A scoping review of patient discharge from intensive care: opportunities and tools to improve care

Nursing care complexity as a predictor of adverse events in patients transferred from ICU to hospital ward after general surgery

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.

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.

Transitions and empowerment theory: A framework for nursing interventions during intensive care unit patient transition

OBJECTIVES

1) To explore the main characteristics of intensive care unit transition according to patients' lived experience and 2) To identify nursing therapeutics to facilitate patients' transition from the intensive care unit to the inpatient unit.

METHODOLOGY

Secondary Analysis (SA) of the findings of a descriptive qualitative study on the experience of patients admitted to an ICU during the transition to the inpatient unit, based on the Nursing Transitions Theory. Data for the primary study were generated from 48 semi-structured interviews of patients who had survived critical illness in 3 tertiary university hospitals.

RESULTS

Three main themes were identified during the transition of patients from the intensive care unit to the inpatient unit: 1) nature of ICU transition, 2) response patterns and 3) nursing therapeutics. Nurse therapeutics incorporates information, education and promotion of patient autonomy; in addition to psychological and emotional support.

CONCLUSIONS

Transitions Theory as a theoretical framework helps to understand patients' experience during ICU transition. Empowerment nursing therapeutics integrates the dimensions aimed at meeting patients' needs and expectations during ICU discharge.

A Multiple Baseline Trial of an Electronic ICU Discharge Summary Tool for Improving Quality of Care

OBJECTIVE

Effective communication between clinicians is essential for seamless discharge of patients between care settings. Yet, discharge summaries are commonly not available and incomplete. We implemented and evaluated a structured electronic health record-embedded electronic discharge (eDischarge) summary tool for patients discharged from the ICU to a hospital ward.

DESIGN

Multiple baseline trial with randomized and staggered implementation.

SETTING

Adult medical-surgical ICUs at four acute care hospitals serving a single Canadian city.

PATIENTS

Health records of patients 18 years old or older, in the ICU 24 hours or longer, and discharged from the ICU to an in-hospital patient ward between February 12, 2018, and June 30, 2019.

INTERVENTION

A structured electronic note (ICU eDischarge tool) with predefined fields (e.g., diagnosis) embedded in the hospital-wide electronic health information system.

MEASUREMENTS AND MAIN RESULTS

We compared the percent of timely (available at discharge) and complete (included goals of care designation, diagnosis, list of active issues, active medications) discharge summaries pre and post implementation using mixed effects logistic regression models. After implementing the ICU eDischarge tool, there was an immediate and sustained increase in the proportion of patients discharged from ICU with timely and complete discharge summaries from 10.8% (preimplementation period) to 71.1% (postimplementation period) (adjusted odds ratio, 32.43; 95% CI, 18.22-57.73). No significant changes were observed in rapid response activation, cardiopulmonary arrest, death in hospital, ICU readmission, and hospital length of stay following ICU discharge. Preventable (60.1 vs 5.7 per 1,000 d; p = 0.023), but not nonpreventable (27.3 vs 40.2 per 1,000d; p = 0.54), adverse events decreased post implementation. Clinicians perceived the eDischarge tool to produce a higher quality discharge process.

CONCLUSIONS

Implementation of an electronic tool was associated with more timely and complete discharge summaries for patients discharged from the ICU to a hospital ward.

Healthcare delivery and recovery after critical illness

PURPOSE OF REVIEW

To summarize improvements and innovations in healthcare delivery which could be implemented to improve the recovery experience after critical illness for adult survivors and their families.

RECENT FINDINGS

For survivors of critical illness, the transitions in care during their recovery journey are points of heightened vulnerability associated with adverse events. Survivors of critical illness often have errors in the management of their medications during the recovery period. A multicomponent intervention delivered for 30 days that focused on four key principles of improved recovery care after sepsis care was associated with a durable effect on 12-month rehospitalization and mortality compared with usual care. A recent multicentre study which piloted integrating health and social care for critical care survivors demonstrated improvements in health-related quality of life and self-efficacy at 12 months. Multiple qualitative studies provide insights into how peer support programmes could potentially benefit survivors of critical illness by providing them mechanism to share their experiences, to give back to other patients, and to set more realistic expectations for recovery.

SUMMARY

Future research could focus on exploring safety outcomes as primary endpoints and finding ways to develop and test implementation strategies to improve the recovery after critical illness.

Impact of customised ICU handover protocol on the quality of ICU discharge reports

Background

The aim of this investigation was to evaluate the impact of implementing a handover protocol, based on a standardised mnemonic tool specific for a cardiovascular intensive care unit (ICU), on the quality of information transferred during ICU discharge.

Methods

In this prospective pre–post study, we evaluated the implementation of an ICU discharge handover protocol in 168 patients who underwent coronary artery bypass graft surgery. The primary outcome was the quality of the information. In the preintervention phase, 84 ICU standard discharge reports were evaluated. During the intervention period, a new handover protocol which included a written discharge report based on the I-PASS (illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver) mnemonic tool was implemented. After the intervention, 84 new reports were assessed. The reports were evaluated by the ward physicians and by an external independent examiner using a standardised questionnaire. ICU discharge time and postoperative length of stay were also analysed.

