How do critical care nurses define the discharge planning process?

A qualitative study portraying nurses' perspectives on transitional care between intensive care units and hospitals wards

INTRODUCTION

The transition process from the intensive care unit (ICU) to hospital ward may impact the illness trajectory and compromise the continuity of safe care for ICU survivors. ICU and ward nurses are involved with the transition and are responsible for the quality of the transitional care.

AIM

The aim was to explore ICU and ward nurses' views on assignments in relation to patients' transition between ICU and hospital ward.

METHODS

We conducted a qualitative study with 20 semi-structured interviews with ICU nurses and ward nurses and analysed data by content analysis.

SETTING

A university hospital with 690 beds and an 11-bed mixed medical/surgical ICU.

FINDINGS

The overarching themes were (1) 'Ritual of hand over' with the categories: (a) 'Ready, able and willing', (b) 'Transfer of responsibility' and (c) 'Nice to know versus need to know' and (2) 'From lifesaving care to rehabilitative care' with the categories: (a) 'Complex care needs persist', (b) 'Fight or flight mode' and (c) '"Weaning" the family'. Nurses were highly focused on the ritual of the actual handover of the patient and discussed readiness as an indicator of quality and the feeling of passing on the responsibility. Nurses had different opinions on what useful knowledge was and thus necessary to communicate during handover. Although patients' complex care needs may not have been resolved when exiting the ICU, ward nurses had to receive patients in a setting where nurses were mostly comfortable within their own specialty - this was worrying for both type of nurses. Patients could enter the ward very exhausted and weak or in 'fight mode' and demand rehabilitation at a pace the ward was not capable of delivering. ICU nurses encouraged families to be demanding after the ICU stay, and ward nurses asked them to trust them and steep back.

Challenges of the patient transition process from the intensive care unit: a qualitative study

Background

The transition of patients from the intensive care unit (ICU) to the general ward is challenging. This study aimed to explain the challenges that patients face during the transition process.

Methods

In this qualitative research of conventional content analysis, data collection was conducted between February 2018 and July 2019 in educational hospitals. After obtaining informed consent, purposive sampling was performed with 22 nurses, intensive care physicians, anesthesiologists, and patients and their families using in-depth semi-structured interviews until data saturation.

Results

The content analysis yielded three main themes in the challenges patients face during the transition process from the ICU: mixed feelings regarding transition (happiness/hope, worry/uncertainty, abandonment); care break (different atmosphere, the difference between the program and the quality of care, assigning care to the patient and family, and care culture and beliefs); and search for support and information (ineffective communication, self-care capacity of patient and family, ineffective and disrupted training, and weak follow-up programs), which inflicts care shock in the patients.

Conclusions

The results showed that patients and their families were in a state of care shock during the ICU transition process and were sometimes disconcerted. It is necessary to design and implement care models according to the needs and challenges patients face during the transition period from ICU (patient-centered), based on the evidence available, and after considering the field of medicine and the accessibility of care in the country. The transition process can be improved and enhanced by obtaining knowledge about ICU care and related challenges as well as organizing a learning environment.

The Analysis of the Influencing Factors related to the Effectiveness of Discharge Planning Implementation in Hospitals: A Systematic Review

Introduction: Discharge Planning is one of the agendas that is a part of nursing duties. This is not only complicated but it is also a long-term activity, starting from when the patients are admitted to hospital until they are allowed to go home. Factually, it cannot be denied that effective nursing discharge planning implementation will provide benefits for the patient, their family and the professionals within the health care setting. Based on those facts, the author composed this systematic review with the purpose of identifying the influential factors that have a role in terms of the effectiveness of nursing discharge planning implementation in hospitalsMethods: The researcher conducted their investigation in February 2019 and this involved the exploration of scientific papers from ProQuest and Scopus using the keywords ‘nursing discharge planning’, ‘effectiveness’ and ‘implementation’. This paper identified 15 relevant research articles from 500 original full texts. These papers were analyzed according to the inclusion criteria and the impeding factors in discharge planning implementation. It involved 1 quasi-RCT and 14 descriptive research studies.Results: As a result, from the 10.000 respondents, it was found that the enhancing factors include effective communication at 43% and the factors causing impedance in nursing discharge planning effectiveness includes the continuity of staff at 38 %.Conclusion: The dominant factor of impedance as stated in the interview sessions was a lack of time to do the nursing discharge planning properly.

