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Güven B, Topçu S, Hamarat E, Ödül Özkaya B, Güreşci Zeydan A. Nursing care complexity as a predictor of adverse events in patients transferred from ICU to hospital ward after general surgery. Intensive Crit Care Nurs 2024; 82:103637. [PMID: 38309145 DOI: 10.1016/j.iccn.2024.103637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/05/2024]
Abstract
OBJECTIVES Predicting the likelihood of adverse events following discharge from the intensive care unit (ICU) can contribute to improving the quality of surgical care. This study aimed to evaluate the impact of nursing care complexity as a predictor of adverse event development in general surgery patients transferred from the ICU to the hospital ward. METHODS A prospective observational study was conducted with 100 patients in the ICU and general surgical inpatient unit of a training and research hospital in Istanbul, Turkey. The Nursing Care Complexity tool was used by ICU and hospital ward nurses to measure nursing complexity. RESULTS A total of 65 adverse events developed in 51 patients during hospital ward hospitalization after discharge from the ICU. Nursing care complexity evaluations by the ICU nurses predicted overall and some specific adverse events, while hospital ward nurses' evaluations predicted ICU readmission and some follow-up abnormalities such as patients' blood pressure, pulse rate, and laboratory results. CONCLUSION The results of the current study validate that nursing care complexity can serve as a valuable tool for predicting the risk of adverse events and ICU readmission following discharge from the ICU. IMPLICATIONS FOR CLINICAL PRACTICE The use of the Nursing Care complexity tool by the ICU and even hospital ward nurses after ICU discharge may have a significant impact on patient outcomes and contribute to the recognition of nursing efforts.
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Affiliation(s)
- Betül Güven
- Bezmialem Vakıf University, Faculty of Health Sciences-Nursing, Istanbul, Türkiye.
| | - Serpil Topçu
- Demiroğlu Bilim University, Florence Nightingale School of Nursing, İstanbul, Türkiye.
| | - Elif Hamarat
- Bakırköy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Türkiye.
| | - Birgül Ödül Özkaya
- Bakırköy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Türkiye.
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Falconer N, Snoswell C, Morris C, Barras M. The right time and place: the need for seven‐day pharmacist service models. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2021. [DOI: 10.1002/jppr.1761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Nazanin Falconer
- School of Pharmacy Pharmacy Australia Centre of Excellence The University of Queensland Brisbane Australia
- Department of Pharmacy Princess Alexandra Hospital Metro South Health Brisbane Australia
- Centre for Health Services Research Faculty of Medicine The University of Queensland The University of Queensland Brisbane Australia
| | - Centaine Snoswell
- Department of Pharmacy Princess Alexandra Hospital Metro South Health Brisbane Australia
- Centre for Health Services Research Faculty of Medicine The University of Queensland The University of Queensland Brisbane Australia
| | - Christopher Morris
- Department of Internal Medicine Princess Alexandra Hospital Metro South Health Brisbane Australia
| | - Michael Barras
- School of Pharmacy Pharmacy Australia Centre of Excellence The University of Queensland Brisbane Australia
- Department of Pharmacy Princess Alexandra Hospital Metro South Health Brisbane Australia
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Duke GJ, Shann F, Knott CI, Oberender F, Pilcher DV, Roodenburg O, Santamaria JD. Hospital-acquired complications in critically ill patients. CRIT CARE RESUSC 2021; 23:285-291. [PMID: 38046077 PMCID: PMC10692509 DOI: 10.51893/2021.3.oa5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The national hospital-acquired complications (HAC) system has been promoted as a method to identify health care errors that may be mitigated by clinical interventions. Objectives: To quantify the rate of HAC in multiday stay adults admitted to major hospitals. Design: Retrospective observational analysis of 5-year (July 2014 - June 2019) administrative dataset abstracted from medical records. Setting: All 47 hospitals with on-site intensive care units (ICUs) in the State of Victoria. Participants: All adults (aged ≥ 18 years) stratified into planned or unplanned, surgical or medical, ICU or other ward, and by hospital peer group (tertiary referral, metropolitan, regional). Main outcome measures: HAC rates in ICU compared with ward, and mixed-effects regression estimates of the association between HAC and i) risk of clinical deterioration, and ii) admission hospital site (intraclass correlation coefficient [ICC] > 0.3). Results: 211 120 adult ICU separations with mean hospital mortality of 7.3% (95% CI, 7.2-7.4%) reported 110 132 (42.6%) HAC events (commonly, delirium, infection, arrhythmia and respiratory failure) in 62 945 records (29.8%). Higher HAC rates were reported in elective (cardiac [50.3%] and non-cardiac [40.6%]) surgical subgroups compared with emergency medical subgroup (23.9%), and in tertiary (35.4%) compared with non-tertiary (22.7%) hospitals. HAC was strongly associated with on-admission patient characteristics (P < 0.001), but was weakly associated with hospital site (ICC, 0.08; 95% CI, 0.05-0.11). Conclusions: Critically ill patients have a high burden of HAC events, which appear to be associated with patient admission characteristics. HAC may an indicator of hospital admission complexity rather than hospital-acquired complications.