Results

The overall quality of the reports was evaluated as ‘completely understood’ by the ward physicians in 17 patients (21%) in the preintervention phase compared with 45 patients (54.9%) in the postintervention phase (p<0.001). The independent examiner classified one report (1.2% of the total number) as ‘excellent’ in the preintervention phase and 30 (35.7%) in the postintervention phase (p<0.001). After protocol implementation, patients were released from the ICU 58 min later (p<0.001). There was no difference in the length of postoperative hospital stay.

Conclusion

Implementation of a customised handover protocol when discharging patients from the ICU was associated with improvement in the quality of the information transferred but also with ICU discharge occurring at a later time of day.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Barriers and facilitators to resuming meaningful daily activities among critical illness survivors in the UK: a qualitative content analysis

OBJECTIVE

To identify critical illness survivors' perceived barriers and facilitators to resuming performance of meaningful activities when transitioning from hospital to home.

DESIGN

Secondary content analysis of semistructured interviews about patients' experiences of intensive care (primary analysis disseminated on the patient-facing website www.healthtalk.org). Two coders characterised patient-perceived barriers and facilitators to resuming meaningful activities. To facilitate clinical application, we mapped the codes onto the Person-Task-Environment model of performance, a patient-centred rehabilitation model that characterises complex interactions among the person, task and environment when performing activities.

SETTING

United Kingdom, 2005-2006.

PARTICIPANTS

39 adult critical illness survivors, sampled for variation among demographics and illness experiences.

RESULTS

Person-related barriers included negative mood or affect, perceived setbacks; weakness or limited endurance; pain or discomfort; inadequate nutrition or hydration; poor concentration/confusion; disordered sleep/hallucinations/nightmares; mistrust of people or information; and altered appearance. Task-related barriers included miscommunication and managing conflicting priorities. Environment-related barriers included non-supportive health services and policies; challenging social attitudes; incompatible patient-family coping (emotional trauma and physical disability); equipment problems; overstimulation; understimulation; and environmental inaccessibility. Person-related facilitators included motivation or attitude; experiencing progress; and religion or spirituality. Task-related facilitators included communication. Environment-related facilitators included support from family, friends or healthcare providers; supportive health services and policies; equipment; community resources; medications; and accessible housing. Barriers decreased and facilitators increased over time. Six barrier-facilitator domains dominated based on frequency and emphasis across all performance goals: mood/motivation, setbacks/progress, fatiguability/strength; mis/communication; lack/community support; lack/health services and policies.

CONCLUSIONS

Critical illness survivors described a comprehensive inventory of 18 barriers and 11 facilitators that align with the Person-Task-Environment model of performance. Six dominant barrier-facilitator domains seem strong targets for impactful interventions. These results verify previous knowledge and offer novel opportunities for optimising patient-centred care and reducing disability after critical illness.

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.

Co-development of a transitions in care bundle for patient transitions from the intensive care unit: a mixed-methods analysis of a stakeholder consensus meeting

Background

Intensive care unit (ICU) patients undergoing transitions in care are at increased risk of adverse events and gaps in medical care. We evaluated existing patient- and family-centered transitions in care tools and identified facilitators, barriers, and implementation considerations for the application of a transitions in care bundle in critically ill adults (i.e., a collection of evidence-based patient- and family-centred tools to improve outcomes during and after transitions from the intensive care unit [ICU] to hospital ward or community).

Methods

We conducted a concurrent mixed methods (quan + QUAL) study, including stakeholders with experience in ICU transitions in care (i.e., patient/family partners, researchers, decision-makers, providers, and other knowledge-users). First, participants scored existing transitions in care tools using the modified Appraisal of Guidelines, Research and Evaluation (AGREE-II) framework. Transitions in care tools were discussed by stakeholders and either accepted, accepted with modifications, or rejected if consensus was achieved (≥70% agreement). We summarized quantitative results using frequencies and medians. Second, we conducted a qualitative analysis of participant discussions using grounded theory principles to elicit factors influencing AGREE-II scores, and to identify barriers, facilitators, and implementation considerations for the application of a transitions in care bundle.

Results

Twenty-nine stakeholders attended. Of 18 transitions in care tools evaluated, seven (39%) tools were accepted with modifications, one (6%) tool was rejected, and consensus was not reached for ten (55%) tools. Qualitative analysis found that participants’ AGREE-II rankings were influenced by: 1) language (e.g., inclusive, balance of jargon and lay language); 2) if the tool was comprehensive (i.e., could stand alone); 3) if the tool could be individualized for each patient; 4) impact to clinical workflow; and 5) how the tool was presented (e.g., brochure, video). Participants discussed implementation considerations for a patient- and family-centered transitions in care bundle: 1) delivery (e.g., tool format and timing); 2) continuity (e.g., follow-up after ICU discharge); and 3) continuous evaluation and improvement (e.g., frequency of tool use). Participants discussed existing facilitators (e.g., collaboration and co-design) and barriers (e.g., health system capacity) that would impact application of a transitions in care bundle.

