again, this is,
Speaker: The ATS really saying that we're excited about this too.
Speaker: We're excited about improving transitions of care.
Speaker: We're excited about talking about a diagnostic pause and diagnostic uncertainty and really discussing what we think the diagnosis is.
Speaker: And we're really thrilled and honored that this work is getting implemented and rolled out nationally.
Speaker: Absolutely.
Speaker: I agree.
Speaker: And just a couple of comments, and then I want to hear a little bit more about each component.
Speaker: But first, I understand that the Betty Moore Foundation is a foundation that has been really interested in critical care.
Speaker: Do I believe to a family member?
Speaker: These are the, I think, where the owners of Intel are one of those big soft companies.
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
Speaker: It's just about finding a better way to do things that are important and that we do every day.
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?
Speaker: It's about the mental model that we'll talk about.
Speaker: And the
Speaker: That is so true.
Speaker: That is so true.
Speaker: Your reflection is so bright.
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.
Speaker: And the Gordon and Betty Moore Foundation has been instrumental in the field of healthcare, particularly in the field of diagnosis.
Speaker: So after his
Speaker: you know, incredible innovations and revolutionizing the field of, you know, of Intel and engineering, he really turned his,
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.
Speaker: And so what a generous person.
Speaker: The Moore Foundation has funded a lot of really innovative healthcare projects, like you mentioned, due to personal experiences.
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.
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.
Speaker: But actually, culture change, changing communication, changing practice patterns are sometimes actually more difficult to change than technology.
Speaker: And yet, um,
Speaker: more cost effective.
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.
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.
Speaker: Absolutely.
Speaker: So let's take an ICU pause, deep dive.
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.
Speaker: Absolutely.
Speaker: So diving in.
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.
Speaker: It'll show up in your EHR when you use this template.
Speaker: So I is kind of your chief complaint, chief concern.
Speaker: It's your ICU admission reason.
Speaker: So that's where you say if they were admitted for hypoxia, encephalopathy, that's right up front, the ICU admission reason.
Speaker: Your C is for code status, DPOA, designated power of attorney information, goals of care.
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.
Speaker: But the C in code status, we really wanted to put that up front because people felt like that was really important
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.
Speaker: And not only the code status, but also putting in the designated power of attorney or the surrogate's information up front.
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.
Speaker: Because oftentimes that stuff is really buried.
Speaker: You have to look in multiple places in the chart.
Speaker: So we wanted to put that phone number, family contact information, code status right up front.
Speaker: U is this really interesting thing.
Speaker: U stands for uncertainty measure or diagnostic pause.
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?
Speaker: In some cases, it's going to be easy, right?
Speaker: The working diagnosis at the time of transfer was COVID pneumonia.
Speaker: Straightforward, we diagnose them with COVID, they're better.
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.
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,
Speaker: This is a slam dunk open and shut case of COVID pneumonia or MRSA pneumonia or Pseudomonas UTI.
Speaker: Or this is a complicated case.
Speaker: You know, this is a case where there's a little bit of uncertainty.
Speaker: And research shows that explicitly discussing diagnostic uncertainty or embedding a diagnostic pause can actually reduce the risk of diagnostic errors.
Speaker: So that's the U for uncertainty.
Speaker: The P is for pending tests at the time of transfer.
Speaker: So our prior work really showed that pending tests, right?
Speaker: That cytology that's still cooking, the ANA, ANCA's that are still cooking in the lab.
Speaker: Prior tests are often lost either at hospital discharge or between other care transitions like ICU to ward.
Speaker: And often the new team doesn't really know what's cooking and pending to follow up on.
Speaker: So you're calling out explicitly P for pending tests.
Speaker: A is for the active consultants.
Speaker: Who's still following?
Speaker: So is ID following?
Speaker: Is PT, OT following?
Speaker: What about wound care?
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.
Speaker: So everyone's on the same page, shared mental model, A for active consultants.
Speaker: The second U is for unprescribing, quote.