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Affiliation(s)
- Graeme J. Duke
- Intensive Care Service, Eastern Health, Melbourne, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- INSIGHT Committee, Critical Care Clinical Network, Safer Care Victoria, Melbourne, VIC, Australia
| | - Frank Shann
- INSIGHT Committee, Critical Care Clinical Network, Safer Care Victoria, Melbourne, VIC, Australia
- Intensive Care Department, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Cameron I. Knott
- INSIGHT Committee, Critical Care Clinical Network, Safer Care Victoria, Melbourne, VIC, Australia
- Intensive Care Department, Bendigo Health, Bendigo, VIC, Australia
- Intensive Care Department, Austin Health, Melbourne, VIC, Australia
| | - Felix Oberender
- INSIGHT Committee, Critical Care Clinical Network, Safer Care Victoria, Melbourne, VIC, Australia
- Paediatric Intensive Care Department, Monash Children’s Hospital, Melbourne, VIC, Australia
| | - David V. Pilcher
- INSIGHT Committee, Critical Care Clinical Network, Safer Care Victoria, Melbourne, VIC, Australia
- Intensive Care Department, Alfred Health, Melbourne, VIC, Australia
- Centre for Outcomes and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia
| | - Owen Roodenburg
- Intensive Care Service, Eastern Health, Melbourne, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - John D. Santamaria
- INSIGHT Committee, Critical Care Clinical Network, Safer Care Victoria, Melbourne, VIC, Australia
- Critical Care Department, St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
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Abstract
OBJECTIVES To examine adverse events and associated factors and outcomes during transition from ICU to hospital ward (after ICU discharge). DESIGN Multicenter cohort study. SETTING Ten adult medical-surgical Canadian ICUs. PATIENTS Patients were those admitted to one of the 10 ICUs from July 2014 to January 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two ICU physicians independently reviewed progress and consultation notes documented in the medical record within 7 days of patient's ICU discharge date to identify and classify adverse events. The adverse event data were linked to patient characteristics and ICU and ward physician surveys collected during the larger prospective cohort study. Analyses were conducted using multivariable logistic regression. Of the 451 patients included in the study, 84 (19%) experienced an adverse event, the majority (62%) within 3 days of transfer from ICU to hospital ward. Most adverse events resulted only in symptoms (77%) and 36% were judged to be preventable. Patients with adverse events were more likely to be readmitted to the ICU (odds ratio, 5.5; 95% CI, 2.4-13.0), have a longer hospital stay (mean difference, 16.1 d; 95% CI, 8.4-23.7) or die in hospital (odds ratio, 4.6; 95% CI, 1.8-11.8) than those without an adverse event. ICU and ward physician predictions at the time of ICU discharge had low sensitivity and specificity for predicting adverse events, ICU readmissions, and hospital death. CONCLUSIONS Adverse events are common after ICU discharge to hospital ward and are associated with ICU readmission, increased hospital length of stay and death and are not predicted by ICU or ward physicians.
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Herling SF, Brix H, Andersen L, Jensen LD, Handesten R, Knudsen H, Bove DG. A qualitative study portraying nurses' perspectives on transitional care between intensive care units and hospitals wards. Scand J Caring Sci 2021; 36:947-956. [PMID: 33908642 DOI: 10.1111/scs.12990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 02/04/2021] [Accepted: 03/14/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Suzanne Forsyth Herling
- Research Unit: ACES, Department of Anesthesiology, Copenhagen University Hospital Herlev Gentofte, Herlev, Denmark.,The Neuroscience Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen Ø, Denmark
| | - Helene Brix
- ICU, Department of Anesthesiology, Copenhagen University Hospital Herlev Gentofte, Herlev, Denmark
| | - Lise Andersen
- ICU, Department of Anesthesiology, Copenhagen University Hospital Herlev Gentofte, Herlev, Denmark
| | - Liz Daugaard Jensen
- ICU, Department of Anesthesiology, Copenhagen University Hospital Herlev Gentofte, Herlev, Denmark
| | - Rie Handesten
- ICU, Department of Anesthesiology, Copenhagen University Hospital Herlev Gentofte, Herlev, Denmark
| | - Heidi Knudsen
- ICU, Department of Anesthesiology, Copenhagen University Hospital Herlev Gentofte, Herlev, Denmark
| | - Dorthe Gaby Bove
- Emergency Department, Copenhagen University Hospital, Hillerød, Denmark
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Risk factors for readmission to ICU and analysis of intra-hospital mortality. Med Clin (Barc) 2021; 158:58-64. [PMID: 33516522 DOI: 10.1016/j.medcli.2020.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Critical patients, despite initial recovery in the intensive care unit (ICU), may require readmission to the ICU or even die in the same hospital episode. The objectives are to determine the incidence and to identify risk factors for ICU readmission, and to determine hospital mortality. METHODS Observational cohort study of all patients admitted consecutively for more than 24hours to the ICU of the University Hospital of Getafe between April 1, 2018 and September 30, 2018 and discharged alive from their first ICU admission. RESULTS Of the 164 patients alive at ICU discharge, 14 (8.5%) were readmitted to ICU (2.4% at≤48hours). The adjusted risk of ICU readmission was higher in patients with disabling neurological deficits prior to ICU admission [odds ratio (OR) 7.96, 95% confidence interval (CI) 1.55-40.92] or who received vasoactive drugs (OR 5.07, 95% CI 1.41-18.29) during their ICU stay. Readmitted patients had higher hospital mortality (4 of 14 [29%] versus 5 of 150 [3%], P<.001) and longer hospital stay (74.5 [37.5-99.75] days versus 16 [9-34] days, median [interquartile range], P=.001). CONCLUSIONS Patients with disabling neurological deficits prior to hospital admission or who received vasoactive drugs during their ICU stay have a higher risk of readmission to the ICU, which increases hospital stay and mortality.
