SCCM Pod-529: Bridging the Gap: Communication During Sepsis Transfers

---

Patients with sepsis are regularly transferred to intensive care units, but there is a dearth of literature that describes the type of communication occurring between the receiving and referring clinicians after these transfers take place. The Society of Critical Care Medicine’s (SCCM) Diagnostic Excellence Program sought to gain a better understanding of these communications through an in-depth survey. In this podcast, host Kyle B. Enfield, MD, discusses the survey results with grant principal investigator Greg S. Martin, MD, MSc, FCCM.

Dr. Martin also discusses a new toolkit created by SCCM to facilitate better transfer communication. Learn more about the toolkit and the Diagnosis Excellence Program at sccm.org/diagnosticexcellence.

The Diagnostic Excellence Program is funded by the Gordon and Betty Moore Foundation through a grant program administered by the Council of Medical Specialty Societies to support the development and dissemination of resources and programs to improve the timeliness, accuracy, safety, efficiency, patient-centeredness, and equity of diagnostic outcomes for patients in the United States.

Dr. Martin, a past SCCM president, is the James Paullin Distinguished Professor and division director of pulmonary, allergy, critical care and sleep medicine at Emory University. He is an international authority on critical care medicine and an expert on sepsis, COVID-19, and ARDS, having conducted groundbreaking clinical trials on these conditions, coauthored the Sepsis-3 definition, and published seminal papers for diagnosing and treating critically ill patients.

*If you are unable to play the podcast please click here to download the file.

Transcript:

Announcer: This podcast is funded by the Gordon and Betty Moore Foundation through a grant program administered by the Council of Medical Specialty Societies.

Dr. Enfield: Hello and welcome to the Society of Critical Care Medicine Podcast. I’m your host, Kyle Enfield. Today we are joined by Greg Martin, MD, MSC, to discuss the results of a sepsis survey centered on referring and receiving clinicians.

Septic and suspected septic shock patients are regularly transferred to intensive care units. However, there is a dearth of literature that describes the type of communication occurring between the receiving and referring clinicians after those transfers take place. Dr. Martin is the James Paullin Distinguished Professor and division director of pulmonary allergy and critical care medicine and sleep medicine at Emory University.

He is an international authority on critical care medicine and an expert in sepsis, COVID-19, and ARDS, having conducted groundbreaking clinical trials on these conditions, coauthored the Sepsis-3 definition, and published seminal papers for diagnosing and treating critically ill patients. Dr. Martin served as the president of the Society of Critical Care Medicine in 2021 through 2022 and served on the NIH COVID-19 Guideline Panel for the United States. Welcome. Dr. Martin, before we start, do you have any other disclosures we should know about?

Dr. Martin: I don’t. Thanks, Kyle. It’s great to be here.

Dr. Enfield: I got a chance to look at some of the data from this survey, but maybe we should start off by: What was the impetus for doing this research project and why did you get interested in this topic?

Dr. Martin: It’s a great question. A lot of it is about the fact that sepsis is one of the most common conditions we encounter, certainly in the ICU, but really in all health systems. We also know it’s one of the more difficult diagnoses to make so it becomes a bit of a conundrum. It’s challenging for people in all different settings, whether you’re in an outpatient setting, but certainly in the emergency department, in the hospital, and even in the ICU. And that leads to a lot of diagnostic challenges but really a diagnostic dilemma. We have a strong sense of how often the diagnosis is delayed or missed, and being able to better understand that and improve the care of patients from a diagnostic perspective is really important.

Dr. Enfield: So the primary goal of this was really to understand how referring providers or those admitting patients to the ICU learned about the care of the patient after the ICU team saw them. Is that correct?

Dr. Martin: That’s correct. We wanted to make sure we were getting feedback from both receiving physicians, for instance, physicians in the ICU who would be taking care of patients coming in with sepsis or septic shock but also referring physicians who may be in the ED, may be in a ward where the patient needs to transfer into an ICU or to a higher-level setting to try and make sure that we understand both sides of it and how feedback works.

