The user experience of critical care discharge: a meta-synthesis of qualitative research

Patients' experiences of preparing for transfer from the intensive care unit to a hospital ward: A multicentre qualitative study

BACKGROUND

The transfer from an intensive care unit (ICU) to a regular ward often causes confusion and stress for patients and family members. However, little is known about the patients' perspective on preparing for the transfer.

AIM

The purpose of the study was to describe patients' experiences of preparing for transfer from an ICU to a ward.

STUDY DESIGN

Individual interviews with 14 former ICU patients from three urban hospitals in Stockholm, Sweden were conducted 3 months after hospital discharge. Qualitative content analysis was used to interpret the interview transcripts. Reporting followed the consolidated criteria for reporting qualitative research checklist.

RESULTS

The results showed that the three categories, the discharge decision, patient involvement, and practical preparations were central to the patients' experiences of preparing for the transition from the intensive care unit to the ward. The discharge decision was associated with a sense of relief, but also worry about what would happen on the ward. The patients felt that they were not involved in the decision about the discharge or the planning of their health care. To handle the situation, patients needed information about planned care and treatment. However, the information was often sparse, delivered from a clinician's perspective, and therefore not much help in preparing for transfer.

CONCLUSIONS

ICU patients experienced that they were neither involved in the process of forthcoming care nor adequately prepared for the transfer to the ward. Relevant and comprehensible information and sufficient time to prepare were needed to reduce stress and promote efficient recovery.

RELEVANCE TO CLINICAL PRACTICE

The study suggests that current transfer strategies are not optimal, and a more person-centred discharge procedure would be beneficial to support patients and family members in the transition from the ICU to the ward.

A thematic analysis of staff perspectives on the impact of a mental health nurse (RMN) in a critical care unit

Background

Recent guidelines in the UK have shaped Critical Care Units (CCUs) to bring the mental health needs of patients, and staff wellbeing to the forefront of service provision. A health board based in NHS Wales has trialled the secondment of a Mental Health Nurse (RMN) within a CCU to help service provision adhere to such guidelines.

Methods

Critical care staff were invited to attend focus groups to share their experiences of how the RMN influenced service provision.

Results

Thematic analysis identified five main themes; including 'smoother care pathways', 'a holistic approach to care', 'co-production', 'knowledge and confidence' and 'staff wellbeing'. Each of these themes reflected how the RMN had both direct and indirect benefits on patient and staff wellbeing.

Conclusion

This qualitative exploration suggests that staff perceived value in the role of the RMN for both staff and patient outcomes, although further measures were considered necessary to improve staff-wellbeing within a critical care environment. This service evaluation supports recommendations for commissioning a RMN permanently in a CCU.

Experiences of Inter-Hospital Transfers (IHT) by Patients and Relatives during the COVID-19 Pandemic in France: A Qualitative Study

BACKGROUND

The first wave of the COVID-19 epidemic led to a rapid and unexpected saturation of the French ICU, forcing the health care system to adapt. Among other emergency measures, inter-hospital transfers were carried out.

OBJECTIVE

To assess the psychological experience of patients and their relatives regarding inter-hospital transfers.

METHODS

Semi-structured interviews were conducted with transferred patients and their relatives. A phenomenological study design was used to examine subjective experiences and their meanings for the participants.

RESULTS

The analysis found nine axes pertaining to the experiences of IHT (inter-hospital transfers), grouped in three super-ordinate themes: Information about inter-hospital transfers, differences in patients' and relatives' experiences, and host hospital experience. It appears that patients felt little impacted by the transfers, unlike relatives who experienced intense anxiety when the transfer was announced. Good communications between patients and their relatives resulted in a good level of satisfaction regarding their host hospitals. COVID-19 and its somatic consequences seem to have had more psychological impact on the participants than the transfers by themselves.

CONCLUSION

Our results suggest that there are limited current psychological consequences of the IHT implemented during the first wave of COVID-19, although the involvement of patients and their relatives in the organization of the IHT at the time of transfer could further limit them.

