The patient's thoughts and feelings about their transfer from intensive care to the general ward

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.

Intra-NICU Patient Transfers: A Study of Frequency and Family and Staff Perceptions

AIMS

(a) Quantify frequency of patient moves within a NICU with single patient and semi-private rooms (SPR). (b) Compare staff and parent perceptions of these moves.

METHODS

A hospital administrative database was evaluated to quantify the frequency of moves. A Room Change Questionnaire was devised to evaluate perceptions from NICU families and staff.

RESULTS

Most families reported experiencing at least 1 patient move (92 percent), with the majority reporting at least 3 moves (58 percent). Staff perceived moves as negative significantly more than parents (p < .01), and overreported negative family perceptions (p < .01). Overall, moves did not bother families (52 percent); however, most families who moved 3 or more times reported at least 1 negative perception (63 percent).

CONCLUSION

SFRs increase the number of patient moves. NICU staff's perception is significantly more negative than family's perception; however, most families who were moved frequently reported at least 1 negative perception.

A phenomenological study on the experiences of patient transfer from the intensive care unit to general wards

Objectives

This study aimed to derive an in-depth understanding of the transfer experience of intensive care unit (ICU) patients in South Korea through a phenomenological analysis.

Methods

Participants were 15 adult patients who were admitted to a medical or surgical ICU at a university hospital for more than 48 hours before being transferred to a general ward. Data were collected three to five days after their transfer to the general ward from January to December 2017 through individual in-depth interviews and were analyzed using Colaizzi’s phenomenological data analysis method, phenomenological reduction, intersubjective reduction, and hermeneutic circle. Data analysis yielded eight themes and four theme clusters related to the unique experiences of domestic ICU patients in the process of transfer to the general ward.

Results

The four main themes of the patients’ transfer experiences were “hope amid despair,” “gratitude for being alive,” “recovery from suffering,” and “seeking a return to normality.”

Conclusion

Our findings expand the realistic and holistic understanding from the patient’s perspective. This study’s findings can contribute to the development of appropriate nursing interventions that can support preparation and adaptation to the transfer of ICU patients.

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

INTRODUCTION

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

AIM

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

METHODS

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

SETTING

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

FINDINGS

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Effectiveness of an Electronic Communication Tool on Transitions in Care From the Intensive Care Unit: Protocol for a Cluster-Specific Pre-Post Trial

BACKGROUND

Transitions in care are vulnerable periods in health care that can expose patients to preventable errors due to incomplete or delayed communication between health care providers. Transitioning critically ill patients from intensive care units (ICUs) to other patient care units (PCUs) is particularly risky, due to the high acuity of the patients and the diversity of health care providers involved in their care. Instituting structured documentation to standardize written communication between health care providers during transitions has been identified as a promising means to reduce communication breakdowns. We developed an evidence-informed, computer-enabled, ICU-specific structured tool-an electronic transfer (e-transfer) tool-to facilitate and standardize the composition of written transfer summaries in the ICUs of one Canadian city. The tool consisted of 10 primary sections with a user interface combination of structured, automated, and free-text fields.

OBJECTIVE

Our overarching goal is to evaluate whether implementation of our e-transfer tool will improve the completeness and timeliness of transfer summaries and streamline communications between health care providers during high-risk transitions.

METHODS

This study is a cluster-specific pre-post trial, with randomized and staggered implementation of the e-transfer tool in four hospitals in Calgary, Alberta. Hospitals (ie, clusters) were allocated randomly to cross over every 2 months from control (ie, dictation only) to intervention (ie, e-transfer tool). Implementation at each site was facilitated with user education, point-of-care support, and audit and feedback. We will compare transfer summaries randomly sampled over 6 months postimplementation to summaries randomly sampled over 6 months preimplementation. The primary outcome will be a binary composite measure of the timeliness and completeness of transfer summaries. Secondary measures will include overall completeness, timeliness, and provider ratings of transfer summaries; hospital and ICU lengths of stay; and post-ICU patient outcomes, including ICU readmission, adverse events, cardiac arrest, rapid response team activation, and mortality. We will use descriptive statistics (ie, medians and means) to describe demographic characteristics. The primary outcome will be compared within each hospital pre- and postimplementation using separate logistic regression models for each hospital, with adjustment for patient characteristics.

