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Bourne RS, Jeffries M, Meakin E, Norville R, Ashcroft DM. Qualitative Insights Into Patients' and Family Members' Experiences of In-Hospital Medication Management After a Critical Care Episode. CHEST CRITICAL CARE 2024; 2:100072. [PMID: 38911128 PMCID: PMC11190841 DOI: 10.1016/j.chstcc.2024.100072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
Background Patient recovery after a critical illness can be protracted, requiring a care continuum that extends along a patient pathway from the critical care unit, hospital ward, and into the community care setting. High-quality care on patient transfer from critical care, including medication safety, is facilitated by education for patients and families, family engagement, support systems, and health care professional (HCP)-patient communication. Currently, uncertainty exists regarding how HCPs can and should engage with critical care patients and family members about their medication. Research Question What are the views and experiences of critical care patients and family members about their involvement in, communication about, understanding of, and decision-making related to their medication after transfer from critical care to the hospital ward? Study Design and Methods This qualitative study used semistructured interviews, conducted with critical care patients and family members after transfer from critical care to a hospital ward in a large National Health Service hospital trust. Anonymized transcripts of interviews were analyzed thematically using a coding framework developed from understandings of patient and family engagement in medication administration. Results Twenty-seven participants (15 patients and 12 family members of patients) completed the interviews. We identified five themes and 15 subthemes, providing an overview of patients' and family members' views on medication management during acute illness and ongoing recovery. Themes identified were: impact of acute illness and treatment burden on preexisting illness, preexisting knowledge and capability, beliefs about persons roles and expectations, care continuity and individualized information exchange, and engagement in practice. Interpretation This study demonstrated that critical care patients and family members want to engage with HCPs about medication administration. HCPs must take an individualized approach to communication and timing, acknowledging the dynamic interplay between patients and family members, using multimodal forms of communication.
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Affiliation(s)
- Richard S. Bourne
- Critical Care Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
- Department of Pharmacy, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
- Division of Pharmacy & Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England
- National Institute for Health and Care Research Greater Manchester Patient Safety Research Collaboration, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England
| | - Mark Jeffries
- Division of Pharmacy & Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England
- National Institute for Health and Care Research Greater Manchester Patient Safety Research Collaboration, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England
| | - Eleanor Meakin
- Critical Care Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
| | | | - Darren M. Ashcroft
- Division of Pharmacy & Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England
- National Institute for Health and Care Research Greater Manchester Patient Safety Research Collaboration, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, England
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Ji J, Yang L, Yang H, Zeng C, Tang W, Lu Q. Pediatricians' Perspectives on Introducing Transitional Care into Handover Between Pediatric Intensive Care Units and General Wards. Int J Gen Med 2024; 17:1991-2000. [PMID: 38741677 PMCID: PMC11089302 DOI: 10.2147/ijgm.s460000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/23/2024] [Indexed: 05/16/2024] Open
Abstract
Background Despite the availability of a considerable number of studies on transitional care, few qualitative studies have synthesized physicians' perspectives on PICU-to-ward transition to develop a comprehensive transitional care curriculum. The aim of this study is to explore physicians' perceptions and management of the transition of critically ill children from the PICU to the general ward, with the aim of providing an evidence-based curriculum. Methods A qualitative study was conducted between July and August 2022. The study involved semi-structured interviews with 11 participants, and data analysis was carried out using NVivo 12.0 software through thematic analysis method. Results Based on the data analysis, three main themes were identified: recognition of professional roles during transition, difficulties during implementation transitional care and suggestions for improving transitional care. Conclusion The insights of doctors can be valuable in improving transitional care for critically ill children during PICU-to-Ward transition and in developing relevant curricula. It is essential to introduce standardized clinical pathways and strengthen curricula on critical elements, including communication and follow-up.
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Affiliation(s)
- Jianlin Ji
- School of Nursing, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Liling Yang
- Nursing Department, Children's Hospital of Shanghai, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Hanlin Yang
- School of Nursing, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Chengxi Zeng
- School of Nursing, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Wenjuan Tang
- Nursing Department, Children's Hospital of Shanghai, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Qunfeng Lu
- School of Nursing, Shanghai Jiao Tong University, Shanghai, People's Republic of China
- Department of Nursing, Shanghai Jiao Tong University School of Medicine Affiliated Sixth People's Hospital, Shanghai, People's Republic of China
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Hiller M, Burisch C, Wittmann M, Bracht H, Kaltwasser A, Bakker J. The current state of intensive care unit discharge practices - Results of an international survey study. Front Med (Lausanne) 2024; 11:1377902. [PMID: 38774398 PMCID: PMC11106471 DOI: 10.3389/fmed.2024.1377902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 03/26/2024] [Indexed: 05/24/2024] Open
Abstract
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.
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Affiliation(s)
- Maike Hiller
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Hospital Patient Monitoring, Philips Medizin Systeme Böblingen GmbH, Böblingen, Germany
| | - Christian Burisch
- Regional Government Düsseldorf, State of North Rhine-Westphalia, Düsseldorf, Germany
| | - Maria Wittmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Hendrik Bracht
- Department of Anesthesiology, Intensive Care, Emergency and Transfusion Medicine and Pain Therapy, University Hospital Bielefeld Bethel, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Arnold Kaltwasser
- Academy of the District Hospitals Reutlingen, Kreiskliniken Reutlingen, Reutlingen, Germany
| | - Jan Bakker
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, Netherlands
- New York University School of Medicine and Columbia University College of Physicians and Surgeons, New York, NY, United States
- Department of Intensive Care, Pontifcia Universidad Catolica de Chile, Santiago de Chile, Chile
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Xuan G, Juan D, Xurui Z, Fei L. Real emotional experience of family members of patients transported within hospital in neurosurgical intensive care unit: A descriptive qualitative study. Nurs Open 2024; 11:e2151. [PMID: 38770898 PMCID: PMC11107143 DOI: 10.1002/nop2.2151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 03/05/2024] [Accepted: 03/21/2024] [Indexed: 05/22/2024] Open
Abstract
AIM To understand the real experience of family members of patients in neurosurgical intensive care unit (NICU) during intra-hospital transport (IHT), explore their inner needs and provide effective intervention measures for the construction of standardized IHT plan. DESIGN A descriptive qualitative study. METHODS For the purposes of this study, 10 family members of IHT patients were included using a purposive sampling method. Semi-structured in-depth interviews were used to collect the data, Nvivo 11 software was used to organize the data, and Colaizzi's 7-step descriptive phenomenology method was used to analyse the data. RESULTS A total of three themes and nine subthemes were extracted, namely: Experience of emotional changes at different stages (uncertainty before transfer, complex internal activity during transit, ambivalence after transfer); Perception of problems in IHT (poor doctor-patient communication, weak awareness of risk assessment, deficiencies in the transfer procedure); Consciousness of the real needs (emotional respect and closeness, stay informed of the progression of the disease, greater social support). CONCLUSION Family members of patients in the NICU have complex internal experiences and multiple support needs during IHT, reflecting the need for further standardization of the transport process. In the future, we should improve the mode of safe IHT involving doctors, nurses and family members of patients, ensure the safety of patient transport, meet the social support needs of family members and improve the experience of IHT and the medical satisfaction of family members.
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Affiliation(s)
- Guo Xuan
- Department of NeurosurgeryJingzhou Hospital Affiliated to Yangtze UniversityJingzhouHubeiChina
| | - Ding Juan
- Nursing DepartmentJingzhou Hospital Affiliated to Yangtze UniversityJingzhouHubeiChina
| | - Zeng Xurui
- Department of NeurosurgeryJingzhou Hospital Affiliated to Yangtze UniversityJingzhouHubeiChina
| | - Liu Fei
- Medicine DepartmentYangtze UniversityJingzhouHubeiChina
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DeGrazia RJ, Kalkat M, Miller L, Niessen T, Chatterjee S, Wright S. Transforming the transfer process: A quality improvement project to assess and improve transfer notes. J Healthc Risk Manag 2024; 43:6-13. [PMID: 37726956 DOI: 10.1002/jhrm.21558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/29/2023] [Indexed: 09/21/2023]
Abstract
Transfer notes (TNs) standardize handoffs from one inpatient unit to another to optimize patient safety. They are especially important when patients are downgraded from high acuity settings such as intensive care units (ICU). Despite this, there is a paucity of evidence around safe transfers. The study objective was to assess the impact of a quality improvement initiative on the completion rate and quality of TNs. A retrospective chart review of TNs was conducted at a single academic center in Baltimore, MD. We analyzed 76 MICU to floor transfers pre-intervention and 73 transfers during the intervention period. Note quality was determined using a novel TN assessment tool; validity evidence was established. Chi-square analysis was used to compare the presence and quality of TNs. There was a statistically significant increase in note completion rate from 19.7% to 42.5 % during the study (p < 0.003). There was a statistically significant increase in mean quality of completed TNs (10.3 pre-intervention vs. 12.3 intervention period: maximum score 15, p = 0.005). This QI intervention appears to have translated into more consistent and higher quality TNs. These improvements should facilitate better and safer care of patients moving from MICU to medical floors.
