Barriers and facilitators to improve safety and efficiency of the ICU discharge process: a mixed methods study

The current state of intensive care unit discharge practices - Results of an international survey study

Background

Increasing pressure on limited intensive care capacities often requires a subjective assessment of a patient's discharge readiness in the absence of established Admission, Discharge, and Transfer (ADT) guidelines. To avoid suboptimal care transitions, it is important to define clear guidelines for the admission and discharge of intensive care patients and to optimize transfer processes between the intensive care unit (ICU) and lower care levels. To achieve these goals, structured insights into usual ICU discharge and transfer practices are essential. This study aimed to generate these insights by focusing on involved stakeholders, established processes, discharge criteria and tools, relevant performance metrics, and current barriers to a timely and safe discharge.

Method

In 2022, a structured, web-based, anonymous cross-sectional survey was conducted, aimed at practicing ICU physicians, nurses, and bed coordinators. The survey consisted of 29 questions (open, closed, multiple choice, and scales) that were divided into thematic blocks. The study was supported by several national and international societies for intensive care medicine and nursing.

Results

A total of 219 participants from 40 countries (105 from Germany) participated in the survey. An overload of acute care resources with ~90% capacity utilization in the ICU and the general ward (GW) leads to not only premature but also delayed patient transfers due to a lack of available ward and intermediate care (IMC) beds. After multidisciplinary rounds within the intensive care team, the ICU clinician on duty usually makes the final transfer decision, while one-third of the panel coordinates discharge decisions across departmental boundaries. By the end of the COVID-19 pandemic, half of the hospitals had implemented ADT policies. Among these hospitals, nearly one-third of the hospitals had specific transfer criteria established, consisting primarily of vital signs and laboratory data, patient status and autonomy, and organization-specific criteria. Liaison nurses were less common but were ranked right after the required IMC capacities to bridge the care gap between the ICU and normal wards. In this study, 80% of the participants suggested that transfer planning would be easier if there was good transparency regarding the capacity utilization of lower care levels, a standardized transfer process, and improved interdisciplinary communication.

Conclusion

To improve care transitions, transfer processes should be managed proactively across departments, and efforts should be made to identify and address care gaps.

Inspiratory muscle training for mechanically ventilated patients in the intensive care unit: Obstacles and facilitators for implementation. A mixed method quality improvement study

BACKGROUND

Mechanically ventilated patients are at risk of developing inspiratory muscle weakness (IMW), which is associated with failure to wean and poor outcomes. Inspiratory muscle training (IMT) is a recommended intervention during and after extubation but has not been widely adopted in Dutch intensive care units (ICUs).

OBJECTIVES

The objective of this study was to explore the potential, barriers, and facilitators for implementing IMT as treatment modality for mechanically ventilated patients.

METHODS

This mixed-method, proof-of-concept study was conducted in a large academic hospital in the Netherlands. An evidence-based protocol for assessing IMW and training was applied to patients ventilated for ≥24 h in the ICU during an 8-month period in 2021. Quantitative data on completed measurements and interventions during and after ICU-stay were collected retrospectively and were analysed descriptively. Qualitative data were collected through semistructured interviews with physiotherapists executing the new protocol. Interview data were transcribed and thematically analysed.

FINDINGS

Of the 301 screened patients, 11.6% (n = 35) met the inclusion criteria. Measurements were possible in 94.3% of the participants, and IMW was found in 78.8% of the participants. Ninety-six percent started training in the ICU, and 88.5% continued training after transfer to the ward. Follow-up measurements were achieved in 73.1% of the patients with respiratory muscle weakness. Twelve therapists were interviewed, of whom 41.7% regularly worked in the ICU. When exploring reasons for protocol deviation, three themes emerged: "professional barriers", "external factors", and "patient barriers".

CONCLUSIONS

Implementation of measurements of and interventions for IMW showed to be challenging in this single centre study. Clinicians' willingness to change their handling was related to beliefs regarding usefulness, effectiveness, and availability of time and material. We recommend that hospitals aiming to implement IMT during or after ventilator weaning consider these professional and organisational barriers for implementation of novel, evidence-based interventions into daily clinical practice.

Ethical considerations in evaluating discharge readiness from the intensive care unit

Evaluating readiness for discharge from the intensive care unit (ICU) is a critical aspect of patient care. Whereas evidence-based criteria for ICU admission have been established, practical criteria for discharge from the ICU are lacking. Often discharge guidelines simply state that a patient no longer meets ICU admission criteria. Such discharge criteria can be interpreted differently by different healthcare providers, leaving a clinical void where misunderstandings of patients' readiness can conflict with perceptions of what readiness means for patients, families, and healthcare providers. In considering ICU discharge readiness, the use and application of ethical principles may be helpful in mitigating such conflicts and achieving desired patient outcomes. Ethical principles propose different ways of understanding what readiness might mean and how clinicians might weigh these principles in their decision-making process. This article examines the concept of discharge readiness through the lens of the most widely cited ethical principles (autonomy [respect for persons], nonmaleficence/beneficence, and justice) and provides a discussion of their application in the critical care environment. Ongoing bioethics discourse and empirical research are needed to identify factors that help determine discharge readiness within critical care environments that will ultimately promote safe and effective ICU discharges for patients and their families.

