1
|
A Multiple Baseline Trial of an Electronic ICU Discharge Summary Tool for Improving Quality of Care. Crit Care Med 2022; 50:1566-1576. [PMID: 35972243 DOI: 10.1097/ccm.0000000000005638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Effective communication between clinicians is essential for seamless discharge of patients between care settings. Yet, discharge summaries are commonly not available and incomplete. We implemented and evaluated a structured electronic health record-embedded electronic discharge (eDischarge) summary tool for patients discharged from the ICU to a hospital ward. DESIGN Multiple baseline trial with randomized and staggered implementation. SETTING Adult medical-surgical ICUs at four acute care hospitals serving a single Canadian city. PATIENTS Health records of patients 18 years old or older, in the ICU 24 hours or longer, and discharged from the ICU to an in-hospital patient ward between February 12, 2018, and June 30, 2019. INTERVENTION A structured electronic note (ICU eDischarge tool) with predefined fields (e.g., diagnosis) embedded in the hospital-wide electronic health information system. MEASUREMENTS AND MAIN RESULTS We compared the percent of timely (available at discharge) and complete (included goals of care designation, diagnosis, list of active issues, active medications) discharge summaries pre and post implementation using mixed effects logistic regression models. After implementing the ICU eDischarge tool, there was an immediate and sustained increase in the proportion of patients discharged from ICU with timely and complete discharge summaries from 10.8% (preimplementation period) to 71.1% (postimplementation period) (adjusted odds ratio, 32.43; 95% CI, 18.22-57.73). No significant changes were observed in rapid response activation, cardiopulmonary arrest, death in hospital, ICU readmission, and hospital length of stay following ICU discharge. Preventable (60.1 vs 5.7 per 1,000 d; p = 0.023), but not nonpreventable (27.3 vs 40.2 per 1,000d; p = 0.54), adverse events decreased post implementation. Clinicians perceived the eDischarge tool to produce a higher quality discharge process. CONCLUSIONS Implementation of an electronic tool was associated with more timely and complete discharge summaries for patients discharged from the ICU to a hospital ward.
Collapse
|
2
|
Shahid A, Sept B, Kupsch S, Brundin-Mather R, Piskulic D, Soo A, Grant C, Leigh JP, Fiest KM, Stelfox HT. Development and pilot implementation of a patient-oriented discharge summary for critically Ill patients. World J Crit Care Med 2022; 11:255-268. [PMID: 36051938 PMCID: PMC9305680 DOI: 10.5492/wjccm.v11.i4.255] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/06/2022] [Accepted: 06/18/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients leaving the intensive care unit (ICU) often experience gaps in care due to deficiencies in discharge communication, leaving them vulnerable to increased stress, adverse events, readmission to ICU, and death. To facilitate discharge communication, written summaries have been implemented to provide patients and their families with information on medications, activity and diet restrictions, follow-up appointments, symptoms to expect, and who to call if there are questions. While written discharge summaries for patients and their families are utilized frequently in surgical, rehabilitation, and pediatric settings, few have been utilized in ICU settings.
AIM To develop an ICU specific patient-oriented discharge summary tool (PODS-ICU), and pilot test the tool to determine acceptability and feasibility.
METHODS Patient-partners (i.e., individuals with lived experience as an ICU patient or family member of an ICU patient), ICU clinicians (i.e., physicians, nurses), and researchers met to discuss ICU patients’ specific informational needs and design the PODS-ICU through several cycles of discussion and iterative revisions. Research team nurses piloted the PODS-ICU with patient and family participants in two ICUs in Calgary, Canada. Follow-up surveys on the PODS-ICU and its impact on discharge were administered to patients, family participants, and ICU nurses.
RESULTS Most participants felt that their discharge from the ICU was good or better (n = 13; 87.0%), and some (n = 9; 60.0%) participants reported a good understanding of why the patient was in ICU. Most participants (n = 12; 80.0%) reported that they understood ICU events and impacts on the patient’s health. While many patients and family participants indicated the PODS-ICU was informative and useful, ICU nurses reported that the PODS-ICU was “not reasonable” in their daily clinical workflow due to “time constraint”.
CONCLUSION The PODS-ICU tool provides patients and their families with essential information as they discharge from the ICU. This tool has the potential to engage and empower patients and their families in ensuring continuity of care beyond ICU discharge. However, the PODS-ICU requires pairing with earlier discharge practices and integration with electronic clinical information systems to fit better into the clinical workflow for ICU nurses. Further refinement and testing of the PODS-ICU tool in diverse critical care settings is needed to better assess its feasibility and its effects on patient health outcomes.
