Transfer out of intensive care: a qualitative exploration of patient and family perceptions

Relatives' experiences of the transition from intensive care to home for acutely admitted intensive care patients-A qualitative study

BACKGROUND

Acute admission to an intensive care unit (ICU) can negatively affect quality of life for patients and their relatives. Relatives play an important caregiving role after the patient's admission. More knowledge and understanding of their needs are necessary as the patient transitions home.

AIM

This study aims to explore relatives' experiences of acutely admitted ICU patients' transition from the ICU to a general ward and then home.

STUDY DESIGN

A qualitative study with a phenomenological approach was conducted. Interviews were in-depth and featured open-ended questions. The interviews took place after the patients transitioned from ICU to home and were conducted online by videoconference. Data were analysed using Colaizzi's seven-step method.

RESULTS

Twelve relatives of acutely admitted ICU patients were interviewed. Five main themes emerged: (1) mixed feelings, (2) sense of not being involved, (3) limited information provision, (4) lack of acknowledgement as a caregiver, and (5) an uncertain future perspective. Relatives experience major uncertainties during transitions and prefer to be actively involved in care and care decisions.

CONCLUSIONS

This study indicates that relatives of ICU patients experience a lack of guidance during the transitions from the ICU to a general ward and to home, or a follow-up facility. More focus is needed on the themes of mixed feelings, the sense of not being involved, limited information provision, lack of acknowledgement as a caregiver, and an uncertain future perspective. This increased focus might improve the guidance during these transitions.

RELEVANCE TO CLINICAL PRACTICE

The insights from this study may help to improve the care of patients and their relatives during the transitions.

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.

Family member's experiences with and evaluation of an ICU Liaison Nurse Service: A qualitative study

BACKGROUND

Family members of critically ill patients often experience anxiety when their relatives are transferred from ICU to another level of care. ICU liaison nurse (ICULN) visits have been associated with improved support for patients, their families and nursing staff but has not been extensively studied in the non-English speaking setting. Yet, cross-country variations such as how hospital care is delivered and by who means that innovations such as the ICULN may not be able to be simply transferred to other contexts and may not have similar outcomes.

AIM

The aim of this study was to investigate family member's experiences with and evaluation of ICULN support service in one Swedish ICU.

STUDY DESIGN

A qualitative evaluation study was undertaken, recruiting family members of former ICU patients. Audio-taped in-depth interviews were conducted. Data were analysed by content analysis.

FINDINGS

Fifteen family members were interviewed. Two categories: Minds the gap between intensive care and the next care level and providing stability in an uncertain situation were identified. The ICULN supported the family members both directly, when the ICULNs listened to their questions and met their needs, and indirectly, when the ICULNs took responsibility for the patients and their physical and psychological conditions and wellbeing.

CONCLUSION

Families valued and were satisfied with the ICULN service but also gave suggestions to improve the service in this particular hospital context.

RELEVANCE TO CLINICAL PRACTICE

The study showed that an ICULN support service met several needs of family members and therefore was a beneficial way to support patients and family members in the transition from the ICU to the ward.

The role of the ICU liaison nurse services on anxiety in family caregivers of patients after ICU discharge during COVID-19 pandemic: a randomized controlled trial

Background

With the onset of the COVID-19 pandemic and the need to maintain social distancing and changes in wards' structure, families no longer access the routine support they received during the hospitalization of their patients in the ICU. This study aimed to determine the effects of ICU liaison nurse services on the anxiety in patients’ family caregivers after ICU discharge during the COVID-19 pandemic.

Methods

This randomized controlled trial was performed in western Iran from February 2020, to March 2021. Sixty subjects were selected from the family caregivers of the patients transferred from the ICU and were randomly assigned to the control (n = 30) and the intervention groups (n = 30). The control group received routine transfer care. In the intervention group, liaison nurse services were offered in 4 dimensions: patient support, family support, training, support of the ward’s staff, and the evaluation of the destination ward. The participants’ anxiety was measured using the Spielberger State Anxiety Inventory immediately after the patient transfer and 6 h after admission to the general ward. Data analyzed with SPSS V16, descriptive and inferential statistics, including Chi-square test, Mann–Whitney test, Wilcoxon test, and Generalized Linear Model with cumulative logit link function. Results were reported at a 0.05 significance level.