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Affiliation(s)
- Robert J DeGrazia
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Meher Kalkat
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Leslie Miller
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Timothy Niessen
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Souvik Chatterjee
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Scott Wright
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
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Meiring-Noordstra A, van der Meulen IC, Onrust M, Hafsteinsdóttir TB, Luttik ML. Relatives' experiences of the transition from intensive care to home for acutely admitted intensive care patients-A qualitative study. Nurs Crit Care 2024; 29:117-124. [PMID: 37154290 DOI: 10.1111/nicc.12918] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 03/28/2023] [Accepted: 04/06/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Acute admission to an intensive care unit (ICU) can negatively affect quality of life for patients and their relatives. Relatives play an important caregiving role after the patient's admission. More knowledge and understanding of their needs are necessary as the patient transitions home. AIM This study aims to explore relatives' experiences of acutely admitted ICU patients' transition from the ICU to a general ward and then home. STUDY DESIGN A qualitative study with a phenomenological approach was conducted. Interviews were in-depth and featured open-ended questions. The interviews took place after the patients transitioned from ICU to home and were conducted online by videoconference. Data were analysed using Colaizzi's seven-step method. RESULTS Twelve relatives of acutely admitted ICU patients were interviewed. Five main themes emerged: (1) mixed feelings, (2) sense of not being involved, (3) limited information provision, (4) lack of acknowledgement as a caregiver, and (5) an uncertain future perspective. Relatives experience major uncertainties during transitions and prefer to be actively involved in care and care decisions. CONCLUSIONS This study indicates that relatives of ICU patients experience a lack of guidance during the transitions from the ICU to a general ward and to home, or a follow-up facility. More focus is needed on the themes of mixed feelings, the sense of not being involved, limited information provision, lack of acknowledgement as a caregiver, and an uncertain future perspective. This increased focus might improve the guidance during these transitions. RELEVANCE TO CLINICAL PRACTICE The insights from this study may help to improve the care of patients and their relatives during the transitions.
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Affiliation(s)
- Aaltje Meiring-Noordstra
- Nursing Science, Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ingeborg C van der Meulen
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Research Group Nursing Diagnostics, Hanze University of Applied Science Groningen, Groningen, The Netherlands
| | - Marisa Onrust
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Thóra B Hafsteinsdóttir
- Nursing Science, Program in Clinical Health Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
- Nursing Science Julius Center of Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marie Louise Luttik
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Family Care, University of Applied Sciences Hanzehogeschool, lectorate in Nursing Diagnostics, Groningen, The Netherlands
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Gullberg A, Joelsson-Alm E, Schandl A. Patients' experiences of preparing for transfer from the intensive care unit to a hospital ward: A multicentre qualitative study. Nurs Crit Care 2023; 28:863-869. [PMID: 36325990 DOI: 10.1111/nicc.12855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/27/2022] [Accepted: 09/28/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The transfer from an intensive care unit (ICU) to a regular ward often causes confusion and stress for patients and family members. However, little is known about the patients' perspective on preparing for the transfer. AIM The purpose of the study was to describe patients' experiences of preparing for transfer from an ICU to a ward. STUDY DESIGN Individual interviews with 14 former ICU patients from three urban hospitals in Stockholm, Sweden were conducted 3 months after hospital discharge. Qualitative content analysis was used to interpret the interview transcripts. Reporting followed the consolidated criteria for reporting qualitative research checklist. RESULTS The results showed that the three categories, the discharge decision, patient involvement, and practical preparations were central to the patients' experiences of preparing for the transition from the intensive care unit to the ward. The discharge decision was associated with a sense of relief, but also worry about what would happen on the ward. The patients felt that they were not involved in the decision about the discharge or the planning of their health care. To handle the situation, patients needed information about planned care and treatment. However, the information was often sparse, delivered from a clinician's perspective, and therefore not much help in preparing for transfer. CONCLUSIONS ICU patients experienced that they were neither involved in the process of forthcoming care nor adequately prepared for the transfer to the ward. Relevant and comprehensible information and sufficient time to prepare were needed to reduce stress and promote efficient recovery. RELEVANCE TO CLINICAL PRACTICE The study suggests that current transfer strategies are not optimal, and a more person-centred discharge procedure would be beneficial to support patients and family members in the transition from the ICU to the ward.
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Affiliation(s)
- Agneta Gullberg
- Department of Cardiology and Medical Intensive Care, Stockholm, Sweden
| | - Eva Joelsson-Alm
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesiology and Intensive Care, Stockholm, Sweden
| | - Anna Schandl
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesiology and Intensive Care, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Roumeliotis N, Desforges J, French ME, Dupre-Roussel J, Fiest KM, Lau VI, Lacroix J, Carnevale FA. Patient and Family Experience With Discharge Directly Home From the Pediatric ICU. Hosp Pediatr 2023; 13:954-960. [PMID: 37667850 DOI: 10.1542/hpeds.2023-007332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
BACKGROUND Children are increasingly discharged directly from the PICU. Transitions have been recognized as a period of increased patient and caregiver stress and risk of adverse events. No study has evaluated patient and caregiver outcomes after direct discharge from the PICU. This study aimed to explore the family's experiences with discharge directly home (DDH) from the PICU. METHODS This exploratory mixed-methods study was conducted in the PICU of the Institution is Sainte-Justine Hospital from February to July 2021. We included families of children expected to be DDH within 12 hours. Semistructured interviews were conducted at discharge, followed by telephone interviews 7 and 28 days post-PICU discharge. We measured comfort on a 5-point Likert scale and screened for anxiety using the Generalized Anxiety Disorder-7 tool. RESULTS Families of 25 patients were interviewed. Thematic analysis of the interviews revealed several themes, such as feeling stress and anxiety, feeling confident, anticipating home care, and needing support. These findings complemented the quantitative findings; the median comfort score was 4 (comfortable) (interquartile range 4-5) and 8 (interquartile range 4-12) for the Generalized Anxiety Disorder-7 on the day of discharge, with 16 reporting clinically significant anxiety. In the 28-day study period, 2 patients were readmitted and 6 had visited the emergency department. CONCLUSIONS Despite feelings of anxiety, many families felt comfortable with DDH from the PICU. Increasing our understanding of the patient and family experiences of discharge from the PICU will help to better support these patients and their families during transition.