One element that we think about a lot is how do we make sure sepsis is diagnosed and how care can be delivered in a timely manner. We have evidence-based guidelines, we have a lot of quality improvement initiatives, but the feedback piece is another one that really particularly is helpful to clinicians and health systems to be able to better understand where there are gaps that we can make improvements at that level, whether it’s application of evidence or is it simply the fact that clinicians recognize in their system that they could do better but they really don’t know the system or the process for getting feedback and helping other people to improve.

Dr. Enfield: So, really honing in on that part of communication that requires both the sender and the receiver to understand what’s going on with the patient they’re taking care of?

Dr. Martin: That’s right. Exactly.

Dr. Enfield: Let’s talk a little bit about what you learned from the sender in this case, the person who’s providing feedback to that ward or ER physician. What did you learn about the people who responded to the survey and what did you learn about how they give feedback?

Dr. Martin: One of the things we learned is that certainly the referring physicians who most often were in an emergency department, but some on wards, is that they often were very interested in hearing feedback, particularly in terms of, were they correct in the diagnosis, what happened with the patient after they were admitted or transferred to that next level of care, but also that they were not routinely getting feedback. So they both wanted more feedback, but they weren’t getting the kind of feedback that really would be helpful.

On top of that, there’s also the fact that, even though it was sort of secondary in terms of what we were asking about, but it also became apparent that people not only wanted feedback and they had some ways of informally doing it, but often the systems in place weren’t facilitating that. So simplistically, for example, electronic health records we often use, they’re often part of our daily practice, but they’re not really built for feedback and connectivity and particularly sharing what’s happened to a patient or what the current status of a patient is. We wanted to try and understand from the referring physician perspective how often they get feedback, how often they want feedback, but also then, in what way would they like to receive that feedback.

Dr. Enfield: And what did you learn about that latter? What way do they want to receive that feedback?

Dr. Martin: Most people, there are two elements to that. There’s when do they want to receive it and also how do they want to receive it? Most of them wanted to receive it electronically, using the EHR or maybe email. The other one that was obviously not surprisingly but very common was more personal. They’d like to have a phone call. They’d like to have a discussion about the patient.

I think the fact that those both appear is the nature of healthcare, that people are busy and it may be, in some ways, easier to put something into an electronic system and then someone can pick it up whenever they’re available. Whereas if you call someone, they may or may not be readily available to have that discussion at that time, but they want the feedback and they generally want to make it easy and useful.

In terms of when they receive it, that was another element that was really interesting. Most people wanted feedback certainly sometime during the hospital stay. Some people wanted it on the day of admission, you know, tell me what happened when you received the patient. Were there other things that you needed to do immediately? Were there things that we should have perhaps done in the sending setting where we could have done it, for instance, in the emergency department? And some people not uncommonly said, well, maybe on day two or day three, right? Sometime relatively early in the hospitalization.

A smaller number of people wanted it later, for instance, on hospital discharge. They wanted sort of more of the entire capture of what happened to that patient that I admitted last week and tell me the rest of their course so that I can think about what happened on the early end. But most people wanted it relatively early, sort of on the first day or so, maybe once was enough, and they wanted it often electronically just to make it sort of fit their workflow or their life.

Dr. Enfield: Yeah, I was wondering about that personal phone call because that synchronous communication, talking directly to someone, can be hard with our systems, which are often very shift based, particularly in the emergency department and sometimes on the wards that, you know, I’m the attending physician in the ICU, I’m seeing a patient, it may be 24 hours before we really feel like we have a good grasp of what’s going on with that patient. Calling the ED provider, I can imagine getting a lot of, you know, they’re not here today or they’re working nights now, and that’s going to be difficult.

So it’s good that people recognize that the EHR could be a tool for that. Do you think that in this early first kind of study on this, you have some ideas about what parts of feedback do they want? Are the providers most interested in what was the final diagnosis? Are they most interested in what we could have done differently?