Collapse
Affiliation(s)
- Anmol Shahid
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
| | - Bonnie Sept
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
| | - Shelly Kupsch
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
| | - Rebecca Brundin-Mather
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
| | - Danijela Piskulic
- Department of Psychiatry, Hotchkiss Brain Institute, Calgary T2N 4Z6, Alberta, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
| | - Christopher Grant
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
| | - Jeanna Parsons Leigh
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
- School of Health Administration, Dalhousie University, Halifax B3H 4R2, Nova Scotia, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
| |
Collapse
|
3
|
Weetman K, Dale J, Scott E, Schnurr S. Discharge communication study: a realist evaluation of discharge communication experiences of patients, general practitioners and hospital practitioners, alongside a corresponding discharge letter sample. BMJ Open 2021; 11:e045465. [PMID: 34290064 PMCID: PMC8296817 DOI: 10.1136/bmjopen-2020-045465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To develop a programme theory for the intervention of patients receiving discharge letters. DESIGN We used a realist evaluation approach and captured multiple perspectives of hospital discharge to refine our previously developed programme theory. General practitioner (GP), patient and hospital clinician views of a single discharge event in which they were all involved were collected using semi-structured interviews and surveys. These were then triangulated to match the corresponding discharge letter. Data were qualitatively synthesised and compared in meta-matrices before interrogation with realist logic of analysis to develop the programme theory that maps out how patients receiving discharge letters works in specific contexts. SETTING 14 GP practices and four hospital trusts in West Midlands, UK. PARTICIPANTS 10 complete matched cases (GP, patient and hospital practitioner), and a further 26 cases in which a letter was matched with two out of the three participants. RESULTS We identified seven context mechanism outcome configurations not found through literature searching. These related to the broad concepts of: patient preference for receiving letters, patient comprehension of letters, patient-directed letters, patient harm and clinician views on patients receiving letters. 'Patient choice' was important to the success (or not) of the intervention. Other important contexts for positive effects included: letters written in plain English, lay explanations for jargon, verbal information also provided, no new information in letter and patient choice acknowledged. Three key findings were: patient understanding is perhaps greater than clinicians perceive, clinician attitudes are a barrier to patients receiving letters and that, negative outcomes more commonly manifested when patients had not received letters, rather than when they had. CONCLUSIONS We suggest how patients receiving discharge letters could be improved to enhance patient outcomes. Our programme theory has potential for use in different healthcare contexts and as a framework for policy development relating to patient discharge.
Collapse
Affiliation(s)
- Katharine Weetman
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| | - Jeremy Dale
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| | - Emma Scott
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| | | |
Collapse
|
4
|
Pellet J, Weiss M, Rapin J, Jaques C, Mabire C. Nursing discharge teaching for hospitalized older people: A rapid realist review. J Adv Nurs 2020; 76:2885-2896. [DOI: 10.1111/jan.14511] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/20/2020] [Accepted: 06/30/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Joanie Pellet
- Institute of Higher Education and Research in Healthcare‐IUFRSUniversity of LausanneLausanne University Hospital Lausanne Switzerland
| | - Marianne Weiss
- Marquette University College of Nursing Milwaukee WI USA
| | - Joachim Rapin
- Faculty of Nursing University of Montreal Montreal Quebec Canada
- Lausanne University Hospital Lausanne Switzerland
| | - Cecile Jaques
- Medical Library Lausanne University Hospital and University of Lausanne Lausanne Switzerland
| | - Cedric Mabire
- Institute of Higher Education and Research in Healthcare‐IUFRSUniversity of LausanneLausanne University Hospital Lausanne Switzerland
- Lausanne University Hospital Lausanne Switzerland
| |
Collapse
|
5
|
Hervé MEW, Zucatti PB, Lima MADDS. Transition of care at discharge from the Intensive Care Unit: a scoping review. Rev Lat Am Enfermagem 2020; 28:e3325. [PMID: 32696919 PMCID: PMC7365613 DOI: 10.1590/1518-8345.4008.3325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 04/07/2020] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE to map the available evidence on the components of the transition of care, practices, strategies, and tools used in the discharge from the Intensive Care Unit (ICU) to the Inpatient Unit (IU) and its impact on the outcomes of adult patients. METHOD a scoping review using search strategies in six relevant health databases. RESULTS 37 articles were included, in which 30 practices, strategies or tools were identified for organizing and executing the transfer process, with positive or negative impacts, related to factors intrinsic to the Intensive Care Unit and the Inpatient Unit and cross-sectional factors regarding the staff. The analysis of hospital readmission and mortality outcomes was prevalent in the included studies, in which trends and potential protective actions for a successful care transition are found; however, they still lack more robust evidence and consensus in the literature. CONCLUSION transition of care components and practices were identified, in addition to factors intrinsic to the patient, associated with worse outcomes after discharge from the Intensive Care Unit. Discharges at night or on weekends were associated with increased rates of readmission and mortality; however, the association of other practices with the patient's outcome is still inconclusive.