Investigating areas for improvement in the transition from hospital-to-home for frail older adults: A mixed methods study

Background

The planning and execution of discharge plans to successfully transition frail older adults from hospital-to-home can be a complicated endeavour.

Objective

To identify areas for improvement in the transitional process of frail older adults who were discharged from hospital based, geriatric units to their homes in the community.

Method

A prospective multi-phased mixed methods design was used, and cross-case thematic analysis of Phase 2 data were triangulated with Phase 1 findings.

Results

Thematic analysis findings indicated several related areas of importance within the transitional process: 1) Coordination of discharge; 2) Transition-to-home planning; 3) Home and community care; 4) Following of recommendations; and, 5) Medical follow-up.

Conclusions

Strengthening communication between stakeholders, as well as the implementation of harmonized policies and guidelines are needed to facilitate more consistent care delivery and provide patients and families with information on what to expect during the transitional process.

Identifying the factors affecting on interaction of faculty member: A meta-synthesis

BACKGROUND

The ability to interact and communicate effectively is one of the factors affecting the performance of faculty members, which is considered one of their basic competencies. The purpose of this study was to identify the factors affecting on interaction of faculty member with student and colleague, through the synthesis of literature.

MATERIALS AND METHODS

The research method was qualitative with a meta-synthesis approach. Meta-synthesis was performed with Sandelowski and Barroso method. After the research of databases in the period 1995-2021, 259 studies were collected and finally 48 sources were selected and were included in the analysis phase. Coding method was used to analyze the data.

RESULTS

Analyzing the findings of previous researchers and synthesizing the results, 155 codes, 18 subcategories, and 6 categories were identified and validated through kappa coefficient. The categories included "emotional-cognitive factor," "sociocultural factor," "communication factor," "professional factor," "educational factors," and "management factor."

CONCLUSION

Based on the findings of this study and the importance of faculty members' interactions in medical universities, it is recommended that university officials and administrators use the results of this study to provide a suitable platform for creating and strengthening these interactions through holding workshops.

Patient experiences of an intensive care Liaison Nurse support service

OBJECTIVES

To illuminate patients' experiences of being a part of an liaison nurse support service focused on supporting recently transferred intensive care unit patients.

RESEARCH METHODOLOGY/DESIGN

A qualitative inductive descriptive design including in-depth interviews was chosen.

SETTING

A project including an liaison nurse support service-intervention was undertaken during a 16-week period at a University hospital in Sweden. The liaison nurse support service was available Monday-Friday 10 am - 6 pm and nurses visited the patient 1-4 times after transfer to the ward.

MAIN OUTCOME MEASURES

Of the 109 patients who were visited by the liaison nurse support service, 14 agreed to be interviewed about their experiences of the transfer. Data was analysed by inductive content analysis.

FINDINGS

One overall theme, An advocate in a vulnerable situation emerged from the data. Four subthemes were identified: Ensures transfer of information between the intensive care unit and the general ward, Makes the circumstances understandable and coordinates between the care levels and Offers emotional support and stability in an uncertain situation.

CONCLUSION

The liaison nurse support service contributed to ensuring accurate transfer of information, solved problems when the patient themselves did not have control or strength and provided emotional support.

Patients' experience while transitioning from the intensive care unit to a ward

BACKGROUND

Intensive care unit (ICU) patients can experience emotional distress and post-traumatic stress disorder when they leave the ICU, also referred to as post-intensive care syndrome. A deeper understanding of what patients go through and what they need while they are transitioning from the ICU to the general ward may provide input on how to strengthen patient-centred care and, ultimately, contribute to a positive experience.

AIM

To describe the patients' experience while transitioning from the ICU to a general ward.

DESIGN

A descriptive qualitative study.

METHOD

Data were gathered through in-depth interviews and analysed using a qualitative content analysis. The qualitative study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research guidelines.