Using the National Early Warning Score (NEWS/NEWS 2) in different Intensive Care Units (ICUs) to predict the discharge location of patients

BACKGROUND

The National Early Warning Score (NEWS/NEWS 2) has been adopted across the National Health Service (NHS) in the U.K. as a method of escalating care for deteriorating patients. Intensive Care Unit (ICU) resources are limited and in high demand, with patient discharge a focal point for managing resources effectively. There are currently no universally accepted methods for assessing discharge of patients from an ICU, which can cause premature discharges and put patients at risk of subsequent deterioration, readmission to ICU or death.

METHODS

We tested the ability of the NEWS to discriminate patients within 24h of admission to an ICU in a U.S. hospital during 2001-2012, by their end discharge location: home; hospital ward; nursing facility; hospice and death. The NEWS performance was compared across five different ICU specialties, using the area under the receiver operating characteristic (AUROC) curve and a large vital signs database (n=2,723,055) collected from 28,523 critical care admissions.

RESULTS

The NEWS AUROC (95% CI) at 24h following admission: all patients 0.727 (0.709-0.745); Coronary Care Unit (CCU) 0.829 (0.821-0.837); Cardiac Surgery Recovery Unit (CSRU) 0.844 (0.838-0.850); Medical Intensive Care Unit (MICU) 0.778 (0.767-0.791); Surgical Intensive Care Unit (SICU) 0.775 (0.762-0.788); Trauma Surgical Intensive Care Unit (TSICU) 0.765 (0.751-0.773).

CONCLUSIONS

The NEWS has reasonable discrimination for any ICU patient's discharge location. The NEWS has greater ability to discriminate patients in the Coronary Care Unit (CCU) and Cardiac Surgery Recovery Unit (CSRU) compared to other ICU specialties. The NEWS has the real potential to be applied within a universal discharge planning tool for ICU, improving patient safety at the point of discharge.

Effectiveness of discharge-planning on physical quality of life of patients with ischemic heart disease

Background and Aim:

One of the goals of health care team is to improve the quality of life of patients during and after hospitalization period. Therefore, this study aimed to examine the effect of performing discharge planning on ischemic heart disease patient's physical quality of life.

Methods:

This quasi-experimental study was performed on 74 ischemic heart disease patients which randomly allocated to discharge-planning group (n = 37) and usual care group (n = 37). The discharge-planning included the patients’ educational needs, self-care instructions for patients, and caregivers. This program was performed through supporting patients during hospitalization and after discharge. The physical aspect of quality of life was assessed by standard questionnaire Short Form 36 and the data were analyzed through Mann–Whitney, independent t-test, variance analysis, Friedman and Wilcoxon.

Results:

There was no significant difference between intervention and control groups in physical aspects of the quality of life before intervention (P = 0.423) while two groups were significantly different after intervention (P = 0.000) and quality of life of patients in the case group improved significantly.

Conclusion:

Applying the discharge-planning program as an effective, efficient, cost-effective, and noninvasive intervention on physical aspects of the quality of ischemic heart disease patients’ lives is useful and helpful. Hence, it is recommended to use this program to promote and improve the quality of ischemic heart disease patients’ lives.

Registered Nurses and Discharge Planning in a Taiwanese ED: A Neglected Issue?

Published research on discharge planning is written from the perspective of hospital wards and community services. Limited research focuses on discharge planning in the emergency department (ED). The objective of this study was to identify ED nurses' perceptions of factors influencing the implementation of discharge planning. This qualitative study collected data from 25 ED nurses through in-depth interviews and a drawing task in which participants were asked to depict on paper the implementation of discharge planning in their practice. Factors influencing discharge planning were grouped into three categories: discharge planning as a neglected issue in the ED, heavy workload, and the negative attitudes of ED patients and their families. The study highlighted a need for effective discharge planning to be counted as an essential clinical competency for ED nurses and factored into their everyday workload. Nurses perceived that organizational culture, and parents' and relatives' attitudes were barriers to implementing discharge teaching in the ED.