Conclusions

Findings will inform future research to develop a transitions in care bundle for transitions from the ICU, co-designed with patients, families, providers, researchers, decision-makers, and knowledge-users.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07392-2.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Improving Communication with Patients Discharged from the Emergency Department with Noncardiac Chest Pain: A Scoping Review with Narrative Synthesis

Background

This scoping review with narrative synthesis aimed to analyze scholarly peer-reviewed articles reporting on improving communication with patients discharged from the emergency department with noncardiac chest pain and qualitatively narrate on and summarize items that can be used in guiding communication with patients discharged from the emergency department with noncardiac chest pain.

Methods

The databases of EMBASE/PubMed, Scopus, COCHRANE, CInAHL/EBESCO, UW libraries, and Google Scholar were searched using relevant MeSH and key terms up to February 06, 2020. The selected articles were analyzed for their contents. Items guiding discharge communication were summarized qualitatively.

Results

Twenty-five articles were eligible for full review. These were published in between 1994 and 2020. Of those, 16 (64.0%) originated from the United States and 4 (16%) used some interventional design. A total of 45 different items that could be used in guiding discharge communication with patients presenting to the emergency department with chest pain were identified from the studies included in this review. Items were grouped under 6 categories that were related to initial assessment (8 items), information on diagnosis (7 items), information on discharge (9 items), follow-up suggestions (7 items), symptoms that promote return to the emergency department (7 items), and treatment plan (7 items).

Conclusion

Communication with patients discharged from the emergency department with noncardiac chest pain can be improved. Results of this investigation might be helpful in guiding quality improvement projects aimed for further improvement of communication with patients discharged from the emergency department with noncardiac chest pain.

Scoping review of augmented renal clearance in critically ill pediatric patients

Augmented renal clearance (ARC), a phenomenon of enhanced elimination of renal solutes, has been described in adult critically ill patients, but little is known about the phenomenon in children. The aim of this scoping review was to gather and summarize all evidence on ARC in pediatric patients to examine its breadth and depth including prevalence, risk factors, and pharmacokinetic alterations and identify any gaps for further areas of inquiry. PubMed, Embase, and Web of Science were searched for titles, abstracts, or keywords that focused on ARC. Non-English studies, reviews, and nonhuman studies were excluded. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines. Data were extracted on article type, study details, patient population, ARC definition and prevalence, methods of renal function assessment, and study results. A total of 215 citations were found with 25 citations meeting the criteria for inclusion in pediatrics (2102 total patients); the majority of studies (84%) focused on pharmacokinetics (PK) of antimicrobial agents. The median/mean age range was 1.25-12 years. There were a total of 10 different definitions of ARC. The prevalence of ARC ranged from 7.8% to 78%. The most common method for documenting creatinine clearance (CrCl) was the modified Schwartz equation (64%). Only 20% of studies reported risk factors for ARC including low serum creatinine, increasing age, febrile neutropenia, male, septic shock, and treatment with antibiotics. Glycopeptide antimicrobials were the most evaluated class (42.9%) among the 21 antimicrobial drug studies. All studies reported increased drug clearance and/or poor probability of achieving target concentrations of the agents studied. ARC showed variable prevalence in pediatric patients likely due to the lack of a standard definition and many studies not considering age-related changes in CrCl with pediatric intensive care unit (PICU) patients. ARC was shown to impact PK of antibiotics commonly administered to pediatric patients, which may necessitate changes in standard dosing regimens.

Patients' experience while transitioning from the intensive care unit to a ward

BACKGROUND

Intensive care unit (ICU) patients can experience emotional distress and post-traumatic stress disorder when they leave the ICU, also referred to as post-intensive care syndrome. A deeper understanding of what patients go through and what they need while they are transitioning from the ICU to the general ward may provide input on how to strengthen patient-centred care and, ultimately, contribute to a positive experience.

AIM

To describe the patients' experience while transitioning from the ICU to a general ward.

DESIGN

A descriptive qualitative study.

METHOD

Data were gathered through in-depth interviews and analysed using a qualitative content analysis. The qualitative study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research guidelines.

FINDINGS

Forty-eight interviews were conducted. Impact on emotional well-being emerged as a main theme, comprising four categories with six subcategories.

CONCLUSION

Transition from the ICU can be a shock for the patient, leading to the emergence of a need for information, and an impact on emotional well-being that has to be planned for carefully and addressed prior to, during, and following transition from the ICU to the general ward.

RELEVANCE TO CLINICAL PRACTICE

It is essential that nurses understand patients' experiences during transfer, identifying needs and concerns to be able to develop and implement new practices such as ICU Liaison Nurse or Nurse Outreach for the follow-up of these patients, the inclusion of a consultant mental health nurse, and the application of patient empowerment during ICU discharge.

