Discharge from intensive care: a view from the ward

Intrahospital Handovers before and after the Implementation of ISBAR Communication: A Quality Improvement Study on ICU Nurses' Handovers to General Medical Ward Nurses

BACKGROUND

Research finds a lack of structure as well as varying and incomplete content in intrahospital handovers. This study aimed to improve intrahospital handovers by implementing structured ISBAR communication (identification, situation, background, assessment and recommendation).

METHODS

This quality improvement study was conducted observing 25 handovers given by nurses from the intensive care unit to nurses from general medical wards at baseline and after the implementation of the ISBAR communication tool. The 26-item ISBAR scoring tool was used to audit the handovers. In addition, the structure of the ISBAR communication and time spent on the handovers were observed.

RESULTS

There were no significant improvements from baseline to post-intervention regarding adherence to the ISBAR communication scoring tool. The structure of the handovers improved from baseline to post-intervention (p = 0.047). The time spent on handovers declined from baseline to post-intervention, although not significantly.

CONCLUSIONS

The items in the ISBAR communication scoring tool can act as a guide for details that need to be reported during intrahospital handovers to strengthen patient safety. Future research calls for studies measuring satisfaction among nurses regarding using different handover tools and studies using multifaceted training interventions.

The chain of survival and rehabilitation for sepsis: concepts and proposals for healthcare trajectory optimization

This article describes the structures and processes involved in healthcare delivery for sepsis, from the prehospital setting until rehabilitation. Quality improvement initiatives in sepsis may reduce both morbidity and mortality. Positive outcomes are more likely when the following steps are optimized: early recognition, severity assessment, prehospital emergency medical system activation when available, early therapy (antimicrobials and hemodynamic optimization), early orientation to an adequate facility (emergency room, operating theater or intensive care unit), in-hospital organ failure resuscitation associated with source control, and finally a comprehensive rehabilitation program. Such a trajectory of care dedicated to sepsis amounts to a chain of survival and rehabilitation for sepsis. Implementation of this chain of survival and rehabilitation for sepsis requires full interconnection between each link. To date, despite regular international recommendations updates, the adherence to sepsis guidelines remains low leading to a considerable burden of the disease. Developing and optimizing such an integrated network could significantly reduce sepsis related mortality and morbidity.

Patient transfer from intensive care units to general wards: An exploratory qualitative study of ward nurses' experiences of patient safety

AIM

Patient transfer from intensive care units (ICUs) to general wards is a routine part of hospital care. However, if the transfer is not optimal, it can result in increased readmissions to the ICU, increased stress and discomfort for the patient and, thus, a threat to patient safety. The aim of this study was to explore how general ward nurses experience patient safety during patient transfers from ICUs to general wards.

DESIGN

A qualitative design based on a phenomenological approach was used.

METHODS

Two focus group interviews were conducted with a total of eight nurses from a medical ward and a surgical ward at one hospital in Norway. The data were analysed using systematic text condensation.

RESULTS

The nurses' experiences of patient safety during patient transfer had four themes: (1) the importance of preparedness; (2) the importance of the handover of information; (3) stress and a lack of resources and (4) a feeling of two different worlds.

CONCLUSION

In order to promote patient safety, the informants highlighted the importance of being well prepared for transfer, and to have optimal handover of information. Stress, lack of resources and a feeling of two different worlds may pose threats to patient safety.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

We suggest several intervention studies testing the effect of intervention improving patient safety during the transfer process are designed, and that increased knowledge in this area is used to develop local practice recommendations.

PATIENT OR PUBLIC CONTRIBUTION

The participants of this study were nurses and this contribution has been explained in the Data collection section. There was no patient contribution in this study.

Development and pilot implementation of a patient-oriented discharge summary for critically Ill patients

BACKGROUND

Patients leaving the intensive care unit (ICU) often experience gaps in care due to deficiencies in discharge communication, leaving them vulnerable to increased stress, adverse events, readmission to ICU, and death. To facilitate discharge communication, written summaries have been implemented to provide patients and their families with information on medications, activity and diet restrictions, follow-up appointments, symptoms to expect, and who to call if there are questions. While written discharge summaries for patients and their families are utilized frequently in surgical, rehabilitation, and pediatric settings, few have been utilized in ICU settings.