Results

A statistically significant difference was observed in baseline anxiety levels (P = 0.035) and age group (P < 0.001) between the intervention and control groups. After moderating baseline anxiety levels, the age group, and marital status, the impact of the intervention was significant (X² = 10.273, df = 1, P < 0.001), meaning that the intervention could reduce the relative chances of developing higher levels of anxiety by 92.1% (OR: 0.08, 95%CI: 0.017–0.373, P < 0.001).

Conclusions

This study confirmed the positive impact of nursing services on reducing anxiety in family caregivers during the COVID-19 pandemic. It is recommended to use these services, especially during the COVID-19 condition, to facilitate the patient transfer, support the patient's family, and reduce the health care gap between the ICU and the ward.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-01034-6.

Patient discharge from intensive care: an updated scoping review to identify tools and practices to inform high-quality care

BACKGROUND

Critically ill patients require complex care and experience unique needs during and after their stay in the intensive care unit (ICU). Discharging or transferring a patient from the ICU to a hospital ward or back to community care (under the care of a general practitioner) includes several elements that may shape patient outcomes and overall experiences. The aim of this study was to answer the question: what elements facilitate a successful, high-quality discharge from the ICU?

METHODS

This scoping review is an update to a review published in 2015. We searched MEDLINE, EMBASE, CINAHL, and Cochrane databases from 2013-December 3, 2020 including adult, pediatric, and neonatal populations without language restrictions. Data were abstracted using different phases of care framework models, themes, facilitators, and barriers to the ICU discharge process.

RESULTS

We included 314 articles from 11,461 unique citations. Two-hundred and fifty-eight (82.2%) articles were primary research articles, mostly cohort (118/314, 37.6%) or qualitative (51/314, 16.2%) studies. Common discharge themes across all articles included adverse events, readmission, and mortality after discharge (116/314, 36.9%) and patient and family needs and experiences during discharge (112/314, 35.7%). Common discharge facilitators were discharge education for patients and families (82, 26.1%), successful provider-provider communication (77/314, 24.5%), and organizational tools to facilitate discharge (50/314, 15.9%). Barriers to a successful discharge included patient demographic and clinical characteristics (89/314, 22.3%), healthcare provider workload (21/314, 6.7%), and the impact of current discharge practices on flow and performance (49/314, 15.6%). We identified 47 discharge tools that could be used or adapted to facilitate an ICU discharge.

CONCLUSIONS

Several factors contribute to a successful ICU discharge, with facilitators and barriers present at the patient and family, health care provider, and organizational level. Successful provider-patient and provider-provider communication, and educating and engaging patients and families about the discharge process were important factors in a successful ICU discharge.

ICU Volunteer "Transition Guides": A Prospective Study on Improving the Patient Transfer Experience

BACKGROUND

This study was conducted to measure the impact of a volunteer "Transition Guide" on patient experience and psychological stress during the transition from ICUs to general medical and surgical wards.

METHODS

Between July 2017 and February 2020, medical and surgical patients from nine ICUs at a single tertiary care hospital were accompanied by a uniquely trained volunteer Transition Guide to aid them at the time of transfer to general medical/surgical wards, when available. If a Transition Guide was not available, they were transferred without one. The following day, patients were surveyed with a tool assessing overall satisfaction, multiple aspects in the domain of communication, and psychological stress associated with the transition process. When available, family members and ward nurses who admitted patients from the ICU were surveyed.

RESULTS

Target enrollment was 300 patients in each group. Due to COVID-19 and institutional restrictions on volunteers, only 264 underwent transfer with a Guide, while 305 transferred without one. Of all patients approached, 95% with a Guide and 96% without a Guide completed the survey. Patients who were accompanied by a Transition Guide reported a better overall transition, better communication, greater understanding, better resolution of concerns, and less stress than those who did not have a Transition Guide (p < 0.05 for all).

CONCLUSION

Among a cohort of formerly critically ill patients subsequently transferred to general medical and surgical wards, the presence of a volunteer Transition Guide significantly improved patient experience, enhanced patient communication and understanding, and reduced stress associated with the transfer process. Hospitals may consider this expanded and specialized role for volunteerism in the health care setting to improve patient-centered outcomes.

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.