Organizational attributes that contribute to the learning & improvement capabilities of healthcare organizations: a scoping review

BACKGROUND

This study aims to explore and identify the organizational attributes that contribute to learning and improvement capabilities (L&IC) in healthcare organizations. The authors define learning as a structured update of system properties based on new information, and improvement as a closer correspondence between actual and desired standards. They highlight the importance of learning and improvement capabilities in maintaining high-quality care, and emphasize the need for empirical research on organizational attributes that contribute to these capabilities. The study has implications for healthcare organizations, professionals, and regulators in understanding how to assess and enhance learning and improvement capabilities.

METHODS

A systematic search of peer-reviewed articles published between January 2010 and April 2020 was carried out in the PubMed, Embase, CINAHL, and APA PsycINFO databases. Two reviewers independently screened the titles and abstracts and conducted a full-text review of potentially relevant articles, eventually adding five more studies identified through reference scanning. Finally, a total of 32 articles were included in this review. We extracted the data about organizational attributes that contribute to learning and improvement, categorized them and grouped the findings step-by-step into higher, more general-level categories using an interpretive approach until categories emerged that were sufficiently different from each other while also being internally consistent. This synthesis has been discussed by the authors.

RESULTS

We identified five attributes that contribute to the L&IC of healthcare organizations: perceived leadership commitment, open culture, room for team development, initiating and monitoring change, and strategic client focus, each consisting of multiple facilitating aspects. We also found some hindering aspects.

CONCLUSIONS

We have identified five attributes that contribute to L&IC, mainly related to organizational software elements. Only a few are identified as organizational hardware elements. The use of qualitative methods seems most appropriate to understand or assess these organizational attributes. We feel it is also important for healthcare organisations to look more closely at how clients can be involved in L&IC.

TRIAL REGISTRATION

Not applicable.

Improving Communication in Intensive Care Unit to Ward Transitions: Protocol for Multisite National Implementation of the ICU-PAUSE Handoff Tool

BACKGROUND

The intensive care unit (ICU)-ward transfer poses a particularly high-risk period for patients. The period after transfer has been associated with adverse events and additional work for care teams related to miscommunication or omission of information. Standardized handoff processes have been found to reduce communication errors and adverse patient events in other clinical environments but are understudied at the ICU-ward interface. We previously developed an electronic ICU-ward transfer tool, ICU-PAUSE, which embeds the key elements and diagnostic reasoning to facilitate a safe transfer of care at ICU discharge.

OBJECTIVE

The aim of this study is to evaluate the implementation process of the ICU-PAUSE handoff tool across 10 academic medical centers, including the rate of adoption and acceptability, as perceived by clinical care teams.

METHODS

ICU-PAUSE will be implemented in the medical ICU across 10 academic hospitals, with each site customizing the tool to their institution's needs. Our mixed methods study will include a combination of a chart review, quantitative surveys, and qualitative interviews. After a 90-day implementation period, we will conduct a retrospective chart review to evaluate the rate of uptake of ICU-PAUSE. We will also conduct postimplementation surveys of providers to assess perceptions of the tool and its impact on the frequency of communication errors and adverse events during ICU-ward transfers. Lastly, we will conduct semistructured interviews of faculty stakeholders with subsequent thematic analysis with the goal of identifying benefits and barriers in implementing and using ICU-PAUSE.

RESULTS

ICU-PAUSE was piloted in the medical ICU at Barnes-Jewish Hospital, the teaching hospital of Washington University School of Medicine in St. Louis, in 2019. As of July 2022, implementation of ICU-PAUSE is ongoing at 6 of 10 participating sites. Our results will be published in 2023.

CONCLUSIONS

Our process of ICU-PAUSE implementation embeds each step of template design, uptake, and customization in the needs of users and key stakeholders. Here, we introduce our approach to evaluate its acceptability, usability, and impact on communication errors according to the tenets of sociotechnical theory. We anticipate that ICU-PAUSE will offer an effective handoff tool for the ICU-ward transition that can be generalized to other institutions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40918.

Cognition and practice on transitional care during the transfer from intensive care unit to a general ward among health care professionals: A qualitative study

AIM

The aim of this study is to explore the cognition and practice on transitional care during the transfer from intensive care unit to a general ward among health care professionals in China.

BACKGROUND

Due to the significant differences in the medical and humanistic environment at home and abroad, the safety of patients during the transmission from intensive care unit to the general ward is often ignored when their conditions become stable. There are few qualitative studies on the cognition and practice on transitional care during the transfer from intensive care unit to the ward among health care professionals in China.