Collapse
|
6
|
Hoffmann M, Schwarz CM, Pregartner G, Weinrauch M, Jantscher L, Kamolz L, Brunner G, Sendlhofer G. Attitudes of physicians towards target groups and content of the discharge summary: a cross-sectional analysis in Styria, Austria. BMJ Open 2019; 9:e034857. [PMID: 31852713 PMCID: PMC6937118 DOI: 10.1136/bmjopen-2019-034857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The discharge summary (DS) represents one of the most important instruments to ensure a safe patient discharge from the hospital. They sometimes have poor quality in content and often include medical jargon, which the patient and their relatives cannot easily understand. Therefore, many risks for patient safety exist. This study investigated the questions for whom the DS is and which contents are necessary to ensure a safe treatment. DESIGN Cross-sectional analysis. SETTING Styria, Austria. PARTICIPANTS 3948 internal and external physicians were consulted. INTERVENTIONS An online survey consisting of 24 questions was conducted. The survey was distributed to physicians working in the province of Styria, Austria, in 2018 over a period of 6 months. MAIN OUTCOMES AND MEASURES Attitudes of internal and external physicians in terms of target group, content and health literacy. RESULTS In total, 1060 physicians participated in the survey. The DS is considered as a communication tool among physicians (97.9%) and the patients are also indicated as addressees (73.5%). Furthermore, there is a high level of agreement that understandable information in the DS leads to fewer questions of the patients (67.9%). CONCLUSION In conclusion, the DS is not only seen as a document for the further treating physician but is also relevant for the patient. Incorporating the patient into their treatment at all levels may possibly strengthen the individual health literacy of the patient and their caring relatives.
Collapse
Affiliation(s)
- Magdalena Hoffmann
- Executive Department for Quality and Risk Management, Hospital of the Federal State of Styria and University Hospital Graz, Graz, Austria
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Christine Maria Schwarz
- Executive Department for Quality and Risk Management, Hospital of the Federal State of Styria and University Hospital Graz, Graz, Austria
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics und Documentation, Medical University of Graz, Graz, Austria
| | - Maximilian Weinrauch
- Executive Department for Quality and Risk Management, Hospital of the Federal State of Styria and University Hospital Graz, Graz, Austria
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Lydia Jantscher
- Executive Department for Quality and Risk Management, Hospital of the Federal State of Styria and University Hospital Graz, Graz, Austria
| | - Lars Kamolz
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Gernot Brunner
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Gerald Sendlhofer
- Executive Department for Quality and Risk Management, Hospital of the Federal State of Styria and University Hospital Graz, Graz, Austria
- Research Unit for Safety in Health, Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| |
Collapse
|
7
|
Weetman K, Wong G, Scott E, MacKenzie E, Schnurr S, Dale J. Improving best practice for patients receiving hospital discharge letters: a realist review. BMJ Open 2019; 9:e027588. [PMID: 31182447 PMCID: PMC6561435 DOI: 10.1136/bmjopen-2018-027588] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/25/2019] [Accepted: 05/15/2019] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To understand how different outcomes are achieved from adult patients receiving hospital discharge letters from inpatient and outpatient settings. DESIGN Realist review conducted in six main steps: (1) development of initial theory, (2) searching, (3) screening and selection, (4) data extraction and analysis, (5) data synthesis and (6) programme theory (PT) refinement. ELIGIBILITY CRITERIA Documents reporting evidence that met criteria for relevance to the PT. Documents relating solely to mental health or children aged <18 years were excluded. ANALYSIS Data were extracted and analysed using a realist logic of analysis. Texts were coded for concepts relating to context, mechanism, outcome configurations (CMOCs) for the intervention of patients receiving discharge letters. All outcomes were considered. Based on evidence and our judgement, CMOCs were labelled 'positive' or 'negative' in order to clearly distinguish between contexts where the intervention does and does not work. RESULTS 3113 documents were screened and 103 were included. Stakeholders contributed to refining the PT in step 6. The final PT included 48 CMOCs for how outcomes are affected by patients receiving discharge letters. 'Patient choice' emerged as a key influencer to the success (or not) of the intervention. Important contexts were identified for both 'positive' CMOCs (eg, no new information in letter) and 'negative' CMOCs (eg, letter sent without verifying patient contact details). Two key findings were that patient understanding is possibly greater than clinicians perceive, and that patients tend to express strong preference for receiving letters. Clinician concerns emerged as a barrier to wider sharing of discharge letters with patients, which may need to be addressed through organisational policies and direction. CONCLUSIONS This review forms a starting point for explaining outcomes associated with whether or not patients receive discharge letters. It suggests several ways in which current processes might be modified to support improved practice and patient experience.
