title: An analysis of messages sent between nurses and physicians in deteriorating internal medicine patients to help identify issues in failures to rescue.
abstract: To evaluate in patients who deteriorate and require transfer to the intensive care unit (ICU), how many have a critical text message communicating deterioration and what is the quality of this message? Is message quality, message response or the timeliness of rapid response team (RRT) activation related to death?
  
  
  
  We conducted a retrospective chart review of all ICU transfers from General Internal Medicine (GIM) wards from January 2012 until August 2014. All critical messages (CM) in the 48h prior to ICU transfer were analyzed for RRT calling criteria, time to RRT activation, message quality, presence of vitals, and the quality and timeliness of physician response.
  
  
  
  Of the 236 patients in the study, 93 (39%) had a CM in the 48h prior to ICU transfer. Within this subset, 76 patients did not have prior RRT activation and the median times from CM to RRT activation and CM to ICU transfer were 8.9 [IQR 2.9, 20.7] and 15.6 [IQR 9.0, 28.7] hours, respectively. Only 45% of messages contained 2 or more vitals and only 3% of messages contained Situation, Background, Assessment, and Recommendations (SBAR). Physician response was timely (3 [IQR 2, 17] min) but response quality was poor; nearly one quarter of responses only acknowledged receipt. Among message characteristics, only the number of SBAR elements was correlated with in-hospital survival (p=0.047).
  
  
  
  Communication between nurses and physicians about critically ill patients could be improved. There appear to be significant gaps in the quality of messages, their responses, and delays in RRT activation.
authors.affiliation: School of Health Policy and Management, York University, 4700 Keele Street, Toronto, Ontario, M3J 1P3, Canada.
authors.forename: Hannah J
authors.initials: HJ
authors.lastname: Wong
authors.affiliation: University Health Network, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.
authors.forename: Rachel
authors.initials: R
authors.lastname: Bierbrier
authors.affiliation: University Health Network, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.
authors.forename: Philip
authors.initials: P
authors.lastname: Ma
authors.affiliation: Institute for Better Health, Trillium Health Partners, 100 Queensway West, Mississauga, Ontario, L5B 1B8, Canada.
authors.forename: Sherman
authors.initials: S
authors.lastname: Quan
authors.affiliation: University Health Network, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada.
authors.forename: Sannie
authors.initials: S
authors.lastname: Lai
authors.affiliation: University Health Network, 200 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada; Department of Medicine, University of Toronto, 190 Elizabeth Street, Toronto, Ontario, M5G 2C4, Canada. Electronic address: robert.wu@uhn.ca.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Wu
mesh_terms: D016638:Critical Illness / Q000628:therapy*; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D033183:Interdisciplinary Communication; D007388:Internal Medicine / Q000592:standards*; D008297:Male; D008875:Middle Aged; D009741:Nursing Staff, Hospital; D019555:Physician-Nurse Relations; D010820:Physicians; D012189:Retrospective Studies; D060145:Text Messaging / Q000706:statistics & numerical data*
keywords: Communication; Deterioration; Intensive care; Mortality; Outcomes; Rapid response team