METHODS

With a qualitative research design, 20 medical and nursing staff in the neurosurgery intensive care unit and ward were interviewed from May 2021 to August 2021. NVivo 11.0 software was utilized for Colaizzi's (1978) method of data analysis.

RESULTS

Based on data analysis, perceptions of transitional care, the influencing factors for transitional care and the recommendations for improving transitional care were obtained.

CONCLUSION

To ensure the continuity of care and improve patient safety during the period from intensive care unit to a general ward in China, we should clarify the expectation for the content of intensive care unit transitional care services, establish the transitional nursing team, guide nursing work, standardize the handover mode and process from intensive care unit to the general ward, promote the communication and coordination of health care professionals and improve the transitional nursing security system from the perspective of institutional level.

IMPLICATIONS FOR NURSING MANAGEMENT

This study can be used as a guide to help health care professionals provide a reference for the comprehensive development of transitional care services and the formulation of targeted intervention measures during the transfer from intensive care unit to a general ward in China.

Intensive care nurses' knowledge and use of a nursing checklist: A cross-sectional survey

AIM

This descriptive study was conducted to determine the awareness of nurses working in intensive care units about the daily patient checklist.

BACKGROUND

Checklists are used in the daily follow-up and evaluation of patients admitted to the intensive care unit.

METHOD

The research was carried out with 180 nurses through the social media account of the Turkish Intensive Care Specialists Association Nurse Commission between July 2021 and March 2022. Data were collected with a descriptive information form and intensive care unit daily patient checklist. Necessary permissions were obtained before the study.

RESULTS

Among nurses, 45.0% of them got 15 full points from the Checklist. Moreover, 81.1% of the nurses stated that they knew that a checklist should be used to help eliminate the deficiencies of daily care and treatment in the intensive care unit, while 66.7% stated that they used a checklist. It was determined that nurses knew the most about parameters 'Check the daily infection parameters', 'Glycaemic control', 'Therapy', and the least about parameters 'Thromboprophylaxis', 'Ulcer prevention', 'Hypo-hyper delirium' and 'Use a daily checklist'.

CONCLUSION

It was determined that the level of awareness of intensive care unit nurses about some parameters that should be followed daily for patient care was low.

IMPLICATIONS FOR NURSING MANAGEMENT

Checklists can be used as a guide for health care professionals in the routine daily evaluation of intensive care unit patients. It is thought that these reminder abbreviations will provide efficiency in preventing the disruption of applications, reducing medical errors, reducing mortality and morbidity, and cost.

Lost in relocation: longitudinal surveys evaluating the effectiveness of ICU to ward handover after the introduction of an Electronic Patient Record

BACKGROUND

Poor communication and lack of standardised handover practices contribute to adverse events. Intensive care organisations recommend standardised, structured written and verbal handover.

OBJECTIVES

Investigate the effectiveness of, and barriers to, Intensive Care Unit (ICU) patient handover at ward transfer. Screen for patient safety incidents related to poor handover and improve practice where deficiencies are identified.

METHODS

A survey of ward doctors about specific ICU to ward transfers and online surveys ascertaining opinions of handover processes were sent to ward-based and ICU doctors at a large, adult, university affiliated, Australian quaternary hospital. Subsequently, we undertook departmental education and created then publicised a new electronic ICU transfer summary. The summary included a mandatory tick-box to confirm verbal handover completion. Surveys re-assessing practice were then performed.

RESULTS

Forty ward-based doctors were surveyed about specific transfers, with 7 (18%) instances of issues related to handover identified. Eighty-seven ward doctors completed the pre-interventions survey; 48 (55%) were aware of the existing written transfer summary. Post-interventions, 47 (75%) of 63 ward doctor responders were aware of it (p<0.05). Pre-interventions, 14 (16%) ward doctors rated ICU handovers as excellent or good, rising to 21 (34%) post-interventions (p<0.05). Thirty-nine ICU doctors completed the pre-interventions survey; 5 (13%) rated ICU to ward handover as excellent or good, rising to 9 (35%) when re-surveyed (p=0.097).

CONCLUSIONS

The perceived quality of ICU to ward handover improved after our interventions. However, ICU doctors continue to transfer patients without verbally handing over, with contacting the ward team representing a significant handover barrier.

Delphi study to derive expert consensus on a set of criteria to evaluate discharge readiness for adult ICU patients to be discharged to a general ward-European perspective

Background/purpose

Discharge decisions in Intensive Care Unit (ICU) patients are frequently taken under pressure to free up ICU beds. In the absence of established guidelines, the evaluation of discharge readiness commonly underlies subjective judgements. The challenge is to come to the right decision at the right time for the right patient. A premature care transition puts patients at risk of readmission to the ICU. Delayed discharge is a waste of resources and may result in over-treatment and suboptimal patient flow. More objective decision support is required to assess the individual patient’s discharge readiness but also the current care capabilities of the receiving unit.