Collapse
Affiliation(s)
- Katharine Weetman
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Emma Scott
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| | | | | | - Jeremy Dale
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK
| |
Collapse
|
8
|
King J, O’Neill B, Ramsay P, Linden MA, Darweish Medniuk A, Outtrim J, Blackwood B. Identifying patients' support needs following critical illness: a scoping review of the qualitative literature. Crit Care 2019; 23:187. [PMID: 31126335 PMCID: PMC6533750 DOI: 10.1186/s13054-019-2441-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/15/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Intensive care survivors suffer chronic and potentially life-changing physical, psychosocial and cognitive sequelae, and supporting recovery is an international priority. As survivors' transition from the intensive care unit to home, their support needs develop and change. METHODS In this scoping review, we categorised patients' support needs using House's Social Support Needs framework (informational, emotional, instrumental, appraisal) and mapped these against the Timing it Right framework reflecting the patient's transition from intensive care (event/diagnosis) to ward (stabilisation/preparation) and discharge home (implementation/adaptation). We searched electronic databases from 2000 to 2017 for qualitative research studies reporting adult critical care survivors' experiences of care. Two reviewers independently screened, extracted and coded data. Data were analysed using a thematic framework approach. RESULTS From 3035 references, we included 32 studies involving 702 patients. Studies were conducted in UK and Europe (n = 17, 53%), Canada and the USA (n = 6, 19%), Australasia (n = 6, 19%), Hong Kong (n = 1, 3%), Jordan (n = 1, 3%) and multi-country (n = 1, 3%). Across the recovery trajectory, informational, emotional, instrumental, appraisal and spiritual support needs were evident, and the nature and intensity of need differed when mapped against the Timing it Right framework. Informational needs changed from needing basic facts about admission, to detail about progress and treatments and coping with long-term sequelae. The nature of emotional needs changed from needing to cope with confusion, anxiety and comfort, to a need for security and family presence, coping with flashbacks, and needing counselling and community support. Early instrumental needs ranged from managing sleep, fatigue, pain and needing nursing care and transitioned to needing physical and cognitive ability support, strength training and personal hygiene; and at home, regaining independence, strength and return to work. Appraisal needs related to obtaining feedback on progress, and after discharge, needing reassurance from others who had been through the ICU experience. CONCLUSIONS This review is the first to identify the change in social support needs among intensive care survivors as they transition from intensive care to the home environment. An understanding of needs at different transition periods would help inform health service provision and support for survivors.
Collapse
Affiliation(s)
- J. King
- Faculty of Health Sciences, School of Rehabilitation Sciences, University of Ottawa, Ottawa, Canada
| | - B. O’Neill
- Centre for Health and Rehabilitation Technologies, INHR, Ulster University, Newtownabbey, Northern Ireland, UK
| | - P. Ramsay
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, Scotland, UK
| | - M. A. Linden
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland, UK
| | - A. Darweish Medniuk
- Department of Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, England, UK
| | - J. Outtrim
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, England, UK
| | - B. Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, 97 Lisburn Road, Belfast, BT9 7BL Northern Ireland, UK
| |
Collapse
|
9
|
Bedford ZC, Bench S. A review of interventions supporting parent's psychological well-being after a child's intensive care unit discharge. Nurs Crit Care 2018; 24:153-161. [PMID: 30537005 DOI: 10.1111/nicc.12405] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 08/29/2018] [Accepted: 11/08/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Having a child admitted to a paediatric intensive care unit (PICU) is a highly stressful experience, and post-traumatic stress among parents is well documented. How best to support these parents is currently unclear. AIM To review research on interventions to support the psychological well-being of parents after their child's discharge from paediatric intensive care. METHODS Searches were conducted using Medline, PsycINFO, PubMed, CINAHL and The Cochrane library in January 2017. Study selection was carried out using pre-specified criteria. Following appraisal of methodological quality and risk of bias, data were extracted and analysed using a narrative synthesis. RESULTS Six quantitative studies met the inclusion criteria. Intervention types included follow-up appointments, telephone calls, educational information and post-admission interviews. Insufficient evidence was found to fully support any intervention in isolation, but findings support a clear trend that some form of follow up is beneficial. CONCLUSIONS Testing costly interventions is challenging and takes time. In the meantime, a low-cost intervention (such as an information leaflet) to raise awareness of potential problems in staff and to provide a support resource for parents is recommended. RELEVANCE TO CLINICAL PRACTICE Parents and carers of children admitted to PICU can develop post-traumatic stress symptoms after their child's discharge from PICU. This article addresses how best to support these parents to improve their psychological well-being.