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Sanson G, Marino C, Valenti A, Lucangelo U, Berlot G. Is my patient ready for a safe transfer to a lower-intensity care setting? Nursing complexity as an independent predictor of adverse events risk after ICU discharge. Heart Lung 2020; 49:407-414. [PMID: 32067723 DOI: 10.1016/j.hrtlng.2020.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 01/24/2020] [Accepted: 02/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients discharged from intensive care units (ICUs) are at risk for adverse events (AEs). Establishing safe discharge criteria is challenging. No available criteria consider nursing complexity among risk factors. OBJECTIVES To investigate whether nursing complexity upon ICU discharge is an independent predictor for AEs. METHODS Prospective observational study. The Patient Acuity and Complexity Score (PACS) was developed to measure nursing complexity. Its predictive power for AEs was tested using multivariate regression analysis. RESULTS The final regression model showed a very-good discrimination power (AUC 0.881; p<0.001) for identifying patients who experienced AEs. Age, ICU admission reason, PACS, cough strength, PaCO2, serum creatinine and sodium, and transfer to Internal Medicine showed to be predictive of AEs. Exceeding the identified PACS threshold increased by 3.3 times the AEs risk. CONCLUSIONS The level of nursing complexity independently predicts AEs risk and should be considered in establishing patient's eligibility for a safe ICU discharge.
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Affiliation(s)
- Gianfranco Sanson
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Strada di Fiume 447, 34100 Trieste, Italy.
| | - Cecilia Marino
- Department of Perioperative Medicine, Intensive Care and Emergency, University Hospital, Trieste, Italy.
| | - Andrea Valenti
- Department of Perioperative Medicine, Intensive Care and Emergency, University Hospital, Trieste, Italy.
| | - Umberto Lucangelo
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Strada di Fiume 447, 34100 Trieste, Italy; Department of Perioperative Medicine, Intensive Care and Emergency, University Hospital, Trieste, Italy.
| | - Giorgio Berlot
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Strada di Fiume 447, 34100 Trieste, Italy; Department of Perioperative Medicine, Intensive Care and Emergency, University Hospital, Trieste, Italy.
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Srinivasan S. A Shift in Time Saves ……. Indian J Crit Care Med 2019; 23:109-110. [PMID: 31097883 PMCID: PMC6487618 DOI: 10.5005/jp-journals-10071-23129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Srinivasan S. A Shift in Time Saves ……. Indian J Crit Care Med 2019;23(3):109-110.
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Affiliation(s)
- Shrikanth Srinivasan
- Department of Critical Care Medicine, Manipal Hospital, Dwarka, New Delhi, India
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Vollam S, Gustafson O, Hinton L, Morgan L, Pattison N, Thomas H, Young JD, Watkinson P. Protocol for a mixed-methods exploratory investigation of care following intensive care discharge: the REFLECT study. BMJ Open 2019; 9:e027838. [PMID: 30813113 PMCID: PMC6347880 DOI: 10.1136/bmjopen-2018-027838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 11/19/2018] [Accepted: 11/20/2018] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Sarah Vollam
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Owen Gustafson
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lisa Hinton
- Nuffield Department of Primary Health Care, University of Oxford, Oxford, UK
| | - Lauren Morgan
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Natalie Pattison
- School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Hilary Thomas
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK
| | - J Duncan Young
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Peter Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Gonzalez CE, Brito-Dellan N, Banala SR, Rubio D, Ait Aiss M, Rice TW, Chen K, Bodurka DC, Escalante CP. Handoff Tool Enabling Standardized Transitions Between the Emergency Department and the Hospitalist Inpatient Service at a Major Cancer Center. Am J Med Qual 2018; 33:629-636. [PMID: 29779398 DOI: 10.1177/1062860618776096] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Communication failures during patient handoff can lead to serious errors. A quality improvement team created a standardized handoff tool/process (DE-PASS: Decisive problem requiring admission, Evaluation time, Patient summary, Acute issues/action list, Situation unfinished/awareness, Signed out to) for admitting patients from the emergency department (ED) to the hospitalist inpatient service of a tertiary cancer center. DE-PASS mirrors the institution's ED workflow, stratifies patients as stable/urgent/emergent, and establishes requirements for verbal and email communications between providers. Comparison of preintervention and postintervention results from the 1-month pilot revealed that within a 24-hour period, DE-PASS reduced the number of intensive care unit transfers by 58% ( P = .393), the number of rapid-response team calls by 39% ( P = .637), and time to inpatient order by 31% ( P = .004). ED physicians' and hospitalists' satisfaction with DE-PASS increased. Reduction in intensive care unit transfers was sustained after the pilot ( P = .029). DE-PASS feasibility was evidenced by 100% uptake. By stratifying patients by risk level, DE-PASS reduced admission-to-evaluation times for unstable patients, potentially improving patient safety.