Factors influencing family member perspectives on safety in the intensive care unit: a systematic review

PURPOSE

Patient safety has developed as a strong marker for healthcare quality. Safety matters are important in the intensive care unit (ICU) where complex clinical decisions are made, intensive technology is used, and families hold a unique role. The aim of this review was to identify and describe factors that influence family member's perceptions of safety in the adult ICU.

DATA SOURCES

Searches were conducted between September and November 2018 and repeated in July 2020 using CINAHL, MEDLINE (EBSCO), PubMed and PsycINFO databases.

STUDY SELECTION

Published primary studies undertaken in adult ICUs and involving adult family member participants exploring safety or feeling safe. No date restrictions were applied.

DATA EXTRACTION

A data extraction form collected information about sample, study design, data collection methods and results from each paper. Methodological quality was assessed using the QualSyst tools for qualitative and quantitative studies. Narrative synthesis was undertaken.

RESULTS OF DATA SYNTHESIS

Twenty papers were included with 11 papers published since 2010. The majority of papers reported on qualitative studies (n = 16). Four factors were identified that influenced whether family members felt that the patient was safe in ICU: family visiting, information and communication, caring and professional competence.

CONCLUSION

In detailing specific practices that make families feel safe and unsafe in ICU, these review findings provide a structure for clinicians, educators and researchers to inform future work and gives opportunity for the family role in patient safety to be reconsidered.

The expressed support needs of families of adults who have survived critical illness: A thematic synthesis

BACKGROUND

Surviving critical illness can result in ongoing psychological, physical and cognitive impairments for both survivors and families. During the time from the critical illness through to the period of adaptation back to community living, families, alongside survivors, have support needs.

OBJECTIVES

This systematic review aimed to provide an in-depth insight into the expressed support needs of families of adults who survived an admission to an intensive care unit and returned to a home environment. It also aimed to explore how these needs change over time, and what support provisions families perceived to be helpful.

METHODS

This was a systematic review using thematic synthesis methodology. Predefined searches were conducted in CINAHL, Medline, PsychINFO, SocIndex, EMbase, Academic Search Complete, EThOS and OpenGrey to locate studies published in English from 2000. Two reviewers screened each study against the inclusion criteria. Quality appraisal was undertaken using Joanna Briggs Institute tools. Extracted data were managed in Nvivo12® and analysed to identify descriptive and analytical themes. The Timing it Right Framework was used to frame changes in need across the recovery continuum.

RESULTS

Thirty-nine studies were included, 30 qualitative, eight quantitative and one mixed methods. Five key family needs were identified across the recovery continuum: for security; to make sense of the situation; finding a balance; holding everything together; and for trust.

DISCUSSION

Families found the following interventions helpful: written information; care coordination and navigation; input from intensive care staff after discharge to support continuity; and provision of family support groups. Although there are similarities between the needs of families and survivors, there are sufficient differences to warrant the development of processes to identify and address family need throughout the recovery continuum.

CONCLUSION

More research is required to develop a tool to better identify the needs of families across the recovery continuum, identify gaps in current service provision, and design interventions to meet these needs.

STUDY REGISTRATION

CRD42019136883 (PROSPERO).

Adverse Events After Transition From ICU to Hospital Ward: A Multicenter Cohort Study

OBJECTIVES

To examine adverse events and associated factors and outcomes during transition from ICU to hospital ward (after ICU discharge).

DESIGN

Multicenter cohort study.

SETTING

Ten adult medical-surgical Canadian ICUs.

PATIENTS

Patients were those admitted to one of the 10 ICUs from July 2014 to January 2016.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Two ICU physicians independently reviewed progress and consultation notes documented in the medical record within 7 days of patient's ICU discharge date to identify and classify adverse events. The adverse event data were linked to patient characteristics and ICU and ward physician surveys collected during the larger prospective cohort study. Analyses were conducted using multivariable logistic regression. Of the 451 patients included in the study, 84 (19%) experienced an adverse event, the majority (62%) within 3 days of transfer from ICU to hospital ward. Most adverse events resulted only in symptoms (77%) and 36% were judged to be preventable. Patients with adverse events were more likely to be readmitted to the ICU (odds ratio, 5.5; 95% CI, 2.4-13.0), have a longer hospital stay (mean difference, 16.1 d; 95% CI, 8.4-23.7) or die in hospital (odds ratio, 4.6; 95% CI, 1.8-11.8) than those without an adverse event. ICU and ward physician predictions at the time of ICU discharge had low sensitivity and specificity for predicting adverse events, ICU readmissions, and hospital death.