Collapse
Affiliation(s)
- Zoe C Bedford
- School of Health and Social Care, London South Bank University, London, UK
| | - Suzanne Bench
- School of Health and Social Care, London South Bank University, London, UK
| |
Collapse
|
10
|
van Mol M, Nijkamp M, Markham C, Ista E. Using an intervention mapping approach to develop a discharge protocol for intensive care patients. BMC Health Serv Res 2017; 17:837. [PMID: 29258524 PMCID: PMC5737483 DOI: 10.1186/s12913-017-2782-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 12/06/2017] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Admission into an intensive care unit (ICU) may result in long-term physical, cognitive, and emotional consequences for patients and their relatives. The care of the critically ill patient does not end upon ICU discharge; therefore, integrated and ongoing care during and after transition to the follow-up ward is pivotal. This study described the development of an intervention that responds to this need. METHODS Intervention Mapping (IM), a six-step theory- and evidence-based approach, was used to guide intervention development. The first step, a problem analysis, comprised a literature review, six semi-structured telephone interviews with former ICU-patients and their relatives, and seven qualitative roundtable meetings for all eligible nurses (i.e., 135 specialized and 105 general ward nurses). Performance and change objectives were formulated in step two. In step three, theory-based methods and practical applications were selected and directed at the desired behaviors and the identified barriers. Step four designed a revised discharge protocol taking into account existing interventions. Adoption, implementation and evaluation of the new discharge protocol (IM steps five and six) are in progress and were not included in this study. RESULTS Four former ICU patients and two relatives underlined the importance of the need for effective discharge information and supportive written material. They also reported a lack of knowledge regarding the consequences of ICU admission. 42 ICU and 19 general ward nurses identified benefits and barriers regarding discharge procedures using three vignettes framed by literature. Some discrepancies were found. For example, ICU nurses were skeptical about the impact of writing a lay summary despite extensive evidence of the known benefits for the patients. ICU nurses anticipated having insufficient skills, not knowing the patient well enough, and fearing legal consequences of their writings. The intervention was designed to target the knowledge, attitudes, self-efficacy, and perceived social influence. Building upon IM steps one to three, a concept discharge protocol was developed that is relevant and feasible within current daily practice. CONCLUSION Intervention mapping provided a comprehensive framework to improve ICU discharge by guiding the development process of a theory- and empirically-based discharge protocol that is robust and useful in practice.