Methods

In a modified online Delphi process, an international panel of 27 intensive care experts reached consensus on a set of 28 intensive care discharge criteria. An initial evidence-based proposal was developed further through the panelists’ edits, adding, comments and voting over a course of 5 rounds. Consensus was defined as achieved when ≥ 90% of the experts voted for a given option on the Likert scale or in a multiple-choice survey. Round 1 to 3 focused on inclusion and exclusion of the criteria based on the consensus threshold, where round 3 was a reiteration to establish stability. Round 4 and 5 focused on the exact phrasing, values, decision makers and evaluation time frames per criterion.

Results

Consensus was reached on a standard set of 28 ICU discharge criteria for adult ICU patients, that reflect the patient’s organ systems ((respiratory (7), cardiovascular (9), central nervous (1), and urogenital system (2)), pain (1), fluid loss and drainages (1), medication and nutrition (1), patient diagnosis, prognosis and preferences (2) and institution-specific criteria (4). All criteria have been specified in a binary decision metric (fit for ICU discharge vs. needs further intensive therapy/monitoring), with consented value calculation methods where applicable and a criterion importance rank with “mandatory to be met” flags and applicable exceptions.

Conclusion

For a timely identification of stable intensive care patients and safe and efficient care transitions, a standardized discharge readiness evaluation should be based on patient factors as well as organizational boundary conditions and involve multiple stakeholders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08160-6.

Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis

Background

Patients recovering from an episode in an intensive care unit (ICU) frequently experience medication errors on transition to the hospital ward. Structured handover recommendations often underestimate the challenges and complexity of ICU patient transitions. For adult ICU patients transitioning to a hospital ward, it is currently unclear what interventions reduce the risks of medication errors.

The aims were to examine the impact of medication-related interventions on medication and patient outcomes on transition from adult ICU settings and identify barriers and facilitators to implementation.

Methods

The systematic review protocol was preregistered on PROSPERO. Six electronic databases were searched until October 2020 for controlled and uncontrolled study designs that reported medication-related (ie, de-prescribing; medication errors) or patient-related outcomes (ie, mortality; length of stay). Risk of bias (RoB) assessment used V.2.0 and ROBINS-I Cochrane tools. Where feasible, random-effects meta-analysis was used for pooling the OR across studies. The quality of evidence was assessed by Grading of Recommendations, Assessment, Development and Evaluations.

Results

Seventeen studies were eligible, 15 (88%) were uncontrolled before-after studies. The intervention components included education of staff (n=8 studies), medication review (n=7), guidelines (n=6), electronic transfer/handover tool or letter (n=4) and medicines reconciliation (n=4). Overall, pooled analysis of all interventions reduced risk of inappropriate medication continuation at ICU discharge (OR=0.45 (95% CI 0.31 to 0.63), I2=55%, n=9) and hospital discharge (OR=0.39 (95% CI 0.2 to 0.76), I2=75%, n=9). Multicomponent interventions, based on education of staff and guidelines, demonstrated no significant difference in inappropriate medication continuation at the ICU discharge point (OR 0.5 (95% CI 0.22 to 1.11), I2=62%, n=4), but were very effective in increasing de-prescribing outcomes on hospital discharge (OR 0.26 (95% CI 0.13 to 0.55), I2=67%, n=6)). Facilitators to intervention delivery included ICU clinical pharmacist availability and participation in multiprofessional ward rounds, while barriers included increased workload associated with the discharge intervention process.

Conclusions

Multicomponent interventions based on education of staff and guidelines were effective at achieving almost four times more de-prescribing of inappropriate medication by the time of patient hospital discharge. Based on the findings, practice and policy recommendations are made and guidance is provided on the need for, and design of theory informed interventions in this area, including the requirement for process and economic evaluations.

Family caregivers' experiences and needs of transitional care during the transfer from intensive care unit to a general ward: A qualitative study

AIM

To explore the family caregivers' experiences and needs of transitional care during the transfer from an intensive care unit to a general ward in China.

BACKGROUND

The transfer of patients from the intensive care unit to the ward is a vulnerable time for patients and caregivers, exposing the risk of readmission and death. However, there are few qualitative studies on the family caregivers' views of transitional care for their loved ones in China.

METHODS

With a qualitative research design, 15 interviews were conducted with 15 family caregivers of hospitalized patients transferred from the neurosurgery ICU to the general ward. Colaizzi's (1978) method of data analysis was performed using the NVivo 11.0 software.

RESULTS

Based on data analysis, four themes were obtained: perception of transfer decision, the experience of transitional care, the obstacles to maintaining care efficiency and demand for transitional care.

CONCLUSION

In order to enhance the continuity of care and improve patient safety during the transfer from an ICU to a general ward in China, priorities should be given to the implementation of effective strategies and methods, including providing psychological and emotional support, encouraging active participation of caregivers, and various communication and collaboration procedures.

IMPLICATIONS FOR NURSING MANAGEMENT

The findings from this study can be used as a guide to better preparation and awareness among health care professionals to achieve the much-needed demands of family caregivers, as well as the increased quality of transitional care.

Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies

Background

Previous studies have detailed the technical, learning and soft skills healthcare staff deploy to deliver quality improvement (QI). However, research has mainly focused on management and leadership skills, overlooking the skills frontline staff use to improve care. Our research explored which skills mattered to frontline health practitioners delivering QI projects.

Study design

We used a theory-driven approach, informed by communities of practice, knowledge-in-practice-in-context and positive deviance theory. We used case studies to examine skill use in three pseudonymised English hospital Trusts, selected on the basis of Care Quality Commission rating. Seventy-three senior staff orientation interviews led to the selection of two QI projects at each site. Snowball sampling obtained a maximally varied range of 87 staff with whom we held 122 semistructured interviews at different stages of QI delivery, analysed thematically.

Results

Six overarching ‘Socio-Organisational Functional and Facilitative Tasks’ (SOFFTs) were deployed by frontline staff. Several of these had to be enacted to address challenges faced. The SOFFTs included: (1) adopting and promulgating the appropriate organisational environment; (2) managing the QI rollercoaster; (3) getting the problem right; (4) getting the right message to the right people; (5) enabling learning to occur; and (6) contextualising experience. Each task had its own inherent skills.

Conclusion

Our case studies provide a nuanced understanding of the skills used by healthcare staff. While technical skills are important, the ability to judge when and how to use wider skills was paramount. The provision of QI training and fidelity to the improvement programme may be less of a priority than the deployment of SOFFT skills used to overcome barriers. QI projects will fail if such skills and resources are not accessed.

Outcomes of critically ill end-stage kidney disease patients who underwent major surgery

PURPOSE

End-stage kidney disease (ESKD) is a major worldwide health problem. Patients with ESKD are thought to have a significant risk for development of complications following an operation. However, the study of ESKD and its outcomes following major operations remains rare, particularly in critical illness. Therefore, this study aimed to demonstrate how the outcomes of ESKD patients were affected when they underwent a major operation and were admitted to the intensive care unit (ICU), compared with non-ESKD patients.

METHODS

A retrospective matched case cohort study was conducted in 122 critically ill surgical patients who underwent a major operation and were admitted to the ICU, during 2013 and 2016. Sixty-one ESKD patients who required long-term dialysis were enrolled and compared with 61 matched non-ESKD patients. The matching criteria were the same age interval (±5 years), gender, and type of operation. The ICU mortality was compared to the primary outcome of the study.

RESULTS

Patients' baseline characteristics between ESKD and non-ESKD were similar to a priori matching criteria and other demographics, except for pre-existing diabetes mellitus and hypertension, which were found significantly more in ESKD (p = 0.03 and 0.04, respectively). For operations, ESKD showed a higher grade of the American Society of Anesthesiologist (ASA) physical status (p < 0.001), but there were no differences for emergency surgery (p = 0.71) and duration of operation (p = 0.34). At ICU admission, the severity of illness measured by the Sequential Organ Failure Assessment (SOFA) score was greater in ESKD (8.9 ± 2.6 vs 5.6 ± 2.5; p < 0.001). However, after eliminating renal domain, SOFA non-renal score was equivalent (5.7 ± 2.2 vs 5.2 ± 2.3, p = 0.16). The ICU mortality was significantly higher in critically-ill surgical patients with ESKD than non-ESKD (23% vs 5%, p=0.007), along with hospital mortality rates (34% vs 10%, p = 0.002). The multivariable logistic regression analyses adjusted for age and SOFA non-renal score demonstrated that ESKD had a significant association with ICU and hospital mortality (adjOR = 5.59; 95%CI [1.49-20.88], p = 0.01 and adjOR = 4.55; 95%CI[1.67-12.44], p = 0.003, respectively).

CONCLUSION

Patients who underwent a major operation and needed intensive care admission with pre-existing ESKD requiring long-term dialysis were associated with greater mortality than patients without ESKD. More careful assessment before, during, and after major surgical procedures should be performed in this group of patients to improve post-operative outcomes.

Predictors of Early and Late Unplanned Intensive Care Unit Readmission: A Retrospective Cohort Study

PURPOSE

Intensive care unit (ICU) readmission is considered one of the major quality indicators of critical care. Reducing ICU readmission can improve patients' outcomes and optimize health resources, but there are limited data on the predictors of unplanned ICU readmission. This study aimed to identify the risk factors associated with unplanned ICU readmission within 48 hr (early) and after 48 hr (late) from ICU discharge.

DESIGN

Retrospective cohort study.

METHODS

Data were collected from patients' electronic medical records in a 24-bed medical ICU at a tertiary academic medical center in Busan, South Korea. Among all the patients admitted to the medical ICU (n = 1,033) between January 2015 and December 2017, 739 eligible patients were analyzed. A multivariable multinomial logistic regression model was conducted to identify predictors of ICU readmission.

