SCCM Pod-530 PCCM: Essential Communication in Pediatric Critical Care Transfers

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Host Maureen A. Madden, DNP, RN, CPNC-AC, CCRN, FCCM, sits down with Christina L. Cifra, MD, MS, to discuss communication strategies for interfacility transfers to the pediatric intensive care unit (PICU). Dr. Cifra shares insights from her recent study on verbal handoffs during transfers, examining the challenges and vital elements of communication during these high-stakes situations (Thirnbeck CK, et al. Pediatr Crit Care Med. 2024;52:162-171). Dr. Cifra is an attending physician in the Division of Medical Critical Care at Boston Children's Hospital and assistant professor of pediatrics at Harvard Medical School in Boston, Massachusetts.

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Transcript:

Dr. Madden: Hello and welcome to the Society of Critical Care Medicine Podcast. I’m your host, Maureen Madden. Today I’ll be speaking with Dr. Christina L. Cifra, MD, MS, about the article, “Interfacility Referral Communication for PICU Transfer,” published in the June 2024 issue of Pediatric Critical Care Medicine. To access the full article, visit pccmjournal.org. Dr. Cifra is an attending physician in the Division of Medical Critical Care at Boston Children’s Hospital and assistant professor of pediatrics at Harvard Medical School in Boston, Massachusetts. Welcome, Dr. Cifra. Before we start, do you have any disclosures to report?

Dr. Cifra: Hi, Maureen. I’m very happy to be here. Thank you for inviting me. I do not have any disclosures.

Dr. Madden: Wonderful. I’d like you to first talk about why this study? Why did you come up with this?

Dr. Cifra: My work has pretty much been rooted in patient safety since fellowship, very interested in how we can change systems so that patients don’t have to suffer adverse events in our care. I did my fellowship at Johns Hopkins. At that time, the Armstrong Patient Safety Institute was just starting, and that’s how I got started in this type of research. My focus really is in diagnostic safety or diagnostic error, and that’s what I had been studying before I sort of stumbled onto this area.

It’s because when we were looking at admissions to the pediatric intensive care unit, we were looking quite broadly through mixed-methods research at what the factors are that really affect the diagnostic process for these critically ill kids that we admit to the unit, looking at vulnerabilities in that process because we were looking for ways to intervene to prevent diagnostic error. We saw that the conversations and the transfer of information from referring hospitals to the pediatric ICU is really the lowest-hanging fruit that we can find, that we observed in what the PICU staff had referred to as an area that’s really ripe for intervention in terms of improving the diagnostic process.

We started out with that and, aside from diagnosis, we saw that it also improves management because improving that transfer of information and making sure that we have shared mental models of patients as they go from one place to the other during these critical transitions is really important for their care.

Dr. Madden: I think it’s really an amazing area to focus on, and I appreciate that you have done that. Within the title, it talks about referral communication on the premise that it’s interfacility, but it also talks about the similarities that can be in place from shift-to-shift handoffs or within intrafacility handovers. Would you mind talking a little bit about I-PASS in that regard?

Dr. Cifra: Absolutely. I think it’s mind-boggling that it’s only been a decade ago that we had concrete evidence showing that how we communicate with each other within the healthcare team affects the care of patients. Specifically, we found that standard communication for intrahospital handoffs, you know, when I hand off to a fellow attending physician or when the nurses hand off to each other when they go off shift, when we communicate in standard fashion, we found that medical errors take a dive. These are near misses, these are errors that are preventable, these are errors that cause harm. I think that’s quite remarkable.

The one big and most famous handoff program of them all that really has been studied quite broadly across many settings since that time that we found that out is I-PASS. I-PASS is a handoff program, and I-PASS stands for the mnemonic of the information elements that should be included in every handoff. I-PASS stands for I, illness severity, P, patient summary, A, action items, S, situation awareness, and another S, synthesis. These five elements of information need to be included in every handoff.

We’ve shown that it’s very effective in keeping patients safe during transitions of care in the hospital. But we haven’t really shown whether it’s applicable for communication and handoffs across hospitals, across teams that could be very different from each other, between clinicians that have been trained quite differently and have different expertise and experience.

A lot of our data about I-PASS is among people who know each other, among people who are trained similarly or have been working together in the same unit in the hospital for quite a period of time. So I was really interested in looking at whether, first, it would be applicable to this particular setting of interfacility transitions of critically ill children and whether we actually follow some of the principles of I-PASS, and whether we follow it because it’s applicable to that setting or is it because we’re just so used to unstructured communication in these situations?

Dr. Madden: We, I think, all have learned a lot in the past two decades or so about communication and checklists and other structured processes so we can really inform our care and, as you say, reduce those errors in whatever section they happen to be. And having been part of interfacility transport, I know communication is a key element. In the study, it talks about poor communication, and I have a preference or a bias for ineffective communication.