Stakeholder views regarding patient discharge from intensive care: Suboptimal quality and opportunities for improvement

OBJECTIVE

To provide the first description of intensive care unit (ICU) discharge practices from the perspective of Canadian ICU administrators, and ICU providers from Canada, the United States and the United Kingdom.

METHODS

The authors identified 140 Canadian ICUs and administered a survey to ICU administrators (unit manager, director) to obtain an institutional perspective. Also surveyed were members of professional critical care associations in Canada, the United States and the United Kingdom, using membership distribution lists, to obtain a provider perspective.

RESULTS

A total of 118 ICU administrators (114 ICUs [81%]) and 737 ICU providers (denominator unknown) responded to the survey. Administrator and provider respondents reported that ICU physicians are primarily responsible for determining the timing (70% and 77%, respectively) and safety (94% and 96%) for patients discharged from ICU. The majority of respondents indicated that patient summaries (87% and 85%) and medication reconciliation (78% and 79%) were part of their institutions' discharge process. One-half of respondents reported the use of discharge protocols, while a minority indicated that checklists (46% and 44%), electronic tools (19% and 28%) or outreach follow-up (44% and 33%) were used. The majority of respondents rated current ICU discharge practices to be of medium quality (57% and 58% scored 3 on a five-point scale). Suggested opportunities for improvement included the information provided to patients and families (71% and 59%) and collaboration among hospital units (65% and 66%).

CONCLUSION

Findings from the present study revealed the complexity of the ICU discharge process, considerable practice variation, perception of only medium quality and several proposed opportunities for improvement.

Understanding current intensive care unit nursing handover practices

Clinical handover is critical to clinical decision-making and the provision of safe, high quality, continuing care. Incomplete and inaccurate transfer of information can result in poor outcomes. To assess the content and completeness of the intensive care unit nursing shift-to-shift handover, a prospective, observational study design was used. A semistructured observation sheet based on 10 key principles for handover was used to overtly observe 20 bedside nursing handovers. Descriptive statistics were used to analyse the data. Overall, the content handed over was consistent with the key principles of clinical handover. However, there were some key principles that were minimally addressed or absent from clinical handovers. Development and implementation of a handover tool specific to intensive care will assist in ensuring that all key principles are adhered to so that adverse events associated with miscommunication during clinical handover are reduced and a high standard of care is maintained.

Identifying intensive care unit discharge planning tools: protocol for a scoping review

BACKGROUND

Transitions of care between providers are vulnerable periods in healthcare delivery that expose patients to preventable errors and adverse events. Patient discharge from the intensive care unit (ICU) to a medical or surgical hospital ward is one of the most challenging and high risk transitions of care. Approximately 1 in 12 patients discharged will be readmitted to ICU or die before leaving the hospital. Many more patients are exposed to unnecessary healthcare, adverse events and/or are disappointed with the quality of their care. Our objective is to conduct a scoping review by systematically searching the literature to identify ICU discharge planning tools and their supporting evidence-base including barriers and facilitators to their use.

METHODS AND ANALYSIS

Systematic searching of the published health literature will be conducted to identify the existing ICU discharge planning tools and supporting evidence. Literature (research and non-research) reporting on the tools used to facilitate decision making and/or communication at ICU discharge with patients of any age will be included. Outcomes will include adverse events and provider and patient/family-reported outcomes. Two investigators will independently review the abstracts (screen 1) to identify those meeting the inclusion criteria and then independently assess the full text articles (screen 2) to determine if they meet the inclusion criteria. Data collection will include information on citations and identified tools. A quality assessment will be performed on original research studies. A descriptive summary will be developed for each tool.

ETHICS AND DISSEMINATION

Our scoping review will synthesise the literature for ICU discharge planning tools and identify the opportunities for knowledge to action and gaps in evidence where primary evidence is necessary. This will serve as the foundational element in a multistep research programme to standardise and improve the quality of care provided to patients during ICU discharge. Ethics approval is not required for this study.

Staff perception of patient discharge from ICU to ward-based care

BACKGROUND

The quality of information exchange between intensive care unit (ICU) and ward nurses, when patients are transferred out of intensive care, is important to the continuity of safe care.

AIM

This research aimed to explore nurses' experiences of the discharge process from ICU to the ward environment.