RESULTS

Participating hospitals were cluster randomized to the intervention between July 2018 and January 2019. Preliminary extraction of ICU patient admission lists was completed in September 2019. We anticipate that evaluation data collection will be completed by early 2021, with first results ready for publication in spring or summer 2021.

CONCLUSIONS

This study will report the impact of implementing an evidence-informed, computer-enabled, ICU-specific structured transfer tool on communication and preventable medical errors among patients transferred from the ICU to other hospital care units.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03590002; https://www.clinicaltrials.gov/ct2/show/NCT03590002.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18675.

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.

Protocol for a mixed-methods exploratory investigation of care following intensive care discharge: the REFLECT study

INTRODUCTION

A substantial number of patients discharged from intensive care units (ICUs) subsequently die without leaving hospital. It is unclear how many of these deaths are preventable. Ward-based management following discharge from ICU is an area that patients and healthcare staff are concerned about. The primary aim of REFLECT (Recovery Following Intensive Care Treatment) is to develop an intervention plan to reduce in-hospital mortality rates in patients who have been discharged from ICU.

METHODS AND ANALYSIS

REFLECT is a multicentre mixed-methods exploratory study examining ward care delivery to adult patients discharged from ICU. The study will be made up of four substudies. Medical notes of patients who were discharged from ICU and subsequently died will be examined using a retrospective case records review (RCRR) technique. Patients and their relatives will be interviewed about their post-ICU care, including relatives of patients who died in hospital following ICU discharge. Staff involved in the care of patients post-ICU discharge will be interviewed about the care of this patient group. The medical records of patients who survived their post-ICU stay will also be reviewed using the RCRR technique. The analyses of the substudies will be both descriptive and use a modified grounded theory approach to identify emerging themes. The evidence generated in these four substudies will form the basis of the intervention development, which will take place through stakeholder and clinical expert meetings.

ETHICS AND DISSEMINATION

Ethical approval has been obtained through the Wales Research and Ethics Committee 4 (17/WA/0107). We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media.

TRIAL REGISTRATION NUMBER

ISRCTN14658054.

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.

Nurses' experience of the transfer of ICU patients to general wards: A great responsibility and a huge challenge

AIMS AND OBJECTIVES

The aim of the study was to describe nurses' experiences of patients' transition from ICUs to general wards and their suggestions for improvements.

BACKGROUND

In the ICU, the most seriously ill patients with life-threatening conditions and multiple organ dysfunction syndromes are cared for and carefully monitored by specially trained professionals using advanced techniques for the prevention of failure of vital functions. The transfer of ICU patients to general wards means a change from a high to a lower level, including the loss of one-to-one nursing and a reduction of visible monitoring equipment and general close attention.

DESIGN

A qualitative descriptive design.

METHODS

Eight nurses from three different inpatient units in Norway, five from a university hospital and three from a local hospital were selected through a convenience sample. Interviews with open questions were conducted, and qualitative content analysis was used to explore the data.

RESULTS

Nurses' experiences were described in one main category: ICU patients' transition-a great responsibility and a huge challenge, and two generic categories: (i) a challenging transition for nurses, patients and relatives and (ii) dialogue and competencies as tools for improvement, with six subcategories.

CONCLUSION

A number of factors affected patient care, such as poor cooperation, communication, reporting, expertise and clinical gaze. It was clear that the general wards had major challenges, and a number of improvements were suggested.

RELEVANCE TO CLINICAL PRACTICE

This study shows that there is still a gap between the ICU and general wards and that nurses continue to struggle with this. It is therefore important that the managers responsible for the quality of care together with the professionals take seriously the criticism in the present and previous studies and work towards a safe transition for patients.