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Affiliation(s)
| | | | | | | | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
| | - Jacques Lacroix
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Franco A Carnevale
- Ingram School of Nursing, McGill University, Montreal, Quebec, Canada
- Pediatric ICU, Montreal Children's Hospital, Montreal, Quebec, Canada
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Pokharel S, Khawaja Z, Williams J, Mithwani AA, Strain K, Khanna P, Rychtera A, Kiryanova V, Tang K, Mathura P, Hylton C, Ambasta A. Patient perceptions of in-hospital laboratory blood testing: A patient-oriented and patient co-designed qualitative study. Health Expect 2023; 27:e13880. [PMID: 37751312 PMCID: PMC10726148 DOI: 10.1111/hex.13880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/25/2023] [Accepted: 09/14/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Indiscriminate use of laboratory blood testing in hospitals contributes to patient discomfort and healthcare waste. Patient engagement in low-value healthcare can help reduce overuse. Understanding patient experience is necessary to identify opportunities to improve patient engagement with in-hospital laboratory testing. OBJECTIVES To understand patient experience with the process of in-hospital laboratory blood testing. METHODS We used a qualitative study design via semistructured interviews conducted online or over the phone. Participants were adult patients or family members/caregivers (≥18 years of age) with a recent (within 12 months of interview) experience of hospitalization in Alberta or British Columbia, Canada. We identified participants through convenience sampling and conducted interviews between May 2021 and June 2022. We analysed transcripts using thematic content analysis. Recruitment was continued until code saturation was reached. RESULTS We interviewed 16 participants (13 patients, 1 family member and 2 caregivers). We identified four themes from patients' experiences of in-hospital laboratory blood testing: (i) patients need information from healthcare teams about expected blood testing processes, (ii) blood draw processes should consider patient comfort and preferences, (iii) patients want information from their healthcare teams about the rationale and frequency of blood testing and (iv) patients need information on how their testing results affect their medical care. CONCLUSION Current laboratory testing processes in hospitals do not facilitate shared decision-making and patient engagement. Patient engagement with laboratory testing in hospitals requires an empathetic healthcare team that provides clear communication regarding testing procedures, rationale and results, while considering patient preferences and offering opportunities for involvement. PATIENT OR PUBLIC CONTRIBUTION We interviewed 16 patients and/or family members/caregivers regarding their in-hospital laboratory blood testing experiences. Our findings show correlations between patient needs and patient recommendations to make testing processes more patient-centred. To bring a lived-experience lens to this study, we formed a Patient Advisory Council with 9-11 patient research partners. Our patient research partners informed the research design, co-developed participant recruitment strategies, co-conducted data collection and informed the data analysis. Some of our patient research partners are co-authors of this manuscript.
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Affiliation(s)
- Surakshya Pokharel
- Ward of the 21st Century, Calgary Zone of Alberta Health ServicesUniversity of CalgaryCalgaryCanada
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryCalgaryCanada
| | - Zoha Khawaja
- Ward of the 21st Century, Calgary Zone of Alberta Health ServicesUniversity of CalgaryCalgaryCanada
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryCalgaryCanada
| | - Jonathan Williams
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryCalgaryCanada
| | - Adnan Adil Mithwani
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryCalgaryCanada
| | - Kimberly Strain
- Strategy for Patient Oriented Research (SPOR) Support UnitCalgaryAlbertaCanada
| | - Prachi Khanna
- Department of Biology, Faculty of ScienceUniversity of British ColumbiaVancouverCanada
| | - Anna Rychtera
- Strategy for Patient Oriented Research (SPOR) Support UnitVancouverBritish ColumbiaCanada
- Michael Smith Health ResearchVancouverBritish ColumbiaCanada
| | - Veronika Kiryanova
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryCalgaryCanada
| | - Karen Tang
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryCalgaryCanada
- O'Brien Institute of Public Health, Cumming School of MedicineUniversity of CalgaryCalgaryCanada
| | - Pamela Mathura
- Department of MedicineUniversity of AlbertaEdmontonCanada
| | - Chris Hylton
- Graduate StudiesLaval UniversityQuebec CityCanada
| | - Anshula Ambasta
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryCalgaryCanada
- Department of Anesthesia, Pharmacology and Therapeutics, Therapeutics InitiativeUniversity of British ColumbiaVancouverCanada
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Cuzco C, Delgado-Hito P, Marin-Pérez R, Núñez-Delgado A, Romero-García M, Martínez-Momblan MA, Martínez-Estalella G, Castro P. Transitions and empowerment theory: A framework for nursing interventions during intensive care unit patient transition. ENFERMERIA INTENSIVA 2023; 34:138-147. [PMID: 37246109 DOI: 10.1016/j.enfie.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 10/03/2022] [Indexed: 05/30/2023]
Abstract
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.
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Affiliation(s)
- C Cuzco
- Área de Vigilancia Intensiva, Hospital Clínic de Barcelona, Barcelona, Spain; Departamento de Enfermería Fundamental y Medicoquirúrgica, Escuela de Enfermería, Universidad de Barcelona, Barcelona, Spain; Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - P Delgado-Hito
- Departamento de Enfermería Fundamental y Medicoquirúrgica, Escuela de Enfermería, Universidad de Barcelona, Barcelona, Spain; Grupo de Investigación Enfermera del Instituto de Investigación Biomédica de Bellvitge (GRIN-IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.
| | - R Marin-Pérez
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Grupo de Investigación Enfermera del Instituto de Investigación Biomédica de Bellvitge (GRIN-IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - A Núñez-Delgado
- Unidad de Cuidados Intensivos de Traumatología, Hospital Vall d'Hebron, Barcelona, Spain
| | - M Romero-García
- Departamento de Enfermería Fundamental y Medicoquirúrgica, Escuela de Enfermería, Universidad de Barcelona, Barcelona, Spain; Grupo de Investigación Enfermera del Instituto de Investigación Biomédica de Bellvitge (GRIN-IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - M A Martínez-Momblan
- Departamento de Enfermería Fundamental y Medicoquirúrgica, Escuela de Enfermería, Universidad de Barcelona, Barcelona, Spain
| | - G Martínez-Estalella
- Área de Vigilancia Intensiva, Hospital Clínic de Barcelona, Barcelona, Spain; Departamento de Enfermería Fundamental y Medicoquirúrgica, Escuela de Enfermería, Universidad de Barcelona, Barcelona, Spain; Grupo de Investigación Enfermera del Instituto de Investigación Biomédica de Bellvitge (GRIN-IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | - P Castro
- Área de Vigilancia Intensiva, Hospital Clínic de Barcelona, Barcelona, Spain; Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Facultad de Medicina y Ciencias de la Salud, Universidad de Barcelona, Barcelona, Spain
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Moss SJ, Racine N, Ahmed S, Birnie K, Cherak MS, Curran JA, Halperin D, Halperin SA, Harley M, Hu J, Leppan L, Nickel A, Russell K, Solis M, Smith S, Soo A, Stelfox M, Tutelman PR, Stelfox HT, Fiest KM, Parsons Leigh J. Codesigning a user-centred digital psychoeducational tool for youth mental well-being with families in Canada: study protocol for a sequential exploratory mixed methods study. BMJ Open 2023; 13:e072533. [PMID: 37369410 PMCID: PMC10410808 DOI: 10.1136/bmjopen-2023-072533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION On 11 March 2020, WHO declared the novel coronavirus (COVID-19) disease a global pandemic. Governments globally implemented physical distancing measures and closure of public institutions that resulted in varying implications to youth mental well-being (eg, social isolation, reduced extracurricular activities). These impacts may have detrimental short-term and long-term effects on youth mental well-being; care for youth with mental health disorders was already overstretched, underfunded and fragmented before the pandemic and youth are not often considered in mental health initiatives. There is a pressing need to partner with youth and families to target and improve youth mental well-being prior to the onset of a mental health disorder, as well as to conduct research on youth mental well-being needs related to pandemic recovery. Here we present a protocol for partnering with youth and families to codesign a user-centred digital tool for youth mental well-being. METHODS AND ANALYSIS We will conduct a national research study to develop a catalogue of recommendations specific to supporting youth mental well-being, and a digital tool to support youth mental well-being through three phases of work: (1) expert consultation on data related to supporting youth mental well-being existing within our Pandemic Preparedness Research Program; (2) codesign of an innovative digital tool for youth mental well-being; and (3) assessment of the tool's usability and acceptability. ETHICS AND DISSEMINATION This study has been approved by the Dalhousie Research Ethics Board (2023-6538) and the Conjoint Health Research Ethics Board (23-0039). This study will complement ongoing foundational research in youth conducted by our team that involves partnering with youth and families to understand the unique implications of the pandemic on this population.