DESIGN

The study was conducted in a New Zealand Metropolitan hospital, using an exploratory descriptive design we adapted a questionnaire based on Whittaker and Ball's research on ICU patient handover.

METHOD

The questionnaires were then analysed using a descriptive thematic approach.

RESULTS

The response rate of 48% included 45 ICU and 47 ward nurses. Key findings were that the written and verbal communication needs differ dependent upon setting and the timing of a discharge. Timing of handover also requires negotiation.

CONCLUSIONS

Being able to negotiate the timing and nature of handover is important for nurses. In addition, standardized approaches to communication are believed to enhance patient safety.

RELEVANCE TO CLINICAL PRACTICE

Standardized handover, with content and processes that are mutually negotiated, is crucial to providing the safest environment for patients.

Feasibility of discharge planning in intensive care units: a pilot study

BACKGROUND

Although there is widespread acceptance that hospital discharge planning should begin at hospital admission, early discharge planning is usually delayed for clinically unstable patients in intensive care units.

OBJECTIVE

This pilot study explored the feasibility of beginning the hospital's discharge planning process within 24 hours of an admission to the intensive care unit.

METHODS

Medical records of 15 patients were used to create case summaries generated from information available within 24 hours of admission to the intensive care unit. Twelve unit staff members (registered nurses, clinical nurse specialists, social workers, and discharge planning nurses) predicted the presence and absence of patient self-care deficits at hospital discharge and rated their confidence in making predictions.

RESULTS

More than half (55%) of patient self-care deficits present at hospital discharge were identified within 24 hours of admission to the unit. Although confidence in predicting deficits increased significantly when more information was available closer to hospital discharge for clinical nurse specialists and staff nurses, confidence for discharge planning nurses and social workers was as high for decisions based on admission information as it was for decisions based on information available at hospital discharge.

CONCLUSIONS

The results provide a preliminary indication that staff in intensive care units may contribute to the early identification of patients' postacute care needs. The results also help to identify methods to study the discharge planning process within intensive care units.

An integrated review of the literature on challenges confronting the acute care staff nurse in discharge planning

AIMS AND OBJECTIVES

This integrative review presents and synthesises previous research investigating practices, perceptions and experiences of bedside staff nurses relative to hospital discharge planning.

BACKGROUND

Preparation for hospital discharge should begin at or prior to admission. Forces in the acute care environment, however, often impede comprehensive discharge planning. Evidence-based redesign of discharge planning processes is a priority for nurses and health care leaders.

DESIGN

An integrative review.

METHOD

The review was undertaken using eleven search terms to electronically scan CINAHL, Medline, PsycINFO and Dissertations and Theses databases for the period 1990-2009. Hand searching of reference lists and author searches was also conducted. Sixty English language articles were reviewed; 38 of these 60 publications met the study inclusion criteria.

RESULTS

Seven themes were identified across the studies. These themes were intra- and interdisciplinary communication; systems and structures; time; role confusion; care continuity; knowledge; and the invisibility of the staff nurse role in discharge planning.

CONCLUSIONS

Acute care bedside nurses frequently encounter significant barriers while providing discharge-related care. Although these barriers have been identified consistently in numerous studies spanning nearly two decades, few published reports address interventions designed to overcome identified obstacles and inefficiencies. Additional discharge planning redesign initiatives, which include rigorous evaluation of patient outcomes, are needed.

RELEVANCE TO CLINICAL PRACTICE

As the direct caregivers with the most consistent presence and knowledge of patients' postdischarge needs, acute care bedside staff nurses play a critical role in preparing patients and families for the transition from hospital to home. Nurses are uniquely positioned to identify barriers and opportunities in discharge planning processes and contribute significantly to evidence-based reform initiatives. Effective and efficient patient-centred discharge planning processes can facilitate the transition from hospital to home and begin to address the adverse events experienced by some patients in the immediate postdischarge period.

Readmission to intensive care: a qualitative analysis of nurses' perceptions and experiences

OBJECTIVE

The purpose of this study was to identify and describe the experiences and perceptions of nurses regarding the factors that contribute to the readmission of patients to intensive care.

METHODS

Twenty-one nurses participated in the study. Unstructured interviews were conducted to ascertain participants' perceptions and experiences. Interview transcripts were analyzed using a constant comparison method to identify major conceptual categories.