Medical Complications of Intra-Hospital Patient Transports: Implications for Architectural Design and Research

Literature on healthcare architecture and evidence-based design has rarely considered explicitly that patient outcomes may be worsened by intra-hospital transport (IHT), which is defined as transport of patients within the hospital. The article focuses on the effects of IHTs on patient complications and outcomes, and the implications of such impacts for designing safer, better hospitals. A review of 22 scientific studies indicates that IHTs are subject to a wide range of complications, many of which occur frequently and have distinctly detrimental effects on patient stability and outcomes. The research suggests that higher patient acuity and longer transport durations are associated with more frequent and serious IHT-related complications and outcome effects. It appears no rigorous research has compared different hospital designs and layouts with respect to having possibly differential effects on transport-related complications and worsened outcomes. Nonetheless, certain design implications can be extracted from the existing research literature, including the importance of minimizing transport delays due to restricted space and congestion, and creating layouts that shorten IHT times for high-acuity patients. Limited evidence raises the possibility that elevator-dependent vertical building layouts may increase susceptibility to transport delays that worsen complications. The strong evidence indicating that IHTs trigger complications and worsen outcomes suggests a powerful justification for adopting acuity-adaptable rooms and care models that substantially reduce transports. A program of studies is outlined to address gaps in knowledge.

Physical and Mental Health of Patients Immediately After Discharge From Intensive Care Unit and 24 Hours Later

Background:

Monitoring the health status of patients discharged from intensive care units is a crucial method of service evaluation.

Objectives:

This study aimed to assess the physical and mental health status of patients immediately after discharge from the ICU and 24 hours later.

Patients and Methods:

This descriptive comparative study was conducted on 104 patients discharged from the ICUs of a referral trauma center in Shiraz, Southwest Iran. Physical parameters, including respiratory rate, need for supplemental oxygen, heart rate, blood pressure, and need for cardiac monitoring, were assessed. Hospital anxiety and depression scale (HADS) was used for mental health evaluation. The mental and physical status of patients were assessed before ICU discharge and 24 hours later; data were recorded in information forms and were analyzed using SPSS statistical software version 17.

Results:

At the time of discharge, the respiratory rate of 28% of the participants was more than 24 minutes, and 95.2% received supplemental oxygen. However, after 24 hours these values decreased to 10% and 21.6%, respectively. The mean heart rate and systolic blood pressure were within the normal range at both time points. Additionally, 63% of the patients had anxiety scores above 11 at both time points, reflecting high anxiety. The number of patients who reported depression increased from 58.7% at ICU discharge to 69.6% after 24 hours.

Conclusions:

Despite the considerable improvement in most of the patients’ physical condition in the first 24 hours after discharge from ICU, a significant number of them remain at risk for the development of adverse effects from this transition. The high prevalence of mental health disorders in these patients reveals the necessity to conduct follow-up consultations.

Exploring views on what is important for patient-centred care in end-stage renal disease using Q methodology

BACKGROUND

This study aimed to explore views on what is considered important for Patient-Centred Care (PCC) among patients and the healthcare professionals treating them in a haemodialysis department.

METHODS

Interviews were conducted among 14 patients with end-stage renal disease receiving dialysis and 12 healthcare professionals (i.e. 2 doctors, 4 staff members, and 6 nurses) working at a haemodialysis department. Participants were asked to rank-order 35 statements representing eight dimensions of PCC previously discussed in the literature. Views on PCC, and communalities and differences between them, were explored using by-person factor analysis.

RESULTS

Four views on what is important for PCC in end-stage renal disease were identified. In viewpoint 1, listening to patients and taking account of their preferences in treatment decisions is considered central to PCC. In viewpoint 2, providing comprehensible information and education to patients so that they can take charge of their own care is considered important. In viewpoint 3, several aspects related to the atmosphere at the department were put forward as important for PCC. In viewpoint 4, having a professional or acquaintance that acts as care coordinator, making treatment decisions with or for them, was considered particularly beneficial. All views agreed about the relative importance of certain PCC dimensions; the patient preferences and information and education dimensions were generally considered most important, while the family and friends and the access to care dimensions were considered least important.

CONCLUSIONS

The four views on PCC among patients in a haemodialysis department and the professionals treating them suggest that there is no one size fits all strategy for providing PCC to patients with end-stage renal disease. Some patients may benefit from educational interventions to improve their self-management skills and place them in charge of their own care, whereas other patients may benefit more from the availability of a care coordinator to make decisions for them, or with them. Furthermore, our results suggest that not all eight dimensions of PCC need to be given equal consideration in the care for patients with end-stage renal disease in order to improve patient outcomes.

