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

A qualitative study of old patients' experiences of the quality of the health services in hospital and 30 days after hospitalization

Background

The number of people aged 80 years and above is projected to triple over the next 30 years. People in this age group normally have at least two chronic conditions. The impact of multimorbidity is often significantly greater than expected from the sum of the effects of each condition. The World Health Organization has indicated that healthcare systems must prepare for a change in the focus of clinical care for older people. The World Health Organization (WHO) defines healthcare quality as care that is effective, efficient, integrated, patient centered, equitable and safe. The degree to which healthcare quality can be defined as acceptable is determined by services’ ability to meet the needs of users and adapt to patients’ expectations and perceptions.

Method

We took a phenomenological perspective to explore older patients’ subjective experiences and conducted semistructured individual interviews. Eighteen patients (aged from 82 to 100 years) were interviewed twice after discharge from hospital. The interview transcriptions were analyzed thematically.

Results

The patients found their meetings with the health service to be complex and demanding. They reported attempting to restore a sense of security and meaning in everyday life, balancing their own needs against external requirements. Five overarching themes emerged from the interviews: hospital stay and the person behind the diagnosis, poor communication and coordination, life after discharge, relationship with their next of kin, and organizational and systemic determinants.

Conclusion

According to the WHO, to deliver quality healthcare, services must include all six of the dimensions listed above. Our findings show that they do not. Healthcare focused on measurable values and biomedical inquiries. Few opportunities for participation, scant information and suboptimal care coordination left the patients with a feeling of being in limbo, where they struggled to find balance in their everyday life. Further work must be done to ensure that integrated services are provided without a financial burden, centered on the needs and rights of older people.

Informal caregivers' views on the quality of healthcare services provided to older patients aged 80 or more in the hospital and 30 days after discharge

Background

In the European Union (EU), informal caregivers provide 60% of all care. Informal caregiving ranges from assistance with daily activities and provision of direct care to helping care recipients to navigate within complex healthcare and social services systems. While recent caregiver surveys document the impact of informal caregivers, systematic reviews show that they have unmet needs.

Because of the political desire to reduce the length of hospital stays, older patients are discharged from the hospital ‘quicker and sicker’ than before. The transition between different levels of the healthcare system and the period after hospital discharge is critical for elderly patients.

Caregivers’ perspectives on the quality of older patients’ care journeys between levels of the healthcare system may provide valuable information for healthcare providers and policymakers. This study aims to explore older patient’s informal caregivers’ views on healthcare quality in the hospital and in the first 30 days after hospitalisation.

Method

We conducted semi-structured individual interviews with 12 participants to explore and describe informal caregivers’ subjective experiences of providing care to older relatives. The interviews were then transcribed and analysed thematically.

Results

The analysis yielded the overarching theme ‘Informal caregivers – a health service alliance – quality contributor’, which was divided into four main themes: ‘Fast in, fast out’, ‘Scant information’, ‘Disclaimer of responsibility’ and ‘A struggle to secure professional care’. The healthcare system seemed to pay little attention to ensuring mutual understandings between those involved in discharge, treatment and coordination. The participants experienced that the healthcare providers’ main focus was on the patients’ diseases, although the health services are supposed to view patients holistically.

Conclusion

Based on the information given by informal caregivers, health services must take into account each person’s needs and preferences. To deliver quality healthcare, better coordination between inter-professional care teams and the persons they serve is necessary. Health professionals must strengthen the involvement of caregivers in transitions between care and healthcare. Future work should evaluate targeted strategies for formal caregivers to cooperate, support and empower family members as informal caregivers.

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.

Experiences of elderly patients regarding participation in their hospital discharge: a qualitative metasummary

BACKGROUND

Ageing patients are discharged from the hospital 'quicker and sicker' than before, and hospital discharge is a critical step in patient care. Older patients form a particularly vulnerable group due to multimorbidity and frailty. Patient participation in healthcare is influenced by government policy and an important part of quality improvement of care. There is need for greater insights into the complexity of patient participation for older patients in discharge processes based on aggregated knowledge.