CONCLUSIONS

Adverse events are common after ICU discharge to hospital ward and are associated with ICU readmission, increased hospital length of stay and death and are not predicted by ICU or ward physicians.

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

INTRODUCTION

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

AIM

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

METHODS

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

SETTING

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

FINDINGS

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

Examining the hurdles in defining the practice of Nurse Navigators

BACKGROUND

Nurse navigators are an emerging workforce providing care to people with multiple chronic conditions. The role of the navigators is to identify patients requiring support in negotiating their health care.

PURPOSE

A critical discourse analysis was used to examine qualitative data collected from nurse navigators and consenting navigated patients to identify key indicators of how nurse navigators do their work and where the success of their work is most evident.

DISCUSSION

Nurse navigators help patients who have lost trust in the health system to re-engage with their interdisciplinary health care team. This re-engagement is the final step in a journey of addressing unmet needs, essential to hospital avoidance.

CONCLUSION

Nurse navigators provide a continuum of authentic and holistic care. To acknowledge the true value of nurse navigators, their performance indicators need to embrace the value-added care they provide.

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

Background

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

Methods

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

Results

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

Conclusions

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

A Systematic Review of Clinical Outcomes Associated With Intrahospital Transitions

Previous transitional care research has focused on transitions occurring between community and hospital settings. Little is known regarding intrahospital transitions and how they affect care quality. A systematic review was therefore conducted to synthesize the literature regarding clinical outcomes associated with intrahospital transitions. Literature published between January 2003 and December 2018 and indexed in Medline/PubMed, CINAHL, and PsychINFO were reviewed using PRISMA guidelines. Articles were limited to English language and peer-reviewed. Articles were excluded if they focused on transitions occurring from or to the hospital, discharge/discharge planning, or postdischarge follow-up. Data abstraction included study characteristics, sample characteristics, and reported clinical outcomes. Fourteen studies met inclusion criteria, primarily using cross-sectional, cohort, or retrospective chart review quantitative designs. Data were analyzed and synthesized based on outcomes reported. Major outcomes emerging from the articles included delirium, hospital length of stay, mortality, and adverse events. Delirium, hospital length of stay, and morbidity and mortality rates were associated with delayed transfers and transfers to inappropriate units. In addition, increased fall risk and infection rates were associated with higher rates of transfer. Intrahospital transitions represent critical periods of time where the quality of care being provided may be diminished, negatively affecting patient safety and outcomes.

Impact of Patient and Family Involvement in Long-Term Outcomes

Surviving a critical illness can have long-term effects on both patients and families. These effects can be physical, emotional, cognitive, and social, and they affect both the patient and the family. Family members play a key role in helping their loved one recover, and this recovery process can take considerable time. Transferring out of an intensive care unit, and discharging home from a hospital, are important milestones, but they represent only the beginning of recovery and healing after a critical illness. Recognizing that these challenges exist both for patients and families is important to improve critical illness outcomes.

Geriatric nurse involvement during intra-hospital transitions

Geriatric nurses are skilled in the special needs of hospitalized older adults. While significant focus has been placed on improving care transitions upon discharge, less attention has been placed on intra-hospital transitions. Intra-hospital transitions represent transfers occurring between hospital units or rooms. Intra-hospital transitions challenge normal nursing workflow and require careful consideration of care coordination to prevent adverse events for older adults. Frequent changes in environment and a lack of consistency in care may support the development or prolongation of delirium as older adults are transferred between units and rooms. Additional adverse event risks include infections and falls, which also increases with each transfer. Geriatric nurse involvement can enhance communication between units as well as ensuring appropriate geriatric assessments occur. Geriatric nurses are thus well positioned to act as leaders during intra-hospital transitions, potentially reducing these and adverse events.

Identifying patients' support needs following critical illness: a scoping review of the qualitative literature

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.