AIM

To develop an ICU specific patient-oriented discharge summary tool (PODS-ICU), and pilot test the tool to determine acceptability and feasibility.

METHODS

Patient-partners (i.e., individuals with lived experience as an ICU patient or family member of an ICU patient), ICU clinicians (i.e., physicians, nurses), and researchers met to discuss ICU patients' specific informational needs and design the PODS-ICU through several cycles of discussion and iterative revisions. Research team nurses piloted the PODS-ICU with patient and family participants in two ICUs in Calgary, Canada. Follow-up surveys on the PODS-ICU and its impact on discharge were administered to patients, family participants, and ICU nurses.

RESULTS

Most participants felt that their discharge from the ICU was good or better (n = 13; 87.0%), and some (n = 9; 60.0%) participants reported a good understanding of why the patient was in ICU. Most participants (n = 12; 80.0%) reported that they understood ICU events and impacts on the patient's health. While many patients and family participants indicated the PODS-ICU was informative and useful, ICU nurses reported that the PODS-ICU was "not reasonable" in their daily clinical workflow due to "time constraint".

CONCLUSION

The PODS-ICU tool provides patients and their families with essential information as they discharge from the ICU. This tool has the potential to engage and empower patients and their families in ensuring continuity of care beyond ICU discharge. However, the PODS-ICU requires pairing with earlier discharge practices and integration with electronic clinical information systems to fit better into the clinical workflow for ICU nurses. Further refinement and testing of the PODS-ICU tool in diverse critical care settings is needed to better assess its feasibility and its effects on patient health outcomes.

Nursing Interventions for Patient Empowerment during Intensive Care Unit Discharge: A Systematic Review

Intensive care unit discharge is an important transition that impacts a patient's wellbeing. Nurses can play an essential role in this scenario, potentiating patient empowerment. A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (the PRISMA Statement. Embase), PubMed/MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), CUIDEN Plus, and LILACS databases; these were evaluated in May 2021. Two independent reviewers analyzed the studies, extracted the data, and assessed the quality of evidence. Quality of the studies included was assessed using the Cochrane risk-of-bias tool. Of the 274 articles initially identified, eight randomized controlled trials that reported on nursing interventions had mainly focused on patients' ICU discharge preparation through information and education. The creation of ICU nurse-led teams and nurses' involvement in critical care multidisciplinary teams also aimed to support patients during ICU discharge. This systematic review provides an update on the clinical practice aimed at improving the patient experience during ICU discharge. The main nursing interventions were based on information and education, as well as the development of new nursing roles. Understanding transitional needs and patient empowerment are key to making the transition easier.

Factors contributing to poor sleep in critically ill patients: A systematic review and meta-synthesis of qualitative studies

OBJECTIVE

To examine the causes of poor sleep in critically ill patients from nurses' experiences.

REVIEW METHODOLOGY

A meta-synthesis following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research statement was conducted. Articles were searched systematically in the CINAHL, MEDLINE and Embase databases up to January 2020. Study selection and data extraction were performed by two authors working independently. Included articles were critically evaluated by both authors using the Critical Appraisal Screening Programme tool.

FINDINGS

The meta-synthesis resulted in four analytical themes: (1) Inherent factors of critical illness, (2) Lack of implementation of evidence-based practice, (3) Lack of relational collaboration, (4) Hospital organisation and culture.

CONCLUSION

This literature review indicates that promoting critically ill patients' sleep is difficult. Evidence-based interventions should be implemented into practice in order for nurses to be able to meet the patients' needs and improve sleep. Furthermore, the team surrounding the patient must have support from the health care organisation, and a culture change is necessary to improve communication between them to reach a shared goal to improve critically ill patients' sleep.

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.