RESULTS

Five main themes were identified that contributed to the readmission of patients to intensive care: premature discharge from intensive care, delayed medical care at the ward level, heavy nursing workloads, lack of adequately qualified staff, and clinically "challenging" patients who demanded a different skill set from the nurses.

CONCLUSION

Discharging patients early from the intensive care unit when they are clinically unstable creates issues around workload and significantly challenges ward staff. It also increases the likelihood of patients being readmitted to the intensive care unit. Hospital managers need to look at ways of increasing the knowledge and skills of ward staff or identify more appropriate environments for managing these acutely ill patients.

Emergency department nurses' understanding and experiences of implementing discharge planning

AIM

This paper is a report of a study conducted to describe emergency department nurses' understanding and experiences of implementing discharge planning.

BACKGROUND

Discharge planning in the emergency department is an important issue because of increased healthcare costs and greater emphasis on continuity of care. When executed as a collaborative process involving a multi-disciplinary team with the patient and family, discharge planning provides continuity of care for patients, less demand on hospitals, improvement in community services and in the services of other healthcare organizations.

METHOD

The qualitative approach of phenomenography was used in this study. Thirty-two emergency department nurses were recruited between July and September 2005. Semi-structured interviews were conducted.

FINDINGS

From interviewees' descriptions of implementing discharge planning, six categories were established: implementing discharge planning as 'getting rid of my patients', completing routines, being involved in patient education, professionally accountable practice, autonomous practice and demonstrating professional emergency department nursing care. The referential meaning of implementing discharge planning 'in the outcome space' was the professional commitment to emergency department provision of effective discharge services.

CONCLUSION

The results of this research contribute to knowledge of emergency department nurses' experience in the implementation of the discharge planning process. Key requirements for the provision of manageable discharge services both in Taiwan and worldwide highlighted by this study include adequate workloads, sufficient time, clear policies and standards of discharge planning and enhancement of professional commitment.

Discharge planning: communication, education and patient participation

For the most part, discharge from hospital is routine and uneventful. However, for a percentage of people, discharge from acute care requires careful planning to ensure continuity of care. This is particularly the case with older patients who have complex medical needs. This literature review reveals that the essential elements for discharge planning are: communication, coordination, education, patient participation and collaboration between medical personnel. Outcomes measures of successful discharge planning include patient satisfaction and quality of life. Smooth and efficient coordination of this process reduces stress and anxiety for the patient, family, nurse, doctor, hospital and community services.

Discharge Knowledge and Concerns of Patients Going Home With a Wound

PURPOSE

To examine patients' wound care knowledge and concerns prior to discharge from an acute care hospital.

DESIGN

Comparative descriptive study of patients with wounds.

SETTING AND SUBJECTS

Participants (N = 76) included 17 men and 59 women who were African American (n = 33, 43.4%) or Caucasian (n = 43, 56.6%) and ranged in age from 20 to 83 years (M = 48, SD = 13). There were 67 persons with acute wounds and 9 with chronic wounds. All were scheduled to be discharged home from a large urban acute care hospital.

INSTRUMENTS

The questionnaire for this study included the following sections: Demographic, Admission and Discharge, Health, Wound Care, Beliefs about Wounds and their Care, Pain and Wounds, Literacy and Learning, and Discharge Concerns.

RESULTS

Participants' greatest concerns about going home were: (1) how active to be at home, (2) wound pain, (3) looking for wound complications, and (4) watching for wound infection. Many participants did not know the dressing (38.2%) or solution to cleanse the wound (58.7%) at home. Most had taken care of a wound before (67.1%), could see (68.4%) and reach (69.7%) the wound, and had looked at it (64.5%) during the hospitalization. Patients with acute and chronic wounds did not differ significantly in their concerns about their wound or their fear of taking care of their wound. Participants generally had appropriate knowledge about wounds and hand washing, nutrition, going out of the home, and cigarette smoking. They had incorrect information about drying out wounds and leaving them open to breathe the air. The majority of patients with chronic wounds preferred getting answers to questions about their wound and its care from their physician followed by their clinic and family/friends. Patients with acute wounds overwhelmingly chose their physician as a source of information about their wound and its care, followed by calling a nurse at the hospital and using the Internet.