The Lifetime Effects of Injury: Postintensive Care Syndrome and Posttraumatic Stress Disorder

Postintensive care syndrome (PICS) is a heterogeneous syndrome marked by physical, cognitive, and mental health impairments experienced by critical care survivors. It is a syndrome that bears significant human and health care costs. Additional research is needed to identify risk factors and diagnostic, preventative, and treatment strategies for PICS. Trauma intensive care unit patients are particularly vulnerable to posttraumatic stress disorder, which shares some of the adverse long-term consequences of PICS and also requires additional research into effective preventative and management strategies.

Parents' and carers' experiences of transition and aftercare following a child's discharge from a paediatric intensive care unit to an in-patient ward setting: A qualitative systematic review

OBJECTIVES

To explore parents' experiences of transition and aftercare following their child's discharge from a paediatric intensive care unit to an in-patient ward.

METHODS

A qualitative systematic review was conducted. Electronic databases CINAHL, MEDLINE, EMBASE, Psych INFO, and ASSIA were searched for qualitative studies with no date limits imposed. Methodological quality was assessed using the JBI QARI standardised critical appraisal instrument. Data were extracted into a standardised data extraction tool. Findings were pooled using a meta-aggregative approach.

RESULTS

Four studies were included in the final review that included a total of 95 participants. Forty-nine findings were extracted and through an iterative process resulting in four synthesised findings being developed. These included: (1) Dynamic emotional response pre, peri and post-transfer; (2) Involvement in care absent but fundamental to functioning; (3) Changes in care delivery and environment provoking adverse emotions and (4) Transition as a physical, emotional and social balancing act.

CONCLUSION

Transitioning from the paediatric intensive care unit to an in-patient ward can be a challenging time for parents, exposing them to a turbulent emotional and social status, and depleting their personal resources. Parents are aware of differences in the organisation and delivery of care between clinical areas which can compound the adversity experienced. Health professionals need to provide targeted support in order to mitigate these negative emotional, physical and social effects experienced.

Ward visits- one essential step in intensive care follow-up. An interview study with critical care nurses' and ward nurses'

OBJECTIVE

The aim of this study was to describe critical care nurses' and ward nurses' perceptions of the benefits and challenges with a nurse-led follow-up service for intensive care-survivors at general wards.

BACKGROUND

Patients recently transferred from intensive care to the general ward are still vulnerable and require complex care. There are different models of intensive care follow-up services and some include ward visits after transfer from intensive care. Research methodology/design: This study had a qualitative design. Data from 13 semi-structured interviews with Swedish critical care nurses and ward nurses were analysed using qualitative content analysis.

FINDINGS

The findings consisted of one theme, namely, "Being a part of an intra-organisational collaboration for improved quality of care", and four subthemes: "Provides additional care for the vulnerable patients, "Strengthens ward-based critical care", "Requires coordination and information", and "Creates an exchange of knowledge". The nurse-led follow-up service detected signs of deterioration and led to better quality of care. However, shortage of time, lack of interaction, feedback and information about the function of the follow-up service led to problems.

CONCLUSION

The findings indicate that ward visits should be included in the intensive care follow-up service. Furthermore, intra-organisational collaboration seems to be essential for intensive care survivors' quality of care.

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.

Experiences of gestational diabetes and gestational diabetes care: a focus group and interview study

Background

Gestational diabetes mellitus (GDM) is an increasingly common condition of pregnancy. It is associated with adverse fetal, infant and maternal outcomes, as well as an increased risk of GDM in future pregnancies and type 2 diabetes for both mother and offspring. Previous studies have shown that GDM can result in an emotionally distressing pregnancy, but there is little research on the patient experience of GDM care, especially of a demographically diverse UK population. The aim of this research was to explore the experiences of GDM and GDM care for a group of women attending a large diabetes pregnancy unit in southeast London, UK, in order to improve care.

Methods

Framework analysis was used to support an integrated analysis of data from six focus groups with 35 women and semi-structured interviews with 15 women, held in 2015. Participants were purposively sampled and were representative of the population being studied in terms of ethnicity, age, deprivation score and body mass index (BMI).

Results

We identified seven themes: the disrupted pregnancy, projected anxiety, reproductive asceticism, women as baby machines, perceived stigma, lack of shared understanding and postpartum abandonment. These themes highlight the often distressing experience of GDM. While most women were grateful for the intensive support they received during pregnancy, the costs to their personal autonomy were high. Women described feeling valued solely as a means to produce a healthy infant, and felt chastised if they failed to adhere to the behaviours required to achieve this. This sometimes had an enduring impact to the potential detriment of women’s long-term psychological and physical health.