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Affiliation(s)
| | - Nicole Racine
- School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
| | - Sofia Ahmed
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kathryn Birnie
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michal S Cherak
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Janet A Curran
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Donna Halperin
- School of Nursing, St Francis Xavier University, Antigonish, Nova Scotia, Canada
| | - Scott A Halperin
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Micaela Harley
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jia Hu
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Laura Leppan
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Angie Nickel
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kristine Russell
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - May Solis
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Stacie Smith
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Andrea Soo
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Maia Stelfox
- Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Perri R Tutelman
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Kirsten M Fiest
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Hachen M, Musy SN, Fröhlich A, Jeitziner MM, Kindler A, Perrodin S, Zante B, Zúñiga F, Simon M. Developing a reflection and analysis tool (We-ReAlyse) for readmissions to the intensive care unit: A quality improvement project. Intensive Crit Care Nurs 2023; 77:103441. [PMID: 37178615 DOI: 10.1016/j.iccn.2023.103441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/29/2023] [Accepted: 04/14/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Readmissions to the intensive care unit are associated with poorer patient outcomes and health prognoses, alongside increased lengths of stay and mortality risk. To improve quality of care and patients' safety, it is essential to understand influencing factors relevant to specific patient populations and settings. A standardized tool for systematic retrospective analysis of readmissions would help healthcare professionals understand risks and reasons affecting readmissions; however, no such tool exists. PURPOSE This study's purpose was to develop a tool (We-ReAlyse) to analyze readmissions to the intensive care unit from general units by reflecting on affected patients' pathways from intensive care discharge to readmission. The results will highlight case-specific causes of readmission and potential areas for departmental- and institutional-level improvements. METHOD A root cause analysis approach guided this quality improvement project. The tool's iterative development process included a literature search, a clinical expert panel, and a testing in January and February 2021. RESULTS The We-ReAlyse tool guides healthcare professionals to identify areas for quality improvement by reflecting the patient's pathway from the initial intensive care stay to readmission. Ten readmissions were analyzed by using the We-ReAlyse tool, resulting in key insights about possible root causes like the handover process, patient's care needs, the resources on the general unit and the use of different electronic healthcare record systems. CONCLUSIONS The We-ReAlyse tool provides a visualization/objectification of issues related to intensive care readmissions, gathering data upon which to base quality improvement interventions. Based on the information on how multi-level risk profiles and knowledge deficits contribute to readmission rates, nurses can target specific quality improvements to reduce those rates. IMPLICATIONS FOR CLINICAL PRACTICE AND RESEARCH With the We-ReAlyse tool, we have the opportunity to collect detailed information about ICU readmissions for an in-depth analysis. This will allow health professionals in all involved departments to discuss and either correct or cope with the identified issues. In the long term, this will allow continuous, concerted efforts to reduce and prevent ICU readmissions. To obtain more data for analysis and to further refine and simplify the tool, it may be applied to larger samples of ICU readmissions. Furthermore, to test its generalizability, the tool should be applied to patients from other departments and other hospitals. Adapting it to an electronic version would facilitate the timely and comprehensive collection of necessary information. Finally, the tool's emphasis comprises reflecting on and analyzing ICU readmissions, allowing clinicians to develop interventions targeting the identified problems. Therefore, future research in this area will require the development and evaluation of potential interventions.
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Affiliation(s)
- Martina Hachen
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Sarah N Musy
- Institute of Nursing Science, University of Basel, Basel, Switzerland.
| | - Annina Fröhlich
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Marie-Madlen Jeitziner
- Institute of Nursing Science, University of Basel, Basel, Switzerland; Department of Intensive Care Medicine, Inselspital, University Hospital Bern, Bern, Switzerland.
| | - Angela Kindler
- Department of Physiotherapy, Inselspital, University Hospital Bern, Bern, Switzerland.
| | - Stéphanie Perrodin
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Bjoern Zante
- Department of Intensive Care Medicine, Inselspital, University Hospital Bern, Bern, Switzerland.
| | - Franziska Zúñiga
- Institute of Nursing Science, University of Basel, Basel, Switzerland.
| | - Michael Simon
- Institute of Nursing Science, University of Basel, Basel, Switzerland.
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13
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A Quality Improvement Project to Decrease Suboptimal Patient Transfers between Two Neonatal Units. Pediatr Qual Saf 2023; 8:e635. [PMID: 36798109 PMCID: PMC9925099 DOI: 10.1097/pq9.0000000000000635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 01/18/2023] [Indexed: 02/16/2023] Open
Abstract
Poorly executed transitions of care in health care systems are associated with safety concerns and patient dissatisfaction. We noticed several problems in the transfer process between our neonatal intensive care unit (NICU) and special care nursery (SCN) and designed this quality improvement project to address them. The aim was to decrease suboptimal transfers from the NICU to the SCN by 50% over 9 months. We defined suboptimal transfers as the discharge of a patient within 3 days of transfer from the NICU to the SCN or the return of a patient to the NICU within 5 days of the transfer. Methods We formed a multidisciplinary team and collected baseline data from October 2019 to December 2020. Major interventions included implementing a transfer checklist and algorithm. We utilized 3 staff surveys to evaluate the progress of the project. We used statistical process control charts to track project measures over time. Results Patient demographics and SCN length of stay were similar for the baseline and postintervention periods. We decreased suboptimal transfers over 21 months (January 2021 to September 2022), achieved a significantly increased rate of parent notification before transfers (81% baseline versus 93% postintervention), and increased staff satisfaction with the transfer process (15% baseline versus 43% postintervention). Conclusions We successfully improved the transfer process from our NICU to the SCN via a quality improvement project. Increased staff satisfaction and the lack of perception of additional burden to the staff from the new process are expected to sustain our results.
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Daoust D, Dodin P, Sy E, Lau V, Roumeliotis N. Prevalence and Readmission Rates of Discharge Directly Home From the PICU: A Systematic Review. Pediatr Crit Care Med 2023; 24:62-71. [PMID: 36594800 DOI: 10.1097/pcc.0000000000003114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Critically ill patients are increasingly being discharged directly home from PICU as opposed to discharged home, via the ward. The objective was to assess the prevalence, safety, and satisfaction of discharge directly home from PICUs. DATA SOURCES We searched PubMed, Medline, EMBASE, PsycINFO, and CINAHL for studies published between January 1991 and June 2021. STUDY SELECTION We included observational or randomized studies, of children up to 18 years old, that reported on the prevalence, safety, or satisfaction of discharge directly home from the PICU, compared with the ward. Safety outcomes included readmission, unplanned visits to hospital, and any adverse events. We excluded case series, reviews, and studies discharging patients to other facilities. DATA EXTRACTION Two independent reviewers evaluated 88 full-text articles; five studies met eligibility (362,868 patients). Only one study had discharge directly home as a primary outcome. DATA SYNTHESIS Prevalence of discharge directly to home from the PICU ranged from less than 1% to 23% (random effects proportion 7.7 [95% CI, 1.3-18.6]). Readmissions to the PICU (only safety outcome) were significantly lower in the discharge directly home group compared with the ward group, in two of three studies (p < 0.0001). No studies reported on patient or family satisfaction. CONCLUSIONS The prevalence of discharge directly home from the PICU ranges from 1% to 23%. PICU readmission rates do not appear to increase after discharge directly home. Caution is needed in the interpretation of the results, given the significant heterogeneity of the included studies. Further high-quality studies are needed to evaluate the safety of discharge directly home from the PICU and support families in this transition.