Dr. Martin: Yeah, a lot of it was around personal or quality improvement. They strongly wanted to know, for instance, was the diagnosis correct? Also, were there things that maybe have been missed, but maybe just things that could have been done in a more timely manner? For instance, if the patient arrived in the ICU and a vasopressor needed to be started or the patient needed to be intubated and mechanical ventilation started, like those are the kinds of things that they wanted to make sure in that connection from one setting to another, was there a timely element that needed to be done earlier or needed to change?

But overall, really what was remarkable is almost everyone wanted something that was both either sort of personal improvement or quality improvement, right? Tell me a little bit more about, was the diagnosis correct? What else needed to happen? How did the patient do? Was there anything particularly that you would have done differently? That kind of thing came through pretty consistently that people wanted to know were there opportunities for improvement from where we saw the patient as the referring clinician to later in that receiving space as the receiving clinician.

Dr. Enfield: And what about from the receiver’s standpoint? What did you find out about that group of people and how they felt about feedback?

Dr. Martin: Now, similarly, they were also interested in sharing feedback. In many ways, they had similar experience. They often had given some feedback. They were often interested in sharing feedback. They also didn’t necessarily have a consistent way to do it. For some of the things we were just talking about, between schedules and priorities, how do you make that work smoothly? We asked a lot of the same questions about, how would you like that to happen? How would you often be able to do it in your system, for instance?

But not surprisingly, a lot of people wanted to share that feedback because there’s often a strong connection between the referring clinician and the receiving clinician. And a lot of it was still around, you know, what were the things, for instance, that you recognized when you saw the patient? And again, were there things perhaps that you had to do immediately to try and stabilize the patient or were there other things that became more evident in the next day that weren’t so obvious when the patient first arrived in your unit?

Dr. Enfield: Any speculation on how we might make this easy for the ICU doctor receiving the patient? I know, at UVA, we’ve often been asked, can you send a note to the ER physician who admitted this patient about the diagnosis? But also people want primary care physicians to get notifications that there are patients in the ICU. It can be a significant source of work for that provider who’s often pretty busy already. What do you think we can do to make this easy?

Dr. Martin: Yeah, that’s a good question. Part of what we were doing this survey for was to think about that exact question: How often do people want feedback? What’s their experience with feedback? And how would, for instance, it work best? That’s why the next thing we did is we really worked on creating a toolkit that we could use for that. And some of that needs to be adaptable.

Every hospital and every health setting is a bit different. As you just said, sometimes primary care or the patient’s primary care physician may be intimately involved and very in touch with everything happening with the patient. And they want to know that the patient is in the hospital. They want to know what the working diagnosis is. What we were really focusing on is more that intrahospital communication, meaning sort of between the referring and receiving clinician and how do we build a tool to help with that.

The electronic tool system, meaning sort of electronic health record, probably is a good foundation for that. But there are a lot of other ways to do it. And we could, in fact, build things that are run within the EHR that could be deployed in a variety of different electronic health systems.

Or, for instance, you could build something completely separate. And that level of flexibility might be important if this is really going to help improve communication and ultimately improve patient care. If you’ve got to make it useful and adaptable for a variety of different health settings or where people are working.

Dr. Enfield: I imagine that there are going to be a series of papers that come out from this, maybe some additional research projects. What do you think is next in this line of questioning?

Dr. Martin: We used this as a first step because we had a strong sense that there’s an opportunity for improving sepsis care. And a lot of that was around improving communication, which ultimately really should help improve diagnosis. If we’re thinking about sepsis as a difficult diagnosis, sometimes a misdiagnosis, the opportunity to share feedback and try and make improvements in care is something that involves or needs better communication.

Now, the next step is much more around implementation. How do we take what we’ve learned and begin to make changes? Some of that might be piloting in different health systems, right? We have large teaching health systems with different provider mixes, different types of people in levels of care. We have smaller settings.

And, as we were talking about earlier, sometimes you have a lot of people working in an ED and a lot of people working in an ICU. How do you get individual feedback from one person to another, particularly if they’re working shifts that aren’t synchronous? There are a lot of elements that we need to take into account, which is why we think about toolkits and tools in general that might be usable for any variety of settings. One next step would be to take what we’ve learned and really build a feedback system that could be tested as an implementation tool, at least as a pilot, in a few different health systems where they have an interest in this and would be eager to test it.