Speaker: And what that means is it's basically just a way of calling out the high-risk medications.
Speaker: Um,
Speaker: Many of us have EHRs where it will import a giant med list that is often still contains outdated things.
Speaker: It still might say norepinephrine.
Speaker: It still might say purple fall.
Speaker: It might auto import like 10 saline flushes for no clear reason.
Speaker: We've all seen that before.
Speaker: Right.
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.
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.
Speaker: We held the home anticoag because we were there bleeding, but you should restart that.
Speaker: or we started new antibiotics and we anticipate they're gonna end in 10 days.
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.
Speaker: And we call that unprescribing for you.
Speaker: The S is the traditional summary of the problems and to-dos.
Speaker: So the S is where you usually see in a transfer note or a discharge summary, you know, the problem-based to-dos.
Speaker: So problem number one,
Speaker: Acute kidney injury, they were on dialysis, they got better.
Speaker: The main to-do for you is to follow up, you know, follow up the daily BMP.
Speaker: Or, you know, the new problem is respiratory failure, hypoxemic respiratory failure now improved.
Speaker: CTPE was negative.
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.
Speaker: And E is your pertinent physical exam at the time of transfer.
Speaker: So it's again, calling out your pertinent physical exam to say, hey, they're leaving with this line in place.
Speaker: They still have a pick line in place.
Speaker: They still have a Foley in place.
Speaker: This was their mental status at the time of transfer, which is still not perfect.
Speaker: This is their abdominal exam at the time of transfer.
Speaker: So pertinent physical exam with calling out the important things.
Speaker: And different health systems, depending on your health system, might use this tool differently.
Speaker: Because as you see, it contains billable elements.
Speaker: It has medical decision making.
Speaker: It has to-dos.
Speaker: It has a pertinent physical exam.
Speaker: You're analyzing things.
Speaker: And so many of us in critical care, we're using time-based billing anyways.
Speaker: And so this is a billable note if you want to use this as your progress note for the day.
Speaker: Depending on your context, some people might be using this as a
Speaker: progress note and billing directly on that.
Speaker: Some people might be using this as a separate standalone transfer note.
Speaker: Either way it works.
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,
Speaker: P, pending tests, A, active consults, U, unprescribing, which basically means calling out the meds, high risk.
Speaker: S is your summary, and E is your pertinent physical exam.
Speaker: And that is what this letter stands for.
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.
Speaker: And you can go to the ATS website or to our paper at ATS Scholar to read more about it.
Speaker: And we'll definitely include all the links.
Speaker: I was looking at the ATS link.
Speaker: I was preparing for the podcast and you have videos.
Speaker: You can download the EMR dot phrase.
Speaker: There's examples.
Speaker: I mean, there's a lot of great stuff that I think would make it.
Speaker: very intuitive for people to try to take that and start doing it.
Speaker: I believe that the heavy lifting is changing the culture, like you said.
Speaker: But clearly, there's a lot of elements that are very, very powerful here.
Speaker: I think that if you always did it the same way, you would get better and better at it.
Speaker: And I can also see how in many practices,
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.
Speaker: So I believe that by having a structure that can almost work like a flipped classroom, right?
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.
Speaker: And ultimately,
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
Speaker: That's exactly right.
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.
Speaker: And so the dot phrase is, of course, kind of an easy, seamless way to do that.
Speaker: And some institutions, they don't like that.
Speaker: They don't like a dot phrase that you plop in.
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.
Speaker: That works great too.
Speaker: And so you can really go about it either way.
Speaker: And again,
Speaker: I appreciate your mentioning that it seems pretty user-friendly and easy to use.
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
Speaker: at our institutions.
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.
Speaker: Again,
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.
Speaker: It's really about changing the way we communicate, changing the way to document and culture change around that.
Speaker: But it's not, you know, it doesn't cost much.
Speaker: It standardizes the care, improves the care.
Speaker: And we've received feedback from the sites that have already implemented that.
Speaker: People are spending less time doing exactly as you said, they're doing less rework.