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Affiliation(s)
- Daphne Daoust
- Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Philippe Dodin
- Medical Librarian, Centre Hospitalier Universitaire (CHU) Sainte-Justine, Montreal, QC, Canada
| | - Eric Sy
- Department of Medicine, College of Medicine, University of Saskatchewan, Regina, SK, Canada
| | - Vincent Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nadia Roumeliotis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
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15
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Zhan Y, Yu J, Zhang W, Wan Y, Chen Y, Wang Y, Li S. Cognition and practice on transitional care during the transfer from intensive care unit to a general ward among health care professionals: A qualitative study. J Nurs Manag 2022; 30:4569-4577. [PMID: 36281794 DOI: 10.1111/jonm.13878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 07/21/2022] [Accepted: 10/02/2022] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Yuxin Zhan
- Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.,School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiaohua Yu
- Department of Nursing, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wenya Zhang
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yali Wan
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi Chen
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yinyue Wang
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suyun Li
- Department of Nursing, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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16
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A Multiple Baseline Trial of an Electronic ICU Discharge Summary Tool for Improving Quality of Care. Crit Care Med 2022; 50:1566-1576. [PMID: 35972243 DOI: 10.1097/ccm.0000000000005638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Cuzco C, Delgado-Hito P, Marin-Pérez R, Núñez-Delgado A, Romero-García M, Martínez-Momblan M, Martínez-Estalella G, Castro P. Teoría de las transiciones y empoderamiento: un marco para las intervenciones enfermeras durante la transición del paciente de la unidad de cuidados intensivos. ENFERMERIA INTENSIVA 2022. [DOI: 10.1016/j.enfi.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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18
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Shahid A, Sept B, Kupsch S, Brundin-Mather R, Piskulic D, Soo A, Grant C, Leigh JP, Fiest KM, Stelfox HT. Development and pilot implementation of a patient-oriented discharge summary for critically Ill patients. World J Crit Care Med 2022; 11:255-268. [PMID: 36051938 PMCID: PMC9305680 DOI: 10.5492/wjccm.v11.i4.255] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/06/2022] [Accepted: 06/18/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Anmol Shahid
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
| | - Bonnie Sept
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
| | - Shelly Kupsch
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
| | - Rebecca Brundin-Mather
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
| | - Danijela Piskulic
- Department of Psychiatry, Hotchkiss Brain Institute, Calgary T2N 4Z6, Alberta, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
| | - Christopher Grant
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
| | - Jeanna Parsons Leigh
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
- School of Health Administration, Dalhousie University, Halifax B3H 4R2, Nova Scotia, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary T2N 4Z6, Alberta, Canada
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19
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Rosgen BK, Plotnikoff KM, Krewulak KD, Shahid A, Hernandez L, Sept BG, Morrissey J, Robertson K, Fraser N, Niven DJ, Straus SE, Leigh JP, Stelfox HT, Fiest KM. 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. BMC Health Serv Res 2022; 22:10. [PMID: 34974832 PMCID: PMC8722038 DOI: 10.1186/s12913-021-07392-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 12/07/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Brianna K Rosgen
- Department of Critical Care Medicine, University of Calgary, 3260 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada.,Department of Community Health Sciences, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
| | - Kara M Plotnikoff
- Department of Critical Care Medicine, University of Calgary, 3260 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Karla D Krewulak
- Department of Critical Care Medicine, University of Calgary, 3260 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Anmol Shahid
- Department of Critical Care Medicine, University of Calgary, 3260 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Laura Hernandez
- Department of Critical Care Medicine, University of Calgary, 3260 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Bonnie G Sept
- Department of Critical Care Medicine, University of Calgary, 3260 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
| | - Jeanna Morrissey
- Critical Care Strategic Clinical Network, Alberta Health Services, 10030 - 107 Street NW, Edmonton, AB, T5J 3E4, Canada
| | - Kristin Robertson
- Critical Care Strategic Clinical Network, Alberta Health Services, 10030 - 107 Street NW, Edmonton, AB, T5J 3E4, Canada
| | - Nancy Fraser
- Critical Care Strategic Clinical Network, Alberta Health Services, 10030 - 107 Street NW, Edmonton, AB, T5J 3E4, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, 3260 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada.,Critical Care Strategic Clinical Network, Alberta Health Services, 10030 - 107 Street NW, Edmonton, AB, T5J 3E4, Canada
| | - Sharon E Straus
- Department of Medicine, Institute for Health Policy, Management and Evaluation, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada
| | - Jeanna Parsons Leigh
- Department of Medicine, School of Health Administration, Dalhousie University, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary, 3260 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada.,Critical Care Strategic Clinical Network, Alberta Health Services, 10030 - 107 Street NW, Edmonton, AB, T5J 3E4, Canada.,O'Brien Institute for Public Health, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary, 3260 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada. .,Department of Community Health Sciences, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada. .,O'Brien Institute for Public Health, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada. .,Department of Psychiatry, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada.
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20
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Plotnikoff KM, Krewulak KD, Hernández L, Spence K, Foster N, Longmore S, Straus SE, Niven DJ, Parsons Leigh J, Stelfox HT, Fiest KM. Patient discharge from intensive care: an updated scoping review to identify tools and practices to inform high-quality care. Crit Care 2021; 25:438. [PMID: 34920729 PMCID: PMC8684123 DOI: 10.1186/s13054-021-03857-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/04/2021] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Kara M Plotnikoff
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Karla D Krewulak
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Laura Hernández
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Krista Spence
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Nadine Foster
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Shelly Longmore
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Toronto, ON, M5B 1W8, Canada
- Department of Geriatric Medicine, Faculty of Medicine, University of Toronto, 6 Queen's Park Crescent West, Third Floor, Toronto, ON, M5S 3H2, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Jeanna Parsons Leigh
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Faculty of Health, School of Health Administration, Dalhousie University, Sir Charles Tupper Medical Building, 2nd Floor, 5850 College Street, Halifax, NS, B3H 4R2, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- Department of Psychiatry, Cumming School of Medicine, University of Calgary and Alberta Health Services, 3134 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
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21
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Zhan Y, Yu J, Chen Y, Liu Y, Wang Y, Wan Y, Li S. Family caregivers' experiences and needs of transitional care during the transfer from intensive care unit to a general ward: A qualitative study. J Nurs Manag 2021; 30:592-599. [PMID: 34799985 DOI: 10.1111/jonm.13518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Yuxin Zhan
- Department of Nursing, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiaohua Yu
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi Chen
- Department of Nursing, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yufang Liu
- Department of Nursing, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yingyue Wang
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yali Wan
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Suyun Li
- Department of Nursing, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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22
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Nursing Interventions for Patient Empowerment during Intensive Care Unit Discharge: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111049. [PMID: 34769569 PMCID: PMC8582948 DOI: 10.3390/ijerph182111049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 10/16/2021] [Accepted: 10/17/2021] [Indexed: 11/17/2022]
Abstract
Intensive care unit discharge is an important transition that impacts a patient's wellbeing. Nurses can play an essential role in this scenario, potentiating patient empowerment. A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (the PRISMA Statement. Embase), PubMed/MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), CUIDEN Plus, and LILACS databases; these were evaluated in May 2021. Two independent reviewers analyzed the studies, extracted the data, and assessed the quality of evidence. Quality of the studies included was assessed using the Cochrane risk-of-bias tool. Of the 274 articles initially identified, eight randomized controlled trials that reported on nursing interventions had mainly focused on patients' ICU discharge preparation through information and education. The creation of ICU nurse-led teams and nurses' involvement in critical care multidisciplinary teams also aimed to support patients during ICU discharge. This systematic review provides an update on the clinical practice aimed at improving the patient experience during ICU discharge. The main nursing interventions were based on information and education, as well as the development of new nursing roles. Understanding transitional needs and patient empowerment are key to making the transition easier.