The development of a measurement instrument focusing on team collaboration in patient transfer processes

Purpose

Team collaboration is essential to ensure the quality of care and patient safety when critically ill patients are transferred from an intensive care unit (ICU) to a general ward. Measuring team collaboration in the patient transfer process can help gain insights into how team collaboration is perceived and how it can be improved. The purpose of this paper is to describe the development and testing of a questionnaire aiming to measure perceived team collaboration in the patient transfer process from ICU to the general ward. This study also aims to analyze the results to see how the survey could help improve team collaboration within ICU transitional care.

Design/methodology/approach

Statements, factors and main areas intended to measure perceived team collaboration were developed from a theory. The questionnaire was tested in two ICUs at two hospitals located in Sweden, and the results were analyzed statistically.

Findings

The results showed that the questionnaire could be used for measuring perceived team collaboration in this process. The results from the survey gave insights that can be useful when improving team collaboration in ICU transitional care.

Research limitations/implications

The collaboration between two research subjects, Nursing Science and Quality Management, has given new perspectives in how cultural and systemic differences and opportunities can help improving team collaboration in ICU transitional care, by shifting focus from the individual to team, culture, system, process and continuous improvement.

Practical implications

The developed questionnaire can be used to measure perceived team collaboration and to identify areas for improving team collaboration in the ICU transitional care process.

Originality/value

There is a sparse amount of research about measuring team collaboration in ICU transitional care, and this study contributes to filling this research gap.

Improving ICU transitional care by combining quality management and nursing science – two scientific fields meet in a systematic literature review

Purpose

The purpose of this literature review was to explore to what extent quality management (QM) and nursing science offer complementary perspectives to provide better quality care, by looking at QM core concepts and tools.

Design/methodology/approach

A systematic literature review was conducted. Papers published in academic journals between January 2013 and December 2019 were included. A deductive content analysis was chosen using QM core values as an analytical framework.

Findings

The results showed that QM core values, methodologies and tools were found in the reviewed articles about intensive care unit (ICU) transitional care. The results indicated that core values in QM and the core competencies within nursing science in ICU transitional care are mutually dependent upon each other and exist as a whole. ICU transitional care is, however, a complex interpersonal process, characterized by differences in organizational cultures and core values and involving multidisciplinary teams that collaborate across hospital units. The QM core value that was least observed was committed leadership.

Research limitations/implications

Combining QM and nursing science can contribute to a deeper understanding of how to improve the ICU transitional care process by bringing complementary perspectives.

Practical implications

The included articles portray how QM is applied in ICU transitional care. Implications for future research focus on enhancing the understanding of how QM and nursing science can bring complementary perspectives in order to improve ICU transitional care and how QM values, methodologies and tools can be used in ICU transitional care. Committed leadership and team collaboration in ICU transitional care are areas that call for further research.

Originality/value

The findings contribute to the body of literature by providing important insights in terms of how QM core values, methodologies and tools are present in research about ICU transitional care and how the two research subjects, namely, QM and nursing science, bring complementary perspectives.

Healthcare providers' knowledge and handling of impairments after intensive unit treatment: A questionnaire survey

BACKGROUND

Numerous patients experience long-term impairments after discharge from the intensive care unit (ICU), including physical, psychological and cognitive deficiencies. This study aims to investigate the knowledge and handling of post-intensive care impairments among Danish doctors and nurses in the medical and surgical wards.

METHODS

An electronic questionnaire survey was distributed to consultants and development nurses, head nurses and assistant head nurses at departments of abdominal surgery and internal medicine of hospitals with an ICU in the Region Zealand of Denmark.

RESULTS

We invited 350 employees to participate, 48% responded. Most participants, 82.8% nurses and 86.6% doctors, reported their knowledge of in-hospital needs of the ICU patients to be average or higher. Sixty per cent of doctors reported having average or higher knowledge of the patients' post-discharge needs. More than half the doctors (60.2%) reported that they "Rarely" or "Never" addressed possible ICU-related impairments in the discharge summary. During hospital admission, 22.9% replied "No screening performed" for physical impairment, while the rates for psychological and cognitive impairments were 70.7% and 57.3%, respectively. Most respondents believed that doctors (92.8%) and nurses (92.1%) in the ward and ICU doctors (89.4%) play an important role in detecting ICU-related impairments; 63.8% felt that general practitioners play a key role.