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.
Speaker: Now you have a one note place to look where all the key items are there.
Speaker: So there's a lot less rework that has to be done.
Speaker: The other thing that people appreciate is the diagnostic pause.
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?
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?
Speaker: And so that you, the uncertainty, the diagnostic pause is a point for us to take a deep breath and say, hey,
Speaker: These are the to-dos, and I think the main process going on here is COVID pneumonia.
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.
Speaker: So it's a really cool concept that's a relatively low lift,
Speaker: that the sites that have implemented have found it really useful, pragmatic, and not a lot of extra work.
Speaker: You talked about implicit bias at the beginning, and I think another bias that is pervasive in medicine is anchoring bias.
Speaker: And I think this is a great tool to unanchor ourselves from maybe the wrong diagnosis, right?
Speaker: I mean, whatever somebody labels a patient in the ED used to stick with that patient until the day they leave the hospital.
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.
Speaker: So I think it's a great tool.
Speaker: I love it.
Speaker: Yep.
Speaker: Thank you, that's exactly right.
Speaker: I think anchoring bias is one of the most common cognitive biases that affect care transitions, right?
Speaker: Whether it's ED to wards or ED to ICU, as you mentioned, ICU to ward, and even inpatient to outpatient.
Speaker: So taking that moment for a diagnostic pause at any of those transitions is really valuable.
Speaker: We will have a piece coming out shortly with the AHRQ that really talks about diagnosis at all these care transitions.
Speaker: But of course, being an intensivist and hospitalist, the ICU to ward transition is my passion.
Speaker: I think Herb Spencer was the one who said that the aim of education is not knowledge by action.
Speaker: So let's talk about a call to action for our listeners in terms of improving the transitions of care.
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?
Speaker: This is a great question.
Speaker: And I should have said earlier, you know, I'm a clinician.
Speaker: I'm not a big clinician.
Speaker: R01 grant funded research.
Speaker: I'm a clinician with a passion.
Speaker: I'm an educator.
Speaker: And this is really a passion project.
Speaker: I really believe that if you, like me, felt bothered that, ah, this process is suboptimal, we could be doing this better.
Speaker: I worry about my patients that I've sent out and could I have done it better?
Speaker: Could I have prevented ICU readmissions?
Speaker: I might ask you first to think about, A, what is my current process at my institution?
Speaker: We made that process map in our first paper, looking at the three different institutions process maps.
Speaker: And it was eye opening just to see the, to localize the legion, to see where are those opportunities for the voltage drop.
Speaker: So I think first things first is think about what is the current process at your institution.
Speaker: The second thing to do if you want to make a change, if you want to do culture change, it seems intimidating.
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.
Speaker: I think aligning this mission with existing incentives or quality improvement projects that your institution is doing is really helpful.
Speaker: After ATS put out this call for ICU pause, a number of institutions approached us saying,
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.
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.
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.
Speaker: Or we've been talking about our ICU readmissions.
Speaker: We've been talking about how our hospitalist medicine service is very dissatisfied with our transfers.
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.
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.
Speaker: So try to align your interest with existing priorities or existing pain points.
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.
Speaker: It's nationally used.
Speaker: It's standardized.
Speaker: It's all there.
Speaker: And it's a relatively low lift, low cost, and lots of sites are doing it.
Speaker: We also will have an in-person meetup at ATS for those of you who are going to ATS.
Speaker: So ATS is hosting an ICU pause sort of
Speaker: Ask Me Anything session on the Monday, May 22nd at 1030 a.m.
Speaker: in D.C.
Speaker: as well.
Speaker: And all the sites are going to get together.
Speaker: People who are interested should come by.
Speaker: There'll be some free swag about the ATS ICU pause.
Speaker: And so it's just an opportunity to get to meet people who've already implemented or who are in the implementation journey.
Speaker: So it's really exciting times.
Speaker: Perfect.
Speaker: So Lakshmi, thank you so much for sharing this very important initiative and your work.