FINDINGS

Forty-eight interviews were conducted. Impact on emotional well-being emerged as a main theme, comprising four categories with six subcategories.

CONCLUSION

Transition from the ICU can be a shock for the patient, leading to the emergence of a need for information, and an impact on emotional well-being that has to be planned for carefully and addressed prior to, during, and following transition from the ICU to the general ward.

RELEVANCE TO CLINICAL PRACTICE

It is essential that nurses understand patients' experiences during transfer, identifying needs and concerns to be able to develop and implement new practices such as ICU Liaison Nurse or Nurse Outreach for the follow-up of these patients, the inclusion of a consultant mental health nurse, and the application of patient empowerment during ICU discharge.

Engaging Patients and Families to Help Research Inform and Advance Patient and Family-Centered Care in Critical Care Medicine

Intensive care unit (ICU) patient, and family member engagement is evolving in both critical care medicine practice and research. The results of two qualitative critical care research projects led by ICU survivors and family members show how patient-partner research training can inform the critical care community of meaningful priorities in the traumatic ICU context. The resulting creation of a prioritized list of critical care research topics builds further on the construct of patient-centered care.

Is my patient ready for a safe transfer to a lower-intensity care setting? Nursing complexity as an independent predictor of adverse events risk after ICU discharge

BACKGROUND

Patients discharged from intensive care units (ICUs) are at risk for adverse events (AEs). Establishing safe discharge criteria is challenging. No available criteria consider nursing complexity among risk factors.

OBJECTIVES

To investigate whether nursing complexity upon ICU discharge is an independent predictor for AEs.

METHODS

Prospective observational study. The Patient Acuity and Complexity Score (PACS) was developed to measure nursing complexity. Its predictive power for AEs was tested using multivariate regression analysis.

RESULTS

The final regression model showed a very-good discrimination power (AUC 0.881; p<0.001) for identifying patients who experienced AEs. Age, ICU admission reason, PACS, cough strength, PaCO₂, serum creatinine and sodium, and transfer to Internal Medicine showed to be predictive of AEs. Exceeding the identified PACS threshold increased by 3.3 times the AEs risk.

CONCLUSIONS

The level of nursing complexity independently predicts AEs risk and should be considered in establishing patient's eligibility for a safe ICU discharge.

Patients' experiences in Australian hospitals: a systematic review of evidence

Objective Patients are uniquely positioned to provide insightful comments about their care. Currently, a lack of comparable patient experience data prevents the emergence of a detailed picture of patients' experiences in Australian hospitals. The present study addresses this gap by identifying factors reported in primary research as relating to positive and negative experiences of patients in Australian hospitals. Methods Evidence from Australian qualitative studies of patients of all ages reporting their experiences in any hospital or day procedure centre was synthesised. A range of text words, synonyms and subject headings was developed and used to undertake a systematic search of seven electronic databases from January 1995 to July 2015 and the grey literature. Two reviewers independently screened the titles, abstracts or executive summaries and applied the inclusion criteria. Data were synthesised in a meta-narrative. Results Thirty-nine publications were included: 33 articles from database searches and six from the grey literature. Quality improvement researchers produced the dominant narrative and the nursing perspective was strong. Six themes emerged: 'Reciprocal communication and information sharing', 'Interpersonal skills and professionalism', 'The care environment', 'Emotional support', 'Discharge planning and process' and 'Correct treatment and physical outcomes'. Conclusion Tangible opportunities to enhance the patient experience are apparent. Small changes to the way that the health system operates and is resourced and the way that health professionals engage with patients could substantially improve care. Examples include inviting patients and carers to contribute to decision making and discussions about their treatment options and care preferences. What is known about the topic? Patient experience is identified as a key component of an optimal health system, along with improving the health of populations and reducing the per capita costs of care. The use of patient experience data has been associated with improved clinical effectiveness and patient safety. What does this paper add? Patient experience data are currently not routinely captured and difficulties exist as to where this information is available. These data are gathered using a variety of different methods that prohibit the development of a national picture. As a step towards overcoming this barrier, the present study identifies the common elements of healthcare experience reported by patients in Australia as being positive or negative. What are the implications for practitioners? Ensuring that patients and carers are active partners in their care is at the centre of a positive patient experience. Health professionals should provide patients with opportunities to make decisions about their care and ask questions, and to provide clear information before, during and after hospitalisation to enhance patients' experiences in Australian hospitals.