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Affiliation(s)
| | | | - Srinivas R Banala
- 1 The University of Texas MD Anderson Cancer Center, Houston, TX.,2 Baylor College of Medicine, Houston, TX
| | - David Rubio
- 1 The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mohamed Ait Aiss
- 1 The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Terry W Rice
- 1 The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Karen Chen
- 1 The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Diane C Bodurka
- 1 The University of Texas MD Anderson Cancer Center, Houston, TX
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Wibrandt I, Lippert A. Improving Patient Safety in Handover From Intensive Care Unit to General Ward: A Systematic Review. J Patient Saf 2017; 16:199-210. [DOI: 10.1097/pts.0000000000000266] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Yang S, Wang Z, Liu Z, Wang J, Ma L. Association between time of discharge from ICU and hospital mortality: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:390. [PMID: 27903270 PMCID: PMC5131545 DOI: 10.1186/s13054-016-1569-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 11/11/2016] [Indexed: 01/11/2023]
Abstract
Background Epidemiological studies have provided inconsistent results on whether intensive care unit (ICU) discharge at night and on weekends is associated with an increased risk of mortality. This systematic review and meta-analysis aimed to determine whether ICU discharge time was associated with hospital mortality. Methods The PubMed, Embase, and Scopus databases were searched to identify cohort studies that investigated the effects of discharge from the ICU on weekends and at night on hospital mortality, with adjustments for the disease severity at ICU admission or discharge. The primary meta-analysis focused on the association between nighttime ICU discharge and hospital mortality. The secondary meta-analysis examined the association between weekend ICU discharge and hospital mortality. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Results We included 14 studies that assessed outcomes for nighttime versus daytime discharges among 953,312 individuals. Of these 14 studies, 5 evaluated outcomes for weekend versus weekday discharges (n = 70,883). The adjusted OR for hospital mortality was significantly higher among patients discharged during the nighttime, compared to patients discharged during the daytime (OR 1.31, 95% CI 1.25–1.38, P < 0.0001), and the studies exhibited low heterogeneity (I2 = 33.8%, P = 0.105). There was no significant difference in the adjusted ORs for hospital mortality between patients discharged during the weekend or on weekdays (OR 1.03, 95% CI 0.88–1.21, P = 0.68), although there was significant heterogeneity between the studies in the weekday/weekend analysis (I2 = 72.5%, P = 0.006). Conclusions Nighttime ICU discharge is associated with an increased risk of hospital mortality, while weekend ICU discharge is not. Given the methodological limitations and heterogeneity among the included studies, these conclusions should be interpreted with caution, and should be tested in further studies. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1569-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Si Yang
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Zheng Wang
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Zhida Liu
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Jinlai Wang
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Zhengzhou, Henan, China
| | - Lijun Ma
- Department of Respiratory and Critical Care Medicine, Zhengzhou University People's Hospital, Zhengzhou, Henan, China.
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Roque KE, Tonini T, Melo ECP. Adverse events in the intensive care unit: impact on mortality and length of stay in a prospective study. CAD SAUDE PUBLICA 2016; 32:e00081815. [PMID: 27783755 DOI: 10.1590/0102-311x00081815] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 02/22/2016] [Indexed: 02/24/2023] Open
Abstract
This study sought to evaluate the occurrence of adverse events and their impacts on length of stay and mortality in an intensive care unit (ICU). This is a prospective study carried out in a teaching hospital in Rio de Janeiro, Brazil. The cohort included 355 patients over 18 years of age admitted to the ICU between August 1, 2011 and July 31, 2012. The process we used to identify adverse events was adapted from the method proposed by the Institute for Healthcare Improvement. We used a logistical regression to analyze the association between adverse event occurrence and death, adjusted by case severity. We confirmed 324 adverse events in 115 patients admitted over the year we followed. The incidence rate was 9.3 adverse events per 100 patients-day and adverse event occurrence impacted on an increase in length of stay (19 days) and in mortality (OR = 2.047; 95%CI: 1.172-3.570). This study highlights the serious problem of adverse events in intensive care and the risk factors associated with adverse event incidence. Resumo: Este estudo teve como objetivo avaliar a ocorrência de eventos adversos e o impacto deles sobre o tempo de permanência e a mortalidade na unidade de terapia intensiva (UTI). Trata-se de um estudo prospectivo desenvolvido em um hospital de ensino do Rio de Janeiro, Brasil. A coorte foi formada por 355 pacientes maiores de 18 anos, admitidos na UTI, no período de 1º de agosto de 2011 a 31 de julho de 2012. O processo de identificação de eventos adversos baseou-se em uma adaptação do método proposto pelo Institute for Healthcare Improvement. A regressão logística foi utilizada para analisar a associação entre a ocorrência de evento adverso e o óbito, ajustado pela gravidade do paciente. Confirmados 324 eventos adversos em 115 pacientes internados ao longo de um ano de seguimento. A taxa de incidência foi de 9,3 eventos adversos por 100 pacientes-dia, e a ocorrência de evento adverso impactou no aumento do tempo de internação (19 dias) e na mortalidade (OR = 2,047; IC95%: 1,172-3,570). Este estudo destaca o sério problema dos eventos adversos na assistência à saúde prestada na terapia intensiva e os fatores de risco associados à incidência de eventos.