CONCLUSION

Doctors and nurses generally reported having average or higher knowledge of ICU patients' in-hospital needs, but few screened systematically for ICU-related impairments. Most respondents believed that detecting these problems is a shared responsibility between professionals in the primary and, especially, the secondary healthcare sector.

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.

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

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

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 impact of a standardized inter-department handover on nurses' perceptions and performance in Republic of Korea

AIMS

To evaluate the impact of a standardized inter-department nursing handover protocol from intensive care units to general wards on the nurses' perceptions and performance.

METHODS

We developed an inter-department nursing handover protocol based on the situation, background, assessment and recommendation technique. All participating paediatric nurses were trained in this new protocol, which was then implemented for nine months in eight units of a children's hospital in the Republic of Korea. Data were extracted from a questionnaire and handover auditing using audio recording.

RESULTS

Following the protocol's introduction, nurses' perceptions of handover effectiveness significantly improved (F = 5.17, p = .007), while their experience of handover errors significantly decreased (F = 12.85, p < .001). Furthermore, the prevalence of additive calls per handover decreased from 70.7% to 45.9% (χ²  = 9.88, p = .002), and the prevalence of handover-related errors decreased from 51.2% to 32.4% (χ²  = 5.63, p = .023). Handover accuracy significantly increased (t = -5.12, p < .001) without prolonging the handover duration.

CONCLUSIONS

The handover protocol positively influenced the nurses' perception of handover and clinical performance.

IMPLICATIONS FOR NURSING MANAGEMENT

A standardized inter-department handover helped intensive care unit nurses to improve their organisation and to provide ward nurses with sufficient information during handover, which could ensure safer transitions from intensive care units to wards.

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

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

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

Admission into an intensive care unit (ICU) may result in long-term physical, cognitive, and emotional consequences for patients and their relatives. The care of the critically ill patient does not end upon ICU discharge; therefore, integrated and ongoing care during and after transition to the follow-up ward is pivotal. This study described the development of an intervention that responds to this need.

METHODS

Intervention Mapping (IM), a six-step theory- and evidence-based approach, was used to guide intervention development. The first step, a problem analysis, comprised a literature review, six semi-structured telephone interviews with former ICU-patients and their relatives, and seven qualitative roundtable meetings for all eligible nurses (i.e., 135 specialized and 105 general ward nurses). Performance and change objectives were formulated in step two. In step three, theory-based methods and practical applications were selected and directed at the desired behaviors and the identified barriers. Step four designed a revised discharge protocol taking into account existing interventions. Adoption, implementation and evaluation of the new discharge protocol (IM steps five and six) are in progress and were not included in this study.

RESULTS

Four former ICU patients and two relatives underlined the importance of the need for effective discharge information and supportive written material. They also reported a lack of knowledge regarding the consequences of ICU admission. 42 ICU and 19 general ward nurses identified benefits and barriers regarding discharge procedures using three vignettes framed by literature. Some discrepancies were found. For example, ICU nurses were skeptical about the impact of writing a lay summary despite extensive evidence of the known benefits for the patients. ICU nurses anticipated having insufficient skills, not knowing the patient well enough, and fearing legal consequences of their writings. The intervention was designed to target the knowledge, attitudes, self-efficacy, and perceived social influence. Building upon IM steps one to three, a concept discharge protocol was developed that is relevant and feasible within current daily practice.

CONCLUSION

Intervention mapping provided a comprehensive framework to improve ICU discharge by guiding the development process of a theory- and empirically-based discharge protocol that is robust and useful in practice.

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.

Standardizing Handoff Communication: Content Analysis of 27 Handoff Mnemonics

This study synthesizes information contained in 27 mnemonics to identify what information should be communicated during a handoff. Clustering and content analysis resulted in 12 primary information clusters that should be communicated. Given the large amount of information identified, it would be beneficial to use a structured handoff communication tool developed using a participatory approach. In addition, we recommend local standardization of information communicated during handoffs with variation across settings.

