Perceived facilitators and barriers to high-quality transfers from ICU to hospital ward, identified by providers
| Theme and subtheme | Facilitators | Barriers | Quote |
|---|---|---|---|
| Resource availability | |||
| Staff availability | Ward | “What works fairly well is that we as a hospital group are available on a 24-hour basis and we have a good working relationship with the ICU physicians.” Ward provider (Interview 1) | |
| Material resources (e.g., beds, medical record) | Ward | ICU and ward | “… not uncommon situation will be it’s a crunch for beds in the ICU and the ICU fellow (fourth- or fifth-year resident) will call the internal medicine senior (second- or third-year resident) in the evening and say listen we have got this patient here in ICU you have got to come here and transfer them.” Ward provider (Interview 30) |
| Duration of transfer process | ICU and ward | “We tee up the transfer by doing the discharge summary, contacting a service to accept the patient, agreeing on the transfer, and that’s kind of the process. The part that is more variable is that after someone says I accept [the patient] there is often a long delay before they leave the ICU, so that is the part I guess I have less control over or where I feel much can get lost. Because there is a period of time where the patient is physically still under my care but the decision-making is more shared then.” ICU provider (Interview 28) | |
| Timing of transfer (e.g., shift change, at night) | ICU and ward | “Sometimes on my end I have two patients. If somebody is stable enough to be transferred out, I don’t have a whole lot of time to spend with them. I have to get back to my station or if I have an admission waiting in the emergency department than you know, I feel pressed for time.” ICU provider (Interview 22) | |
| Transfer tools | ICU and ward | “At our site we have a transfer record form that details patient name, age, goals of care and certain standard things that should be done and that you should be telling the other nurse so when people from ICU use that and follow along that really well, we really get to know a good picture of the patient. Those are the most successful transfers, when both teams use that form.” Ward provider (Interview 21) | |
| ICU follow-up post transfer | ICU and ward | “We have a medical emergency team that follows up with all of the patients being discharged from ICU just to make sure that the unit has support, that they know if they have questions or if the patient all of a sudden becomes more ill they call the medical emergency team. So it’s a nice bridging program.” ICU provider (Interview 3) | |
| Communication | |||
| Multipronged (e.g., multiple v. singular [or no] forms of communication used) | ICU and ward | ICU and ward | “I think multiple forms of communication need to happen for there to be a well-rounded transfer of care. It’s my expectation that if I am on service [the ICU team] would communicate verbally and in a written note or text message.” ICU provider (Interview 26) |
| Communication between most responsible team members (e.g., attending to attending v. trainee to trainee) | ICU | ICU and ward | “The ultimate report I get about the patient is from my junior resident who has no idea what is going on. They do their best but they don’t really have a good sense of the patient’s trajectory and the major issues and so on. As the internist who is going to take care of the patient, I don’t ever get to talk to someone who actually knows the patient well.” Ward provider (Interview 30) |
| Interprofessional (e.g., communication across professions v. within professions) | ICU and ward | ICU | “I would also let the [receiving nurse] know that outreach was aware of the discharge and that they would follow up with them and that they could call back. I would give them my name and they could call back if they had any questions.” ICU provider (Interview 14) |
| Availability of patient information at point of transfer | Ward | ICU | “… due to the rotational nature of our work, the physician who actually receives the patient may be a different physician [than the accepting physician], and the intensivist at the time of transfer may be different [than the sending physician]. The patient may be transferred in the evening when somebody’s on call and covering. Familiarity is somewhat limited.” ICU provider (Interview 31) |
| Institutional culture | |||
| Patient- and family-centred care | ICU and ward | “We kind of let the families know [about transfers of care] as an afterthought, or the family will call us and we will say oh yeah sorry we transferred that patient.” Ward provider (Interview 29) | |
| Professionalism | ICU | Ward | “… some of the doctors are not willing to do a transfer note. And that does create difficulty for us because we don’t necessarily have the time to dig through every page of the chart to discover what events have transpired and what the decision process was.” Ward provider (Interview 1) |
| Importance placed on transfer by care team | ICU and ward | “People argue that it’s [having sending and receiving teams conduct in-person transfers] impossible because of busy schedules etc., but we need to say no, transfers are a critical component of the care of patients. This is a goal that we should aspire to.” ICU provider (Interview 18) | |
Note: ICU = intensive care unit.