Discharge planning considerations for the neonatal intensive care unit

Neonatal intensive care unit (NICU) discharge readiness is the primary caregivers' masterful attainment of technical care skills and knowledge, emotional comfort and confidence with infant care by the time of discharge. NICU discharge preparation is the process of facilitating discharge readiness. Discharge preparation is the process with discharge readiness as the goal. Our previous work described the importance of NICU discharge readiness and strategies for discharge preparation from an American medical system perspective. NICU discharge planning is, however, of international relevance as challenges in relation to hospital discharge are a recurring global theme. In this manuscript, we conceptualise NICU discharge preparation with international perspective.

Delayed transfers of care for older people: a wider perspective

Delayed transfers of care (DTOC), often unhelpfully referred to as 'bed blocking', has become a byword for waste and inefficiency in healthcare systems throughout the world. An estimated 2.7 million bed days are occupied each year in England by older people no longer in need of acute treatment, estimated to cost £820 million (2014/15) in inpatient care. Policy and media attention have often been drawn to this narrative of financial waste, resulting in policy setting that directly targets the level of DTOC, but has done little to put patient health first. These figures and policies portray a misleading image of the delays as primarily of concern in terms of their financial burden on acute hospital care, with little consideration given to the quantification on patient health or wider societal impacts. In spite of the multi-factorial decision-making process that occurs for each patient discharge, current evaluation frameworks and national policy setting fail to reflect the complexity of the process. In this commentary, we interrogate the current approach to the quantification of the DTOC impact and explore how policies and evaluation methods can do more to reflect the true impact of the delays.

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

OBJECTIVES

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

DESIGN

Multicenter cohort study.

SETTING

Ten adult medical-surgical Canadian ICUs.

PATIENTS

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

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Mixed-method research protocol: Development and evaluation of a nursing intervention in patients discharged from the intensive care unit

AIM

(a) To understand patients' lived experience at intensive care unit (ICU) discharge and (b) to evaluate the impact of a nursing empowerment intervention (NEI) on patients' anxiety and depression levels at ICU discharge.

DESIGN

A mixed-methods approach will be applied.

METHODS

In the qualitative phase, the hermeneutic phenomenological method will be used. Participants will be patients from three university hospitals who will be selected by purposive sampling. Data will be gathered through in-depth interviews and analysed using content analysis. The qualitative data obtained will be employed to develop the nursing intervention. Subsequently, a multicenter, parallel-group, experimental pre-test/post-test design with a control group will be used to measure the effectiveness of the nursing empowerment intervention in the quantitative phase by means of the Hospital Anxiety and Depression Scale (HADS). Simple random probabilistic sampling will include 172 patients in this phase.

Bridging the Gap Between the Intensive Care Unit and the Acute Medical Care Unit

BACKGROUND

Despite a growing cohort of intensive care unit (ICU) survivors, little is known about the early ICU aftercare period.

OBJECTIVE

To identify gaps in early ICU aftercare and factors associated with poor hospital outcomes.

METHODS

A multisite, retrospective study (January 1 to December 31, 2017) was conducted among randomly selected patients admitted to the medical ICU and subsequently transferred to acute medical care units. Records were reviewed for patient characteristics, ICU course, and early ICU aftercare practices and syndromes. Associations between practices and hospital outcomes were calculated with χ2 and Wilcoxon rank sum tests, followed by logistic regression.

RESULTS

One hundred fifty-one patients met inclusion criteria (mean [SD] age, 64.2 [19.1] years; 51.7% male; 44.4% White). The most frequent diagnoses were sepsis (35.8%) and respiratory failure (33.8%). During early ICU aftercare, 46.4% had dietary restrictions, 25.8% had bed rest orders, 25.0% had a bladder catheter, 26.5% had advance directive documentation, 33.8% had dysphagia, 34.3% had functional decline, and 23.2% had delirium. Higher Charlson Comorbidity Index (odds ratio, 1.6) and midodrine use on medical units (odds ratio, 7.5) were associated with in-hospital mortality; mechanical ventilation in the ICU was associated with rapid response on medical unit (odds ratio, 12.9); and bladder catheters were associated with ICU readmission (odds ratio, 5.2).

CONCLUSIONS

Delirium, debility, and dysphagia are frequently encountered in early ICU aftercare, yet bed rest, dietary restriction, and lack of advance directive documentation are common. Future studies are urgently needed to characterize and address early ICU aftercare.