ANMCO Position Paper: hospital discharge planning: recommendations and standards

The hospital discharge is often poorly standardized and affected by discontinuity and fragmentation of care, putting patients at high risk of both post-discharge adverse events and early readmission. The present ANMCO document reviews the modifiable components of the hospital discharge process related to adverse events or re-hospitalizations and suggests the optimal methods for redesigning the whole discharge process. The key principles for proper hospital discharge or transfer of care acknowledge that the hospital discharge: • is not an isolated event, but a process that has to be planned as soon as possible after the admission, ensuring that the patient and the caregiver understand and contribute to the planned decisions, as equal partners; • is facilitated by a comprehensive systemic approach that begins with a multidimensional evaluation process; • must be organized by an operator who is responsible for the coordination of all phases of the hospital patient journey, involving afterward the general practitioner and transferring to them the information and responsibility at discharge; • is the result of an integrated multidisciplinary team approach; • appropriately uses the transitional and intermediate care services; • is carried out in an organized system of care and continuum of services; and • programs the passage of information to after-discharge services.

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

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

Effects of a medical emergency team follow-up programme on patients discharged from the medical intensive care unit to the general ward: a single-centre experience

RATIONALE, AIMS AND OBJECTIVES

The aim of this study was to analyse the effects of the follow-up programme implemented by the Asan Medical Center Medical Emergency Team (MET).

METHOD

A quasi-experimental pre-post intervention design was used, retrospectively reviewed. The follow-up programme includes respiratory care, regular visits and communication between the attending doctors and MET nurse for patients discharged from the medical intensive care unit (MICU) to the general ward. This programme has been implemented since February 2013. Outcomes of patients before and at 1 year after the introduction of the programme were retrospectively reviewed.

RESULTS

A total of 1229 patients were enrolled and divided two groups (Before, n = 624; After the introduction of the programme, n = 625). Forty-six patients (3.7%) were readmitted to the ICU within 72 hours, and there was no significant difference found between the two groups (3.7% versus 3.7%, P = 0.996). Respiratory distress was the most common reason for readmission (67.4%). Cardiac arrest developed in four (0.6%) Before patients; whereas, no cardiac arrest occurred in the After group (0.0%, P = 0.062) cases. A total of 223 patients were discharged to the step-down units. The SOFA (sequential organ failure assessment) score was significantly higher in the step-down unit patients than general ward patients (4.9 ± 2.8 versus 6.2 ± 3.1, P = 0.000). In the analysis restricted to patients discharged to step-down units, unplanned ICU readmissions significantly decreased in the After group (9.3% versus 2.6%, P = 0.034).

CONCLUSIONS

The implementation of the MET follow-up programme did not change the rate of ICU readmission and cardiac arrest; however, its introduction was associated with the reduced ICU readmission of the high-risk patient populations discharged to the step-down unit.

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.

Improving clinical handover between intensive care unit and general ward professionals at intensive care unit discharge

Purpose

To systematically review and evaluate the effectiveness of interventions in order to improve the safety and efficiency of patient handover between intensive care unit (ICU) and general ward healthcare professionals at ICU discharge.

Methods

PubMed, CINAHL, PsycINFO, EMBASE, Web of Science, and the Cochrane Library were searched for intervention studies with the aim to improve clinical handover between ICU and general ward healthcare professionals that had been published up to and including June 2013. The methods for article inclusion and data analysis were pre-specified and aligned with recommendations outlined in the PRISMA guideline. Two reviewers independently extracted data (study purpose, setting, population, method of sampling, sample size, intervention characteristics, outcome, and implementation activities) and assessed the quality of the included studies.

Results

From the 6,591 citations initially extracted from the six databases, we included 11 studies in this review. Of these, six (55 %) reported statistically significant effects. Effective interventions included liaison nurses to improve communication and coordination of care and forms to facilitate timely, complete and accurate handover information. Effective interventions resulted in improved continuity of care (e.g., reduced discharge delay) and in reduced adverse events. Inconsistent effects were observed for use of care, namely, reduction of length of stay versus increase of readmissions to higher care. No statistically significant effects were found in the reduction of mortality. The overall methodological quality of the 11 studies reviewed was relatively low, with an average score of 4.5 out of 11 points.