Conclusions

This study reveals the experiences of a demographically diverse group of patients with GDM, reflecting findings from previous studies globally and extending analysis to the context of improving care. Healthcare delivery may need to be reoriented to improve the pregnancy experience and help ensure women are engaged and attentive to their own health, particularly after birth, without compromising clinical pregnancy outcomes. Areas for consideration in GDM healthcare include: improved management of emotional responses to GDM; a more motivational approach; rethinking the medicalisation of care; and improved postpartum care.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1657-9) contains supplementary material, which is available to authorized users.

Patient transfer from the intensive care unit to a general ward

The transfer of patients from the intensive care unit (ICU) to a general ward can present several challenges for nurses. Such patients are at high risk of adverse outcomes, including readmission to the ICU, and increased nosocomial infections and mortality, with a resultant increase in hospital costs. This article explores the challenges of transferring patients from the ICU and uses evidence to examine ways to address them to ensure optimal care for a complex patient group. Transfer time, factors affecting general ward care, handover processes, recognition of deterioration and education, intensive care outreach, and the psychological factors affecting these patients are examined.

A multi-center prospective cohort study of patient transfers from the intensive care unit to the hospital ward

PURPOSE

To provide a 360-degree description of ICU-to-ward transfers.

METHODS

Prospective cohort study of 451 adults transferred from a medical-surgical ICU to a hospital ward in 10 Canadian hospitals July 2014-January 2016. Transfer processes documented in the medical record. Patient (or delegate) and provider (ICU/ward physician/nurse) perspectives solicited by survey 24-72 h after transfer.

RESULTS

Medical records (100%) and survey responses (ICU physicians-80%, ICU nurses-80%, ward physicians-46%, ward nurses-64%, patients-74%) were available for most transfers. The median time from initiation to completion of transfer was 25 h (IQR 6-52). ICU physicians and nurses reported communicating with counterparts via telephone (78 and 75%) when transfer was requested (82 and 24%) or accepted (31 and 59%) and providing more elements of clinical information than ward physicians (mean 4.7 vs. 3.9, p < 0.001) and nurses (5.0 vs. 4.4, p < 0.001) reported receiving. Patients were more likely to report satisfaction with the transfer when they received more information (OR 1.32, 95% CI 1.18-1.48), had their questions addressed (OR 3.96, 95% CI 1.33-11.84), met the ward physician prior to transfer (OR 4.61, 95% CI 2.90-7.33), and were assessed by a nurse within 1 h of ward arrival (OR 4.70, 95% CI 2.29-9.66). Recommendations for improvement included having a documented care plan travel with the patient (all stakeholders), standardized face-to-face handover (physicians), avoiding transfers at shift change (nurses) and informing patients about pending transfers in advance (patients).

CONCLUSIONS

ICU-to-ward transfers are characterized by failures of patient flow and communication; experienced differently by patients, ICU/ward physicians and nurses, with distinct suggestions for improvement.

Transitioning the complex trauma patient from the ICU: acute care nurses' perceptions of readiness

Trauma centers improve patient outcomes through the provision of expert care by trauma surgeons and nurses. While the American College of Surgeons stipulates that trauma centers must have qualified nurses, there is no clear definition of qualified, nor is there a recommendation for trauma nurse readiness beyond the emergency department or intensive care. In a newly designated level II trauma center, it was recognized that nurses were unprepared to provide care to complex trauma patients. This study explored nurses' perceptions of their knowledge, skills and confidence in complex trauma care utilizing a novel transitional care model.

Prospective cohort study protocol to describe the transfer of patients from intensive care units to hospital wards

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.