FINDINGS

Out of the 739 patients analyzed, 66 (8.9%) were readmitted to the medical ICU: 13 (1.8%) as early readmission and 53 (7.1%) as late readmission. Two significant predictors were identified for early readmission: ICU admission from the ward (odds ratio [OR] = 4.14; 95% confidence interval [CI] 1.25, 13.67) and mechanical ventilation support >14 days (OR = 13.25; 95% CI 1.78, 98.89). For late ICU admission, there were four risk factors: ICU admission from the ward (OR = 2.69; 95% CI 1.44, 5.05), tracheostomy placement (OR = 3.58; 95% CI 1.49, 8.59), mechanical ventilation support >14 days (OR = 4.77; 95% CI 1.67, 13.63), and continuous renal replacement therapy (OR = 4.57; 95% CI 2.42, 8.63).

CONCLUSIONS

To prevent unplanned ICU readmission in patients at high risk, it is necessary to investigate further the role of clinical judgment and communication within the ICU clinical team and institutional-level support regarding ICU readmission events.

CLINICAL RELEVANCE

Both ICU nurses and nurses in post-ICU settings should be aware of the potential risk factors associated with early and late ICU readmission. Predictors and readmission strategies may be different for early and late readmissions. Prospective multicenter studies are needed to examine how these factors influence post-ICU outcomes.

Survivors of Critical Illness and Their Relatives. A Qualitative Study on Hospital Discharge Experience

Rationale: To target rehabilitation needs of survivors of critical illness and their relatives in a timely and adequate manner, a thorough needs assessment is recommended when hospital discharge planning is initiated. In light of existing evidence on physical and psychological consequences of critical illness for patients and family, it is currently unclear if current hospital discharge procedures suffice to meet the needs of this group.Objectives: To explore hospital discharge experience and to identify perceived barriers and enablers for a positive transition experience from hospital to home or rehabilitation facility as perceived by survivors of critical illness and their families.Methods: We performed a grounded theory study with semi-structured interviews among a group of survivors of critical illness and their relatives (n = 35) discharged from 16 hospitals across the Netherlands. Interviews were audio recorded and transcribed verbatim. Using constant comparative methods, initial and focused coding was applied to the data, which were further labeled into major categories and subcategories, ultimately leading to the identification of key concepts. Triangulation was applied through several reflexivity meetings at different stages of the study.Results: Twenty-two former intensive care unit patients and 13 relatives were interviewed. The mean age was 53 (standard deviation ± 11.2) and 60% were female. Median intensive care unit and hospital length of stay were 14 days (interquartile range, 9.75-24.5) and 35 days (interquartile range, 21.75-57.25), respectively. Thematic analyses led to identification of seven key concepts, representing barriers and enablers to a positive transition experience. "Existing in a fragmented reality," "being overlooked," and "feeling disqualified" were identified barriers and "feeling empowered," "encountering empathic and expert professionals," "managing recovery expectations," and "family engagement" were identified as enablers for a positive perceived transition experience.Conclusions: Findings of this study suggest that current hospital discharge practice for survivors of critical illness is driven by speed and efficiency, rather than by individual needs assessments, despite advocacies for patient- and family-centered care. Discharge strategies should be customized to facilitate adequate and comprehensive assessment of aftercare needs, conducted at the right time and within the right context, encouraging empowerment and a positive perceived transition from hospital to home.

Reducing work pressure and IT problems and facilitating IT integration and audit & feedback help adherence to perioperative safety guidelines: a survey among 95 perioperative professionals

Background

To improve perioperative patient safety, guidelines for the preoperative, peroperative, and postoperative phase were introduced in the Netherlands between 2010 and 2013. To help the implementation of these guidelines, we aimed to get a better understanding of the barriers and drivers of perioperative guideline adherence and to explore what can be learned for future implementation projects in complex organizations.

Methods

We developed a questionnaire survey based on the theoretical framework of Van Sluisveld et al. for classifying barriers and facilitators. The questionnaire contained 57 statements derived from (a) an instrument for measuring determinants of innovations by the Dutch Organization for Applied Scientific Research, (b) interviews with quality and safety policy officers and perioperative professionals, and (c) a publication of Cabana et al. The target group consisted of 232 perioperative professionals in nine hospitals. In addition to rating the statements on a five-point Likert scale (which were classified into the seven categories of the framework: factors relating to the intervention, society, implementation, organization, professional, patients, and social factors), respondents were invited to rank their three most important barriers in a separate, extra open-ended question.

Results

Ninety-five professionals (41%) completed the questionnaire. Fifteen statements (26%) were considered to be barriers, relating to social factors (N = 5), the organization (N = 4), the professional (N = 4), the patient (N = 1), and the intervention (N = 1). An integrated information system was considered an important facilitator (70.4%) as well as audit and feedback (41.8%). The Barriers Top-3 question resulted in 75 different barriers in nearly all categories. The most frequently reported barriers were as follows: time pressure (16% of the total number of barriers), emergency patients (8%), inefficient IT structure (4%), and workload (3%).

