Handover and referrals

Occasionally being the recipient and chronically being the origin of incoherent handovers and referrals has made the author appreciate the competent delivery of a well-crafted structured monologue. This topic is embedded in the CICM syllabus as "Handover and referrals" from Section 2.2.1 in the second edition of the CICM Syllabus for the Second Part Examination. For this topic, as well as the rest of them, the candidates are expected to "discuss and demonstrate effective, respectful and empathetic, professional, culturally safe and patient/family centred communication skills". One might initially recoil from the idea of a handover or referral becoming culturally unsafe or unprofessional and disrespectful, but then on reflection, we will all remember something of the sort (perhaps with a twitch of PTSD). 

Where would information for something like this come from? CICM do not have a specific handover  guideline or policy document, which is odd because for a decent sized ICU with 12-14 complex patients, the handover between day and night teams might take 30-60 minutes, which means around 8% of each ICU day (and 16% of each trainee's day) is taken up by either taking or giving handover. There are statements to the effect of "your ICU should have a policy already" and generic non-ICU guidelines regarding appropriate handover processes can be seen in various official sources (eg. at safetyandquality.gov.au, "Communicating for Safety"). All of the official health bureaucrat documents tend to reference this AMA document or this NSW Health policy which have somehow become influential.

Definitions

Throughout one's training, the dominant perspective will usually be to view handover as a stressful process of displaying one's meagre mental commodities before the group of peers and seniors, during which one struggles against sleep deprivation to present half-remembered patient details which the day shift are perfectly capable of looking up themselves. However, that is not handover.

Handover is the transfer of information and of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis

- AMA 2006

So, it's only handover if it comes with accountability, otherwise it's just gossip. To incorporate the exchange of responsibility into handover is clever, because it implies the information exchange occurs as an aside to something rather more serious, i.e. you are not only being told about things, but you are also being expected to act on them, to continue the uninterrupted care, and to otherwise take ownership of the situation which you acknowledge you have now inherited.

Principles of handover

Question 3 from the second paper of 2024 asks for principles of handover, which is a meta subject separate from the content of the handover. The chronically disorganised person may find it remarkable that handover should have some kind of distinct principles, or that these should be sufficiently well-established that they might appear in high-stakes exit exams for ICU specialists, but this is fact.  These are not exactly scientific (handover is not a law of physics), but many readers will be familiar with local policies and procedures, such as this NSW Health policy, that confidently list "the seven (7) key principles" that "provide a framework to guide the structure and process for safe clinical handover". These seven imperatives are listed here as canonical:

Where did these principles come from, one might ask. There might be, on first inspection, no obvious burning bush from whence these commandments might have emanated. The "principles" seem to emerge spontaneously in pages like this one, which are not tagged with any specific author. A faceless committee must have created them, one might surmise; or they formed spontaneously, like crystals, from the condensation of major historical mishaps. For example the directive to have dedicated time and space, as well as to document the occurrence of a handover, seem to come from The Garling Inquiry.  Similarly, Bomba & Prakash (2005) reviewed the practices of handover at Woolongong Hospital (at that stage a modest 270 bed facility) and made some observations ("unstructured, informal and error prone") that suggested a more controlled process was called for;  the invective from Miller (1998) recommended it extend in multidisciplinary directions; and some coroner reports have offered opinions about leadership and the need to minimise distractions. 

So, if these principles are created on the basis of Notable Things that Went Horribly Wrong, or on the basis of good positive examples, then where might one find an itemised list of such things? Nowhere it seems. There are citations, and the motivated person who pursues lines of bibliography to their origins will eventually come across things like Wong et al (2008), an exhaustive 114-page document compiled by two eminent communications scholars and a gastroenterologist for the Australian Commission on Safety and Quality in Health Care, or the the 2016 document "Safe handover: safe patients" from the AMA (which was in fact lifted almost entirely from the BMA document by the same name). These documents are interesting, insofar as they represent an idealised version of the kind of work environment most practicing clinicians would only recognise from their dreams. For example, statements such as "includes all grades of staff from each included specialty", "teams from all units should attend" and "the involvement of senior clinicians is essential" can provokes only bitter laughter from people whose daily experience of medicine features massive sprawling hospitals.  It is, however, difficult to argue with the positive potential of an idea where everyone comes together to listen to the same exchange of information.

It does not help that other authors, performing literature reviews presumably of much the same literature, have created some completely different principles. Are these to be regarded equally valid? Considering that nothing especially scientific has gone into formulating them, their validity is probably derived from the authority of their maker, or from the scope of their acceptance and popularity, or from their incorporation into government-funded framework documents. One could conceive of a Council of Nicea type situation where the ACSQHC piled all the competing documents on an altar and included only those that did not fall off, explaining that the spirits of Quality and Safety preserved divinely inspired works on the pedestal and permitted the spurious and heretical to fall over the edges. The floor of that chamber would have therefore been littered with the following:

From this, the reader must derive the only possible conclusion; that people publish handover principles as an almost involuntary reaction to becoming appointed as a quality and safety officer. Certainly the wide variation in espoused principles does not help the credibility of any single set of principles. Also unhelpful is the fact that none of these have been tested for efficacy, at least outside of extreme internal parochialism (eg. "our study found the MEH-SBAR mnemonic reduced the volume of junior nurse tittering outside of Matron Susan's office by 34%"). Perhaps the only serious data in this scene comes from a NEJM paper from 2014 (Starmer et al) who presented data from over ten thousand patient admissions collected in nine paediatric residency programs across North America. The authors used an exhausting-sounding I-PASS Handoff Bundle, which included such corporate training favourites as "a computer module to allow for independent learning", "a 1-hour role-playing and simulation session", "a logo, posters, and other materials", " and "a 2-hour workshop ... to teach TeamSTEPPS teamwork and communication skills". Though the study measured several variables which could not have helped but to improve (eg. the increased inclusion of the protocol elements in the handover was pretty much inevitable), this intense intervention did reduce the rate of preventable adverse events by 30%, which is a substantial amount. 