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23
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Cuzco C, Delgado-Hito P, Marín Pérez R, Núñez Delgado A, Romero-García M, Martínez-Momblan MA, Martínez Estalella G, Carmona Delgado I, Nicolas JM, Castro P. Patients' experience while transitioning from the intensive care unit to a ward. Nurs Crit Care 2021; 27:419-428. [PMID: 34402141 DOI: 10.1111/nicc.12697] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 06/05/2021] [Accepted: 07/23/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Cecilia Cuzco
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain.,Department of Fundamental and Medical-Surgical Nursing, School of Nursing, Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.,Biomedical Research Institute August Pi Sunyer (IDIBAPS), Hospital Clínic Barcelona, Barcelona, Spain.,Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Pilar Delgado-Hito
- Department of Fundamental and Medical-Surgical Nursing, School of Nursing, Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.,Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.,Nursing Research Group (GRIN), Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,International Research Project: Proyecto HU-CI, Madrid, Spain
| | - Raquel Marín Pérez
- Nursing Research Group (GRIN), Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,Department of Cardiology, Hospital Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Marta Romero-García
- Department of Fundamental and Medical-Surgical Nursing, School of Nursing, Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.,Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.,Nursing Research Group (GRIN), Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain.,International Research Project: Proyecto HU-CI, Madrid, Spain
| | - María Antonia Martínez-Momblan
- Department of Fundamental and Medical-Surgical Nursing, School of Nursing, Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.,Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Gemma Martínez Estalella
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain.,Department of Fundamental and Medical-Surgical Nursing, School of Nursing, Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.,Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.,Nursing Research Group (GRIN), Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - José María Nicolas
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain.,Biomedical Research Institute August Pi Sunyer (IDIBAPS), Hospital Clínic Barcelona, Barcelona, Spain.,Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain.,Biomedical Research Institute August Pi Sunyer (IDIBAPS), Hospital Clínic Barcelona, Barcelona, Spain.,Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
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24
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Millward K, McGraw C, Aitken LM. The expressed support needs of families of adults who have survived critical illness: A thematic synthesis. Int J Nurs Stud 2021; 122:104048. [PMID: 34392173 DOI: 10.1016/j.ijnurstu.2021.104048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 07/20/2021] [Accepted: 07/20/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Surviving critical illness can result in ongoing psychological, physical and cognitive impairments for both survivors and families. During the time from the critical illness through to the period of adaptation back to community living, families, alongside survivors, have support needs. OBJECTIVES This systematic review aimed to provide an in-depth insight into the expressed support needs of families of adults who survived an admission to an intensive care unit and returned to a home environment. It also aimed to explore how these needs change over time, and what support provisions families perceived to be helpful. METHODS This was a systematic review using thematic synthesis methodology. Predefined searches were conducted in CINAHL, Medline, PsychINFO, SocIndex, EMbase, Academic Search Complete, EThOS and OpenGrey to locate studies published in English from 2000. Two reviewers screened each study against the inclusion criteria. Quality appraisal was undertaken using Joanna Briggs Institute tools. Extracted data were managed in Nvivo12® and analysed to identify descriptive and analytical themes. The Timing it Right Framework was used to frame changes in need across the recovery continuum. RESULTS Thirty-nine studies were included, 30 qualitative, eight quantitative and one mixed methods. Five key family needs were identified across the recovery continuum: for security; to make sense of the situation; finding a balance; holding everything together; and for trust. DISCUSSION Families found the following interventions helpful: written information; care coordination and navigation; input from intensive care staff after discharge to support continuity; and provision of family support groups. Although there are similarities between the needs of families and survivors, there are sufficient differences to warrant the development of processes to identify and address family need throughout the recovery continuum. CONCLUSION More research is required to develop a tool to better identify the needs of families across the recovery continuum, identify gaps in current service provision, and design interventions to meet these needs. STUDY REGISTRATION CRD42019136883 (PROSPERO).
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Affiliation(s)
- Kat Millward
- School of Health Sciences, City, University of London, 10 Northampton Square, London EC1V 0HB, United Kingdom.
| | - Caroline McGraw
- School of Health Sciences, City, University of London, 10 Northampton Square, London EC1V 0HB, United Kingdom.
| | - Leanne M Aitken
- School of Health Sciences, City, University of London, 10 Northampton Square, London EC1V 0HB, United Kingdom.
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25
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Trovó SA, Cucolo DF, Perroca MG. Transfer of patients in hospital units: impacts on nursing workload. Rev Esc Enferm USP 2021; 55:e0327. [PMID: 34161440 DOI: 10.1590/s1980-220x2020024903727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 11/06/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To measure the average time spent by the nursing team in transferring patients; to compare the activities observed during the performance of this intervention with those described by the Nursing Interventions Classification and to investigate the intensity of its influence on the workload. METHOD Observational study using timekeeping software conducted in two hospitals in the northwest region of the State of São Paulo. 200 patient transfers were monitored by the team using two validated instruments. RESULTS The average time spent by nurses on transfers ranged from 9.3 (standard deviation = 3.5) to 12.2 (standard deviation = 2.5) minutes and by assistants/ technicians between 7.1 (standard deviation = 2,8) and 11.0 (standard deviation = 2.2) minutes. 63 transfers made by nurses and 87 by assistants/technicians were considered qualified (>70% of the score). The team expended 19.3 to 29% of the working day time in this intervention. CONCLUSION The transfer of patients has an impact on the workload of the team and needs to be considered in the measurement of nursing activities for the calculation and distribution of personnel to improve the quality and continuity of care.
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Affiliation(s)
- Simone Aparecida Trovó
- Faculdade de Medicina de São José do Rio Preto, Programa de Pós-Graduação em Enfermagem, São José do Rio Preto, SP, Brazil
| | - Danielle Fabiana Cucolo
- Universidade Federal de São Carlos, Programa de Pós Graduação em Enfermagem, São Carlos, SP, Brazil.,Pontifícia Universidade Católica de Campinas, Programa de Pós Graduação de Residência Multiprofissinal em Saúde, Campinas, SP, Brazil
| | - Márcia Galan Perroca
- Faculdade de Medicina de São José do Rio Preto, Programa de Pós-Graduação em Enfermagem, São José do Rio Preto, SP, Brazil
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26
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Cuzco C, Castro Rebollo P, Marín Pérez R, Núñez Delgado AI, Romero García M, Martínez Momblan MA, Estrada Reventós D, Martínez Estalella G, Delgado-Hito P. Mixed-method research protocol: Development and evaluation of a nursing intervention in patients discharged from the intensive care unit. Nurs Open 2021; 8:3666-3676. [PMID: 33955196 PMCID: PMC8510756 DOI: 10.1002/nop2.894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/28/2021] [Accepted: 03/29/2021] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Cecilia Cuzco
- Hospital Clinic, Barcelona, Spain.,Faculty of Medicine and Health Sciences, School of Nursing, Department of Fundamental and Medical-Surgical Nursing, Universitat de Barcelona, Barcelona, Spain.,Biomedical Research Institute August Pi Sunyer (IDIBAPS), Hospital Clinic Barcelona, Barcelona, Spain
| | - Pedro Castro Rebollo
- Hospital Clinic, Barcelona, Spain.,Biomedical Research Institute August Pi Sunyer (IDIBAPS), Hospital Clinic Barcelona, Barcelona, Spain.,School of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | | | | | - Marta Romero García
- Faculty of Medicine and Health Sciences, School of Nursing, Department of Fundamental and Medical-Surgical Nursing, Universitat de Barcelona, Barcelona, Spain.,Nursing Research Group (GRIN), Bellvitge Biomedical Research Institute (IDIBELL), l'Hospitalet de Llobregat, Spain
| | - M Antonia Martínez Momblan
- Faculty of Medicine and Health Sciences, School of Nursing, Department of Fundamental and Medical-Surgical Nursing, Universitat de Barcelona, Barcelona, Spain
| | - Dolors Estrada Reventós
- Hospital Clinic, Barcelona, Spain.,Faculty of Medicine and Health Sciences, School of Nursing, Department of Fundamental and Medical-Surgical Nursing, Universitat de Barcelona, Barcelona, Spain.,Biomedical Research Institute August Pi Sunyer (IDIBAPS), Hospital Clinic Barcelona, Barcelona, Spain
| | - Gemma Martínez Estalella
- Hospital Clinic, Barcelona, Spain.,Faculty of Medicine and Health Sciences, School of Nursing, Department of Fundamental and Medical-Surgical Nursing, Universitat de Barcelona, Barcelona, Spain.,Nursing Research Group (GRIN), Bellvitge Biomedical Research Institute (IDIBELL), l'Hospitalet de Llobregat, Spain
| | - Pilar Delgado-Hito
- Faculty of Medicine and Health Sciences, School of Nursing, Department of Fundamental and Medical-Surgical Nursing, Universitat de Barcelona, Barcelona, Spain.,Nursing Research Group (GRIN), Bellvitge Biomedical Research Institute (IDIBELL), l'Hospitalet de Llobregat, Spain
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Ghorbanzadeh K, Ebadi A, Hosseini M, Madah SSB, Khankeh H. Challenges of the patient transition process from the intensive care unit: a qualitative study. Acute Crit Care 2021; 36:133-142. [PMID: 33508186 PMCID: PMC8182156 DOI: 10.4266/acc.2020.00626] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 11/23/2020] [Indexed: 11/30/2022] Open
Abstract
Background The transition of patients from the intensive care unit (ICU) to the general ward is challenging. This study aimed to explain the challenges that patients face during the transition process. Methods In this qualitative research of conventional content analysis, data collection was conducted between February 2018 and July 2019 in educational hospitals. After obtaining informed consent, purposive sampling was performed with 22 nurses, intensive care physicians, anesthesiologists, and patients and their families using in-depth semi-structured interviews until data saturation. Results The content analysis yielded three main themes in the challenges patients face during the transition process from the ICU: mixed feelings regarding transition (happiness/hope, worry/uncertainty, abandonment); care break (different atmosphere, the difference between the program and the quality of care, assigning care to the patient and family, and care culture and beliefs); and search for support and information (ineffective communication, self-care capacity of patient and family, ineffective and disrupted training, and weak follow-up programs), which inflicts care shock in the patients. Conclusions The results showed that patients and their families were in a state of care shock during the ICU transition process and were sometimes disconcerted. It is necessary to design and implement care models according to the needs and challenges patients face during the transition period from ICU (patient-centered), based on the evidence available, and after considering the field of medicine and the accessibility of care in the country. The transition process can be improved and enhanced by obtaining knowledge about ICU care and related challenges as well as organizing a learning environment.