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.

The effect of provision of information on serum cortisol in patients transferred from the coronary care unit to the general ward: A randomised controlled trial

BACKGROUND AND AIM

Patients' transfer from coronary care units to general wards is a main source of anxiety for patients. Transfer anxiety is due to either lack of patients' knowledge or inadequacy of transfer-related information to patients. This study aimed to evaluate the effect of provision of information on the serum cortisol level, as an indicator of anxiety, in patients transferred from the coronary care unit to the general ward.

METHODS

This pretest-posttest randomised clinical trial was conducted on fifty patients transferred from coronary care units to general wards. Patients were selected using a purposeful sampling method and randomly were allocated to control and intervention groups. After taking blood samples for a baseline cortisol measurement, the patients in the control group received routine verbal transfer-related information. The patients in the intervention group were provided with an educational pamphlet consisting of textual and visual data about patients' transfer, continuity of care and the target general ward. The second and the third blood samples were taken for a cortisol measurement half an hour after informing the patients about the transfer order and half an hour after entrance to the general ward, respectively. Descriptive and inferential statistics via the SPSS software v. 21 was used for data analysis.

RESULTS

No statistically significant differences were reported between the groups in terms of demographic characteristics (p > 0.05). The serum levels of cortisol in the intervention group decreased from 40.16 (microgram per decilitre) at the baseline to 36.52 and 34.34 at the second and the third measurement time points, respectively. Conversely, the serum levels of cortisol in the control group increased from 37.48 at the baseline to 40.52 and 41.52 at the second- and the third-time points, respectively. While no statistically significant difference was reported between the groups in the baseline serum level of cortisol, between-group differences were statistically significant at the second- and the third-time points (p < 0.05).

CONCLUSION

Provision of transfer-related information can reduce transfer anxiety among patients, that should be transferred from coronary care units to general wards.

Using an intervention mapping approach to develop a discharge protocol for intensive care patients

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.

Like a hotel, but boring: users' experience with short-time community-based residential aftercare

Background

The discharge process from hospital to home for patients with severe mental illness (SMI) is often complex, and most are in need of tailored and coordinated community services at home. One solution is to discharge patients to inpatient short-stay community residential aftercare (CRA). The aim of this study was to explore how patients with SMI experience a stay in CRA established in a City in Central Norway.

Methods

A descriptive qualitative study with individual interviews and a group interview with 13 persons. The CRA aims to improve the discharge process from hospital to independent supported living by facilitating the establishment of health and social services and preparing the patients. The philosophy is to help patients use community resources by e.g. not offering any organized in-house activities. The main question in the interviews was “How have you experienced the stay at the CRA?” The interviews were analyzed with a thematic approach using systematic text condensation.

Results

The participants experienced the stay at the CRA “Like a hotel” but also boring, due to the lack of organized in-house activities. The patients generally said they were not informed about the philosophy of the CRA before the stay. The participants had to come up with activities outside the CRA and said they got active help from the staff to do so; some experienced this as positive, whereas others wanted more organized in-house activities like they were used to from mental health hospital stays. Participants described the staff in the CRA to be helpful and forthcoming, but they did not notice the staff being active in organizing the aftercare.

Conclusions

The stay at the CRA was experienced as different from other services, with more freedom and focus on self-care, and lack of in-house activities. This led to increased self-activity among the patients, but some wanted more in-house activities. To prepare the patients better for the stay at the CRA, more information about the philosophy is needed in the pre-admission process.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2777-z) contains supplementary material, which is available to authorized users.