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.

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.

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.

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.

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.

A systematic review of relocation stress following in-house transfer out of critical/intensive care units

EXECUTIVE SUMMARY

Objective The objective was to conduct a mixed methods systematic review to determine the occurrence and meaningfulness of relocation stress and the effectiveness of strategies for decreasing transfer anxiety in patients and their families upon transfer from an intensive care unit to a non-intensive care unit and to offer evidence-based recommendations for best practice.Inclusion criteria The review included quantitative and qualitative studies where the participants were adult intensive care patients, family members of adult intensive care patients, intensive care nurses caring for the adult critically ill patient, and ward/unit nurses receiving transfer patients from the ICU (intensive care unit). Studies examining the transfer experience for infants, children or psychiatric patients were excluded from this review.Search strategy The search strategy sought to find both published and unpublished studies and papers limited to the English language. An initial limited search of MEDLINE and CINAHL was undertaken followed by an analysis of text words contained in the title and abstract, and of index terms to describe the article. A second extensive search was then undertaken using identified key words and index terms.Methodological quality Each paper was assessed by two independent reviewers for quality prior to inclusion in the review using the Joanna Briggs Critical Appraisal Tools for experimental, cohort, descriptive, qualitative and expert text papers. Disagreements were discussed and resolved among the reviewers without needing to rely on a third reviewer.Data collection Information was extracted from each paper independently by two reviewers using the JBI extraction tools for quantitiative, qualitaitive and expert opinion papers and narrative table summaries were prepared.Data synthesis Data synthesis aimed to portray an accurate interpretation and synthesis of concepts arising from the experiences of patients and families transferring out of ICU and the nurses on the receiving and sending ends of the transfer.Results A total of 35 studies were identified and of those 25 were included in the review consisting of 15 qualitative studies, 9 quantitative studies and 1 clinical practice guideline. Qualitative papers were analyzed using JBI-QARI and involved categorizing findings and developing synthesized topics from the categories. Three syntheses were developed related to response to transfer, meaning of transfer, and strategies to facilitate successful transfer. Quantitative data could not be pooled and is presented in the narrative table.Conclusion For most, transfer to the general unit was not a traumatic or negative experience but viewed positively as a sign of recovery and sometimes the positive emotions coexisted with uncertainty or fear. The most negative experience was related to lack of observation and care on the general unit where nurses many times were unaware or unresponsive to functional deficits that the patients required assistance with. Patients were consequently challenged to do more for themselves and depending on their success or progress with independence resulted in growing confidence or frustration and embarrassment. The systems of care were not structured to effectively deal with the complex ICU transfer patient.Implications for practice Specific practice recommendations are made for pretransfer from ICU, system improvements to facilitate transfer and posttransfer care while on the general unit.Implications for research Additional research is needed to confirm the frequency of negative relocation stress, test efficacy of direct interventions and explore the meaning of transfer for family members.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Muslim women's experiences of suffering in Jordanian intensive care units: a narrative study

This paper explores Muslim women's experiences of suffering in Jordanian intensive care units. A narrative approach was employed to access women's stories of their critical illness. Sixteen women who had spent at least 48 hours in intensive care were recruited from two hospitals in a Jordanian city and took part in between one and three interviews over a six-month period. Women's accounts of suffering were pervaded with physical, social, spiritual and technological themes. Pain was a central strand in the women's accounts and was experienced often as severe, overwhelming and disturbing to their sleep. The sudden onset of illness, the unfamiliar ICU environment and feeling of uncertainty made it difficult for the women to interpret their experiences. Religious beliefs and cultural norms helped the women make sense of their suffering. Social support, especially from the family, was reported by the women to be essential: a lack of social support was seen as a symbol of death. This study emphasises the importance of looking at a patient who is critically ill as a whole person within the context of their cultural, spiritual and biographical milieu.

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

OBJECTIVES

This review identifies the most significant factors, which impact upon the user experience of progress and recovery from critical illness during the first month after discharge from critical care, and discusses these in relation to the development of effective critical care discharge support strategies.

DESIGN

Meta-synthesis of qualitative primary research.