CONCLUSIONS

Patients were able to verbalize their concerns about going home with a wound. Concerns about discharge may help to direct patient teaching in preparation for discharge. Teaching literature could include the most common concerns, as well as ways to avoid misinformation about wound care. Discharge teaching needs to begin early so that patients feel they have adequate time to learn and ask questions. Further research is needed about patients' wound care knowledge and discharge concerns.

Co-ordination of the discharge planning process in critical care

AIM AND OBJECTIVES

This article reports on the current discharge planning beliefs in relation to the co-ordination of the discharge planning process in the critical care environment in the health care system in the state of Victoria, Australia. As there is a paucity of previous studies examining discharge planning in critical care nursing knowledge about the phenomena is consequently limited.

BACKGROUND

The study reported here is part of a larger study exploring critical care nurses' perceptions and understanding of the discharge planning process in the health care system in the state of Victoria, Australia. While a number of different discharge planning models are reported in the literature there is no agreement on the most effective or the most efficient model.

DESIGN

An exploratory descriptive research design was used for this study.

METHODS

A total of 502 Victorian critical care nurses were approached to take part in the study. A total of 218 participants completed the survey, which represented a nett response rate of 43.4%. The data from the questionnaire were entered into the Statistical Package for Social Sciences (SPSS) Base 10.0. This allowed calculation of descriptive statistics and statistical analysis using chi-square test for goodness-of-fit.

RESULTS

While just over half the participants reported that the discharge planning process in their unit was co-ordinated by a combination of personnel that included a nurse, just under half the participants believed that this was an appropriate model. Another key finding was of those participants who worked in critical care units using primary nursing, just over half responded that the bedside nurse/primary nurse co-ordinated the discharge planning process while just under half responded that a combination of health care team members, including a nurse, co-ordinated the process. Overall there was little support for the designated discharge planning nurse to co-ordinate the process.

CONCLUSIONS

The findings presented here suggest critical care nurses need to examine who has the ultimate responsibility of co-ordinating the critical care patient's discharge plan irrespective of the nursing model employed within the critical care ward. There is the need to ensure that when discharge planning becomes everybody's responsibility it ultimately does not become no-one's responsibility.

RELEVANCE TO CLINICAL PRACTICE

If discharge planning practices are to be changed with the introduction of new discharge planning models in the critical care environment then it is important not only to know current practice but also the perceptions of critical care nurses in terms of who they believe should co-ordinate the discharge planning process.

Factors that enhance or impede critical care nurses' discharge planning practices

INTRODUCTION

Any illness that is serious enough to require admission to the critical care unit will intensify the physical and psychological effects that the patient and their significant others experience. Hence, the discharge needs of patients admitted to critical care are unquestionably complex, diverse and dynamic.

METHODS

Utilising an exploratory descriptive approach 502 critical care nurses, identified from the Australian College of Critical Care Nursing (ACCCN) (Victoria) database were invited to participate in this study. A 31-item questionnaire was developed and distributed. A total of 218 eligible participants completed the survey. One-to-one semi-structured interviews with 13 Victorian critical care nurses were also conducted.

RESULTS

Participants reported that a lack of time was a barrier to discharge planning. Communication however, could enhance or impede the discharge planning process in critical care. Participants considered that the critical pathway, used in the care of cardiothoracic patients, did assist with communication of discharge planning processes, hence enhancing the process.

CONCLUSIONS

While these findings provide some understanding of the factors that enhanced or impeded critical care nurses' discharge planning practices further research is indicated. The findings reported here may, however, provide a starting point for improving the discharge planning process in critical care.

Critical care nurses' beliefs about the discharge planning process: a questionnaire survey

AIM

To report on the beliefs of critical care nurses with regard to the discharge planning process, in Victoria, Australia.

METHODS

An exploratory descriptive design was used. A total of 502 Victorian critical care nurses were approached to take part in the study. A total of 218 eligible participants completed the survey, which represented a net response rate of 43.4%. The data were analysed using descriptive statistics.

RESULTS

The current discharge planning processes are ad hoc and influenced by patient acuity. Critical care nurses believe that workload issues, unplanned discharges and inadequate communication contribute to difficulties implementing the discharge plan.