OBJECTIVE

The aim of this study was to review reported evidence concerning the experiences of older patients aged 65 years and above regarding their participation in the hospital discharge process.

METHODS

We conducted a qualitative metasummary. Systematic searches of Medline, Embase, Cinahl, PsycINFO and SocINDEX were conducted. Data from 18 studies were included, based on specific selection criteria. All studies explored older patients' experience of participation during the discharge process in hospital, but varied when it came to type of discharge and diagnosis. The data were categorised into themes by using thematic analysis.

RESULTS

Our analysis indicated that participation in the discharge process varied among elderly patients. Five themes were identified: (1) complexity of the patients state of health, (2) management and hospital routines, (3) the norm and preference of returning home, (4) challenges of mutual communication and asymmetric relationships and (5) the significance of networks.

CONCLUSIONS

Collaboration between different levels in the health systems and user-friendly information between staff, patient and families are crucial. The complexity of patient participation for this patient group should be recognised to enhance user involvement during discharge from hospital. Interventions or follow-up studies of how healthcare professionals can improve their communication skills and address the tension between client-centred goals and organisational priorities are requested. Organisational structure may need to be restructured to ensure the participation of elderly patients.

Examining the Occurrence of Adverse Events within 72 hours of Discharge from the Intensive Care Unit

Adverse events have negative consequences for patients, including increased risk of death or permanent disability. Reports describe suboptimal patient care on hospital wards and reasons for readmission to the intensive care unit (ICU) but limited data exists on the occurrence of adverse events, their characteristics and outcomes in patients recently discharged from the ICU to the ward. This prospective observational study describes the incidence and outcomes of adverse events within 72 hours of discharge from an Australian ICU over 12 weeks in 2006. Patients were excluded if they were admitted to ICU after booked surgery or uncomplicated drug overdose, were discharged from ICU to the high dependency unit or had a ‘do-not-resuscitate’ order. Clinical antecedents and preventability were determined for each event. Seventeen (10%) of the 167 discharges that met the inclusion criteria were associated with an adverse event, with nine (52%) judged as probably preventable. Seven adverse events occurred from discharges between 1700 and 0700 hours and seven were on weekends. The most common adverse events were related to fluid management (47%). Outcomes included three ICU readmissions, two high dependency unit admissions and two required one-to-one ward nursing. Two adverse events resulted in temporary disability, seven resulted in prolonged hospital stays and two were associated with death. Delay in taking action for abnormal physiological signs and infrequent charting were evident. Whilst the adverse event rate compared favourably with other reports, 64% of the events were considered preventable. A review of support systems and processes is recommended to better target transition from the ICU.

Role of Transitional Care Measures in the Prevention of Readmission After Critical Illness

Transitioning from the critical care unit to the medical-surgical care area is vital to patients' recovery and resolution of critical illness. Such transitions are necessary to optimize use of available hospital resources to meet patient care needs. One in 10 patients discharged from the intensive care unit are readmitted to the unit during their hospitalization. Critical care readmission is associated with significant increases in illness acuity, overall length of stay, and health care costs as well as a potential 4-fold increased risk of mortality. Patients with complex illness, multiple comorbid conditions, and a prolonged initial stay in the critical care unit are at an increased risk of being readmitted to the critical care unit and experiencing poor outcomes. Implementing nurse-driven measures that support continuity of care and consistent communication practices such as critical care outreach services, transitional communication tools, discharge planning, and transitional care units improves transitions of patients from the critical care environment and reduces readmission rates.

A tailored relocation stress intervention programme for family caregivers of patients transferred from a surgical intensive care unit to a general ward

AIMS AND OBJECTIVES

To develop and examine a relocation stress intervention programme tailored for the family caregivers of patients scheduled for transfer from a surgical intensive care unit to a general ward.

BACKGROUND

Family relocation stress syndrome has been reported to be similar to that exhibited by patients, and investigators have emphasised that nurses should make special efforts to relieve family relocation stress to maximise positive contributions to the well-being of patients by family caregivers.