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Affiliation(s)
- Kobra Ghorbanzadeh
- Ph.D. Candidate in Nursing, Department of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.,Department of Nursing, Khalkhal University of Medical Sciences, Khalkhal, Iran
| | - Abbas Ebadi
- Behavioral Sciences Research Center, Lifestyle Institute, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Mohammadali Hosseini
- Department of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | | | - Hamidreza Khankeh
- Health in Emergency and Disaster Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.,Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden
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Parsons Leigh J, Brundin-Mather R, Whalen-Browne L, Kashyap D, Sauro K, Soo A, Petersen J, Taljaard M, Stelfox HT. Effectiveness of an Electronic Communication Tool on Transitions in Care From the Intensive Care Unit: Protocol for a Cluster-Specific Pre-Post Trial. JMIR Res Protoc 2021; 10:e18675. [PMID: 33416509 PMCID: PMC7822720 DOI: 10.2196/18675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
- Jeanna Parsons Leigh
- School of Health Administration, Faculty of Health, Dalhousie University, Halifax, NS, Canada.,Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Rebecca Brundin-Mather
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Liam Whalen-Browne
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Devika Kashyap
- Critical Care Medicine, Alberta Health Services, Calgary, AB, Canada
| | - Khara Sauro
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Oncology, Tom Baker Cancer Centre, Calgary, AB, Canada.,Arnie Charbonneau Cancer Institute, Health Research Innovation Centre, University of Calgary, Calgary, AB, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Critical Care Medicine, Alberta Health Services, Calgary, AB, Canada
| | - Jennie Petersen
- Faculty of Applied Health Sciences, Brock University, St Catharines, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Critical Care Medicine, Alberta Health Services, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Improving ICU transitional care by combining quality management and nursing science – two scientific fields meet in a systematic literature review. INTERNATIONAL JOURNAL OF QUALITY AND SERVICE SCIENCES 2020. [DOI: 10.1108/ijqss-03-2020-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this literature review was to explore to what extent quality management (QM) and nursing science offer complementary perspectives to provide better quality care, by looking at QM core concepts and tools.
Design/methodology/approach
A systematic literature review was conducted. Papers published in academic journals between January 2013 and December 2019 were included. A deductive content analysis was chosen using QM core values as an analytical framework.
Findings
The results showed that QM core values, methodologies and tools were found in the reviewed articles about intensive care unit (ICU) transitional care. The results indicated that core values in QM and the core competencies within nursing science in ICU transitional care are mutually dependent upon each other and exist as a whole. ICU transitional care is, however, a complex interpersonal process, characterized by differences in organizational cultures and core values and involving multidisciplinary teams that collaborate across hospital units. The QM core value that was least observed was committed leadership.
Research limitations/implications
Combining QM and nursing science can contribute to a deeper understanding of how to improve the ICU transitional care process by bringing complementary perspectives.
Practical implications
The included articles portray how QM is applied in ICU transitional care. Implications for future research focus on enhancing the understanding of how QM and nursing science can bring complementary perspectives in order to improve ICU transitional care and how QM values, methodologies and tools can be used in ICU transitional care. Committed leadership and team collaboration in ICU transitional care are areas that call for further research.
Originality/value
The findings contribute to the body of literature by providing important insights in terms of how QM core values, methodologies and tools are present in research about ICU transitional care and how the two research subjects, namely, QM and nursing science, bring complementary perspectives.
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Hervé MEW, Zucatti PB, Lima MADDS. Transition of care at discharge from the Intensive Care Unit: a scoping review. Rev Lat Am Enfermagem 2020; 28:e3325. [PMID: 32696919 PMCID: PMC7365613 DOI: 10.1590/1518-8345.4008.3325] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 04/07/2020] [Indexed: 02/08/2023] Open
Abstract
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.
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31
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Bodley T, Rassos J, Mansoor W, Bell CM, Detsky ME. Improving Transitions of Care between the Intensive Care Unit and General Internal Medicine Ward. A Demonstration Study. ATS Sch 2020; 1:288-300. [PMID: 33870295 PMCID: PMC8043311 DOI: 10.34197/ats-scholar.2019-0023oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 06/15/2020] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Thomas Bodley
- Interdepartmental Division of Critical Care and
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | - James Rassos
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | - Wasim Mansoor
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
| | - Chaim M. Bell
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
- Division of General Internal Medicine, Sinai Health System and University Health Network, Toronto, Ontario, Canada
| | - Michael E. Detsky
- Interdepartmental Division of Critical Care and
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; and
- Division of General Internal Medicine, Sinai Health System and University Health Network, Toronto, Ontario, Canada
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Abstract
Surviving a critical illness can have long-term effects on both patients and families. These effects can be physical, emotional, cognitive, and social, and they affect both the patient and the family. Family members play a key role in helping their loved one recover, and this recovery process can take considerable time. Transferring out of an intensive care unit, and discharging home from a hospital, are important milestones, but they represent only the beginning of recovery and healing after a critical illness. Recognizing that these challenges exist both for patients and families is important to improve critical illness outcomes.
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Improving transitions in care from intensive care units: Development and pilot testing of an electronic communication tool for healthcare providers. J Crit Care 2020; 56:265-272. [DOI: 10.1016/j.jcrc.2020.01.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/08/2019] [Accepted: 01/16/2020] [Indexed: 11/23/2022]
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Abstract
Geriatric nurses are skilled in the special needs of hospitalized older adults. While significant focus has been placed on improving care transitions upon discharge, less attention has been placed on intra-hospital transitions. Intra-hospital transitions represent transfers occurring between hospital units or rooms. Intra-hospital transitions challenge normal nursing workflow and require careful consideration of care coordination to prevent adverse events for older adults. Frequent changes in environment and a lack of consistency in care may support the development or prolongation of delirium as older adults are transferred between units and rooms. Additional adverse event risks include infections and falls, which also increases with each transfer. Geriatric nurse involvement can enhance communication between units as well as ensuring appropriate geriatric assessments occur. Geriatric nurses are thus well positioned to act as leaders during intra-hospital transitions, potentially reducing these and adverse events.
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Affiliation(s)
- Alycia A Bristol
- Hartford Institute for Geriatric Nursing, NYU Rory Meyers College of Nursing, 433 1st Avenue, New York, NY 10010, United States.
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35
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Bowman JA, Jurkovich GJ, Nishijima DK, Utter GH. Older Adults With Isolated Rib Fractures Do Not Require Routine Intensive Care Unit Admission. J Surg Res 2019; 245:492-499. [PMID: 31446191 DOI: 10.1016/j.jss.2019.07.098] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/25/2019] [Accepted: 07/24/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Older adults with isolated rib fractures are often admitted to an intensive care unit (ICU) because of presumedly increased morbidity and mortality. However, evidence-based guidelines are limited. We sought to identify characteristics of these patients that predict the need for ICU care. MATERIALS AND METHODS We analyzed patients ≥50 y old at our center during 2013-2017 whose only indication for ICU admission, if any, was isolated rib fractures. The primary outcome was any critical care intervention (e.g., intubation) or adverse event (e.g., hypoxemia) (CCIE) based on accepted critical care guidelines. We used stepwise logistic regression to identify characteristics that predict CCIEs. RESULTS Among 401 patients, 251 (63%) were admitted to an ICU. Eighty-three patients (33%) admitted to an ICU and 7 (5%) admitted to the ward experienced a CCIE. The most common CCIEs were hypotension (10%), frequent respiratory therapy (9%), and oxygen desaturation (8%). Predictors of CCIEs included incentive spirometry <1 L (OR 4.72, 95% CI 2.14-10.45); use of a walker (OR 2.86, 95% CI 1.29-6.34); increased chest Abbreviated Injury Scale score (AIS 3 OR 5.83, 95% CI 2.34-14.50); age ≥72 y (OR 2.68, 95% CI 1.48-4.86); and active smoking (OR 2.11, 95% CI 1.06-4.20). CONCLUSIONS Routine ICU admission is not necessary for most older adults with isolated rib fractures. The predictors we identified warrant prospective evaluation for development of a clinical decision rule to preclude unnecessary ICU admissions.