But to discuss the referring institution, we know often those intake calls that are coming to tertiary and quaternary children’s facilities that the referring provider is coming from an environment that is having some degree of urgency about the clinical situation of the individual patient that they may not have the resources for or they have a lack of comfort because this is not the population that they care for. How do you teach the intake person, whether it’s part of the transfer center or the fellow in this study situation, to be in control of the communication and to redirect or guide the conversation so that other person who’s the referring provider can give all the appropriate information that’s required to help the child?

Dr. Cifra: Yeah, these calls can be wild in the sense that there’s a sick kid at the center of them. That really heightens emotions, makes us feel rushed and hurried, sometimes for good reason. I do think that there’s a wide variety of referring clinicians and referral hospitals. There are referral hospitals who see quite a bit of acuity, and they do see a good volume of pediatric patients, so they are much more versed in communicating about those patients. Also, if they refer a lot to their tertiary center, then they know what the tertiary center is looking for.

When we examine these calls, and since this study we’ve examined more referral calls, I would say the norm is actually calm and cool and collected referring clinician. It’s quite unusual and really only under these code situations or really emergent situations when the communication is a little bit out of whack. I think, in terms of taking control of the call, to answer your question, we’ve trained fellows and really anyone who wants to take these calls, that sometimes the most effective way really is to let the referring clinician say their spiel, don’t interrupt, just let them give you as much information as they want.

In the beginning, most would give you a very concise story. Then, just be very upfront about it. We’ve since developed a template that would address all these findings from this current study that we’re discussing to integrate that I-PASS mnemonic into these interfacility handoffs. Sometimes what really works is just to be upfront and say, well, that’s great information, I do have to get additional information so that we can prepare our best for this patient. Then just do your questions.

Any information that the referring clinician hasn’t said yet, you can ask your questions then. I think it takes a little bit of time getting used to having a template and using that and making the conversation be as natural as it can. But after that period of experience with the tool, the fellows really, and the attendings who use it actually get a good hang of it and understand what information they need and what information is not as needed for each particular case.

We’ve piloted this in one site and we’ve been quite successful in doing it there. Actually, after the pilot, the PICU where we tested it, they decided to just keep on using it because it’s been very helpful for them. So I think training folks to use a standard tool is, there’s a learning curve, but after that, it’s actually quite straightforward.

Dr. Madden: But within the actual study, it looked at those first-year fellowship in-training persons to receive intake referral calls, and it stated they had didactic lectures and direct feedback from faculty who observed the fellows’ initial referral calls, and then they took them independently. But one of the key statements was: Fellows were not trained on structured handoff tools for interfacility or shift-to-shift intrahospital handoffs. Were you really surprised to find the results that you had that there really was poor communication or missing communication if nobody had a structured process?

Dr. Cifra: Yeah. What’s interesting about this study is we didn’t find differences between brand-new fellows, first-year fellows versus senior fellows. You would think that, as the fellows get on with their training and get more experienced with taking these calls and read better and better, we actually didn’t find that, which was really interesting. Then again, we have a small sample size, so take that with a grain of salt. But I think the structured communication, like having a structured process, really plays an important role in making sure that all the information is gathered.

To answer your question, no, we were not surprised because our lived experience is that these transport calls can be very dicey in terms of the variety of information that you get or don’t get. I think having the fellows undergo a simple one-time didactic lecture and then basically a see-one-do-one-teach-one process in terms of how to take the calls is not enough to make these calls as efficient as possible with good communication between the referring clinician and the accepting PICU fellow.

Dr. Madden: But that’s the premise of your study. And we all know with research that you’ve identified that there’s a dearth of information in this context. So you had to actually publish something to validate your thoughts in order to move forward to improve the situation.

Sometimes we clearly know that we are stating the obvious in that regard. But one of my experiences has been in the Pediatric Fundamental Critical Care course that we had put in one element of the skill station of interfacility transport. We had created a template. And that in my own experience, clearly, if I don’t have something to follow in front of me, typically I will miss an element of importance. But was there any type of template in place for this group that you studied at all?

Dr. Cifra: There was no template at all. But my observations before we started the study, even though we didn’t find a difference in the actual work that was published between first year and junior and senior fellows, my personal observations have been that, when junior fellows take calls, they act more as transcribers of the information. Even if you don’t hear them on the call, you can see them writing on a piece of paper, napkin, whatever it is they have. You can see them writing just left to right, left to right, like they’re transcribing an essay.