Speaker: We'd like to close the podcast with a couple of questions that are unrelated to the clinical topic.
Speaker: Would that be okay?
Speaker: I love it.
Speaker: I mean, we are more than just our jobs.
Speaker: And I think that's really important that we discuss kind of our whole our whole lives.
Speaker: Absolutely.
Speaker: So the first question relates to books.
Speaker: What book or books have influenced you the most or what books have you gifted to others to others more often?
Speaker: I love this question so much.
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.
Speaker: And I love to give gifts and books are one of the best gifts that you can give people.
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,
Speaker: ICU intensive authors books, which is In Shock by Dr. Rana Oddish and Every Deep Drawn Breath by Dr. Wes Ely.
Speaker: Both of these books, I feel like are just mandatory reading for anyone who practices intensive care medicine,
Speaker: Whether you're a practicing clinician, a trainee, or anyone in between, these books changed my life.
Speaker: They changed how I practice critical care.
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.
Speaker: And so I've given those books out a lot to friends and colleagues.
Speaker: Other books that I frequently gifted, so there's this new book, newish book out called Mom Milestones by Dr. Grace Ferris.
Speaker: And she basically is a really talented writer and artist.
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.
Speaker: And it's a book that will make you laugh, make you cry and make you feel seen.
Speaker: for any moms in medicine, especially.
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.
Speaker: And then I also love...
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.
Speaker: And I will say I'm not an introvert, but I'm married to one and I learned a lot about introverts in
Speaker: in reading that book and I give that book out a lot.
Speaker: And then the last book I'd say I recommend is actually really interesting.
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.
Speaker: So I give that book out a lot as well.
Speaker: So I love to give books as gifts and there's so many
Speaker: There's even more, you know, we didn't even get into the fiction category.
Speaker: So more for another day.
Speaker: Next time.
Speaker: And I think that obviously I asked this because in a selfish reason, I want to hear about great books.
Speaker: Some of these I've had the chance to read and agree.
Speaker: There's a couple that I have not read that immediately caught my attention.
Speaker: One is mom milestones as a husband, a father, and trying to be a better person.
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.
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.
Speaker: But the other ones I've read and they are phenomenal.
Speaker: I agree.
Speaker: These are
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.
Speaker: Thank you for that list.
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.
Speaker: This is such a hard question.
Speaker: I think it's almost like what's kind of a quick tip for life?
Speaker: I think that it sounds...
Speaker: It sounds maybe cheesy or really basic, but it's true.
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.
Speaker: I think that when you use people's names, it's incredibly powerful.
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.
Speaker: And that, you know, this is a valued member of your team.
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.
Speaker: So,
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.
Speaker: So I would just make a plug to getting to know names of people you encounter in your teams.
Speaker: You know, the person who you get your daily cappuccino from getting to know their names will just enrich your life.
Speaker: I think it's a great, great tip and definitely something worth investing in, right?
Speaker: Because like you said, nothing says I see you more than being surprised that somebody knows your name.
Speaker: And especially when you don't expect it for whatever reason.
Speaker: So I think it's a great, great answer.
Speaker: And the last question is for closing.
Speaker: What would you want every intensivist to know?
Speaker: It could be a quote or a fact as we close the podcast.
Speaker: This is such a good question too.
Speaker: What would I want every intensivist to know?
Speaker: I think I would have to close by saying thank you.
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.
Speaker: And just to say thank you that that
Speaker: You are all doing an amazing job.
Speaker: You are enough.
Speaker: You are wonderful.
Speaker: You are effective.
Speaker: You are helping people.
Speaker: And just wanted whoever's listening to know that, that I thank you.
Speaker: I think that's a perfect place to stop, Lakshmi.
Speaker: Thank you so much for what you're doing and for taking the time to talk with us today.
Speaker: I definitely look forward to seeing you in person and having you back on the podcast.
Speaker: Thank you so much, Sergio.
Speaker: It was great to be here with you and looking forward to meeting you in real life soon.
Speaker: Thanks.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sounds transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