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Affiliation(s)
- Jessica A Bowman
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California, Davis
| | - Gregory J Jurkovich
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California, Davis; Department of Surgery Outcomes Research Group, University of California, Davis
| | | | - Garth H Utter
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California, Davis; Department of Surgery Outcomes Research Group, University of California, Davis.
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Herling SF, Brix H, Andersen L, Jensen LD, Handesten R, Knudsen H, Bové DG. Patient and spouses experiences with transition from intensive care unit to hospital ward – qualitative study. Scand J Caring Sci 2019; 34:206-214. [DOI: 10.1111/scs.12722] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/14/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Suzanne Forsyth Herling
- Research unit: ACES, Department of Anesthesiology Copenhagen University Hospital Herlev Gentofte Herlev Denmark
- The Neuroscience Center, Rigshospitalet Copenhagen University Hospital Copenhagen Ø Denmark
| | - Helene Brix
- ICU, Department of Anesthesiology Copenhagen University Hospital Herlev Gentofte Herlev Denmark
| | - Lise Andersen
- ICU, Department of Anesthesiology Copenhagen University Hospital Herlev Gentofte Herlev Denmark
| | - Liz Daugaard Jensen
- ICU, Department of Anesthesiology Copenhagen University Hospital Herlev Gentofte Herlev Denmark
| | - Rie Handesten
- ICU, Department of Anesthesiology Copenhagen University Hospital Herlev Gentofte Herlev Denmark
| | - Heidi Knudsen
- ICU, Department of Anesthesiology Copenhagen University Hospital Herlev Gentofte Herlev Denmark
| | - Dorthe Gaby Bové
- Emergency Department Copenhagen University Hospital Nordsjælland, Hillerød Denmark
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37
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Stelfox HT, Niven DJ, Fiest KM. Discharge Home From Critical Care: Comparing Different Healthcare Systems-Reply. JAMA Intern Med 2018; 178:1729-1730. [PMID: 30508059 DOI: 10.1001/jamainternmed.2018.6548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Plate JDJ, Peelen LM, Leenen LPH, Hietbrink F. Optimizing critical care of the trauma patient at the intermediate care unit: a cost-efficient approach. Trauma Surg Acute Care Open 2018; 3:e000228. [PMID: 30402563 PMCID: PMC6203138 DOI: 10.1136/tsaco-2018-000228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 09/13/2018] [Accepted: 09/17/2018] [Indexed: 02/03/2023] Open
Abstract
Background The aim of this study was to describe the case load, safety, and cost savings of critical care of the trauma patient provided at the surgical intermediate care unit (IMCU). Methods This cohort study included all trauma admissions between January 1, 2011 and January 7, 2015 at the general intensive care unit (ICU), stand-alone neuro(surgical) IMCU, and stand-alone (trauma) surgical IMCU. Trauma mechanism, Abbreviated Injury Scale score and Injury Severity Score (ISS), vital signs, laboratory parameters, admission duration, intubation duration, ICU transfer, and in-hospital mortality were prospectively collected. Hypothetical cost savings were calculated using the fixed cost price per IMCU (US$1500) and ICU (US$2500) admission day. Results A total of 1320 admissions were included, 675 (51.1%) at the IMCU and 645 (48.9%) at the ICU. Patients admitted at the IMCU had a median ISS of 17 (11, 22). Their median duration of admission was 32.8 hours (18.8, 62.5). At the IMCU, one patient died due to aneurogenic shock. A subsequent ICU transfer was required in 38 (5.6%) IMCU admissions. Of these transfers, four patients died due to neurological deterioration. At the ICU, the median ISS was 22 (14, 30). Nearly all (n=620, 96.3%) ICU trauma patients required mechanical ventilation. Expected total cost savings due to the presence of the IMCU were US$1 772 785. Discussion A substantial amount of trauma patients in need of critical care can safely be admitted at the IMCU, without the need for further mechanical ventilation. Thereby, the IMCU could fulfill an essential cost-saving role in the management of severely injured trauma patients. Level of evidence Level IV.
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Affiliation(s)
- Joost D J Plate
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Linda M Peelen
- Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, The Netherlands.,Departments of Anesthesiology and Intensive Care Medicine, Utrecht University, Utrecht, The Netherlands
| | - Luke P H Leenen
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Falco Hietbrink
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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de Grood C, Job McIntosh C, Boyd JM, Zjadewicz K, Parsons Leigh J, Stelfox HT. Identifying essential elements to include in Intensive Care Unit to hospital ward transfer summaries: A consensus methodology. J Crit Care 2018; 49:27-32. [PMID: 30343010 DOI: 10.1016/j.jcrc.2018.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/17/2018] [Accepted: 10/04/2018] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
| | - Chloe de Grood
- Department of Community Health Sciences, TRW Building, 3(rd) Floor, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Christiane Job McIntosh
- Cardiovascular Health and Stroke Strategic Clinical Network, Alberta Health Services, 10101 Southport Road SW, Calgary, Alberta T2W 3N2, Canada
| | - Jamie M Boyd
- Department of Community Health Sciences, TRW Building, 3(rd) Floor, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
| | - Karolina Zjadewicz
- Alberta Health Services, Ground Floor, McCaig Tower, University of Calgary, 3134 Hospital Drive NW, Calgary, Alberta T2N 2T9, Canada
| | - Jeanna Parsons Leigh
- Department of Community Health Sciences, TRW Building, 3(rd) Floor, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada; Department of Critical Care Medicine, Ground Floor, McCaig Tower, University of Calgary, 3134 Hospital Drive NW, Calgary, Alberta T2N 2T9, Canada
| | - Henry Thomas Stelfox
- Department of Community Health Sciences, TRW Building, 3(rd) Floor, University of Calgary, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada; Alberta Health Services, Ground Floor, McCaig Tower, University of Calgary, 3134 Hospital Drive NW, Calgary, Alberta T2N 2T9, Canada; Department of Critical Care Medicine, Ground Floor, McCaig Tower, University of Calgary, 3134 Hospital Drive NW, Calgary, Alberta T2N 2T9, Canada.
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40
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Stelfox HT, Soo A, Niven DJ, Fiest KM, Wunsch H, Rowan KM, Bagshaw SM. Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit: A Multicenter Population-Based Cohort Study. JAMA Intern Med 2018; 178:1390-1399. [PMID: 30128550 PMCID: PMC6584269 DOI: 10.1001/jamainternmed.2018.3675] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Andrea Soo
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Health Services, Calgary, Alberta, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Anesthesia and Interdisciplinary Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kathryn M Rowan
- Intensive Care National Audit & Research Centre (ICNARC), London, England
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Alberta Health Services, Edmonton, Alberta, Canada
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Boyd JM, Roberts DJ, Parsons Leigh J, Stelfox HT. Administrator Perspectives on ICU-to-Ward Transfers and Content Contained in Existing Transfer Tools: a Cross-sectional Survey. J Gen Intern Med 2018; 33:1738-1745. [PMID: 30051330 PMCID: PMC6153252 DOI: 10.1007/s11606-018-4590-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 04/20/2018] [Accepted: 07/10/2018] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Jamie M Boyd
- Departments of Critical Care Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Derek J Roberts
- Department of Surgery, University of Calgary and the Foothills Medical Centre, Calgary, Alberta, Canada
| | - Jeanna Parsons Leigh
- Departments of Critical Care Medicine, O'Brien Institute for Public Health, University of Calgary and Alberta Health Services, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary and Alberta Health Services - Calgary Zone, Calgary, Alberta, Canada.
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