The mediating role of spirituality (meaning, peace, faith) between psychological distress and mental adjustment in cancer patients

OBJECTIVE

The objectives of this study were (a) to determine the psychometric properties of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) scale and (b) to provide that FACIT scores behave one-dimensional to establish the mediating role of spiritual well-being in psychological distress and mental adjustment in a sample of patients with non-metastatic, resected cancer.

METHOD

A total of 504 consecutive patients completed the FACIT-Sp, Brief Symptom Inventory, and Mini-Mental Adjustment to Cancer scales. The dimensionality and structure of the scale were assessed by semi-confirmatory factor analysis; the reliability of the derived scale scores was evaluated using the omega coefficient, and regression analysis appraised the FACIT-Sp's mediating role between psychological distress and mental adjustment.

RESULTS

A clear and theoretically interpretable solution in two factors that agreed generally with solutions reported in other languages was obtained for the FACIT item scores and omega reliabilities of the derived Meaning/Peace (0.85) and Faith (0.86) scales were acceptable. The oblique solution in two factors was compatible with an essentially unidimensional solution of general well-being and associated strongly with psychological distress and mental adjustment. Spiritual well-being acted as a partial mediator between psychological distress and mental adjustment strategies, such as fighting spirit, hope, and cognitive avoidance.

CONCLUSIONS

The Spanish version of the FACIT-Sp scale is a reliable and valid clinical evaluation tool, and further highlights the potential clinical implications of spirituality for improving quality of life and adjustment to cancer.

Meeting the needs of critical care patients after discharge home: a qualitative exploratory study of patient perspectives

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.

A Brief Cognitive-Behavioral Psycho-Education (B-CBE) Program for Managing Stress and Anxiety of Main Family Caregivers of Patients in the Intensive Care Unit

Having a loved one in the intensive care unit (ICU) is a stressful event, which may cause a high level of anxiety to the family members. This could threaten their wellbeing and ability to support the patients in, or after discharge from, the ICU. To investigate the outcomes of a brief cognitive-behavioral psycho-education program (B-CBE) to manage stress and anxiety of the main family caregivers (MFCs), a pragmatic quasi-experimental study involving 45 participants (treatment group: 24; control group: 21) was conducted in an ICU. The Depression and Anxiety Stress Scale and the Critical Care Family Need Inventory were used to evaluate the primary outcomes on stress and anxiety, and satisfaction with family needs. The treatment group reported significantly better improvement in the information satisfaction score compared to the control group (p < 0.05; η² = 0.09). Overall main effects were observed on the stress (p < 0.01; η² = 0.20), anxiety (p < 0.01; η² = 0.18), depression (p < 0.05; η² = 0.13), support satisfaction (p < 0.05; η² = 0.13), and comfort satisfaction (p < 0.05; η² = 0.11) scores. The experience of this study suggest that MFCs are in great need of additional support like B-CBE to manage their stress and anxiety. Given the brevity of B-CBE, it is practical for critical care nurses to deliver and MFCs to take within the industrious context of an ICU. More studies are needed to investigate these types of brief psychological interventions.

Patient and carer experience of hospital-based rehabilitation from intensive care to hospital discharge: mixed methods process evaluation of the RECOVER randomised clinical trial

OBJECTIVES

To explore and compare patient/carer experiences of rehabilitation in the intervention and usual care arms of the RECOVER trial (ISRCTN09412438); a randomised controlled trial of a complex intervention of post-intensive care unit (ICU) acute hospital-based rehabilitation following critical illness.

DESIGN

Mixed methods process evaluation including comparison of patients' and carers' experience of usual care versus the complex intervention. We integrated and compared quantitative data from a patient experience questionnaire (PEQ) with qualitative data from focus groups with patients and carers.

SETTING

Two university-affiliated hospitals in Scotland.