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Affiliation(s)
- Keroulay Estebanez Roque
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil
| | - Teresa Tonini
- Escola de Enfermagem Alfredo Pinto, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brasil
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Life-threatening complications after postoperative intermediate care unit discharge: A retrospective, observational study. Eur J Anaesthesiol 2016. [PMID: 26225496 DOI: 10.1097/eja.0000000000000321] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative patients who require intensive monitoring, intervention with an arterial line, vasoactive drugs and prolonged ventilator weaning are admitted to the postoperative intermediate care unit (IMCU). OBJECTIVES The aim of this study was to estimate the prevalence of life-threatening complications within 7 days after IMCU discharge. Furthermore, we searched for associations between perioperative risk factors and these life-threatening complications. DESIGN A retrospective observational study. SETTING The postoperative IMCU of a university hospital in Tokyo, Japan, between 2010 and 2012. PATIENTS All adult patients who stayed in the postoperative IMCU and who were discharged to general wards without being transferred to the ICU were included. MAIN OUTCOME MEASURES A composite outcome of life-threatening complications needing unplanned ICU admission within 7 days after IMCU stay, or death within 7 days after IMCU stay. RESULTS Forty out of 3093 patients (1.3%) presented a life-threatening complication; all had an unplanned ICU admission, and none died. Patients with life-threatening complications had a longer length of hospital stay [median 38.0 (interquartile range, IQR 21.3 to 56.8) days vs. 12.0 (IQR 8.0 to 23.0), P < 0.001] and a higher in-hospital mortality (12.5 vs. 0.7%, P < 0.001). Independent risk factors were an emergency operation before IMCU admission [vs. elective; odds ratio (OR) 20.5; 95% confidence interval (95% CI) 12.2 to 36.0, P < 0.001], higher cumulative perioperative fluid load during the surgical operation and IMCU stay (3000 to 4999 vs. <1000 ml; OR 5.7; 95% CI 1.6 to 23.7, P = 0.009; ≥5000 vs. <1000 ml; OR 7.2; 95% CI 1.3 to 39.6, P = 0.021), mechanical ventilation during IMCU stay less than 6 h (vs. no use; OR 3.6; 95% CI 1.4 to 9.2, P = 0.007). CONCLUSION More than 1% of patients had a life-threatening complication within 7 days after IMCU discharge, but with no deaths. Risk factors were an emergency operation before IMCU admission, higher cumulative perioperative fluid load and a short period of mechanical ventilation during the IMCU stay.
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Sundararajan K, Flabouris A, Thompson C. Diurnal variation in the performance of rapid response systems: the role of critical care services-a review article. J Intensive Care 2016; 4:15. [PMID: 26913199 PMCID: PMC4765019 DOI: 10.1186/s40560-016-0136-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 02/03/2016] [Indexed: 11/17/2022] Open
Abstract
The type of medical review before an adverse event influences patient outcome. Delays in the up-transfer of patients requiring intensive care are associated with higher mortality rates. Timely detection and response to a deteriorating patient constitute an important function of the rapid response system (RRS). The activation of the RRS for at-risk patients constitutes the system’s afferent limb. Afferent limb failure (ALF), an important performance measure of rapid response systems, constitutes a failure to activate a rapid response team (RRT) despite criteria for calling an RRT. There are diurnal variations in hospital staffing levels, the performance of rapid response systems and patient outcomes. Fewer ward-based nursing staff at night may contribute to ALF. The diurnal variability in RRS activity is greater in unmonitored units than it is in monitored units for events that should result in a call for an RRT. RRT events include a significant abnormality in either the pulse rate, blood pressure, conscious state or respiratory rate. There is also diurnal variation in RRT summoning rates, with most activations occurring during the day. The reasons for this variation are mostly speculative, but the failure of the afferent limb of RRT activation, particularly at night, may be a factor. The term “circadian variation/rhythm” applies to physiological variations over a 24-h cycle. In contrast, diurnal variation applies more accurately to extrinsic systems. Circadian rhythm has been demonstrated in a multitude of bodily functions and disease states. For example, there is an association between disrupted circadian rhythms and abnormal vital parameters such as anomalous blood pressure, irregular pulse rate, aberrant endothelial function, myocardial infarction, stroke, sleep-disordered breathing and its long-term consequences of hypertension, heart failure and cognitive impairment. Therefore, diurnal variation in patient outcomes may be extrinsic, and more easily modifiable, or related to the circadian variation inherent in human physiology. Importantly, diurnal variations in the implementation and performance of the RRS, as gauged by ALF, the RRT response to clinical deterioration and any variations in quality and quantity of patient monitoring have not been fully explored across a diverse group of hospitals.
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Affiliation(s)
- Krishnaswamy Sundararajan
- Intensive Care Unit, Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Level 4, ICU, Robert Gerard Wing, Adelaide, 5000 South Australia Australia
| | - Arthas Flabouris
- Intensive Care Unit, Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Level 4, ICU, Robert Gerard Wing, Adelaide, 5000 South Australia Australia
| | - Campbell Thompson
- Department of Medicine, University of Adelaide and the Royal Adelaide Hospital, Adelaide, 5000 South Australia Australia
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Stelfox HT, Bastos J, Niven DJ, Bagshaw SM, Turin TC, Gao S. Critical care transition programs and the risk of readmission or death after discharge from ICU. Intensive Care Med 2015; 42:401-410. [PMID: 26694189 DOI: 10.1007/s00134-015-4173-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/29/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Critical care transition programs have been widely implemented to improve the safety of patient discharge from ICU, but have undergone limited evaluation. We sought to evaluate implementation of a critical care transition program on patient readmission to ICU (72 h) and mortality (14 days). METHODS Interrupted time series analysis of 32,234 consecutive adult patients discharged alive from medical-surgical ICUs in eight hospitals in two cities between January 1, 2002 and January 1, 2012. A multidisciplinary ICU provider team (physician, nurse, respiratory therapist) that serially evaluated each patient after ICU discharge was implemented in three hospitals in one city (study group), but not the five hospitals in the other city (control group). Temporal changes were examined using multivariable, segmented linear regression models. RESULTS After implementation of the program, there was an immediate non-significant decrease in the absolute proportion of patients readmitted to ICU in the study group (-0.4%, 95% CI -1.7 to +1.0%) and a non-significant increase in the absolute proportion of patients readmitted to ICU in the control group (+1.0%, 95% CI -0.3 to +2.2%). Subsequently, there were non-significant changes in the absolute proportion of patients readmitted to ICU in both the study (+0.1% per quarter; 95% CI, -0.1 to +0.2%) and control (-0.1 per quarter; 95% CI, -0.2 to +0.1%) groups over time. No significant changes were observed in mortality. The results were stable across patient subgroups. CONCLUSIONS Implementation of a critical care transition program was not associated with patient readmission to ICU or mortality.