Collapse
Affiliation(s)
- Margo van Mol
- Department of Intensive Care Adults, Erasmus MC University Medical Center, P.O. Box 2040, Room 1005, 3000 CA Rotterdam, The Netherlands
| | - Marjan Nijkamp
- Faculty of Psychology and Educational Sciences, Open University of the Netherlands, Heerlen, The Netherlands
| | - Christine Markham
- Center for Health Promotion and Prevention Research, University of Texas Health Science Center at Houston, School of Public Health, Houston, USA
| | - Erwin Ista
- Department of Intensive Care Children, Erasmus MC University Medical Center - Sophia Children’s Hospital, Rotterdam, The Netherlands
| |
Collapse
|
11
|
Weetman K, Wong G, Scott E, Schnurr S, Dale J. Improving best practise for patients receiving hospital discharge letters: a realist review protocol. BMJ Open 2017; 7:e018353. [PMID: 29133330 PMCID: PMC5695342 DOI: 10.1136/bmjopen-2017-018353] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 09/21/2017] [Accepted: 10/19/2017] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Discharge documents are important for transferring information from hospitals to the referring clinician; in the UK and many countries, this is often the patient's general practitioner or family physician. However, patients may or may not receive their discharge letters, and whether patients should routinely receive discharge letters remains unclear. METHODS AND ANALYSIS The review will consolidate evidence on patients receiving discharge letters through the theory-driven approach of a realist review.The review will be conducted systematically and seek to explain how, why, for whom and in what contexts does this practice 'work'. The review will specifically explore whether there are benefits of this practice and if so what are the important contexts for triggering the mechanisms associated with these outcome benefits. Negative effects will also be considered.Several steps will occur: devising initial rough programme theory, searching the evidence, selecting relevant documents, extracting data, synthesising and finally programme theory refinement. As the process is viewed as iterative, this cycle of steps may be repeated as many times as is necessary to reach theoretical saturation and may not be linear.The initial programme theory will be tested and refined throughout the review process and by stakeholder involvement of National Health Service (NHS) policy makers, practitioners and service users. ETHICS AND DISSEMINATION Formal ethical review is not required. The resulting programme theory is anticipated to explain how the intervention of patients receiving written discharge communication may work in practice, for whom and in what contexts; this will inform best practice of patients receiving discharge communication. The review findings will be disseminated in a peer-reviewed journal and presentations and discussions with relevant organisations and stakeholders. While the review will be from the perspective of the UK NHS, its findings should be relevant to other healthcare systems. PROSPERO REGISTRATION NUMBER CRD42017069863.
Collapse
Affiliation(s)
- Katharine Weetman
- Division of Health Sciences, Primary Care, Warwick Health Sciences, University of Warwick, Coventry, UK
| | - Geoffrey Wong
- Nuffield Department of Primary Care Health Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Emma Scott
- Division of Health Sciences, Primary Care, Warwick Health Sciences, University of Warwick, Coventry, UK
| | | | - Jeremy Dale
- Division of Health Sciences, Primary Care, Warwick Health Sciences, University of Warwick, Coventry, UK
| |
Collapse
|
12
|
Allum L, Connolly B, McKeown E. Meeting the needs of critical care patients after discharge home: a qualitative exploratory study of patient perspectives. Nurs Crit Care 2017. [PMID: 28640509 DOI: 10.1111/nicc.12305] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND With improved survival rates in critical care, increasing focus is being placed on survivorship and how best to support patients in returning to their former activity. Little is known about what support patients themselves view as important, and this has implications for the efficacy and acceptability of services provided. OBJECTIVES To describe former critical care patients' perspectives on the support needed to optimize recovery. STUDY DESIGN This is a qualitative exploratory study of the experiences of support received by critical care survivors. RESEARCH METHODOLOGY Semi-structured interviews were undertaken with 12 critical care survivors recruited from a charity and a patient and public involvement group. The interviews were analysed using thematic analysis to describe patterns in the participants' experiences. FINDINGS Four themes of support were described: effective management of transfer anxiety, tailored information provision, timely access to services and a supportive social network. CONCLUSION Survivors of critical care should be equipped with information about their critical care stay, ongoing health issues and recovery and should be provided with holistic care at home. Critical care follow up was an effective way of meeting many of these needs, but this needs to be flexible to be useful to attendees. Peer support groups (face-to-face and online) provided information, reassurance, a social network and an avenue for those who had longer-lasting problems than current services provide for. RELEVANCE TO CLINICAL PRACTICE Whilst there are commonalities in the problems faced by critical care survivors, recovery is highly individualized, and current support services do not have sufficient flexibility to cater for this. This study shows that many survivors experience after-effects of critical care that outlast the support they are given. These longer-term survivors are often excluded from research studies because of fears of recall bias, resulting in poor understanding of their experiences.