DESIGN

A nonequivalent control group, nonsynchronised pretest-post-test design was adopted.

METHODS

The study subjects were 60 family caregivers of patients with neurosurgical or general surgical conditions in the surgical intensive care unit of a university hospital located in Incheon, South Korea. Relocation stress and family burden were evaluated at three times, that is before intervention, immediately after transfer and four to five days after transfer.

RESULTS

This relocation stress intervention programme was developed for the family caregivers based on disease characteristics and relocation-related needs. In the experimental group, relocation stress levels significantly and continuously decreased after intervention, whereas in the control group, a slight nonsignificant trend was observed. Family burden levels in the control group increased significantly after transfer, whereas burden levels in the experimental group increased only marginally and nonsignificantly. No significant between-group differences in relocation stress or family burden levels were observed after intervention.

CONCLUSIONS

Relocation stress levels of family caregivers were significantly decreased after intervention in the experimental group, which indicates that the devised family relocation stress intervention programme effectively alleviated family relocation stress.

RELEVANCE TO CLINICAL PRACTICE

The devised intervention programme, which was tailored to disease characteristics and relocation-related needs, may enhance the practicality and efficacy of relocation stress management and make meaningful contribution to the relief of family relocation stress, promote patient recovery and enhance the well-being of patients and family caregivers.

Development and Effects of a Transition Nursing Program for Patients and Family Caregivers at a Neurological ICU in Korea

The purpose of this study was to develop a transition nursing program for patients and family caregivers in neurological intensive care units (ICUs) and to evaluate the effects of the program. A literature review, focus group interviews, analysis of medical records, confirmation of validity, and clinical applicability were used to develop the program, which was tested using a pre- and post-test quasi-experimental design. Participants were recruited in 2011. The experimental group (46 patients and their family caregivers) received the developed program before transferring from the neurological ICU to a ward, whereas the control group (48 patients and their family caregivers) received routine care. The results showed that patients and family caregivers in the experimental group had significantly higher transition readiness and satisfaction with transition nursing and lower transition anxiety and transition stress, and family caregivers in the experimental group had a significantly lower burden of caregiving.

Delays in Discharge in Neuro-Oncology: Using a Lean Six Sigma-Inspired Approach to Identify Internal Causes

Discharge planning processes have implications for patients and families, healthcare providers, and organizations at large. As such, delays in discharge may result in suboptimal patient outcomes, increased resource utilization, and overall disruptions to patient flow. A quality improvement project was conducted using a Lean Six Sigma approach to identify internal causes of delays in discharge in newly diagnosed patients with a high grade glioma on a neurosurgical unit. Internal causes of delays in discharge were related to communication. The main subthemes were multidisciplinary rounds, incongruent messages being delivered to patients and families, and discrepancies between team members resulting in unclear plans. Findings from this project may be used to promote more effective communication that will facilitate safe and timely discharge for neuro-oncology patients.

Factors associated with post-intensive care unit adverse events: a clinical validation study

BACKGROUND

Many patients discharged from intensive care units (ICU) have complex care needs, placing them at risk of an adverse event in a ward environment. Currently, there is limited understanding of factors associated with these events in the post-intensive care population. A recent study explored intensive care liaison nurses' opinions on factors associated with these events; 25 factors were identified, highlighting the multifaceted nature of post-intensive care adverse events.

AIM

This study aimed to clinically validate 25 factors intensive care liaison nurses believe are associated with post-intensive care adverse events, to determine the factors' relevance and importance to clinical practice.

DESIGN

Prospective, clinical validation study.

METHOD

Data were prospectively collected on a convenience sample of 52 patients at 4 tertiary referral hospitals in an Australian capital city. All patients had experienced an adverse event after intensive care discharge.

RESULTS

Each of the 25 factors contributed to adverse events in at least 6 patients. The factors associated with the most adverse events were those that related to the patient such as illness severity and co-morbidities.