Conclusions

We identified a wide range of barriers that are believed to hinder the use of the perioperative safety guidelines, while an integrated information system and local data collection and feedback will also be necessary to engage perioperative teams. These barriers need to be locally prioritized and addressed by tailored implementation strategies. These results may also be of relevance for guideline implementation in general in complex organizations.

Trial registration

Dutch Trial Registry: NTR3568.

Voluntarily reported prescribing, monitoring and medication transfer errors in intensive care units in The Netherlands

Background Medication errors occur frequently in intensive care units (ICU). Voluntarily reported medication errors form an easily available source of information. Objective This study aimed to characterize prescribing, monitoring and medication transfer errors that were voluntarily reported in the ICU, in order to reveal medication safety issues. Setting This retrospective data analysis study included reports of medication errors from eleven Dutch ICU's from January 2016 to December 2017. Method We used data extractions from the incident reporting systems of the participating ICU's. The reports were transferred into one database and categorized into type of error, cause, medication (groups), and patient harm. Descriptive statistics were used to calculate the proportion of medication errors and the distribution of subcategories. Based on the analysis, ICU medication safety issues were revealed. Main outcome measure The main outcome measure was the proportion of prescribing, monitoring and medication transfer error reports. Results Prescribing errors were reported most frequently (n = 233, 33%), followed by medication transfer errors (n = 85, 12%) and monitoring errors (n = 27, 4%). Other findings were: medication transfer errors frequently caused serious harm, especially the omission of home medication involving the central nervous system and proton pump inhibitors; omissions and dosing errors occurred most frequently; protocol problems caused a quarter of the medication errors; and medications needing blood level monitoring (e.g. tacrolimus, vancomycin, heparin and insulin) were frequently involved. Conclusion This analysis of voluntarily reported prescribing, monitoring and medication transfer errors warrants several improvement measures in these processes, which may help to increase medication safety in the ICU.

Transition of care at discharge from the Intensive Care Unit: a scoping review

OBJECTIVE

to map the available evidence on the components of the transition of care, practices, strategies, and tools used in the discharge from the Intensive Care Unit (ICU) to the Inpatient Unit (IU) and its impact on the outcomes of adult patients.

METHOD

a scoping review using search strategies in six relevant health databases.

RESULTS

37 articles were included, in which 30 practices, strategies or tools were identified for organizing and executing the transfer process, with positive or negative impacts, related to factors intrinsic to the Intensive Care Unit and the Inpatient Unit and cross-sectional factors regarding the staff. The analysis of hospital readmission and mortality outcomes was prevalent in the included studies, in which trends and potential protective actions for a successful care transition are found; however, they still lack more robust evidence and consensus in the literature.

CONCLUSION

transition of care components and practices were identified, in addition to factors intrinsic to the patient, associated with worse outcomes after discharge from the Intensive Care Unit. Discharges at night or on weekends were associated with increased rates of readmission and mortality; however, the association of other practices with the patient's outcome is still inconclusive.

Preventing Early Bouncebacks to the Neurointensive Care Unit: A Retrospective Analysis and Quality Improvement Pilot

BACKGROUND

Early unplanned readmissions of "bouncebacks" to intensive care units are a healthcare quality metric and result in higher mortality and greater cost. Few studies have examined bouncebacks to the neurointensive care unit (neuro-ICU), and we sought to design and implement a quality improvement pilot to reduce that rate.

METHODS

First, we performed a retrospective chart review of 504 transfers to identify potential bounceback risk factors. Risk factors were assessed on the day of transfer by the transferring physician identifying patients as "high risk" or "low risk" for bounceback. "High-risk" patients underwent an enhanced transfer process emphasizing interdisciplinary communication and rapid assessment upon transfer during a 9-month pilot.

RESULTS

Within the retrospective cohort, 34 of 504 (4.7%) transfers required higher levels of care within 48 h. Respiratory failure and sepsis/hypotension were the most common reasons for bounceback among this group. During the intervention, 8 of 225 (3.6%) transfers bounced back, all of who were labeled "high risk." Being "high risk" was associated with a risk of bounceback (OR not calculable, p = 0.02). Aspiration risk (OR 6.9; 95% CI 1.6-30, p = 0.010) and cardiac arrhythmia (OR 7.1; 95% CI 1.6-32, p = 0.01) were independent predictors of bounceback in multivariate analysis. Bounceback rates trended downward to 2.8% in the final phase (p for trend 0.09). Eighty-five percent of providers responded that the pilot should become standard of care.

CONCLUSION

Patients at high risk for bounceback after transfer from the neuro-ICU can be identified using a simple tool. Early augmented multidisciplinary communication and care for high-risk patients may improve their management in the hospital.