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

Purpose

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

Design/methodology/approach

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

Findings

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

Research limitations/implications

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

Practical implications

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

Originality/value

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

Post-Intensive Care Unit Care. A Qualitative Analysis of Patient Priorities and Implications for Redesign

Rationale: Although survival during critical illness is improving, little evidence exists to guide post-intensive care unit (ICU) care. Understanding patients' needs and priorities is fundamental to improving care quality.Objectives: To describe the evolution of patients' priorities for recovery across the spectrum of post-ICU care.Methods: This was a secondary analysis of 39 semistructured interviews conducted from 2005 to 2006 in participants' homes 19 days to 11 years after hospital discharge after critical illness. Adult critical illness survivors (N = 39) aged 20 years or older from multiple ICUs across the United Kingdom were purposively selected to maximize diversity with respect to time since diagnosis, disease severity, sex, age, ethnicity, socioeconomic group/status, region. age, ICU admitting diagnoses, and length of stay. We used the method of qualitative description to characterize patients' priorities for recovery and their evolution within and between individual patients across three post-ICU periods: ICU transition to wards, early period (approximately the first 2 mo) after discharge to home, and late period (>2 mo) after discharge to home.Results: The analysis revealed 12 core patient priorities during recovery: feeling safe, being comfortable, engaging in mobility, participating in self-care, asserting personhood, connecting with people, ensuring family well-being, going home, restoring psychological health, restoring physical health, resuming previous roles and routines, and seeking new life experiences. In general, priorities evolved from those pertaining to basic survival during the stay on wards to being broader and more aspirational by the late postdischarge period.Conclusions: Understanding patients' priorities for post-ICU care is critical for developing stakeholder-driven clinical guidelines. Engaging other stakeholders (e.g., family members, healthcare providers, and institutionalized and frail older adults) to inform the development of clinical guidelines for post-ICU care, together with the barriers and facilitators faced in achieving patient- and family-centered care, is an important next step.

Are there opportunities to improve care as patients transition through the cancer care continuum? A scoping review protocol

INTRODUCTION

Transitions in Care (TiC) are vulnerable periods in care delivery associated with adverse events, increased cost and decreased patient satisfaction. Patients with cancer encounter many transitions during their care journey due to improved survival rates and the complexity of treatment. Collectively, improving TiC is particularly important among patients with cancer. The objective of this scoping review is to synthesise and map the existing literature regarding TiC among patients with cancer in order to explore opportunities to improve TiC among patients with cancer.

METHODS AND ANALYSIS

This scoping review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Scoping Review Extension and the Joanna Briggs Institute methodology. The PubMed cancer filter and underlying search strategy will be tailored to each database (Embase, Cochrane, CINAHL and PsycINFO) and combined with search terms for TiC. Grey literature and references of included studies will be searched. The search will include studies published from database inception until 9 February 2020. Quantitative and qualitative studies will be included if they describe transitions between any type of healthcare provider or institution among patients with cancer. Descriptive statistics will summarise study characteristics and quantitative data of included studies. Qualitative data will be synthesised using thematic analysis.

ETHICS AND DISSEMINATION

Our objective is to synthesise and map the existing evidence; therefore, ethical approval is not required. Evidence gaps around TiC will inform a programme of research aimed to improve high-risk transitions among patients with cancer. The findings of this scoping review will be published in a peer-reviewed journal and widely presented at academic conferences. More importantly, decision makers and patients will be provided a summary of the findings, along with data from a companion study, to prioritise TiC in need of interventions to improve continuity of care for patients with cancer.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18675.

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.

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.

Improving Transitions of Care between the Intensive Care Unit and General Internal Medicine Ward. A Demonstration Study

Background: In-hospital transfers such as from the intensive care unit (ICU) to the general internal medicine (GIM) ward place patients at risk of adverse events. A structured handover tool may improve transitions from the ICU to the GIM ward. Objective: To develop, implement, and evaluate a customized user-designed transfer tool to improve transitions from the ICU to the GIM ward. Methods: This was a pre-post intervention study at a tertiary academic hospital. We developed and implemented a user-designed, structured, handwritten ICU-to-GIM transfer tool. The tool included active medical issues, functional status, medications and medication changes, consulting services, code status, and emergency contact information. Transfer tool users included GIM physicians, ICU physicians, and critical care rapid response team nurses. An implementation audit and mixed qualitative and quantitative analysis of pre-post survey responses was used to evaluate clinician satisfaction and the perceived quality of patient transfers. Results: The pre-post survey response rate was 51.8% (99/191). Respondents included GIM residents (58.5%), ICU rapid response team physicians and nurses (24.2%), and GIM attending physicians (17.2%). Less than half of clinicians (48.8%) reported that the preintervention transfer process was adequate. Clinicians who used the transfer tool reported that the transfer process was improved (93.3% vs. 48.8%, P = 0.03). Clinician-reported understanding of medication changes in the ICU increased (69.2% vs. 29.1%, P = 0.004), as did their ability to plan for a safe hospital discharge (69.2% vs. 31.0%, P = 0.01). However, only 64.2% of audited transfers used the tool. Frequently omitted sections included home medications (missing in 83.4% of audits), new medications (33.3%), and secondary diagnosis (33.3%). Thematic analysis of free-text responses identified areas for improvement including clarifying the course of ICU events and enhancing tool usability. Conclusion: A user-designed, structured, handwritten transfer tool may improve the perceived quality of patient transfers from the ICU to the GIM wards.

Unplanned Admission to the ICU: A Qualitative Study Examining Family Member Experiences

BACKGROUND

Transfers to the ICU from acute care are common, and it is essential to understand how family members of critically ill patients experience these transitions of care.