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Affiliation(s)
- Henry T Stelfox
- Departments of Critical Care Medicine, and Community Health Sciences, University of Calgary and Alberta Health Services, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
| | - Jaime Bastos
- Departments of Critical Care Medicine, and Community Health Sciences, University of Calgary and Alberta Health Services, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Daniel J Niven
- Departments of Critical Care Medicine, and Community Health Sciences, University of Calgary and Alberta Health Services, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | - T C Turin
- Department of Family Medicine, University of Calgary and Alberta Health Services, Calgary, Canada
| | - Song Gao
- Alberta Health Services, Calgary, Canada
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Elliott M, Page K, Worrall-Carter L. Factors associated with post-intensive care unit adverse events: a clinical validation study. Nurs Crit Care 2014; 19:228-35. [PMID: 24809526 DOI: 10.1111/nicc.12091] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 02/02/2014] [Accepted: 02/04/2014] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Malcolm Elliott
- M Elliott, RN, BN, Doctoral Candidate, St. Vincent's Centre for Nursing Research, Melbourne, Australia
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Wood SD, Coster S, Norman I. Comparing the monitoring of patients transferred from a critical care unit to hospital wards at after-hours with day transfers: an exploratory, prospective cohort study. J Adv Nurs 2014; 70:2757-66. [PMID: 24702103 DOI: 10.1111/jan.12410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2014] [Indexed: 11/30/2022]
Abstract
AIMS To investigate possible factors related to patient monitoring to explain the higher mortality rates associated with after-hours transfers compared with daytime transfers from critical care units to the wards. BACKGROUND International research suggests that patients transferred from critical care units after-hours have a higher mortality rate than transfers during daytime, although the reasons remain unknown. DESIGN A prospective exploratory study. METHODS Twenty-nine patients transferred from a UK critical care unit to a ward within the same hospital after-hours for 10 weeks beginning April 2009 were compared with 29 transfers during daytime hours matched on potentially confounding characteristics. UK Critical Care Unit transfer guidelines have remained unchanged since data collection. Outcomes were as follows: (i) frequency of nursing observations; (ii) time periods from transfer to first medical review; (iii) time period from transfer to first clinical observations; (iv) frequency of transfer to an inappropriate ward; (v) delayed transfers from Critical Care Unit to ward. RESULTS Using Wilcoxon's Rank test (two tail) to compare paired data from the matched groups, observations were recorded significantly less frequently within the first 12 hours for after-hours transfers. Time from transfer to first clinical observations was significantly longer for after-hour transfer patients. The delay from when the patient was ready for ward care and actual transfer was also longer for the after-hours transfer group. CONCLUSIONS Surveillance differences, including time to the first set of observations and frequency of observations in the first 12 hours, are potential factors that may explain the differential mortality associated with after-hours transfers.
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Elliott M, Page K, Worrall-Carter L, Rolley J. Examining adverse events after intensive care unit discharge: outcomes from a pilot questionnaire. Int J Nurs Pract 2013; 19:479-86. [PMID: 24093739 DOI: 10.1111/ijn.12087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Adverse events are common in acute clinical settings but little is known about these events occurring after Intensive Care discharge. This study aimed to develop a reliable and valid tool for exploring clinicians' opinions of factors associated with post-Intensive Care adverse events. A convenience sample of Australian Intensive Care Liaison Nurses was invited to complete and appraise a questionnaire using structured guidelines. Content validity and internal consistency were assessed. Twelve Intensive Care Liaison Nurses completed the questionnaire. Cronbach?s alpha coefficient showed high internal consistency for the questionnaire; all 24 items on the questionnaire had coefficients greater than 0.852. The content validity index of the questionnaire overall was 0.76. The post-Intensive Care adverse events questionnaire demonstrated reliability and validity. It is a tool that can be used to explore clinicians? opinions of factors associated with these events. The tool is important as it facilitates further insight into the causes of post-Intensive Care adverse events.