PARTICIPANTS

240 patients discharged from ICU who required ≥48 hours of mechanical ventilation were randomised into the trial (120 per trial arm). Exclusion criteria comprised: primary neurologic diagnosis, palliative care, current/planned home ventilation and age <18 years. 182 patients completed the PEQ at 3 months postrandomisation. 22 participants (14 patients and 8 carers) took part in focus groups (2 per trial group) at >3 months postrandomisation.

INTERVENTIONS

A complex intervention of post-ICU acute hospital rehabilitation, comprising enhanced physiotherapy, nutritional care and information provision, case-managed by dedicated rehabilitation assistants (RAs) working within existing ward-based clinical teams, delivered between ICU discharge and hospital discharge. Comparator was usual care.

OUTCOME MEASURES

A novel PEQ capturing patient-reported aspects of quality care.

RESULTS

The PEQ revealed statistically significant between-group differences across 4 key intervention components: physiotherapy (p=0.039), nutritional care (p=0.038), case management (p=0.045) and information provision (p<0.001), suggesting greater patient satisfaction in the intervention group. Focus group data strongly supported and helped explain these findings. Specifically, case management by dedicated RAs facilitated greater access to physiotherapy, nutritional care and information that cut across disciplinary boundaries and staffing constraints. Patients highly valued its individualisation according to their needs, abilities and preferences.

CONCLUSIONS

Case management by dedicated RAs improves patients' experiences of post-ICU hospital-based rehabilitation and increases perceived quality of care.

TRIAL REGISTRATION NUMBER

ISRCTN09412438.

Care transitions: a systematic review of best practices

This article reports results from a systematic review used to inform the development of a best practice guideline to assist nurses in understanding their roles and responsibilities in promoting safe and effective client care transitions. A care transition is a set of actions designed to ensure safe and effective coordination and continuity of care as clients experience a change in health status, care needs, health care providers, or location.

Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial

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.

The role of pilot testing for a randomised control trial of a complex intervention in critical care

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.

Project Post Intensive Care eXercise (PIX): A qualitative exploration of intensive care unit survivors' perceptions of quality of life post-discharge and experience of exercise rehabilitation

Patients who survive critical illness often report deterioration in health related quality of life. This has not been shown to improve following post-intensive care unit (ICU) self-directed exercise. The Post Intensive Care eXercise (PIX) study demonstrated improved objectively measured fitness following a supervised exercise programme following critical illness and also suggested beneficial effects on physical and mental health. The qualitative arm of the PIX study reported here utilised focus groups to explore in more detail recovery from critical illness, quality of life following hospital discharge, perceptions of the exercise programme and it's impact on perceived well-being. Sixteen participants (eight of whom underwent the supervised exercise programme) were allocated to four psychologist lead focus groups. Themes identified after hospital discharge centred on social isolation, abandonment, vulnerability and reduced physical activity. However, patients in the exercise group described exercise training as motivating, increasing energy levels and sense of achievement, social interaction and confidence. This study adds to the sparse literature on the patient experience post critical illness. It supports the improvements in physical and mental health suggested with exercise in the PIX study and would support further research in relation to the effects of supervised exercise and rehabilitation programmes post critical illness. It recommends that future comparative outcome studies in this patient population also include interview-based assessment as part of assessment of quality of life and an individual's functional status.

Transfer out of intensive care: an evidence-based literature review

Critical care beds are a finite resource. Transfer or discharge of patients from the intensive care unit affects the flow of patients in critical care. Effective whole hospital bed management is key to the successful management of the critical care service. However, admission to the critical care unit alone can be extremely frightening, distressing, and traumatic not only for the patients but their families as well. Although transfer to the medical floors is a positive step toward physical recovery, it can be equally traumatic, and many patients and their families exhibit stress, fear, and anxiety. The purpose of this article was to systematically review the effects of intensive care unit transfer or discharge to medical-surgical floors on adult critically ill patients, their family members and nurses.