Improving critical care discharge summaries: a collaborative quality improvement project using PDSA

Around 110,000 people spend time in critical care units in England and Wales each year. The transition of care from the intensive care unit to the general ward exposes patients to potential harms from changes in healthcare providers and environment. Nurses working on general wards report anxiety and uncertainty when receiving patients from critical care. An innovative form of enhanced capability critical care outreach called 'iMobile' is being provided at King's College Hospital (KCH). Part of the remit of iMobile is to review patients who have been transferred from critical care to general wards. The iMobile team wished to improve the quality of critical care discharge summaries. A collaborative evidence-based quality improvement project was therefore undertaken by the iMobile team at KCH in conjunction with researchers from King's Improvement Science (KIS). Plan, Do, Study, Act (PDSA) methodology was used. Three PDSA cycles were undertaken. Methods adopted comprised: a scoping literature review to identify relevant guidelines and research evidence to inform all aspects of the quality improvement project; a process mapping exercise; informal focus groups / interviews with staff; patient story-telling work with people who had experienced critical care and subsequent discharge to a general ward; and regular audits of the quality of both medical and nursing critical care discharge summaries. The following behaviour change interventions were adopted, taking into account evidence of effectiveness from published systematic reviews and considering the local context: regular audit and feedback of the quality of discharge summaries, feedback of patient experience, and championing and education delivered by local opinion leaders. The audit results were mixed across the trajectory of the project, demonstrating the difficulty of sustaining positive change. This was particularly important as critical care bed occupancy and through-put fluctuates which then impacts on work-load, with new cohorts of staff regularly passing through critical care. In addition to presenting the results of this quality improvement project, we also reflect on the lessons learned and make suggestions for future projects.

Discharge practices for the intensive care patient: a qualitative exploration in the general ward setting

OBJECTIVE

To explore how registered nurses (RNs) in the general ward perceive discharge processes and practices for patients recently discharged from the intensive care unit (ICU).

BACKGROUND

Patients discharged from the ICU environment often require complicated and multifaceted care. The ward-based RN is at the forefront of the care of this fragile patient population, yet their views and perceptions have seldom been explored.

DESIGN

A qualitative grounded theory design was used to guide focus group interviews with the RN participants.

METHODS

Five semi-structured focus group interviews, including 27 RN participants, were conducted in an Australian metropolitan tertiary referral hospital in 2011. Data analyses of transcripts, field notes and memos used concurrent data generation, constant comparative analysis and theoretical sampling.

RESULTS

Results yielded a core category of 'two worlds' stressing the disconnectedness between ICU and the ward setting. This category was divided into sub categories of 'communication disconnect' and 'remember the family'. Properties of 'what we say', 'what we write', 'transfer' and 'information needs' respectively were developed within those sub-categories.

CONCLUSION

The discharge process for patients within the ICU setting is complicated and largely underappreciated. There are fundamental, misunderstood differences in prioritisation and care of patients between the areas, with a deep understanding of practice requirements of ward based RNs not being understood. The findings of this research may be used to facilitate inter departmental communications and progress practice development.

Organizing safe transitions from intensive care

Background. Organizing and performing patient transfers in the continuum of care is part of the work of nurses and other staff of a multiprofessional healthcare team. An understanding of discharge practices is needed in order to ultimate patients' transfers from high technological intensive care units (ICU) to general wards. Aim. To describe, as experienced by intensive care and general ward staff, what strategies could be used when organizing patient's care before, during, and after transfer from intensive care. Method. Interviews of 15 participants were conducted, audio-taped, transcribed verbatim, and analyzed using qualitative content analysis. Results. The results showed that the categories secure, encourage, and collaborate are strategies used in the three phases of the ICU transitional care process. The main category; a safe, interactive rehabilitation process, illustrated how all strategies were characterized by an intention to create and maintain safety during the process. A three-way interaction was described: between staff and patient/families, between team members and involved units, and between patient/family and environment. Discussion/Conclusions. The findings highlight that ICU transitional care implies critical care rehabilitation. Discharge procedures need to be safe and structured and involve collaboration, encouraging support, optimal timing, early mobilization, and a multidiscipline approach.

Important quality aspects in the transfer process

Purpose

– Admission to and transfer from an intensive care unit affects not only the patient but also his or her relatives. The authors aimed to investigate relatives' perceptions of quality of care during a patient's transfer process from an intensive care unit to a general ward.

Design/methodology/approach

– The study had a mixed method design that included quantitative data and answers to open questions. The participants were 65 relatives of patients who received care in an ICU. They were recruited from two hospitals in Sweden.

