Viewpoint 

May 27, 2025

Optimizing Safety for Patients Transferred From Intensive Care Units to General Medical Wards: A SIMPLER Approach

Donald A. Redelmeier, Barbara Haas, William K. Silverstein

JAMA Intern Med. Published online May 27, 2025. doi:10.1001/jamainternmed.2025.1497

Most patients admitted to an intensive care unit (ICU) survive.¹ A patient, of course, does not return to health instantly even when vasopressors, ventilators, and other invasive technologies are no longer necessary.² This means many need recovery time on a general medical ward (or other de-escalated care settings, such as a step-down unit) for observation, treatment, and discharge planning. These transitions of care can be fraught with pitfalls despite clinicians’ best efforts to ensure safe seamless transfers, particularly if the ICU is a closed unit where the critical care team differs from the ward team.³ The purpose of this Viewpoint is to highlight selected pitfalls and introduce a checklist to support safe ICU transfers of patients to medical wards or step-down units.

Selected Pitfalls

ICU patients are complex and typically require significant effort by a receiving physician for a thoughtful review. This is especially true for patients with long stays, for example, who have received many interventions for many complications. A further cognitive challenge involves identifying and interpreting multiple diagnostic test results that may have accumulated. In addition, some standard ICU interventions are disallowed on a medical ward or step-down unit and need to be scrutinized and stopped on transfer (eg, arterial catheters, systemic vasopressors, hourly urine output monitoring). Together, the demands on the receiving physician can be substantial for understanding a case and devising optimal management.

Transitions of care reflect judgment under uncertainty and also face the risk of unwanted error. For a medical ward patient discharged home, this can mean an unexpected deterioration that leads to an unplanned readmission. For an ICU patient transferred to a ward, this can mean an unanticipated death or return to the ICU (in some cohorts, 1 in 8 transferred patients require ICU readmission).⁴ While clinical judgments are often correct, error can have uneven consequences since transfers judged accurately go relatively unnoticed whereas transfers judged incorrectly may lead to harsh scrutiny. Unfortunately, decision rules for gauging prognosis are in their infancy without the precision needed to resolve tough cases.

A related barrier involves handling dissent and disagreement between ward and ICU physicians. Honest differences of opinion are inevitable, such as judging readiness where one physician may underplay severity whereas another can fear the worst. Sometimes such differences spur a thoughtful dialogue that improves patient care (eg, ICU outreach team for follow-up); however, debate sometimes results in unprofessional views on another physician’s judgment.⁵Patient and family preferences can also fuel disagreements since some are reluctant to leave an ICU due to fears of reduced monitoring, lost ties to familiar personnel, and moving to an unfamiliar hospital location. Clear communication helps facilitate transfers yet no natural pathway is available for conflict resolution around difficult cases.

Potential Checklist

Simplified checklists are common in aviation safety and a few medical settings, including surgery and obstetrics. The theory is that a checklist reduces the risk of forgetting basic details or being distracted by tangential points when facing complexity. A checklist can sometimes also enhance efficiency, improve safety, promote consistency, ease communication, highlight expectations, and help learners understand priorities.⁶ Downsides of a checklist include oversimplification, misalignment to the task, and faulty integration with workflow. Most checklists are based on experience, strive for simplicity, convey face validity, and are initially based on experience. The effectiveness of a checklist inevitably depends on pitfalls prevailing in usual practice.

Here, we propose a 7-step checklist to enhance safe ICU transfers. We use the mnemonic SIMPLER—stable vital signs, intact aeration, medications reviewed, prepared psychology, lingering catheters, extreme laboratory findings, and return plans—to identify steps and ease recall (Table). The first 3 steps are prerequisites in a medical ward and denote the importance of stable vitals signs, intact aeration, and a diligent medication check. The next 3 steps are priorities in the ICU and involve determining patient expectations, managing catheters or other devices, and reviewing laboratory results. The final step concerns contingency plans for unforeseen deteriorations and goals of care. These steps reflect more than 60 combined years of experience with ICU transfers, and refinements are welcome.

The intent of a checklist is to lessen the risk of a mistake in stressful situations by preventing added error from overlooking an ancillary essential. For the SIMPLER checklist, each step is sensible and agreeable to generalists and intensivists, thereby providing some common ground of shared understanding of best practices. Each step is objective, available, and relevant, thereby identifying important issues that can be decided quickly. Each step is relevant to every ICU transfer, thereby offering some comforting initial routine when encountering an otherwise challenging case. Each step requires minimal technology and is feasible in limited-resource settings. As such, the SIMPLER checklist might be a helpful nudge ahead of addressing specific pitfalls arising due to complexity, uncertainty, or dissent.

The main limitation of the SIMPLER checklist is the absence of a clinical trial testing its effectiveness for safe ICU transfers. An individual randomized trial might be ideal, yet the feasibility of enforcing individual assignment is challenging since each step is already available to clinicians, enthusiasts will adopt intuitively, and naysayers cannot be forced. In addition, obtaining funding, achieving blinding, ensuring adherence, and adapting to patient diversity can be further methodologic barriers for a randomized trial.⁷ Similar to many initiatives for quality improvement, therefore, the SIMPLER checklist is a clinical tool that can be taught, learned, refined, retained, and tested with a future cluster randomized trial or other pragmatic research design.

Summary

This Viewpoint discusses potential pitfalls for safe ICU transfers of patients to general medical wards. Each pitfall is connected to clinical behaviors that might be helped by awareness and an easy checklist of necessary minimums. Specific corrections, of course, depend on circumstances, the responsible clinicians, and the nuances of a specific patient. A lack of an organized approach, in contrast, serves only to worsen ICU congestion and compromise communication. An awareness of pitfalls around safe ICU transfers does not make them vanish but may help so that they are not demonized, denied, or dismissed as flukes. A checklist for safe ICU transfers, we suggest, might be one way to help clinicians to reduce some risk and improve patient outcomes.