SCCM Pod-529: Bridging the Gap: Communication During Sepsis Transfers
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This podcast is funded by the Gordon and Betty Moore Foundation through a grant program administered by the Council of Medical Specialty Societies. 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 Pollan Distinguished Professor and Division Director of Pulmonary Allergy and Critical Care Medicine and Sleep Medicine at Emory University. He is an international authority in critical care medicine and an expert in sepsis, COVID-19, and ARDS. Having conducted groundbreaking clinical trials in these conditions, co-authored the Sepsis 3 Definition

and published criminal papers for diagnosing and treating critically ill patients. Dr. Martin served as the president for 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?

I don't. And thanks, Kyle. It's great to be here. So 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?

It's a great question. And 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. And 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. And

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.

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? That's correct. So 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, maybe 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. Because 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. So 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's 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.

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. That's right. Exactly. 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?

Now, 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 where 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 in 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? And what did you learn about that letter? What way do they want to receive that feedback? Yeah,

Yeah, most people, there's 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. And I think the fact that those both appears 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 wanted to make it easy and useful.

In terms of when they receive it, that was another element that was really interesting. So 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.

sometime relatively early in the hospitalization. And 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 could think about what happened on the early end. But most people wanted it relatively early, sort of in 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.

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 app, I can imagine getting a lot of, you know, they're not here today or, you know, 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?

Yeah, a lot of it was around personal or quality improvement. They certainly wanted to know, for instance, was the diagnosis correct? And also, were there things that maybe have been missed, but maybe just things that could have been done in a more timely manner? So, for instance, if the patient arrived into the ICU and 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 and 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.

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 where there were opportunities for improvement from where we saw the patient as the referring clinician to later in that receiving space as the receiving clinician. And what about from the receiver's standpoint? What did you find out about that group of people and how they felt about feedback?

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. And for some of the things we were just talking about between schedules and priorities, how do you make that work smoothly? So 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

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 into your unit?

And any speculation on how we might make this easy for the ICU doctor receiving the patient? I know, you know, at UVA, we've often been asked, you know, can you send a note to the ER physician who admitted this patient about the diagnosis? But also, you know, 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? Yeah.

Yeah, that's a good question. So part of what we were doing this survey for was to think about that exact question is how often do people want feedback? What's their experience with feedback? And how would, for instance, it work best? And 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

their 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 intra-hospital 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's 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. You've got to make it useful and adaptable for a variety of different health settings or where people are working.

So 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? So we use 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.

So 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. So now the next step is much more around implementation. How do we take what we've learned and begin to make changes?

And some of that might be piloting in different health systems, right? So 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. And how do you get individual feedback from one person to another, particularly if they're working shifts that aren't synchronous? So there's 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. So 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 in a few, at least as a pilot, a few different health systems where they have an interest in this and would be eager to test it.

So is that something that STCM as a whole will be taking on? Is that a research project that will be led out of Emory in some way? So this is definitely a team project and it's not all Emory. And there's other people as part of the team. For instance, Tina Seifra at Boston Children's was another part of this team. STCM has been the convener and certainly has had for many, many years.

a strong interest in sepsis. And this initiative really came out of the Council for Medical Specialty Societies, who has really focused a lot in the last few years on diagnostics and diagnostic dilemmas and misdiagnosis. And we realize that sepsis is one of the most common of those, certainly in our setting, in our patients. So putting all those together, SCCM has been the driving force behind a lot of that.

And 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.

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? 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.

And that, 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. And we often think of critical care as the quintessential care team.

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

We didn't really focus as much on barriers. We 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, come down to, and we didn't survey specifically, but often come down to the methods that would be used. And 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.

Yeah, I was sitting here contemplating how, you know, when I go on to 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, you know, good feedback that's meaningful to the person receiving it? And when would I do that? But so I'll have to think about that. And then 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 you.

and using the toolkits when they come out. This will conclude another episode of the Society of Critical Care Medicine's 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. 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, M.D., 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 slash podcast.

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