Conclusions

This review shows that liaison nurses and handover forms are promising interventions to improve the quality of patient handover between the ICU and general ward. More robust evidence is needed on the effectiveness of interventions aiming to improve ICU handover and supportive implementation strategies.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-015-3666-8) contains supplementary material, which is available to authorized users.

Clinical validity of a relocation stress scale for the families of patients transferred from intensive care units

AIMS AND OBJECTIVES

This study was conducted to develop a family relocation stress scale by modifying the Son's Relocation Stress Syndrome Scale, to examine its clinical validity and reliability and to confirm its suitability for measuring family relocation stress.

BACKGROUND

The transfer of ICU patients to general wards is a significant anxiety-producing event for family members. However, no relocation stress scale has been developed specifically for families.

DESIGN

A nonexperimental, correlation design was adopted.

METHODS

The study subjects were 95 family members of 95 ICU patients at a university hospital located in Incheon, South Korea. Face and construct validities of the devised family relocation stress scale were examined. Construct validity was examined using factor analysis and by using a nomological validity test. Reliability was also examined.

RESULTS

Face and content validity of the scale were verified by confirming that its items adequately measured family relocation stress. Factor analysis yielded four components, and the total variance explained by these four components was 63·0%, which is acceptable. Nomological validity was well supported by significant relationships between relocation stress and degree of preparation for relocation, patient self-care ability, family burden and satisfaction with the relocation process. The devised scale was also found to have good reliability.

CONCLUSIONS

The family relocation stress scale devised in this study was found to have good validity and reliability, and thus, is believed to offer a means of assessing family relocation stress.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study provide a reliable and valid assessment tool when nurses prepare families for patient transfer from an ICU to a ward setting, and may also provide useful information to those developing an intervention programme for family relocation stress management.

Admission and discharge practices: High Dependency Unit audit outcome

This paper presents the findings of a retrospective audit of admission and discharge practices of a nurse led High Dependency Unit (Nurse Specials Unit) in Perth, Western Australia. The aim of the study was: to review the effectiveness of the inclusion and exclusion guidelines for patients admitted to the Nurse Special Unit (NSU); to identify characteristics of admitted patients; and to determine the level of adherence to admission protocols for documentation of patient condition, plan of care, medical and Clinical Nurse Consultant review. The sample comprised all patients admitted to the NSU from September 2004 - March 2005, excluding those (50) in the pilot study (n = 154). This audit revealed patients were primarily elderly and admitted for close nursing supervision. Inclusion and exclusion criterion were adhered to, however documentation of patient data, in relation to current status and plan of care, was poorly completed and frequently absent during intra hospital transfer. This lack of clear documentation poses a significant risk to the patient. Further research is required to determine strategies that result in appropriate and useful transfer documentation. In addition, the content of transfer data that permits continuity of care needs to be determined.

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.

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

BACKGROUND

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

AIM

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

DESIGN

Prospective, clinical validation study.

METHOD

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

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.

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.

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

OBJECTIVES

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

DESIGN AND METHODS

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

RESULTS

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

CONCLUSION

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

Understanding the distributed cognitive processes of intensive care patient discharge

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

This is an ethnographic exploratory study.

METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

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.

Staff perception of patient discharge from ICU to ward-based care

BACKGROUND

The quality of information exchange between intensive care unit (ICU) and ward nurses, when patients are transferred out of intensive care, is important to the continuity of safe care.

AIM

This research aimed to explore nurses' experiences of the discharge process from ICU to the ward environment.

DESIGN

The study was conducted in a New Zealand Metropolitan hospital, using an exploratory descriptive design we adapted a questionnaire based on Whittaker and Ball's research on ICU patient handover.

METHOD

The questionnaires were then analysed using a descriptive thematic approach.

RESULTS

The response rate of 48% included 45 ICU and 47 ward nurses. Key findings were that the written and verbal communication needs differ dependent upon setting and the timing of a discharge. Timing of handover also requires negotiation.