CONCLUSION

Clinical care and research should focus on modifiable factors in care processes to reduce the risk of future adverse events in post-intensive care patients.

RELEVANCE TO CLINICAL PRACTICE

Many patients are at risk of post-ICU adverse events due to the contribution of non-modifiable factors. However, by focusing on modifiable factors in care processes, the risk of post-ICU adverse events may be reduced.

Understanding the distributed cognitive processes of intensive care patient discharge

AIMS AND OBJECTIVES

To better understand and identify vulnerabilities and risks in the ICU patient discharge process, which provides evidence for service improvement.

BACKGROUND

Previous studies have identified that 'after hours' discharge and 'premature' discharge from ICU are associated with increased mortality. However, some of these studies have largely been retrospective reviews of various administrative databases, while others have focused on specific aspects of the process, which may miss crucial components of the discharge process.

DESIGN

This is an ethnographic exploratory study.

METHODS

Distributed cognition and activity theory were used as theoretical frameworks. Ethnographic data collection techniques including informal interviews, direct observations and collecting existing documents were used. A total of 56 one-to-one interviews were conducted with 46 participants; 28 discharges were observed; and numerous documents were collected during a five-month period. A triangulated technique was used in both data collection and data analysis to ensure the research rigour.

RESULTS

Under the guidance of activity theory and distributed cognition theoretical frameworks, five themes emerged: hierarchical power and authority, competing priorities, ineffective communication, failing to enact the organisational processes and working collaboratively to optimise the discharge process. Issues with teamwork, cognitive processes and team members' interaction with cognitive artefacts influenced the discharge process.

CONCLUSION

Strategies to improve shared situational awareness are needed to improve teamwork, patient flow and resource efficiency. Tools need to be evaluated regularly to ensure their continuous usefulness.

RELEVANCE TO CLINICAL PRACTICE

Health care professionals need to be aware of the impact of their competing priorities and ensure discharges occur in a timely manner. Activity theory and distributed cognition are useful theoretical frameworks to support healthcare organisational research.

A systematic review of failures in handoff communication during intrahospital transfers

BACKGROUND

Handoffs serve a critical function in ensuring patient care continuity during transitions of care. Studies to date have predominantly focused on intershift handoffs, with relatively little attention given to intrahospital transfers. A systematic literature review was conducted to characterize the nature of handoff failures during intrahospital transfers and to examine factors affecting handoff communication and the effectiveness of current interventions.

METHODS

Primary studies investigating handoff communication between care providers during intrahospital transfers were sought in the English-language literature between 1980 and February 2011. Data for study design, population characteristics, sample size, setting, intervention specifics, and relevant outcome measures were extracted.

DATA SYNTHESIS

Study results were summarized by the impact of communication breakdown during intrahospital transfer of patients, and the current deficiencies in the process. Results of interventions were summarized by their effect on the quality of handoff communication and patient safety.

FINDINGS

The initial search identified 516 individual articles, 24 of which satisfied the inclusion criteria. Some 19 were primary studies on handoff practices and deficiencies, and the remaining 5 were interventional studies. The studies were categorized according to the clinical settings involved in the intrahospital patient transfers.

CONCLUSIONS

There is consistent evidence on the perceived impact of communication breakdown on patient safety during intrahospital transfers. Exposure of handoffs at patient transfers presents challenges that are not experienced in intershift handoffs. The distinct needs of the specific clinical settings involved in the intrahospital patient transfer must be considered when deciding on suitable interventions.

Buffer management to solve bed-blocking in the Netherlands 2000-2010. Cooperation from an integrated care chain perspective as a key success factor for managing patient flows

Introduction

Bed-blocking problems in hospitals reflect how difficult and complex it is to move patients smoothly through the chain of care. In the Netherlands, during the first decade of the 21st century, some hospitals attempted to tackle this problem by using an Intermediate Care Department (ICD) as a buffer for bed-blockers. However, research has shown that ICDs do not sufficiently solve the bed-blocking problem and that bed-blocking is often caused by a lack of buffer management.

