Shared Decision-Making About Inter-ICU Transfer

First Author(s)

• 

  Joseph Flynn

  Resident Physician
  n/a

  Disclosure information not submitted.

Co-Author(s)

• 

  Stephen Mitchell

  Resident
  Atrium Health
  Charlotte, North Carolina

  Disclosure information not submitted.
• 

  Stephanie Taylor, MD, (she/her/hers)

  Wake Forest School of Medicine
  Charlotte, North Carolina

  Disclosure information not submitted.
• SC

  Shih-Hsiung Chou, PhD

  Senior Data Scientist
  Atrium Health, United States

  Disclosure information not submitted.
• BT

  Brice Taylor, MD, MS

  Associate Professor
  Atrium Health, United States

  Disclosure information not submitted.

Title: Shared decision-making about inter-ICU transfer

Introduction:  Inter-intensive care unit (ICU) transfers comprise an estimated 5% of all ICU admissions, but no best-practice guidance exists for decision-making about which patients should undergo transfer. Evidence shows that communication around the transfer decision is poor. We evaluated the frequency of documented shared decision-making (SDM) about inter-ICU transfer and group differences between transfers that involved SDM and those that did not.

Methods:  We retrospectively evaluated 158 patients received in transfer to our tertiary care center between 2014 and 2017. We conducted a granular chart review including progress notes, nursing notes, family meeting notes, transfer notes and discharge summaries to identify whether the patient or family had been involved in the decision to transfer. We used descriptive statistics to report frequencies of shared decision making and chi-square tests to assess for group differences.

Results:  Of 158 patients received in transfer, 20 (13%) had documentation of SDM about the decision to transfer. In the remaining 138 (91%) there was no documentation of patient or family involvement in the transfer decision. Patients with documentation of SDM more frequently had cardiac and hematology/oncology conditions whereas patients without documentation of SDM more frequently had GI bleeding, stroke, and trauma (p=0.008). There was no difference in reasons for transfer (i.e., procedure, specialist, higher level of care) among patients with documented SDM and those without (p = 0.26). Although there was no difference in SDM documentation between patients admitted from a skilled nursing facility (SNF) versus home (P=0.86), none of the patients who had documentation of SDM prior to transfer were admitted from a SNF. Of 10 patients who were not full code prior to transfer, only 3 (30%) had documentation of communication or shared decision making about the decision to transfer.

Conclusions:  The decision to transfer ICU patients is not benign and should incorporate patient and family preferences when possible. Although SDM prior to transfer may be challenging for time-sensitive conditions, improved approaches to eliciting patients preferences and aligning transfer decisions with their preferences is imperative to achieving patient-centered and high-value care.