Dr. Enfield: Is that something that SCCM as a whole will be taking on? Or is that a research project that will be led out of Emory in some way?

Dr. Martin: This is definitely a team project; it’s not all Emory. There are other people as part of the team. For instance, Tina Cifra at Boston Children’s was another part of this team. SCCM has been the convener and certainly has had for many, many years a strong interest in sepsis. This initiative really came out of the Council of Medical Specialty Societies, which has really focused a lot in the last few years on diagnostics and diagnostic dilemmas and misdiagnosis.

We realize that sepsis is one of the most common of those, certainly in our setting and our patients. Putting all those together, SCCM has been the driving force behind a lot of that. I see SCCM as taking these elements, right, running this survey and gathering feedback, now developing toolkits and things that we can use, and then taking the next step to find the right settings where we can use our expertise and test this in a variety of clinical settings.

Dr. Enfield: I also wonder, was there anything that surprised you or the investigators when you did this survey? Was there anything that stood out to you that you were not expecting to see?

Dr. Martin: That’s a really good question. I guess the thing that stood out the most to me is how often people wanted feedback and how often people tried to do it. And sometimes it is done, but it’s remarkable how often people say, oh, I seldom give or receive feedback.

If you think about the way we take care of patients, particularly complex patients and high-acuity patients, communication may be the most important element of making sure that care is consistent and high quality. We often think of critical care as the quintessential care team. It is, but we do a great job communicating within that team that this is an opportunity to take what we’ve learned and expand that to really the rest of the team that cares for patients with sepsis.

And those referring clinicians and also receiving clinicians, if you’re not sort of in that realm or not necessarily already receiving it. Surprising to me was how often people were interested in receiving feedback as an opportunity for improving the care of patients and learning, but how often that has been challenging for them to do.

Dr. Enfield: In the study, did you explore what barriers might exist to the giving of the feedback? I can imagine several that popped into my mind, but was that something that was explicitly looked at in the study? And what did you find?

Dr. Martin: We didn’t really focus as much on barriers. We certainly focused a lot on how people have or would like to receive feedback and the timing of it. The barriers of receiving feedback really often, I think, and we didn’t survey specifically, but often come down to the methods that would be used. So, giving people some choice and some feedback on how has that worked for them or what would they like to see in terms of how feedback would be either given or received?

Dr. Enfield: Yeah, I was sitting here contemplating how, when I go into the ICU next, which won’t be that long, how would I do this and how would I work it into my day to make sure that I’m giving good feedback that’s meaningful to the person receiving it? And when would I do that? I’ll have to think about that over the next couple of days before that next rotation starts.

Well, thank you so much for taking time out of your day today. It’s been a pleasure. I look forward to seeing and using the toolkits when they come out. This will conclude another episode of the Society of Critical Care Medicine Podcast. Don’t forget, if you’re listening on your favorite podcast app and you like what you heard, consider leaving a rating and a review. For the Society of Critical Care Medicine Podcast, I’m Kyle Enfield.

Announcer: This podcast is funded by the Gordon and Betty Moore Foundation through a grant program administered by the Council of Medical Specialty Societies.

Kyle B. Enfield, MD, is an associate professor of medicine in the Division of Pulmonary and Critical Care at the University of Virginia. He received his undergraduate degree from the University of Oklahoma.

The SCCM Podcast is the copyrighted material of the Society of Critical Care Medicine and all rights are reserved. Find more episodes at sccm.org/podcast. This podcast is for educational purposes only. The material presented is intended to represent an approach, view, statement, or opinion of the presenter that may be helpful to others. The views and opinions expressed herein are those of the presenters and do not necessarily reflect the opinions or views of SCCM. SCCM does not recommend or endorse any specific test, physician, product, procedure, opinion, or other information that may be mentioned.

Join or renew your membership with SCCM, the only multiprofessional society dedicated exclusively to the advancement of critical care. Contact a customer service representative at +1 847 827-6888 or visit sccm.org/membership for more information.

Disclaimer