RESEARCH QUESTION

Can we enhance our understanding of family members' experiences during hospital stays complicated by a patient's unplanned admission to the ICU?

STUDY DESIGN AND METHODS

Qualitative interviews were conducted with family members of patients were transferred from acute care to the ICU at a level I trauma center in Seattle, WA (n = 17). To organize data, we used thematic analysis, coupled with a validated conceptual model of clinician-surrogate communication.

RESULTS

Drawing from a validated conceptual model, we used two domains to frame our coding: "information processing" and "relationship building." Within information processing, we coded information disclosure, sensemaking, and expectations; within relationship building, we coded emotional support, trust, and consensus and conflict. Family members wanted timely, accurate information about the patient's condition both during and after transfer. An unplanned ICU admission was a stressful event for family members, who looked to clinicians for emotional support. Developing trust was challenging, because family members struggled to feel like integrated members of the medical team when patients transitioned from one setting to another.

INTERPRETATION

Family of patients who experience an unplanned ICU admission want high-quality communication both during and after a patient's transfer to the ICU. This communication should help family members make sense of the situation, address unmet expectations, and provide emotional support. In addition, interventions that foster family-clinician trust can help family members feel like integrated members of the care team as they face the challenge of navigating multiple different environments within the hospital.

Implementation of population-level screening for frailty among patients admitted to adult intensive care in Alberta, Canada

PURPOSE

A substantial proportion of patients admitted to intensive care units (ICUs) are frail; however, the epidemiology of frailty has not been explored at a population-level. Following implementation of a validated frailty measure into a provincial ICU clinical information system, we describe the population-based prevalence and outcomes of frailty in patients admitted to ICUs.

METHODS

Retrospective cohort study of adult admissions to 17 ICUs. Data were captured using eCritical Alberta. A Clinical Frailty Scale (CFS) score assigned at ICU admission was used to define the exposure (CFS score ≥ 5). Primary outcome was hospital mortality. Secondary outcomes were ICU and hospital stay, and receipt of organ support.

RESULTS

Fifteen thousand two hundred and thirty-eight patients (81%) were assigned a CFS score at ICU admission. Of these, 28% (95% confidence interval [CI], 27 to 28) were frail. Prevalence of frailty was 9-43% across ICUs. Frail patients were older [mean (standard deviation) 63 (15) vs 56 (17) yr; P < 0.001], more likely to be male (54% vs 46% female; P < 0.001), and had higher APACHE II scores [22 (8) vs 17 (8); P < 0.001] compared with non-frail patients. Frail patients received less mechanical ventilation (62% vs 68%; P < 0.001) and vasoactive therapy (24% vs 57%; P < 0.001), but more non-invasive ventilation (22% vs 9%; P < 0.001). Frail patients had higher hospital mortality (23% vs 9%; adjusted odds ratio, 1.80; 95% CI, 1.64 to 2.05, along with longer ICU stay (median [interquartile range] 4 [2-8] vs 3 [2-6] days; P < 0.001), and longer hospital stay (16 [8-36] vs 10 [5-20] days; P < 0.001) compared with non-frail patients.

CONCLUSION

A validated measure of frailty can be implemented at the population level in ICU. Frailty is common in ICU patients and has implications for health service use and clinical outcomes.

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.

Towards a decision support tool for intensive care discharge: machine learning algorithm development using electronic healthcare data from MIMIC-III and Bristol, UK

OBJECTIVE

The primary objective is to develop an automated method for detecting patients that are ready for discharge from intensive care.

DESIGN

We used two datasets of routinely collected patient data to test and improve on a set of previously proposed discharge criteria.

SETTING

Bristol Royal Infirmary general intensive care unit (GICU).

PATIENTS

Two cohorts derived from historical datasets: 1870 intensive care patients from GICU in Bristol, and 7592 from Medical Information Mart for Intensive Care (MIMIC)-III.

RESULTS

In both cohorts few successfully discharged patients met all of the discharge criteria. Both a random forest and a logistic classifier, trained using multiple-source cross-validation, demonstrated improved performance over the original criteria and generalised well between the cohorts. The classifiers showed good agreement on which features were most predictive of readiness-for-discharge, and these were generally consistent with clinical experience. By weighting the discharge criteria according to feature importance from the logistic model we showed improved performance over the original criteria, while retaining good interpretability.

CONCLUSIONS

Our findings indicate the feasibility of the proposed approach to ready-for-discharge classification, which could complement other risk models of specific adverse outcomes in a future decision support system. Avenues for improvement to produce a clinically useful tool are identified.

Improving communication of patient issues on transfer out of intensive care

The written medical handover document is frequently poor in quality and highly variable which raises concerns about patient safety. Intensive care unit (ICU) patients have complex medical and social issues which increases the risk of errors during ongoing hospital treatment. Our project team of four doctors and two nurses aimed to improve the documentation of patient problems as they leave the ICU.

A literature review and process mapping of both medical and nursing transfer documentation helped in understanding the current process. Current problems (CP) were defined as any patient issues which require ongoing thought, management or follow-up.