Collapse
Affiliation(s)
- Laura Allum
- School of Health Science, City, University of London, Northampton Square, London EC1V 0HB, UK.,Lane Fox Clinical Respiratory Physiology Research Unit, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, Lambeth, London SE1 7EH, UK
| | - Bronwen Connolly
- Lane Fox Clinical Respiratory Physiology Research Unit, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, Lambeth, London SE1 7EH, UK.,Centre for Human and Aerospace Physiological Sciences, King's College London, London SE1 9RT, UK.,Guy's & St Thomas' NHS Foundation Trust and King's College London, National Institute of Health Research Biomedical Research Centre, 16th Floor, Tower Wing, Guy's Hospital, Great Maze Pond, London SE1 9RT, UK
| | - Eamonn McKeown
- School of Health Science, City, University of London, Northampton Square, London EC1V 0HB, UK
| |
Collapse
|
13
|
Bench S, Cornish J, Xyrichis A. Intensive care discharge summaries for general practice staff: a focus group study. Br J Gen Pract 2016; 66:e904-e912. [PMID: 27872086 PMCID: PMC5198666 DOI: 10.3399/bjgp16x688045] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 07/14/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Understanding how patients and relatives can be supported after hospital discharge is a UK research priority. Intensive Care Unit (ICU) discharge summaries are a simple way of providing GPs with the information they require to coordinate ongoing care, but little evidence is available to guide best practice. AIM This study aimed at better understanding the information needs of GP staff (GPs and practice nurses) supporting former patients of ICUs and their families following discharge from hospital, and identifying the barriers/facilitators associated with ICU-primary care information transfer. DESIGN AND SETTING This was a qualitative exploratory study of practices and participants throughout the UK. METHOD Audiotaped focus group discussions, complemented by small-group/individual interviews, were conducted with 15 former patients of ICUs, four relatives, and 20 GP staff between June and September 2015. Demographic data were captured by questionnaire and qualitative data were thematically analysed. RESULTS Findings suggest variability in discharge information experiences and blurred lines of responsibility between hospital and GP staff, and patients/relatives. Continuity of care was affected by delayed or poor communication from the hospital; GPs' limited contact with patients from critical care; and a lack of knowledge of the effects of critical illness or resources available to ameliorate these difficulties. Time pressures and information technology were, respectively, the most commonly mentioned barrier and facilitator. CONCLUSION Effective rehabilitation after a critical illness requires a coordinated and comprehensive approach, incorporating the provision of well-completed, timely, and relevant ICU-primary care discharge information. Health professionals need an improved understanding of critical illness, and patients and families must be included in all aspects of the information-sharing process.
Collapse
|
14
|
Bench S, Day T, Heelas K, Hopkins P, White C, Griffiths P. Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial. BMJ Open 2015; 5:e006852. [PMID: 26614615 PMCID: PMC4663421 DOI: 10.1136/bmjopen-2014-006852] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 07/10/2015] [Accepted: 07/20/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To evaluate the feasibility and effectiveness of an information pack, based on self-regulation theory, designed to support patients and their families immediately before, during and after discharge from an intensive care unit (ICU). DESIGN AND SETTING Prospective assessor-blinded pilot cluster randomised controlled trial (RCT; in conjunction with a questionnaire survey of trial participants' experience) in 2 ICUs in England. PARTICIPANTS Patients (+/- a family member) who had spent at least 72 h in an ICU, declared medically fit for discharge to a general ward. RANDOMISATION Cluster randomisation (by day of discharge decision) was used to allocate participants to 1 of 3 study groups. INTERVENTION A user-centred critical care discharge information pack (UCCDIP) containing 2 booklets; 1 for the patient (which included a personalised discharge summary) and 1 for the family, given prior to discharge to the ward. PRIMARY OUTCOME Psychological well-being measured using Hospital Anxiety and Depression Scores (HADS), assessed at 5±1 days postunit discharge and 28 days/hospital discharge. Statistical significance (p≤0.05) was determined using χ(2) and Kruskal-Wallis (H). RESULTS 158 patients were allocated to: intervention (UCCDIP; n=51), control 1: ad hoc verbal information (n=59), control 2: booklet published by ICUsteps (n=48). There were no statistically significant differences in the primary outcome. The a priori enrolment goal was not reached and attrition was high. Using HADS as a primary outcome measure, an estimated sample size of 286 is required to power a definitive trial. CONCLUSIONS Findings from this pilot RCT provide important preliminary data regarding the circumstances under which an intervention based on the principles of UCCDIP could be effective, and the sample size required to demonstrate this. TRIAL REGISTRATION NUMBER Current Controlled Trials ISRCTN47262088; results.