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Affiliation(s)
- Malcolm Elliott
- St Vincent's Centre for Nursing Research, Melbourne, Victoria, Australia; Faculty of Health Science, Holmesglen Institute, Melbourne, Victoria, Australia
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Abstract
BACKGROUND Intensive care unit (ICU) readmission rates are commonly viewed as indicators of ICU quality. However, definitions of ICU readmissions vary, and it is unknown which, if any, readmissions are associated with ICU quality. OBJECTIVE Empirically derive the optimal interval between ICU discharge and readmission for purposes of considering ICU readmission as an ICU quality indicator. RESEARCH DESIGN Retrospective cohort study. SUBJECTS A total of 214,692 patients discharged from 157 US ICUs participating in the Project IMPACT database, 2001-2008. MEASURES We graphically examined how patient characteristics and ICU discharge circumstances (eg, ICU census) were related to the odds of ICU readmissions as the allowable interval between ICU discharge and readmission was lengthened. We defined the optimal interval by identifying inflection points where these relationships changed significantly and permanently. RESULTS A total of 2242 patients (1.0%) were readmitted to the ICU within 24 hours; 9062 (4.2%) within 7 days. Patient characteristics exhibited stronger associations with readmissions after intervals >48-60 hours. By contrast, ICU discharge circumstances and ICU interventions (eg, mechanical ventilation) exhibited weaker relationships as intervals lengthened, with inflection points at 30-48 hours. Because of the predominance of afternoon readmissions regardless of time of discharge, using intervals defined by full calendar days rather than fixed numbers of hours produced more valid results. DISCUSSION It remains uncertain whether ICU readmission is a valid quality indicator. However, having established 2 full calendar days (not 48 h) after ICU discharge as the optimal interval for measuring ICU readmissions, this study will facilitate future research designed to determine its validity.
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Elliott M, Worrall-Carter L, Page K. Factors contributing to adverse events after ICU discharge: A survey of liaison nurses. Aust Crit Care 2013; 26:76-80. [DOI: 10.1016/j.aucc.2012.07.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 06/07/2012] [Accepted: 07/03/2012] [Indexed: 12/22/2022] Open
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Bastero-Miñón P, Russell JL, Humpl T. Frequency, characteristics, and outcomes of pediatric patients readmitted to the cardiac critical care unit. Intensive Care Med 2012; 38:1352-7. [PMID: 22588651 DOI: 10.1007/s00134-012-2592-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 04/24/2012] [Indexed: 12/20/2022]
Abstract
PURPOSE To describe the characteristics and outcomes of patients readmitted to a pediatric cardiac critical care unit (CCCU) from the ward within 72 h of their first discharge. METHODS This was a retrospective analysis of data collected on patients admitted to the CCCU between January 1, 2000 and January 31, 2007. The setting was an 18-bed pediatric CCCU in a tertiary care university hospital. No interventions were performed. RESULTS Among the 4,625 patients admitted to the CCCU, 112 (2.4 %) were readmitted from the ward within 72 h of their discharge. The most common cause for readmission was respiratory symptoms (42.9 %). Significant changes in the chest X-ray prior to discharge were identified retrospectively in 12.5 % of these patients. Cardiovascular symptoms were similarly frequent (40.2 %) among these patients. Nine (8 %) of the patients died during the readmission period, a rate which is considerably higher than the overall CCCU mortality rate (3.8 %) in the same period of time. CONCLUSIONS Respiratory reasons are the most common cause for early CCCU readmission among pediatric cardiac patients. The readmitted patients have higher rates of death compared to the overall pediatric cardiac critical care population. The development of objective predischarge scores might help planning appropriately for discharge to the ward and avoid readmission to the CCU.
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Affiliation(s)
- Patricia Bastero-Miñón
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
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Chaboyer W, Lin F, Foster M, Retallick L, Panuwatwanich K, Richards B. Redesigning the ICU nursing discharge process: a quality improvement study. Worldviews Evid Based Nurs 2011; 9:40-8. [PMID: 22151856 DOI: 10.1111/j.1741-6787.2011.00234.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Wendy Chaboyer
- NHMRC Centre of Research Excellence in Nursing Interventions for Hospitalised Patients, Research Centre for Clinical and Community Practice Innovation, Griffith Health Institute, Griffith University, Gold Coast campus, Queensland, Australia.
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Makris N, Dulhunty JM, Paratz JD, Bandeshe H, Gowardman JR. Unplanned early readmission to the intensive care unit: a case-control study of patient, intensive care and ward-related factors. Anaesth Intensive Care 2010; 38:723-31. [PMID: 20715738 DOI: 10.1177/0310057x1003800338] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The purpose of this study was to identify patient, intensive care and ward-based risk factors for early, unplanned readmission to the intensive care unit. A five-year retrospective case-control study at a tertiary referral teaching hospital of 205 cases readmitted within 72 hours of intensive care unit discharge and 205 controls matched for admission diagnosis and severity of illness was conducted. The rate of unplanned readmissions was 3.1% and cases had significantly higher overall mortality than control patients (odds ratio [OR] 4.7, 95% confidence interval [CI] 2.1 to 10.7). New onset respiratory compromise and sepsis were the most common cause of readmission. Independent risk factors for readmission were chronic respiratory disease (OR 3.7, 95% CI 1.2 to 12, P = 0.029), pre-existing anxiety/depression (OR 3.3, 95% CI 1.7 to 6.6, P < 0.001), international normalised ratio >1.3 (OR 2.3, 95% CI 1.1 to 4.9, P = 0.024), immobility (OR 2.3, 95% CI 1.4 to 3.6, P = 0.001), nasogastric nutrition (OR 2.0, 95% CI 1.0 to 4.0, P = 0.041), a white cell count > 15 x 10(9)/l (OR 2.0, 95% CI 1.2 to 3.4, P = 0.012) and non-weekend intensive care unit discharge (OR 1.9, 95% CI 1.1 to 3.5, P = 0.029). Physiological derangement on the ward (OR 26, 95% CI 8.0 to 81, P < 0.001) strongly predicted readmission, although only 20% of patients meeting medical emergency team criteria had a medical emergency team call made. Risk of readmission is associated with both patient and intensive care factors. Physiological derangement on the ward predicts intensive care unit readmission, however, clinical response to this appears suboptimal.