Development of a multivariable prediction model for identification of patients at risk for medication transfer errors at ICU discharge

INTRODUCTION

Discharge from the intensive care unit (ICU) is a high-risk process, leading to numerous potentially harmful medication transfer errors (PH-MTE). PH-MTE could be prevented by medication reconciliation by ICU pharmacists, but resources are scarce, which renders the need for predicting which patients are at risk for PH-MTE. The aim of this study was to develop a prognostic multivariable model in patients discharged from the ICU to predict who is at increased risk for PH-MTE after ICU discharge, using predictors of PH-MTE that are readily available at the time of ICU discharge.

MATERIAL AND METHODS

Data for this study were derived from the Transfer ICU Medication reconciliation study, which included ICU patients and scored MTE at discharge of the ICU. The potential harm of every MTE was estimated with a validated score, where after MTE with potential for harm were indicated as PH-MTE. Predictors for PH-MTE at ICU discharge were identified using LASSO regression. The c statisticprovided a measure of the overall discriminative ability of the prediction model and the prediction model was internally validated by bootstrap resampling. Based on sensitivity and specificity, the cut-off point of the prediction model was determined.

RESULTS

The cohort contained 258 patients and six variables were identified as predictors for PH-MTE: length of ICU admission, number of home medications and patient taking one of the following medication groups at home: vitamin/mineral supplements, cardiovascular medication, psycholeptic/analeptic medication and medication for obstructive airway disease. The c of the final prediction model was 0.73 (95%CI 0.67-0.79) and decreased to 0.62 according to bootstrap resampling. At a cut-off score of two the prediction model yielded a sensitivity of 70% and a specificity of 61%.

CONCLUSIONS

A multivariable prediction model was developed to identify patients at risk for PH-MTE after ICU discharge. The model contains predictors that are available on the day of ICU discharge. Once external validation and evaluation of this model in daily practice has been performed, its incorporation into clinical practice could potentially allow institutions to identify patients at risk for PH-MTE after ICU discharge, on the day of ICU discharge, thus allowing for efficient, patient-specific allocation of clinical pharmacy services.

TRIAL REGISTRATION

Dutch trial register: NTR4159, 5 September 2013, retrospectively registered.

Information sharing between intensive care and primary care after an episode of critical illness; A mixed methods analysis

INTRODUCTION

Poor quality communication between hospital doctors and GPs at the time of hospital discharge is associated with adverse patient outcomes. This may be more marked after an episode of critical illness, the complications of which can persist long after hospital discharge.

AIMS

1. to evaluate information sharing between ICU staff and GPs after a critical illness 2. to identify factors influencing the flow and utilisation of this information.

METHODS

Parallel mixed methods observational study in an Irish setting, with equal emphasis on quantitative and qualitative data. Descriptive analysis was performed on quantitative data derived from GP and ICU consultant questionnaires. Qualitative data came from semi-structured interviews with GPs and consultants, and were analysed using directed content analysis. Mixing of data occurred at the stage of interpretation.

RESULTS

GPs rarely received information about an episode of critical illness directly from ICU staff, with most coming from patients and relatives. Information received from hospital sources was frequently brief and incomplete. Common communication barriers reported by consultants were insufficient time, low perceived importance and difficulty establishing GP contact. When provided information, GPs seldom actioned specific interventions, citing insufficient guidance in hospital correspondence and poor knowledge about critical illness complications and their management. A majority of all respondents thought that improved information sharing would benefit patients. Cultural influences on practice were identified in qualitative data. A priori qualitative themes were: (1) perceived benefits of information sharing, (2) factors influencing current practice and (3) strategies for optimal information sharing. Emergent themes were: (4) the central role of the GP in patient care, (5) the concept of the "whole patient journey" and (6) a culture of expectation around a GP's knowledge of hospital care.

CONCLUSIONS

Practical and cultural factors contribute to suboptimal information sharing between ICU and primary care doctors around an episode of critical illness in ICU. We propose a three-milestone strategy to improve the flow and utilisation of information when patients are admitted, discharged or die within the ICU.

Identifying essential elements to include in Intensive Care Unit to hospital ward transfer summaries: A consensus methodology

PURPOSE

Transitions of care from the intensive care unit (ICU) to a hospital ward are high risk and contingent on effective communication. We sought to identify essential information elements to be included in an ICU to hospital ward transfer summary tool, and describe tool functionality and composition perceived to be important.

MATERIALS AND METHODS

A panel of 13 clinicians representing ICU and hospital ward providers used a modified Delphi process to iteratively review and rate unique information elements identified from existing ICU transfer tools through three rounds of review (two remote and one in person). Qualitative content analysis was conducted on transcribed audio recordings of the workshop to characterize tool functionality and composition.

RESULTS

A total of 141 unique information elements were reviewed of which 63 were identified by panelists as essential. Qualitative content analyses of panelist discussions identified three themes related to how information elements should be considered when developing an ICU transfer summary tool: 1) Flexibility, 2) Usability, and 3) Accountability.

CONCLUSION

We identified 63 distinct information elements identified as essential for inclusion in an ICU transfer summary tool to facilitate communication between providers during the transition of patient care from the ICU to a hospital ward.