Our progress was tracked using a measure of the number of CPs listed in the free-text field titled ‘Current Problems’ in 50 medical transfer documents. This was graphed on a control chart showing a process in statistical control. Means and control limits were recalculated whenever a process shift occurred.

There was no relationship between the number of CPs listed and length of ICU stay, age of patient, or severity of illness on presentation (Acute Physiologic Assessment and Chronic Health Evaluation II score). An inter-relationship graph identified the key drivers which were amenable to change: (1) the doctors completing the clinical summary at the time of discharge did not have all the information readily available to them and (2) the doctors were uncertain of the types of problem which should be communicated.

Improvements were designed and trialled using Plan-Do-Study-Act cycles to address these two key drivers. At baseline, the average number of CPs per patient was 1.8. After implementation of a paper problem list at the patient bedside, with supporting education, the average increased to 2.7. This was further improved by the addition of a checklist of common patient problems. This increased the average to 3.85.

These improvements were permanently implemented and ongoing audits have shown sustained improvement using statistical process control methods.

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.

Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit: A Multicenter Population-Based Cohort Study

IMPORTANCE

The safety of discharging adult patients recovering from critical illness directly home from the intensive care unit (ICU) is unknown.

OBJECTIVE

To compare the health care utilization and clinical outcomes for ICU patients discharged directly home from the ICU with those of patients discharged home via the hospital ward.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective population-based cohort study of adult patients admitted to the ICU of 9 medical-surgical hospitals from January 1, 2014, to January 1, 2016, with 1-year follow-up after hospital discharge. All adult ICU patients were discharged home alive from hospital, and the propensity score matched cohort (1:1) was based on patient characteristics, therapies received in the ICU, and hospital characteristics.

EXPOSURES

Patient disposition on discharge from the ICU: directly home vs home via the hospital ward.

MAIN OUTCOMES AND MEASURES

The primary outcome was readmission to the hospital within 30 days of hospital discharge. The secondary outcomes were emergency department visit within 30 days and death within 1 year.

RESULTS

Among the 6732 patients included in the study, 2826 (42%) were female; median age, 56 years (interquartile range, 41-67 years); 922 (14%) were discharged directly home, with significant variation found between hospitals (range, 4.4%-44.0%). Compared with patients discharged home via the hospital ward, patients discharged directly home were younger (median age 47 vs 57 years; P < .001), more likely to be admitted with a diagnosis of overdose, substance withdrawal, seizures, or metabolic coma (32% [295] vs 10% [594]; P < .001), to have a lower severity of acute illness on ICU admission (median APACHE II score 15 vs 18; P < .001), and receive less than 48 hours of invasive mechanical ventilation (42% [389] vs 34% [1984]; P < .001). In the propensity score matched cohort (n = 1632), patients discharged directly home had similar length of ICU stay (median, 3.1 days vs 3.0 days; P = .42) but significantly shorter length of hospital stay (median, 3.3 days vs 9.2 days; P < .001) compared with patients discharged home via the hospital ward. There were no significant differences between patients discharged directly home or home via the hospital ward for readmission to the hospital (10% [n = 81] vs 11% [n = 92]; hazard ratio [HR], 0.88; 95% CI, 0.64-1.20) or emergency department visit (25% [n = 200] vs 26% [n = 212]; HR, 0.94; 95% CI, 0.81-1.09) within 30 days of hospital discharge. Four percent of patients in both groups died within 1 year of hospital discharge (n = 31 and n = 34 in the discharged directly home and discharged home via the hospital ward groups, respectively) (HR, 0.90; 95% CI, 0.60-1.35).

CONCLUSIONS AND RELEVANCE

The discharge of select adult patients directly home from the ICU is common, and it is not associated with increased health care utilization or increased mortality.

Administrator Perspectives on ICU-to-Ward Transfers and Content Contained in Existing Transfer Tools: a Cross-sectional Survey

BACKGROUND

The transfer of critically ill patients from the intensive care unit (ICU) to hospital ward is challenging. Shortcomings in the delivery of care for patients transferred from the ICU have been associated with higher healthcare costs and poor satisfaction with care. Little is known about how hospital ward providers, who accept care of these patients, perceive current transfer practices nor which aspects of transfer they perceive as needing improvement.

OBJECTIVE

To compare ICU and ward administrator perspectives regarding ICU-to-ward transfer practices and evaluate the content of transfer tools.

DESIGN

Cross-sectional survey design.

PARTICIPANTS

We administered a survey to 128 medical and/or surgical ICU and 256 ward administrators to obtain institutional perspectives on ICU transfer practices. We performed qualitative content analysis on ICU transfer tools received from respondents.

KEY RESULTS

In total, 108 (77%) ICU and 160 (63%) ward administrators responded to the survey. The ICU attending physician was reported to be "primarily responsible" for the safety (93% vs. 91%; p = 0.515) of patient transfers. ICU administrators more commonly perceived discharge summaries to be routinely included in patient transfers than ward administrators (81% vs. 60%; p = 0.006). Both groups identified information provided to patients/families, patient/family participation during transfer, and ICU-ward collaboration as opportunities for improvement. A minority of hospitals used ICU-to-ward transfer tools (11%) of which most (n = 21 unique) were designed to communicate patient information between providers (71%) and comprised six categories of information: demographics, patient clinical course, corrective aids, mobility at discharge, review of systems, and documentation of transfer procedures.