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Affiliation(s)
- N Makris
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Elliott M, Crookes P, Worrall-Carter L, Page K. Readmission to intensive care: a qualitative analysis of nurses' perceptions and experiences. Heart Lung 2010; 40:299-309. [PMID: 20598372 DOI: 10.1016/j.hrtlng.2010.04.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2007] [Revised: 04/11/2010] [Accepted: 04/14/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The purpose of this study was to identify and describe the experiences and perceptions of nurses regarding the factors that contribute to the readmission of patients to intensive care. METHODS Twenty-one nurses participated in the study. Unstructured interviews were conducted to ascertain participants' perceptions and experiences. Interview transcripts were analyzed using a constant comparison method to identify major conceptual categories. RESULTS Five main themes were identified that contributed to the readmission of patients to intensive care: premature discharge from intensive care, delayed medical care at the ward level, heavy nursing workloads, lack of adequately qualified staff, and clinically "challenging" patients who demanded a different skill set from the nurses. CONCLUSION Discharging patients early from the intensive care unit when they are clinically unstable creates issues around workload and significantly challenges ward staff. It also increases the likelihood of patients being readmitted to the intensive care unit. Hospital managers need to look at ways of increasing the knowledge and skills of ward staff or identify more appropriate environments for managing these acutely ill patients.
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Introduction of Discharge Plan to Reduce Adverse Events Within 72 Hours of Discharge From the ICU. J Nurs Care Qual 2010; 25:73-9. [DOI: 10.1097/ncq.0b013e3181b0e490] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices. Crit Care Med 2009; 37:2775-81. [DOI: 10.1097/ccm.0b013e3181a96379] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices. Crit Care Med 2009. [DOI: 10.1097/00003246-200910000-00015] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Roughead EE, Semple SJ. Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002-2008. AUSTRALIA AND NEW ZEALAND HEALTH POLICY 2009. [PMID: 19671158 DOI: 10.1186/1743-8462-6-18.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND This paper presents Part 1 of a two-part literature review examining medication safety in the Australian acute care setting. This review was undertaken for the Australian Commission on Safety and Quality in Health Care to update a previous national report on medication safety conducted in 2002. This first part of the review examines the extent and causes of medication incidents and adverse drug events in acute care. METHODS A literature search was conducted to identify Australian studies, published from 2002 to 2008, on the extent and causes of medication incidents and adverse drug events in acute care. RESULTS Studies published since 2002 continue to suggest approximately 2%-3% of Australian hospital admissions are medication-related. Results of incident reporting from hospitals show that incidents associated with medication remain the second most common type of incident after falls. Omission or overdose of medication is the most frequent type of medication incident reported. Studies conducted on prescribing of renally excreted medications suggest that there are high rates of prescribing errors in patients requiring monitoring and medication dose adjustment. Research published since 2002 provides a much stronger Australian research base about the factors contributing to medication errors. Team, task, environmental, individual and patient factors have all been found to contribute to error. CONCLUSION Medication-related hospital admissions remain a significant problem in the Australian healthcare system. It can be estimated that 190,000 medication-related hospital admissions occur per year in Australia, with estimated costs of $660 million. Medication incidents remain the second most common type of incident reported in Australian hospitals. A number of different systems factors contribute to the occurrence of medication errors in the Australian setting.
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Affiliation(s)
- Elizabeth E Roughead
- Quality Use of Medicines and Pharmacy Research Centre, Sansom Institute, University of South Australia, GPO Box 2471, Adelaide, 5001.
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Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002-2008. AUSTRALIA AND NEW ZEALAND HEALTH POLICY 2009; 6:18. [PMID: 19671158 PMCID: PMC2733897 DOI: 10.1186/1743-8462-6-18] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Accepted: 08/11/2009] [Indexed: 11/10/2022]
Abstract
Background This paper presents Part 1 of a two-part literature review examining medication safety in the Australian acute care setting. This review was undertaken for the Australian Commission on Safety and Quality in Health Care to update a previous national report on medication safety conducted in 2002. This first part of the review examines the extent and causes of medication incidents and adverse drug events in acute care. Methods A literature search was conducted to identify Australian studies, published from 2002 to 2008, on the extent and causes of medication incidents and adverse drug events in acute care. Results Studies published since 2002 continue to suggest approximately 2%–3% of Australian hospital admissions are medication-related. Results of incident reporting from hospitals show that incidents associated with medication remain the second most common type of incident after falls. Omission or overdose of medication is the most frequent type of medication incident reported. Studies conducted on prescribing of renally excreted medications suggest that there are high rates of prescribing errors in patients requiring monitoring and medication dose adjustment. Research published since 2002 provides a much stronger Australian research base about the factors contributing to medication errors. Team, task, environmental, individual and patient factors have all been found to contribute to error. Conclusion Medication-related hospital admissions remain a significant problem in the Australian healthcare system. It can be estimated that 190,000 medication-related hospital admissions occur per year in Australia, with estimated costs of $660 million. Medication incidents remain the second most common type of incident reported in Australian hospitals. A number of different systems factors contribute to the occurrence of medication errors in the Australian setting.
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