CONCLUSIONS

Being able to negotiate the timing and nature of handover is important for nurses. In addition, standardized approaches to communication are believed to enhance patient safety.

RELEVANCE TO CLINICAL PRACTICE

Standardized handover, with content and processes that are mutually negotiated, is crucial to providing the safest environment for patients.

A longitudinal qualitative exploration of healthcare and informal support needs among survivors of critical illness: the RELINQUISH protocol

INTRODUCTION AND BACKGROUND

Survival following critical illness is associated with a significant burden of physical, emotional and psychosocial morbidity. Recovery can be protracted and incomplete, with important and sustained effects upon everyday life, including family life, social participation and return to work. In stark contrast with other critically ill patient groups (eg, those following cardiothoracic surgery), there are comparatively few interventional studies of rehabilitation among the general intensive care unit patient population. This paper outlines the protocol for a sub study of the RECOVER study: a randomised controlled trial evaluating a complex intervention of enhanced ward-based rehabilitation for patients following discharge from intensive care.

METHODS AND ANALYSIS

The RELINQUISH study is a nested longitudinal, qualitative study of family support and perceived healthcare needs among RECOVER participants at key stages of the recovery process and at up to 1 year following hospital discharge. Its central premise is that recovery is a dynamic process wherein patients' needs evolve over time. RELINQUISH is novel in that we will incorporate two parallel strategies into our data analysis: (1) a pragmatic health services-oriented approach, using an a priori analytical construct, the 'Timing it Right' framework and (2) a constructivist grounded theory approach which allows the emergence of new themes and theoretical understandings from the data. We will subsequently use Qualitative Health Needs Assessment methodology to inform the development of timely and responsive healthcare interventions throughout the recovery process.

ETHICS AND DISSEMINATION

The protocol has been approved by the Lothian Research Ethics Committee (protocol number HSRU011). The study has been added to the UK Clinical Research Network Database (study ID. 9986). The authors will disseminate the findings in peer reviewed publications and to relevant critical care stakeholder groups.

Redesigning the ICU nursing discharge process: a quality improvement study

PURPOSE

To evaluate the impact of a redesigned intensive care unit (ICU) nursing discharge process on ICU discharge delay, hospital mortality, and ICU readmission within 72 hours.

METHODS

A quality improvement study using a time series design and statistical process control analysis was conducted in one Australian general ICU. The primary outcome measure was hours of discharge delay per patient discharged alive per month, measured for 15 months prior to, and for 12 months after the redesigned process was implemented. The redesign process included appointing a change agent to facilitate process improvement, developing a patient handover sheet, requesting ward staff to nominate an estimated transfer time, and designing a daily ICU discharge alert sheet that included an expected date of discharge.

RESULTS

A total of 1,787 ICU discharges were included in this study, 1,001 in the 15 months before and 786 in the 12 months after the implementation of the new discharge processes. There was no difference in in-hospital mortality after discharge from ICU or ICU readmission within 72 hours during the study period. However, process improvement was demonstrated by a reduction in the average patient discharge delay time of 3.2 hours (from 4.6 hour baseline to 1.0 hours post-intervention).

CONCLUSIONS

Involving both ward and ICU staff in the redesign process may have contributed to a shared situational awareness of the problems, which led to more timely and effective ICU discharge processes. The use of a change agent, whose ongoing role involved follow-up of patients discharged from ICU, may have helped to embed the new process into practice.

Socio-Technical Systems Analysis in Health Care: A Research Agenda

Given the complexity of health care and the 'people' nature of healthcare work and delivery, STSA (Sociotechnical Systems Analysis) research is needed to address the numerous quality of care problems observed across the world. This paper describes open STSA research areas, including workload management, physical, cognitive and macroergonomic issues of medical devices and health information technologies, STSA in transitions of care, STSA of patient-centered care, risk management and patient safety management, resilience, and feedback loops between event detection, reporting and analysis and system redesign.

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 failures in handoff communication during intrahospital transfers

BACKGROUND

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

METHODS

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

DATA SYNTHESIS

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

FINDINGS

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

CONCLUSIONS

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

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.