Referall

That referral has been included in this syllabus item, and that it has been separated from handover ,  suggests a deliberate attempt to make the trainees think about the communication process where the information is exchanged without all of the care responsibility - only a part is shared. To be precise, referral involves transfer of care only "for a defined time and particular purpose". 

 For the majority of CICM trainees the process of referral will consist of receiving and sending these communications between specialist services, whereas most of the literature tends to focus on referrals made by primary care/community practitioners to specialists (for the reader with abundant time resources, the excellent 1988 paper by Marshall Marinker will reveal this process for the anti-competitive cartel behaviour that it is).  It is not clear whether by "referral" the syllabus document is concerned with referral to the ICU, or referral by the ICU, or both. The former is studied to death and would have much material to explore, whereas the latter is markedly underinvestigated by comparison. The Australian model typically involves a CICM-trained intensive care specialist as the leader of the medical team involved in the patient, with the admitting specialist service in a consulting role, which leads to to a different pattern of referrals than would occur in an open ICU system such as what was described by Lee (2002) and Mehta et al (2002). Bang et al (2021) found that intensivists referred more frequently to psychiatry, rehab and ortho, and less to respiratory, cardiology and renal.

What are CICM trainees expected to know about this? The raw syllabus entry reads "discuss and demonstrate effective, respectful and empathetic, professional, culturally safe and patient/family centred communication skills" which is unhelpful from the perspective of deliberate exam-focused practice.  Attempting to predict what might be relevant by reading beyond the raw untreated syllabus entry, one might conceive of some questions based on the CICM exam vocabulary. For example, aA "critically evaluate" type of question on this subject might read something like "critically evaluate the role of specialist referrals made by ICU", and would resemble Question 24 from the second paper of 2022, which asked about the role of palliative medicine consultation.

Thus:

• Rationale for external specialist consultation in ICU
  • A closed ICU model puts an intensive care specialist in a leadership position, to provide comprehensive care
  • ​​​​Increased complexity of care for critically ill patients makes it impossible for the intensivist maintain expertise in all subspecialist areas
  • A multidisciplinary multi-specialty approach to care is practiced elsewhere in the hospital, and it would be logical for this to also extend to the sickest patients
  • Ergo, ICU patients require specialist consultation
• Advantages of external specialist consultation in ICU
  • The increased complexity of care for critically ill patients recommends an approach of distributed decisionmaking, to reduce the burden on ICU staff
  • Some decisions, eg. those that relate to ongoing specialist care that is expected to continue beyond the walls of the ICU (eg. the management of diabetic medications) can be outsourced to external non-ICU services, with the argument that patients staying in ICU for a short period of time, whereas the specialist service will continue to care for them longitudinally.
  • Some specialist intervention (eg. surgery, interventional radiology) cannot be accessed except through referral
  • Some specialist interventions (eg. chemotherapy, electroconvusive therapy, radiotherapy) are beyond the remit of intensive care training, and require specialist referral to initiate
  • Under certain circumstances, second and third opinions from specialist services can help reinforce the validity of the diagnosis or prognosis (eg. hypoxic brain injury where the acceptance of the poor prognosis by the survivors may require it)
• Disadvantages of external specialist consultation in ICU
  • Boundaries for the shared model of responsibility are not clear; it is impossible to know who is responsible for the patient if there are adverse events
  • The responsibility for integrating inputs from consulting specialist services remains with the intensivist, which does not help reduce the cognitive burden
  • It is not clear how to resolve conflicting advice from specialist services, or how to resolve competing priorities, except to concentrate the responsibility for decisionmaking with the intensivist
  • The number of referrals generated per patient may be considerable, resulting in significant communication workload
  • The involvement of multiple teams in the care of one patient can lead to disagreement and increased workload in managing the impact of diverging opinions on the patient's perception on their care, and on the understanding of events and choices by the patient and family 
  • Consultation begets consultation which may result in the undesirable or wasteful overinvolvement of specialist services (Stevens et al, 2013)
• Evidence regarding external specialist consultation in ICU
  • Little evidence exists to direct decisions in this area
  • Observational data suggests that, though the pattern of referral changes, the total volume of referrals in the ICU does not change with the introduction of a closed model (Bang et al, 2021). 
  • Some evidence exists that early referrals to specialist areas improve patient outcomes (Mehta et al, 2002).
  • Good communication is key, and knowing the rationale for the consultation can leave bedside staff and families with a better satisfaction Roche et al (2019)
• Own practice statement
  • Something like "I will consult external services for other specialist expertise to collaborate on the care of complex critically ill patients, or to ensure the follow-up of routine maintenance therapies"