Collapse
Affiliation(s)
- Suzanne Bench
- Florence Nightingale Faculty of Nursing and Midwifery, King's College, London, UK
| | - Tina Day
- Florence Nightingale Faculty of Nursing and Midwifery, King's College, London, UK
| | - Karina Heelas
- Critical Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Philip Hopkins
- Critical Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | | | - Peter Griffiths
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| |
Collapse
|
15
|
Buchner DL, Bagshaw SM, Dodek P, Forster AJ, Fowler RA, Lamontagne F, Turgeon AF, Potestio M, Stelfox HT. Prospective cohort study protocol to describe the transfer of patients from intensive care units to hospital wards. BMJ Open 2015; 5:e007913. [PMID: 26155820 PMCID: PMC4499701 DOI: 10.1136/bmjopen-2015-007913] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/20/2015] [Accepted: 04/23/2015] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION The transfer of patient care between the intensive care unit (ICU) and the hospital ward is associated with increased risk of medical error and adverse events. This study will describe patient transfer from ICU to hospital ward by documenting (1) patient, family and provider experiences related to ICU transfer, (2) communication between stakeholders involved in ICU transfer, (3) adverse events that follow ICU transfer and (4) opportunities to improve ICU to hospital ward transfer. METHODS This is a mixed methods prospective observational study of ICU to hospital ward transfer practices in 10 ICUs across Canada. We will recruit 50 patients at each site (n=500) who are transferred from ICU to hospital ward, and distribute surveys to enrolled patients, family members, and healthcare providers (ICU and ward physicians and nurses) after patient transfer. A random sample of 6 consenting study participants (patients, family members, healthcare providers) from each study site (n=60) will be offered an opportunity to participate in interviews to further describe stakeholders' experience with ICU to hospital ward transfer. We will abstract information from patient health records to identify clinical data and use of transfer tools, and identify adverse events that are related to the transfer. ETHICS AND DISSEMINATION Research ethics board approval has been obtained at the coordinating study centre (UofC REB13-0021) and 5 study sites (UofA Pro00050646; UBC-PHC H14-01667; Sunnybrook 336-2014; QCH 14-07; Sherbrooke 14-172). Dissemination of the findings will provide a comprehensive description of transfer from ICU to hospital ward in Canada including the uptake of validated or local transfer tools, a conceptual framework of the experiences and needs of stakeholders in the ICU transfer process, a summary of adverse events experienced by patients after transfer from ICU to hospital ward, and opportunities to guide quality improvement efforts.
Collapse
Affiliation(s)
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Peter Dodek
- Division of Critical Care Medicine and Center for Health Evaluation and Outcome Sciences, St. Paul's Hospital and University of British Columbia, Vancouver, British Columbia, Canada
| | - Alan J Forster
- The Ottawa Hospital Research Institute, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Robert A Fowler
- Department of Medicine, Department of Critical Care Medicine, Sunnybrook Hospital, University of Toronto, Toronto, Canada
| | - François Lamontagne
- Centre de Recherche du CHU de Sherbrooke, Universite de Sherbrooke, Sherbrooke, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, CHU de Quebec Research Center, Quebec City, Canada
| | - Melissa Potestio
- Critical Care Strategic Clinical Network, Alberta Health Services, Calgary, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Canada
| |
Collapse
|
16
|
Day TL, Bench SD, Griffiths PD. The role of pilot testing for a randomised control trial of a complex intervention in critical care. J Res Nurs 2015. [DOI: 10.1177/1744987114547607] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Randomised controlled trials (RCTs) involving diverse population groups in complex health care settings can be difficult to successfully undertake and pose practical and methodological challenges. For this reason, undertaking a pilot study is recommended by the Medical Research Council prior to conducting a definitive trial. This paper reports a pragmatic review of the challenges encountered by the research team during a single centre pilot RCT and discusses how feasible it was to deliver and evaluate a complex intervention in practice. The psycho-social intervention designed for this trial was a ‘user-centred critical care discharge information pack’. The pack was designed to support patients and their families during and after their discharge from a critical care unit. It consisted of two written booklets, one for the patient and one for the family member. In total, 221 patients met our inclusion criteria, of whom 158 (71%) were recruited. The pilot RCT identified important lessons for the design of future trials. Challenges included those associated with the recruitment of potential participants, assessing capacity and obtaining informed consent. Problems with attrition, intervention delivery and the choice of data collection tools and time-points were also apparent. Our findings demonstrate that the evaluation of complex interventions is feasible in clinical practice. The importance of adhering to a robust research protocol, maintaining efficient and effective communication between researchers and clinical staff is emphasised. Findings further support the importance of conducting a pilot study prior to embarking on a definitive RCT.
Collapse
Affiliation(s)
- Tina L. Day
- Lecturer, Florence Nightingale School of Nursing and Midwifery, King’s College London, UK
| | - Suzanne D. Bench
- Lecturer, Florence Nightingale School of Nursing and Midwifery, King’s College London, UK
| | | |
Collapse
|