Effectiveness of critical care discharge information in supporting early recovery from critical illness

Providing patients with information can alleviate or reduce relocation stress, but how best to provide information to patients being discharged from critical care units is unclear. This narrative critical review describes (1) the current evidence base on the use of discharge information for adult critical care patients and (2) the extent of involvement of service users in the design and evaluation of such information. Seven publications reported data from 121 patients, 252 relatives, and 33 nurses. Overall evidence was of low quality but use of individualized information was associated with beneficial physical effects for patients and increased knowledge and satisfaction for their relatives. Findings highlight the significant gaps in our knowledge and understanding. The consequences of such findings for the future development of information that meets service users' needs are discussed. Results should inform the design of future studies on this topic.

Does time of transfer from critical care to the general wards affect anxiety? A pragmatic prospective cohort study

OBJECTIVES

To examine prospectively the impact of transfer time on patient anxiety.

DESIGN

A pragmatic prospective cohort study.

SETTING

14 bed adult intensive care unit (ICU) in a National Health Service teaching hospital trust in the United Kingdom.

METHODS

Critically ill patients staying on the ICU for at least 24 hours and clinically ready for transfer to the general ward completed the Hospital Anxiety and Depression Scale questionnaire (Zigmond and Snaith, 1983) at: pre-transfer - on the critical care (when they were clinically ready for transfer to the general ward), post-transfer - on the general ward.

RESULTS

The post-transfer median (range) score for anxiety was 6 (4-10) for day time and higher at 12.5 (9-16) for night time; this was found to be statistically significant U=80, p=0.011, r=0.37 and the post-transfer incidence of anxiety cases was 22% (8/36) for day time and higher at 64% (7/11) for night time; this was found to be statistically significant U=91, p=0.007, r=0.39.

CONCLUSION

This study suggests that transfers at night time are more anxiety provoking for patients than transfers in the day time.

Providing critical care patients with a personalised discharge summary: a questionnaire survey and retrospective analysis exploring feasibility and effectiveness

OBJECTIVES

This paper reports on the potential value and feasibility of providing patients with a personalised discharge summary of their critical care stay.

DESIGN AND METHODS

Fifty-one patient discharge summaries, written by nurses during a randomised controlled trial, were retrospectively analysed for readability, structure and quality. A questionnaire survey completed by trial patients (n=42), their relatives (n=21) and nurses (n=170) explored user experience and feasibility. Quantitative questionnaire data were analysed descriptively and inferentially; qualitative data were subjected to content analysis.

RESULTS

Most completed summaries achieved at least an average readability score and were of an acceptable quality. Motivation, time constraints and competing priorities were identified as key barriers to writing an effective summary; however, in the majority of cases, writing them had taken less than 15 minutes. Questionnaire data support that patient discharge summaries can help patients, relatives and ward nurses better understand and patients accept, what happened in critical care.

CONCLUSION

Patient discharge summaries are likely to be a useful adjunct to existing discharge information, but further work is required to determine when and how they should be provided. With appropriate training and support, it is feasible for nurses to write discharge summaries in a busy critical care environment.

A Survey of Intensive Care Unit Discharge Communication Practices in the UK

This survey into intensive care unit (ICU) discharge communication practices presents data from 60 responding units in the UK. Of these, 95% provide some form of written or verbal information to ward teams and 86.7% have Critical Care Outreach Teams, which provide the majority of post-discharge follow-up. Very little information is provided to patients, their relatives or GPs, with only 36.7% of units forwarding discharge letters to GPs, and 58.3% that do not formally provide discharge information to patients or relatives. These results highlight areas where the UK intensive care community can improve their communication about patients following discharge from ICU.

Patients' and relatives' experiences of transfer from intensive care unit to wards

AIMS

This literature review looks at the evidence around transferring patients from intensive care units (ICU) to wards. The literature informs us that patients and their families experience problems when being transferred from an ICU environment and that this increases overall anxiety.

BACKGROUND

The effects of surviving critical illness often have a profound psychological impact on patients and families This study examines the experiences of adult patients, and their families, following their transfer from the ICU to the ward.