DATA SOURCES

Qualitative research published in English between 1990 and 2009 was identified using online databases: CINAHL, MEDLINE, EMBASE, British Nursing Index, CDSR, ACP Journal Club, Cochrane library, Social Policy and Practice and PsycInfo. Studies of adult patients, relatives/carers/significant others, which focused on experiences after discharge from an intensive care or high dependency unit to a general ward were retrieved.

REVIEW METHODS

Following screening against inclusion/exclusion criteria, methodological appraisal of studies was conducted using a published framework. Ten studies met the criteria for inclusion.

RESULTS

Five key themes emerged from the meta-synthesis: physical and psychological symptoms; making progress; the need to know; and safety and security.

CONCLUSIONS

Findings from this meta-synthesis and other related literature supports the existence of physical and psychological problems in the immediate period following discharge from critical care to the ward, and suggests that patients and their families have a desire for more control over their recovery. However, this desire is countered by a need to feel safe and protected, culminating in an expression of dependence on healthcare staff. Any effective support strategy needs to take account of these findings.

More than nothing: the lived experience of tracheostomy while acutely ill

While the physical sensations surrounding tracheostomy tube insertion have been reported within nursing and allied healthcare literature, the lived experience of these sensations is poorly described. This appears relevant given the imminent results of the Tracman study (2008). A purposive sample of three participants who had tracheostomy tubes previously within a critical care area or still in situ were recruited. They described their experiences in a face-to-face semi-structured interview that were audio taped. The interviews were transcribed verbatim and analysed using Giorgi's 5 concrete steps of the human scientific phenomenological method (1997). Findings revealed themes that drew attention to the fundamental aspects of the experience. These were: Practical recommendations draw attention to the organisational support required for staff expected to care for these patients in the ward environment. This involves the introduction of evidence based guidelines and competency based care to promote the acquisition of skills required to perform those essential tasks such as suction and stoma care to a high standard. Protected, formalised skills based teaching is seen as fundamental in this process. Patients' felt confident in nursing staff that were able to demonstrate proficiency with such tasks and this is seen as crucial when one considers that the tracheostomy tube is a new experience for patients.

Struggle with a gap between intensive care units and general wards

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

ICU patient's transfer anxiety: a prospective cohort study

OBJECTIVE

The purpose of this study was to quantify the levels of anxiety experienced by Intensive Care Unit (ICU) patients just before transfer to the ward and then twice after transfer to the ward in order to test the hypothesis that anxiety levels would change over the three data collection periods.

DESIGN

A prospective, repeated measure cohort study.

SETTING

A Level 3 ICU in an Australian teaching hospital. The ICU had a liaison nurse service Monday to Friday but there was no medical emergency team service at the time of the study.

SUBJECTS

All adult ICU patients who remained in ICU for greater than 24h were eligible for the study.

MAIN OUTCOME MEASURES

Measurements of anxiety were undertaken using self report on the anxiety subscale of Hospital Anxiety and Depression Scale (HADS-A) on three occasions; after patients were told of their imminent transfer to the ward (Time 1), after 4h on the ward (Time 2) and after one night on the ward (Time 3).

RESULTS

In the 3 months of study 249 patients were admitted to the ICU. However, only 55 (22%) patients were eligible to participate and 44 (80% of the eligible patients) consented. Thirty-five patients (64% of eligible patients) completed all measurement points and represent the final sample. The mean anxiety levels remained low at all measurement points and did not change over time. Anxiety was present in six (17%) patients at Time 1, in three (6.8%) patients at Time 2, and in two (4.5%) patients at Time 3.

CONCLUSION

This small study provides a start to the prospective mapping of anxiety levels on time of transfer and shortly after transfer from an ICU to the wards. It also provides information to researchers who want to examine ICU transfer anxiety. By understanding the anxiety experienced by ICU patients, nurses are better able to provide psychological support and thus more holistic care to this group of patients.

Short- and long-term impact of critical illness on relatives: literature review

AIM

This paper is a report of a literature review undertaken to identify the short- and long-term impact of critical illness on relatives.

BACKGROUND

Patients in intensive care can experience physical and psychological consequences, and their relatives may also experience such effects. Although it is recognized that relatives have specific needs, it is not clear whether these needs are always met and whether further support is required, particularly after intensive care.