Whereas for senior fellows, you see them creating a template for themselves, where they write on the top, they write at the bottom, they write in the middle. They have some sort of system that they’ve worked out. So it naturally comes out. They naturally figure out their own system, which is a template in their heads of how they are going to parcel out the information that they’re getting so that, at a glance, just like a real template, you can see what’s missing, like, oh, I haven’t put something in this corner, that’s where I usually put the weight. So they know when to ask that information.

My thought is that that’s amazing that they learn that just naturally, even though we don’t explicitly teach them that. But why do we have to wait for them to be third-year fellows, right? Why do we have to wait for the expertise to develop? It’s one of those things that can be jump-started by a standard tool.

Dr. Madden: Give them the tools to work with up front. It’s kind of like Atul Gawande and the checklists that have now become really ingrained in our work. Those who are newer to healthcare may not appreciate that this wasn’t always in place, even the same I-PASS in that regard. And when you look at, as you talked about the elements that make up I-PASS, P is for patient summary, but what the critical care person may want to hear versus what is conveyed by the referring individual, there may be some pieces that get lost in there or the relevance may not be appreciated on any side in that regard.

We talked about trying to create standing methods for intake, but also the strategies for the referring provider to have, knowing that oftentimes we have very large catchment areas. Tell me some of your thoughts about how that can become actionable. How do we not just capture the ones that are in our own environment, but how can we make this out to the broader community?

Dr. Cifra: It’s amazing because, for PICUs that have large catchment areas, as you pointed out, it could be 50+ different community hospitals, small EDs, clinics that refer these critically ill patients to them. And for some of these clinics, they could be referring like only one patient a year, which means they’re the ones that really need most of the help. They don’t encounter patients like these critically ill kids all the time. They really need the help. I think it’s impractical to disseminate a standard tool to the 50+ places that refer to you and then expect that they keep up to date. There’s usually a high rate of turnover in community hospitals, which is unfortunate since most of them are critical access hospitals, especially for patients in rural areas.

We decided to attack the problem from the PICU side. With the regionalization of care, a lot of the time there will be more and more transfers to tertiary centers, to pediatric ICUs, for these types of kids. Any tool that we develop needs to be receiver driven, meaning it’s driven by the ICU that’s receiving the patients.

For places that don’t refer to you as much, you kind of hold their hand and walk them through the process of giving you the information that you need. Actually, they like that. They just want you to ask them the questions and then they’ll give you the answers, as opposed to expecting them to do an extemporaneous presentation. It actually takes the pressure off.

And for those places that are used to sending you patients, who send you a high volume of patients, they get used to your template. So those are the places that you might want to target and disseminate that template to them, since they usually have more stable staffing. They’re larger, they’re more structured, they have medical directors and all of that, that can disseminate all this information to the staff that this is what the university or the referral PICU usual information that they would need. Then after a while, the process gets faster, because they anticipate the information that you need and they’re able to give it to you. They know you’re going to ask for certain types of information for specific patients.

Dr. Madden: Okay, so this was a study that happened in one environment and now you’ve changed to a different facility. Were you able to have any changes in the study site or have you brought it and potentially had the opportunity to have changes implemented in your new institution?

Dr. Cifra: Right now, the research question really is, does structured communication for interfacility transport, as opposed to intrahospital handoffs, will it decrease medical errors the same way as intrahospital handoffs did? That’s the research question. Boston Children’s is not an ideal place to test it. We’re talking purely from the research standpoint, not from the operational or QI standpoint.

Since I-PASS was developed at Boston Children’s, everybody uses I-PASS. It’s quite natural here to just immediately go to the I-PASS structure when you’re handing off patients. What we’re doing right now is we’re trying to set up a trial to see whether this tool that we developed, the structured handoff program, we’re calling it I-PASS-to-PICU, to still allude to the I-PASS roots of the tool. I-PASS-to-PICU is this intervention that we’re hoping to implement in five or more hospitals. Then, similar to the I-PASS studies, measure if there’s any change in the rates of adverse events before and after the intervention is implemented.

I think one of the key things as well is, with this particular study that we’re discussing currently, we were able to pinpoint all the differences and similarities between I-PASS for intrahospital handoffs and what I-PASS will look like if we transfer it to the setting of interfacility transfers. We saw that there is a lot of focus on justification for ICU admission.

I think a lot of the tension that happens between referring clinicians and PICU accepting physicians is the triage piece. The PICU receiving physician is always thinking, does this patient belong in the ICU? Whereas the referring clinician is motivated to send that patient somewhere where they can get a higher level of care. What is really interesting when we are listening to these calls is that a lot of the focus early on in the call is justifying that this patient needs the ICU. So maybe the description is just a little bit sicker, the description of the patient is just a little bit extra.

