Complete and timely communication between health care providers is integral to seamless transitions in care [1-3]. The transfer of critically ill patients from the intensive care unit (ICU) to another patient care unit (PCU) is a particularly vulnerable period in patient care, due to the high acuity of patients [4-6] as well as the number of health care providers involved and their professional diversity [7-10]. The movement of patients between units requires a high degree of collaboration, with verbal and written communication between health care providers [1-3] as well as patients and families [1,11-13]. Suboptimal communication during transitions can have profound implications for patients, families, and the health care system [14-16], including increased risk of preventable medical errors, adverse events, redundant testing, readmissions, and dissatisfaction with the quality of care [17-24].

An ICU transfer summary is a clinical document that ICU physicians and nurse practitioners (NPs) often prepare to describe a patient’s stay in the ICU, including active and resolved health issues and the current care plan. The transfer summary is intended to support verbal communication between transferring and accepting medical teams and should provide sufficient detail to serve as a stand-alone communication [25]. Complete and timely exchanges of patient care information during transitions in care are critical, not only for immediate continuity of care but also for efficient coordination of future care [26,27]. As such, the transfer summary should be easily accessible to inpatient and outpatient health care providers as part of the patient’s permanent health care record.

Standardized transfer protocols that structure documentation are integral for preventing failures in patient care due to incomplete and delayed exchange of information [21,28-30]. However, their value can be limited by the very methods used to produce the document. While quick for the clinician to prepare, traditional methods like dictation or handwritten notes in the patient chart have been associated with inaccurate, incomplete, and lengthy delays in communication [17,20,31,32], particularly in comparison to transfer summaries prepared using electronic standardized tools [26,33-39]. The advancements of clinical information systems (CISs) and integrated electronic medical records (EMRs) provide a prime opportunity to optimize text-based communication. Structured templates can facilitate completeness of important patient information as well as substantiate and prompt verbal communication between health care providers at the point of care. They can also provide flexibility, permitting physicians to create a “living” document that can be edited over the course of stay and finalized at the point of patient transfer, effectively facilitating clinical workflow in complex settings. Despite the potential for optimizing efficient interprovider communication, the use of standardized tools to prepare ICU transfer summaries has not been widespread, with factors such as usability [39], cost, and workload [40] being barriers to adoption.

In 2017, we began designing an evidence-informed, computer-enabled, ICU-specific communication tool in the primary, integrated patient care CIS—Sunrise Clinical Manager (Eclipsys Corporation)—used in four acute care hospitals in a single Canadian city. This work was initiated as a quality improvement project to improve upon the conventional system of dictation that physicians and NPs—herein called ICU clinicians—use to prepare medical transfer summaries for ICU patients [41]. To dictate a summary, ICU clinicians use eScription, 2010 release (Nuance Communications), a health information management dictation, speech recognition, and transcription (DST) platform. The clinician verbalizes relevant patient transfer information to create a voice file that is run through speech recognition software to create a text report. The report is then edited by a transcriptionist and sent to the designated ICU clinician for approval before being uploaded for electronic viewing in the CIS as well as to a provincial, web-based health data repository accessible by community-based physicians (Alberta Netcare).

The content and structure of the ICU electronic transfer (e-transfer) tool was based on a national survey of existing transfer summary tools [42], subsequent consensus-based recommendations of two independent multidisciplinary groups of health care providers [41,43], and a heuristic evaluation [41]. The e-transfer tool consists of 10 overarching document sections: visit data, goals of care, allergy and intolerances, diagnoses and visit issues, course in ICU, investigations, medications, discharge to home or community, send copies to, and completion. These sections are designed with a user interface combination of structured fields (eg, checkboxes); automated fields, which pull in relevant patient data from other CIS locations; and free-text fields (see Figure 1). The tool permits ICU clinicians to open an ICU summary as a clinical document directly in the patient’s EMR and edit the summary over the course of the patient’s ICU stay. As with the DST system, the designated ICU clinician must approve transfer summaries. The summaries remain in the CIS and are uploaded to the provincial repository.

In a small pilot test of the e-transfer tool in one ICU [42], electronic summaries had a significantly greater proportion of essential information fields completed overall (median 87.5%) than those prepared by dictation (median 62.5%) and were available to receiving teams closer to patient release (2.3 versus 45.0 hours). Primary users of the e-transfer tool also responded positively to its use, establishing favorable evidence to scale up implementation across additional municipal hospitals.