DATA SOURCES

The following databases were searched for the period 1950-2007: Medline, British Nursing Index and Archive, EMBASE, CINAHL, PsycINFO and EMB Reviews--Cochrane Central Register of Clinical Trials.

SEARCH METHODS

Search terms focused on adult relatives of critically ill adult patients during and after intensive care. Recurrent topics were categorized to structure the review, i.e. 'relatives needs', 'meeting relatives' needs', 'interventions', 'satisfaction', 'psychological outcomes' and 'coping'.

RESULTS

Studies have mainly identified relatives' immediate needs using the Critical Care Family Needs Inventory. There are few studies of interventions to meet relatives' needs and the short- and long-term effects of critical illness on relatives.

CONCLUSION

Despite widespread use of the Critical Care Family Needs Inventory, factors such as local or cultural differences may influence relatives' needs. Relatives may also have unidentified needs, and these needs should be explored. Limited research has been carried out into interventions to meet relatives' needs and the effects of critical illness on their well-being, yet some relatives may experience negative psychological consequences far beyond the acute phase of the illness.

Supporting families through discharge from PICU to the ward: the development and evaluation of a discharge information brochure for families

INTRODUCTION

Discharge from paediatric ICU and transfer to the ward can evoke fear and anxiety. Along with the introduction of the ICU liaison nurse role, the literature suggests that the provision of written information has the greatest potential to reduce transfer anxiety. This paper will discuss the issues associated with discharge from a paediatric ICU, the process of identifying the information needs of families, the development of a written brochure and evaluation of the brochure in practice.

RESULTS

Evaluation of the 'discharge from ICU' brochure found, 95% of parents believed the brochure was easy to read, understand and helpful in improving their understanding of what to expect on the ward. 95% also found it useful to have the transfer ward details written down prior to leaving the PICU. 85% agreed the brochure helped to answer their questions in relation to the transfer.

CONCLUSION

The introduction of a brochure explaining the process of discharge from ICU and what to expect on the wards received positive feedback from families. The brochure provides families with generic information regarding ICU transfer, however, it is important for the ICU liaison nurse to promote discussion and tailor the information for the particular experiences and needs of each patient and family situation.

Re-visiting the ICU Experiences of follow-up visits to an ICU after discharge: a qualitative study

The aim of this study is to describe how people who have been critically ill, and their close relatives experience a post-discharge, follow-up visit to the intensive care unit (ICU) that provided the care. There is a lack of studies from such a standpoint. The study design is qualitative. A total of 18 adults participated; nine had been critically ill and nine were close relatives, all made a post-discharge follow-up visit to an ICU in the northern part of Sweden. The study data was collected through personal interviews, conducted after the follow-up visit, using a narrative approach. The data were then subjected to qualitative thematic content analysis which resulted in four themes: receiving strength from returning together; making sense of the critical-illness experience; feeling grateful to have survived and the possibility of improving the care. People who had been critically ill and close relatives felt that returning together was valuable. Meeting the staff, with whom participants felt they had developed a relationship, made it possible for them to express their gratitude for the treatment and nursing care received, and to suggest improvements. The interviews revealed that the follow-up visit was seen as an important way of learning what had happened and why during the period of critical illness.

'One patient amongst many': a qualitative analysis of intensive care unit patients' experiences of transferring to the general ward

Introduction

Many patients experience 'relocation stress' when they are transferred from an intensive care unit (ICU) to step-down (high dependency) or general ward care, and much has been written about the psychological causes. This qualitative analysis of in-depth, narrative interviews with former ICU patients explores and examines patients' accounts in order to identify additional causes of relocation stress.

Methods

Forty former ICU patients were recruited throughout the UK, using maximum variation sampling, to achieve a broad range of experiences of intensive care. Interviews in people's homes were recorded on video and audio equipment as part of a study for the Database of Personal Experiences of Health and Illness (DIPEx) web resource. All interviews were transcribed, checked and returned to respondents. For this report, a qualitative thematic analysis was used to explore experiences of transfer.