Tool

Buffer management (BM) is a tool that endeavors to balance patient flow in the hospital to nursing home chain of care.

Results

Additional research has indicated that the absence of BM is not the result of providers’ thinking that BM is unnecessary, unethical or impossible because of unpredictable patient flows. Instead, BM is hampered by a lack of cooperation between care providers.

Conclusion

Although stakeholders recognize that cooperation is imperative, they often fail to take the actions necessary to realize cooperation. Our assumption is that this lack of willingness and ability to cooperate is the result of several impeding conditions as well as stakeholders’ perceptions of these conditions and the persistence of their current routines, principles and beliefs (RPBs).

Discussion

We recommend simultaneously working on improving the conditions and changing stakeholders’ perceptions and RPBs.

[Factors influencing relocation stress syndrome in patients following transfer from intensive care units]

PURPOSE

The purpose of this study was to identify the levels of relocation stress syndrome (RSS) and influencing the stress experienced by Intensive Care Unit (ICU) patients just after transfer to general wards.

METHODS

A cross-sectional study was conducted with 257 patients who transferred from the intensive care unit. Data were collected through self-report questionnaires from May to October, 2009. Data were analyzed using the Pearson correlation coefficient, t-test, one-way ANOVA, and stepwise multiple linear regression with SPSS/WIN 12.0.

RESULTS

The mean score for RSS was 17.80+/-9.16. The factors predicting relocation stress syndrome were symptom experience, differences in scope and quality of care provided by ICU and ward nursing staffs, satisfaction with transfer process, length of stay in ICU and economic status, and these factors explained 40% of relocation stress syndrome (F=31.61, p<.001).

CONCLUSION

By understanding the stress experienced by ICU patients, nurses are better able to provide psychological support and thus more holistic care to critically ill patients. Further research is needed to consider the impact of relocation stress syndrome on patients' health outcomes in the recovery trajectory.

Struggle with a gap between intensive care units and general wards

Nursing critically ill patients includes planning and performing safe discharges from Intensive Care Units (ICU) to the general wards. The aim of this study was to obtain a deeper understanding of the main concern in the ICU transitional process-the care before, during, and after the transfer of ICU patients. Interviews were conducted with 35 Swedish nurses and analysed according to grounded theory. The main concern was the nurses' "struggling with a gap." The "gap" was caused by differences in the altered level of care and contributed to difficulties for nurses encountering an overlap during the transitional care. The categories: sheltering, seeking organizational intertwining and striving for control are related to the core category and were used to generate a theory. The nurses sought improved collaboration, and employed patient-centred routines. They wanted access to necessary tools; they relayed or questioned their own competence and sought assurance of the patients' ability to be transferred. If the nurses felt a loss of control, lack of intertwining and lack of collaboration, they sheltered their patients and themselves. Intertwining was more difficult to perform, but actually even more important to do. With knowledge about ICU transitional care, collaboration, routines, and with an organization that provides an educational environment, the process could be improved.

Competence in intensive and critical care nursing: a literature review

This literature review defines and describes the concept of competence in adult intensive care nursing, with special reference to clinical and professional competence. The aim was to see whether and how the studies reviewed defined or described the concept of competence, and which domains of competence have been investigated in intensive and critical care nursing research. The review focuses on empirical studies retrieved from the COCHRANE and MEDLINE (1994-2005) databases. The final analysis comprised 45 studies. The studies were analysed by inductive content analysis. Very few (n=7) of the studies offered any definitions or descriptions of the concept of competence. Clinical and professional competence in intensive and critical care nursing can be defined as a specific knowledge base, skill base, attitude and value base and experience base of intensive and critical care nursing. Clinical competence can be divided into three and professional competence into four constituent domains. In clinical competence, these are the principles of nursing care; clinical guidelines; and nursing interventions. In professional competence, the domains are ethical activity; decision-making; development work; and collaboration. More empirical research is needed to examine competence in intensive and critical care nursing.

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.