In this study, we will evaluate the effectiveness of the ICU e-transfer tool for improved completeness and timeliness of transfer summaries and reduced adverse patient outcomes by comparing transfer summaries produced postimplementation to those produced preimplementation.

We will apply the Donabedian three-pronged model of health care quality (ie, structure, process, and outcome) [44] and the National Health Service Sustainability Model [45] to frame our evaluation of the e-transfer tool. The Donabedian model has been successfully used in multiple contexts to support quality improvement initiatives related to structures (ie, health care context), processes (ie, actions and events in health care), patient outcomes (ie, effects on health status, quality, knowledge, or behavior), and use of resources [46,47]. Similarly, the National Health Service Sustainability Model has been successfully used to predict the likelihood of sustainability for improvement initiatives [48]. In drawing from each of these models, we will ensure that we identify areas that need strengthening and that we are well positioned for sustainability and continual improvement.

This evaluation study takes place in four acute care hospitals servicing a single city, Calgary, Alberta, Canada, which has a referral population of approximately 1.7 million. Three of the four hospitals are academic hospitals operating a combined 56 adult medical-surgical ICU beds; the fourth is a nonacademic, community-based hospital operating 10 ICU beds. The annual ICU admission rate across the city approximates 3000 patients. In addition to the CIS hosting the e-transfer tool (ie, Sunrise Clinical Manager), all ICUs also use a dedicated provincial critical care CIS (ie, eCritical MetaVision) and clinical analytics system (ie, eCritical TRACER) that capture key demographic, clinical, health care service, and outcome data for all ICU patients [49]. ICUs are staffed by multidisciplinary teams; those in academic-based hospitals operate with a clinical fellow and 4 to 10 residents working under the supervision of an attending physician. One ICU has an NP. Critical care resident rotation blocks are 4 weeks in duration. The community-based ICU functions with an attending physician and 4 NPs.

This study uses a cluster-specific pre-post trial design with randomized and staggered implementation of the e-transfer tool across four hospitals.

The e-transfer tool has been sequentially implemented into the four study hospitals at a new site every 2 months. This occurred between July 2018 and January 2019. The study biostatistician (AS), who was not involved with clinical practice in the ICUs, randomized the order of hospitals for implementation. Dictation remained available after implementation, but the ICU e-transfer tool was endorsed as the primary method to prepare ICU transfer summaries; as well, use of the tool was supported with strategies that have been successfully used in previous local initiatives, including in-person and web-based education, point-of-care support, and electronic audit and feedback [50].

ICU patients from the four participating hospitals were eligible for inclusion in the study if the patient (1) was admitted to the ICU during the defined pre-post periods; (2) was 18 years of age or older; (3) had an ICU stay equal to, or longer than, 24 hours; and (4) was transferred from the ICU to an in-hospital PCU. Patient admission lists were extracted retrospectively by a data analyst with the critical care CIS repository (ie, eCritical TRACER). As the primary creators of most ICU transfer summaries [42], NPs and residents were invited to participate in a brief survey soliciting their experience creating transfer summaries.

The University of Calgary Conjoint Health Research Ethics Board reviewed this study (No. 17-2317) and granted a waiver of consent to collect retrospective data from relevant sections of patients’ paper medical records and EMRs. ICU clinicians who submit a survey will have implied their consent. Operational approvals and a data disclosure agreement was established with the provincial health custodian, Alberta Health Services. All protocol modifications will be reviewed by our research ethics board before being implemented. The trial was registered at ClinicalTrials.gov (NCT03590002).

The ICU e-transfer tool was designed to improve and standardize textual communication between clinicians during transitions in care from the ICU to other PCUs. The number of individuals who experience and recover from critical illness in their lifetime is steadily increasing. The proliferation of life-sustaining technologies has resulted in new challenges with transitions in care of newly vulnerable critically ill patients. We have documented significant gaps in continuity of care for ICU patients, one of the most clinically high-risk groups in the health care system [25,32]. The evidence-informed ICU e-transfer tool that we have developed and will evaluate can potentially optimize care across the health care continuum by mitigating communication errors and adverse events and contributing to improved experiences and outcomes for critically ill patients. Our evaluation will identify how the tool performs, what elements are effective, and what elements are ineffective and need to be refined or eliminated.

This research will build a foundation for addressing an identified priority gap in patient care by rigorously evaluating a standardized electronic tool that will be adaptable to individual settings and scalable across health care jurisdictions. The study findings will add to the current literature on the effect of computerized tools on reducing communication breaks between the ICU and other PCUs during transitions in care and to ultimately improve patient safety.