Findings

– A majority perceived the transfer process as important, but analysis also showed that the participants rated it as an area for improvements. The relatives wanted participation, personal insight and control, respectful encounters, proximity, reassurance, continuous quality, reconnection and feedback. The relatives' participation in the transfer process was perceived as inadequate by 61 per cent, and the support that was received after the ICU discharge was perceived as inadequate by 53 per cent. The patients' length of stay in the ICU affected the relatives' perceptions of the quality of care. Overall, the relatives seemed to desire that the transfer process includes a continuous care, a competent staff, available information throughout the transfer process and personal involvement in the care, both before and after the transfer from the ICU.

Research limitations/implications

– The conclusion of this study is that relatives' needs and seeking for a well-planned ICU transitional process organisation with continuous quality before and after transfer, informational strategies that encourage the relatives to be involved and an organisation with competence throughout the healthcare chain are vital for quality.

Practical implications

– The conclusion of this study is that relatives' needs and seeking for a well-planned ICU transitional process organisation with continuous quality before and after transfer, informational strategies that encourage the relatives to be involved and an organisation with competence throughout the healthcare chain are vital for quality.

Originality/value

– The findings have important implications for nursing and nursing management. A relative's perception of the quality of care before and after transfer from ICU may be a valuable source to evaluate the ICU transitional care.

Intensive care survivors' experiences of ward-based care: Meleis' theory of nursing transitions and role development among critical care outreach services

AIMS AND OBJECTIVES

To explore the psychosocial needs of patients discharged from intensive care, the extent to which they are captured using existing theory on transitions in care and the potential role development of critical care outreach, follow-up and liaison services.

BACKGROUND

Intensive care patients are at an increased risk of adverse events, deterioration or death following ward transfer. Nurse-led critical care outreach, follow-up or liaison services have been adopted internationally to prevent these potentially avoidable sequelae. The need to provide patients with psychosocial support during the transition to ward-based care has also been identified, but the evidence base for role development is currently limited.

DESIGN AND METHODS

Twenty participants were invited to discuss their experiences of ward-based care as part of a broader study on recovery following prolonged critical illness. Psychosocial distress was a prominent feature of their accounts, prompting secondary data analysis using Meleis et al.'s mid-range theory on experiencing transitions.

RESULTS

Participants described a sense of disconnection in relation to profound debilitation and dependency and were often distressed by a perceived lack of understanding, indifference or insensitivity among ward staff to their basic care needs. Negotiating the transition between dependence and independence was identified as a significant source of distress following ward transfer. Participants varied in the extent to which they were able to express their needs and negotiate recovery within professionally mediated boundaries.

CONCLUSION

These data provide new insights into the putative origins of the psychosocial distress that patients experience following ward transfer.

RELEVANCE TO CLINICAL PRACTICE

Meleis et al.'s work has resonance in terms of explicating intensive care patients' experiences of psychosocial distress throughout the transition to general ward-based care, such that the future role development of critical care outreach, follow-up and liaison services may be more theoretically informed.

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.

[The transition process from the intensive care unit to the ward: a review of the literature]

The optimum transition process from the ICU to the ward is key to avoiding the appearance of anxiety in the patient and family, increase of re-admissions in the ICU with the consequent increase in costs and jeopardization to the patient's safety.

OBJECTIVE

1) To identify, study and give a critical presentation of the existing evidence on how patients, families and nurses experience the transition from ICU to the ward; 2) to analyze the possible interventions available for the development of an optimum transition process.

METHODOLOGY

A review was made of the evidence available in the main databases. In addition, several journals specialized in Intensive Care were reviewed. Studies with a qualitative, quantitative or mixed approach and reviews on the subject with a systematic methodology or narrative reviews were included.

RESULTS

A total of 23 papers were selected for review, 10 of which were qualitative studies, 11 quantitative and two had combined methodology. «Transfer anxiety» was identified after the analysis of these articles as one of the recurring aspects. Discrepancies regarding who should take responsibility for the preparation of the transition process and when it should be performed were also found. In the literature reviewed, several interventions have been proposed to facilitate an optimal transition process such as developing information brochures, creating a profile of practicing nursing liaison between the ICU and the ward and ICU discharge report.

CONCLUSIONS

This review emphasizes the importance of taking into account the perspectives of patients, families and nurses to perform optimal planning of the transition of the patient from the ICU to the ward to ensure their safety.

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.