FINDINGS

Five themes emerged from this literature review: physical responses, psychological responses, information and communication, safety and security, and the needs of relatives.

CONCLUSIONS

This review reminds us that these problems can be reduced if information and communication around time of transfers were improved.

RELEVANCE TO CLINICAL PRACTICE

As critical care nurses it is essential that we prepare patients and families for transfer to wards.

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.

Efficacy of information interventions in reducing transfer anxiety from a critical care setting to a general ward: a systematic review and meta-analysis

PURPOSE

Our aim was to undertake a comprehensive systematic review on the efficacy of information interventions on reducing anxiety in patients and family members on transfer from a critical care setting to a general ward.

MATERIALS AND METHODS

MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, and Google Scholar databases from 1990 to January 1, 2011, were searched. Bibliographies of identified articles were reviewed. Only high-quality randomized controlled trials comparing an intervention to reduce transfer anxiety with standard care, where transfer anxiety is measured by the validated State Trait Anxiety Inventory, were included. Data were extracted to estimate standard mean differences (SMDs), pooled odds ratios (ORs), and 95% confidence intervals (CIs) using both fixed and random effects model.

RESULTS

Of 266 studies identified in the primary search, 5 studies enrolling 629 participants met the inclusion criteria, family members' transfer anxiety was significantly reduced in the intervention arm of information provision (OR, 1.70; 95% CI, 1.15-2.52; P = .01) compared with those who received standard care (OR, 0.42; 95% CI; 0.276-0.625; P < .001), and patients' transfer anxiety was significantly reduced in one study.

CONCLUSIONS

Providing information to understand a future ward environment can significantly reduce patients' and family members' transfer anxiety from the critical care setting when compared with standard care.

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.

Involving users in the development of effective critical care discharge information: a focus group study

BACKGROUND

Discharge from critical care to a general care unit is a difficult period, and more effective information is needed to support patients and their families at this time.

OBJECTIVES

This study sought the views of patients, relatives and health care staff on (1) the most effective methods of delivering critical care discharge information, (2) the required information content of any proposed strategies, (3) the benefits and limitations of any existing strategies, and (4) potential resource implications.

METHODS

In this qualitative focus group study, 11 adult patients, 8 family members, and 23 health care staff in Eng-land took part in 8 focus group interviews at 2 hospitals. The computer software program NVIVO7 was used for thematic analysis of the data.

RESULTS

Three key themes were identified from the data: (1) considerations related to effective discharge information, (2) goals of critical care discharge information, and (3) resource implications.

CONCLUSIONS

This focus group study provides unique user insight into what influences successful and unsuccessful information giving. Based on real experiences, it adds to the limited international body of current evidence. Findings will be of value in designing future critical care discharge information and identifying the related resource implications.

Intensive care patient diaries in Scandinavia: a comparative study of emergence and evolution

Critical illness and intensive care therapy are often followed by psychological problems such as nightmares, hallucinations, delusions, anxiety, depression, and symptoms of posttraumatic stress. Intensive care patient diaries have been kept by nurses and the patients' family since the early 1990s in the Scandinavian countries to help critically ill patients come to terms with their illness after hospital discharge. The aim of the study was to describe and compare the emergence and evolution of intensive care patient diaries in Denmark, Norway, and Sweden. The study had a comparative international design using secondary analysis of qualitative data generated by key-informant telephone interviews with intensive care nurses (n=114). The study showed that diaries were introduced concurrently in the three Scandinavian countries as a grass-roots initiative by mutual cross-national inspiration. The concept has evolved from a pragmatic practice to an evidence-based domain of inquiry propelled by academically prepared nurses. Several schools of thought were identified in our study: diaries as (i) a therapeutic instrument, (ii) an act of caring, (iii) an expression of empathy, and (iv) a hybrid of the above. Diaries have the potential to fulfill the existential needs of patients who struggle to make sense of their experiences and construct their own illness narrative.