CONCLUSION

ICU and ward administrators have similar perspectives of transfer practices and identified patient/family engagement and communication as priorities for improvement. Key information categories exist.

Decline in functional status after intensive care unit discharge is associated with ICU readmission: a prospective cohort study

OBJECTIVES

To compare the functional status at intensive care unit (ICU) discharge of patients who were later readmitted to the ICU and patients discharged home and to verify whether a decline in functional status is associated with ICU readmission.

DESIGN

Prospective cohort study.

SETTING

ICU at a tertiary teaching hospital.

PARTICIPANTS

Patients admitted to the ICU, ≥18 years old, submitted to invasive mechanical ventilation (IMV), and discharged to the ward.

INTERVENTIONS

Functional assessment at ICU discharge. Discharge Group (DG) (patients discharged home) and Readmission Group (RG) (patients who returned to the ICU) were compared with Mann-Whitney and Chi-square or Exact Fisher tests. Multiple logistic regression verified association.

MAIN OUTCOME MEASURES

Barthel Index, key pinch strength, clinical and demographic data.

RESULTS

Patients in the readmission group presented lower Barthel Index [Median 40 (IQR 20-75) vs 60 (33-83), P=0.033], greater relative variation (pre and post ICU) of the Barthel Index (P=0.04), lower key pinch strength [3.4 (1.8-4.5) vs 4.5 (2.7-6.8)kg·f, P=0.006] and higher APACHE II [18 (12-22) vs 15 (11-20), P=0.027]. Multiple regression found that the relative variation of the Barthel Index was independently associated with ICU readmission (P<0.001), as well as higher APACHE II (P=0.020), shorter IMV duration (P<0.001) and ICU admission without clear diagnosis (P=0.020). The Hosmer-Lemeshow test indicated good adjustment of the model (P=0.99).

CONCLUSION

Readmitted patients presented poorer functional status and lower pinch strength. Relative variation of the Barthel Index was associated with ICU readmission despite other factors, as was higher APACHE II, shorter IMV duration and admission without clear diagnosis.

TRIAL REGISTRATION NUMBER

Not applicable.

The difficulties of discharging hospice patients to care homes at the end of life: A focus group study

BACKGROUND

Discharge from inpatient palliative care units to long-term care can be challenging. In the United Kingdom, hospice inpatients move to a care home if they no longer require specialist palliative care and cannot be discharged home. There is evidence to suggest that patients and families find the prospect of such a move distressing.

AIM

To investigate the issues that arise when patients are transferred from hospice to care home at the end of life, from the perspective of the hospice multidisciplinary team.

DESIGN

A qualitative study, using thematic analysis to formulate themes from focus group discussions with hospice staff.

SETTING/PARTICIPANTS

Five focus groups were conducted with staff at five UK hospices. Participants included multidisciplinary team members involved in discharge decisions. All groups had representation from a senior nurse and doctor at the hospice, with group size between three and eight participants. All but one group included physiotherapists, occupational therapists and family support workers.

RESULTS

A major focus of group discussions concerned dilemmas around discharge. These included (1) ethical concerns (dilemmas around the decision, lack of patient autonomy and allocation of resources); (2) communication challenges; and (3) discrepancies between the ideals and realities of hospice palliative care.

CONCLUSION

Hospice palliative care unit staff find discharging patients to care homes necessary, but often unsatisfactory for themselves and distressing for patients and relatives. Further research is needed to understand patients' experiences concerning moving to care homes for end of life care, in order that interventions can be implemented to mitigate this distress.

Implementation and evaluation of a follow-up programme after intensive care treatment: A practice development project

OBJECTIVES

This study aimed to measure the effects of a newly developed follow-up programme on intensive care unit patient quality of care, as perceived by their relatives, and the appropriateness of the programme according to nurses.

METHODS AND SETTING

This before and after implementation study was conducted in a level III intensive care unit for adult patients and related follow-up wards and included 135 intensive care nurses and 105 general ward nurses. The implemented programme included a personalised poster, a revised discharge protocol and follow-up visits on the ward. Eligible relatives of patients who had remained in the intensive care for a minimum of 48 hours were included.

MAIN OUTCOME MEASURES AND RESULTS

Total quality of care and communication were assessed by relatives as high according to the Quality Monitor. Most intensive care nurses evaluated the usefulness of the discharge protocol as positive (71.8% partly/totally agreed) and in accordance with the patients' needs (82.1% partly/totally agreed).

CONCLUSION

Communication and general support as perceived by patients' relatives improved; however, no influence on the total quality of care of the revised discharge protocol was shown. Nurses considered the programme as useful. The intervention might enable nurses to better respond to the instrumental and affective needs of patients and their relatives.