A really significant finding, even before we finished the study, we actually made changes already to the ICU where we were looking at it, to ask the fellows to indicate acceptance as soon as they have determined that the patient is appropriate for the ICU. They’re just supposed to say, we’re happy to accept this patient. Once you say that, the pressure is off the referring clinician to convince you to accept the patient. Now you have a little bit more objective handoff in terms of what the patient actually looks like right now, what are the vital signs, and what the patient needs in terms of urgent therapy.

It’s the most striking example that I can give you in terms of the difference between intrahospital handoffs peer to peer and interfacility handoffs. In some ways, we needed to revise I-PASS and adapt it to that setting. And now we’re hoping to test it and hoping that it will show us the same effects in terms of decreasing adverse events as I-PASS did.

Dr. Madden: Okay. When do you hopefully anticipate that we’ll see that study result?

Dr. Cifra: We’ve actually developed the tool and it’s actually published. It’s in the Joint Commission journal. One of my fellows is the lead author, Nehal Parikh. She was the most amazing PICU fellow who headed this process. I’m the senior author on the paper. Here in this paper, we detail the development of the tool and how we went from interviews and focus groups of the multidisciplinary PICU staff and referring clinicians to see what information is needed and how the process should go.

Also, we based a lot of the development of this tool on these findings on this current study that we published in Pediatric Critical Care Medicine in terms of all the different considerations and adaptations to I-PASS that we would need to make it applicable for interfacility transfer. So it’s actually there. I would say that we did revise it a little bit more after we published it. The most revised version is what we’re testing for the trial, hopefully.

Dr. Madden: Okay. Well, we’re about out of time, but I have one final question for you. We know the referring institution, as you said, just wants to know you will accept this patient. Is it a process at a freestanding children’s hospital where you are now that the fellow will say, we will accept this patient under the caveat that maybe the further the discussion goes that they don’t require an ICU setting, but yes, they require an inpatient admission? How is that structured into the communication?

Dr. Cifra: There are admission guidelines for every hospital, including Boston, that the fellows are well versed on in terms of who belongs in the ICU and who belongs on the floor. We’re lucky that we have an intermediate care unit. A lot of the in-betweens and gray area patients can usually fit in the intermediate care unit.

I do think that, from this work that we did and all the other work that we’ve done listening to fellows is that most of the really skilled PICU accepting physicians, whether attendings or fellows, would just have a frank discussion about it with the referring clinician and say, I’m not really sure if the patient needs ICU care. They would explain that for sure the child needs to be admitted, for example, but we just need to identify when. And it depends on the hospital. Some hospitals would prefer that the patients go through the ED and the ED can lay eyes on the patient.

Sometimes if you have a well-organized and experienced transport team, the transport team, when they get there, they’re going to call you and also give you their assessment. So you can add that to all the information that you’re getting from the referring clinician, objective data, and from them, to decide further. So I think there’s a lot of flexibility in that process. And I don’t think that process needs to be opaque. It can be transparent to the referring clinician. I’m sure they would understand what we’re trying to do, just really trying to find the best place for this patient.

Dr. Madden: No, absolutely, I agree with you because, as an APP, I do some of these calls as well, and oftentimes on the premise they need the ICU and, as you said, trying to justify it, and the information, is it necessarily completely congruent? So, able to say that we’re accepting. Take that pressure off the referring provider and then have the capacity to say when the transport team gets there, it may be X period of time. And while we do the other interventions we’ve discussed, this child may or may not really require the ICU and they feel very comfortable with that.

I want to make sure if there’s anything else that you wanted to make sure the audience got to hear before we conclude.

Dr. Cifra: Yeah, thanks for giving me the opportunity, Maureen. I think, in closing, what I would say is that this is such a critical transition for the sickest of children that we care for. And I think it’s really important and high time that we pay attention to how information is transferred and how we create mental models of these patients across institutions.

I think it really matters for their care. It matters for the continuity of their care. It matters for the well-being and stress of their parents, for one. Just removing these silos that exist between our tertiary and quaternary care facilities and the community hospitals that first take care of these patients. We should all be working together to make sure that these patients go through their continuum of care as smoothly as possible.

Dr. Madden: I totally agree with you. And I really appreciate you taking the time today, Tina, to talk with me about this study. This concludes another episode of the Society of Critical Care Medicine Podcast. If you’re listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine Podcast, I’m Maureen Madden.

Announcer: Maureen A. Madden, DNP, RN, CPNC, AC, CCRN, FCCM, is a professor of pediatrics at Rutgers Robert Wood Johnson Medical School and a pediatric critical care nurse practitioner in the pediatric intensive care unit at Bristol-Myers Squibb Children’s Hospital in New Brunswick, New Jersey.

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