Results

We found that most people experienced relocation distress not only because of physical and emotional difficulties relating to their illness and treatment and the inevitable anxiety resulting from leaving a protected environment, but also from concrete, practical causes. These included specific concerns about communication, feeding, nursing care and support, as well as ward organization and environment. Written excerpts from the interviews and two video excerpts taken from the DIPEx website illustrate our findings.

Conclusion

We conclude that there are several aspects of care that deserve further examination by researchers and service providers, and that not all of the factors associated with relocation stress should be seen as an inevitable consequence of the psychological adjustment involved in transfer from an ICU.

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

OBJECTIVE

To examine perceptions of ICU transfer held by patients and their family members, focusing specifically on those aspects of transfer perceived as difficult and those perceived as helpful.

DESIGN

Descriptive qualitative case study design.

SETTING

General ICU of a large regional Australian teaching hospital.

PATIENTS

A total of 7 patients and 6 family members were purposefully recruited at one-month post-discharge from hospital. Participants were selected for their ability to recall ICU transfer, the involvement of family members and their ability to articulate their experiences.

MAIN OUTCOME MEASURES

Two focus groups (one for patients and one for families) were conducted in the hospital setting, aimed at capturing the individual and collective perceptions of transfer out of intensive care.

RESULTS

Four themes emerged from the data that reflected the complex and emotional nature of transfer out of intensive care. These themes included (1) a sense of sudden abandonment (2) pervasive feelings of vulnerability and helplessness, (3) a loss of importance and (4) ambivalence about the experience.

CONCLUSIONS

The need for ICU nurses, ward nurses and affiliated healthcare professionals to provide emotional support throughout ICU transfer is the most significant implication of the study. Strategies to provide this support must be developed, implemented and evaluated.

Leaving critical care: facilitating a smooth transition

Patient transfers from one area to another occur frequently within the inpatient healthcare environment. During transfers, nurses pass on information about patients to one another in a variety of ways. This article discusses the types of patient transfers, the problems that can occur throughout the transfer process, and strategies to decrease the identified problems. The perspectives of both the nursing staff and patients/families illustrate concerns related to patient transfers. The most important aspect of the patient transfer is systematically communicating necessary information to the receiving nurse in such a way that patient safety is not compromised and continuity of care is enhanced.

Alteraciones emocionales y necesidades psicológicas de pacientes en una Unidad de Cuidados Intensivos

From the time when a disease whose treatment is going to require hospitalization for a surgical intervention is diagnosed, both the patient and his/her family members or primary caretakers are involved in a process that may involve the experience of several emotional alterations. This work focuses on the description of the different psychological problems and needs manifested by the patients who require, as part of the treatment process and recovery control, admission to an Intensive Care Unit (ICU). During the patient's stay in the ICU, the emotional alterations mentioned most frequently by them are anxiety, stress, depression or the so-called intensive care syndrome, during which factors such as excessive noise that may make sleeping and rest difficult, pain, the methods used for ventilation that prevent the patients from communicating adequately, etc. Furthermore, the patients generally develop a feeling of loss of self-control, the main needs described being the sensation of safety and "knowing what is happening". The experiences lived may continue to produce emotional alterations even months after hospital discharge, with the development of a Posttraumatic Stress Disorder. This justifies a follow-up in order to detect them and treat them adequately. It seems to be appropriate for the treatment of these patients to be multidisciplinary, attending to both the physical needs related with the disease as well as the psychological ones.

Reconsidering the transfer of patients from the intensive care unit to the ward: a case study approach

Evidence indicates that the poorly managed transfer of a patient from the intensive care unit (ICU) to the ward can lead to physical and psychological complications for the patient, and often require ICU readmission and rehospitalization. Reviewing this patient transfer process to improve the quality of care would be a positive step towards enhancing patients' recovery and providing skills to staff. The aim of this paper is to review case studies of transferring ICU patients to general wards in order to identify the shortcomings of this process. A literature review was conducted to evaluate current practices in the ICU transfer process. The results of this paper have clinical implications, suggest approaches to improve support for patients and their carers, and provide strategies to improve the transfer procedure.

Co-ordination of the discharge planning process in critical care

AIM AND OBJECTIVES

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

BACKGROUND

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

DESIGN

An exploratory descriptive research design was used for this study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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