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Lin FF, Chen Y, Rattray M, Murray L, Jacobs K, Brailsford J, Free P, Garrett P, Tabah A, Ramanan M. Interventions to improve patient admission and discharge practices in adult intensive care units: A systematic review. Intensive Crit Care Nurs 2024; 85:103688. [PMID: 38494383 DOI: 10.1016/j.iccn.2024.103688] [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: 10/18/2023] [Revised: 03/08/2024] [Accepted: 03/13/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVES To identify and synthesise interventions and implementation strategies to optimise patient flow, addressing admission delays, discharge delays, and after-hours discharges in adult intensive care units. METHODS This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Five electronic databases, including CINAHL, PubMed, Emcare, Scopus, and the Cochrane Library, were searched from 2007 to 2023 to identify articles describing interventions to enhance patient flow practices in adult intensive care units. The Critical Appraisal Skills Program (CASP) tool assessed the methodological quality of the included studies. All data was synthesised using a narrative approach. SETTING Adult intensive care units. RESULTS Eight studies met the inclusion criteria, mainly comprising quality improvement projects (n = 3) or before-and-after studies (n = 4). Intervention types included changing workflow processes, introducing decision support tools, publishing quality indicator data, utilising outreach nursing services, and promoting multidisciplinary communication. Various implementation strategies were used, including one-on-one training, in-person knowledge transfer, digital communication, and digital data synthesis and display. Most studies (n = 6) reported a significant improvement in at least one intensive care process-related outcome, although fewer studies specifically reported improvements in admission delays (0/0), discharge delays (1/2), and after-hours discharge (2/4). Two out of six studies reported significant improvements in patient-related outcomes after implementing the intervention. CONCLUSION Organisational-level strategies, such as protocols and alert systems, were frequently employed to improve patient flow within ICUs, while healthcare professional-level strategies to enhance communication were less commonly used. While most studies improved ICU processes, only half succeeded in significantly reducing discharge delays and/or after-hours discharges, and only a third reported improved patient outcomes, highlighting the need for more effective interventions. IMPLICATIONS FOR CLINICAL PRACTICE The findings of this review can guide the development of evidence-based, targeted, and tailored interventions aimed at improving patient and organisational outcomes.
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Affiliation(s)
- Frances Fengzhi Lin
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia; Caring Futures Institute, Flinders University, South Australia, Australia; School of Health, University of the Sunshine Coast, Queensland, Australia.
| | - Yingyan Chen
- School of Health, University of the Sunshine Coast, Queensland, Australia
| | - Megan Rattray
- College of Medicine & Public Health, Flinders University, South Australia, Australia
| | - Lauren Murray
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Kylie Jacobs
- Redcliffe Hospital, Redcliffe, Queensland, Australia
| | - Jane Brailsford
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Patricia Free
- Caboolture Hospital, Caboolture, Queensland, Australia
| | - Peter Garrett
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Alexis Tabah
- Redcliffe Hospital, Redcliffe, Queensland, Australia
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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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Lin F, Craswell A, Murray L, Brailsford J, Cook K, Anagi S, Muir R, Garrett P, Pusapati R, Carlini J, Ramanan M. Establishing critical care nursing research priorities for three Australian regional public hospitals: A mixed method priority setting study. Intensive Crit Care Nurs 2023; 77:103440. [PMID: 37104948 DOI: 10.1016/j.iccn.2023.103440] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/04/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE To determine key priorities for critical care nursing research in three Australian regional public hospitals, representing the shared priorities of healthcare professionals and patient representatives. METHODS A three phase priority setting study, including consensus methods (nominal group), survey, qualitative interviews and focus groups were conducted between May 2021 and March 2022. Healthcare professionals and patient representatives from critical care units in regional public hospitals in Australia participated. A patient representative contributed to research design and co-authored this paper. RESULTS In phase one, 29 research topics were generated. In phase two, during a nominal group ranking process, the top 5 priority areas for each site were identified. In the final phase, three themes from focus groups and interviews included patient flow through intensive care, patient care through intensive care journey and intensive care patient recovery. CONCLUSION Identifying context specific research priorities through a priority setting exercise provides insight into the topics that are important to healthcare professionals and to patients in critical care. The top research priorities for nursing research in critical care in regional Australian hospitals include patient flow, patient recovery, and evidence based patient care through the intensive care journey, such as delirium management, pain and sedation, and mobilisation. These shared priorities will be used to guide future nursing research in critical care over the next 3-5 years. IMPLICATIONS FOR CLINICAL PRACTICE The method we used in identifying the research priorities can be used by other researchers and clinicians; close collaboration among researchers and clinicians will be beneficial for practice improvement; and how we can be reassured that our practice is evidence based is worthy of attention.
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Affiliation(s)
- Frances Lin
- School of Health, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia; Sunshine Coast Health Institute, Sunshine Coast, Queensland, Australia.
| | - Alison Craswell
- School of Health, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia; Sunshine Coast Health Institute, Sunshine Coast, Queensland, Australia; Caboolture Hospital, Metro North Hospital and Health Service, Caboolture, Queensland, Australia
| | - Lauren Murray
- Intensive Care Unit, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Jane Brailsford
- Intensive Care Unit, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Katrina Cook
- Caboolture Hospital, Metro North Hospital and Health Service, Caboolture, Queensland, Australia
| | - Shivaprasad Anagi
- Intensive Care Unit, Hervey Bay Hospital, Hervey Bay, Queensland, Australia
| | - Rachel Muir
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia; Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia; Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Kings College London, UK
| | - Peter Garrett
- Intensive Care Unit, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Raju Pusapati
- Intensive Care Unit, Hervey Bay Hospital, Hervey Bay, Queensland, Australia
| | - Joan Carlini
- Department of Marketing, Griffith University, Gold Coast, Queensland, Australia; Consumer Advisory Group, Gold Coast Health, Queensland, Australia
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Metro North Hospital and Health Service, Caboolture, Queensland, Australia
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Diwan M, Mentz G, Romano M, Engoren M. Delayed Discharge From the Intensive Care Unit Is Associated With Longer Hospital Lengths of Stay. J Cardiothorac Vasc Anesth 2023; 37:232-236. [PMID: 36402650 DOI: 10.1053/j.jvca.2022.09.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/19/2022] [Accepted: 09/24/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The study authors sought to determine if delayed discharge from the intensive care unit (ICU) secondary to a lack of floor beds led to longer postoperative hospital length of stay (LOS) or more hospital readmissions. DESIGN A retrospective study comparing patients with delayed discharge from the ICU to patients without delayed discharge. SETTING At a cardiovascular ICU in a tertiary care university hospital. PARTICIPANTS A total of 5,777 patients that were ready for discharge from the ICU after recovering from cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The authors used linear regression to measure postoperative hospital LOS and logistic regression to measure hospital readmission in patients whose transfer out of the ICU was delayed at least overnight to patients who were transferred out the same day. There were 3,903 patients transferred to the stepdown unit on the same day as the transfer order and 1,874 patients were transferred on a subsequent day. The postoperative LOS was shorter in the no delay group (9 ± 9 v 11 ± 10 days, standardized difference = 0.162), whereas the stepdown unit stay was similar (6 ± 6 v 5 ± 6 days, standardized difference = 0.076). The readmission rates were 15% in the no delay group versus 14% in the delayed discharge group (standardized difference = 0.032). After adjustment, the authors found by linear regression that delayed discharge was associated with an increase (0.72 [95% CI 0.43-1.01] days, p < 0.001) in postoperative LOS but was not associated with readmission. CONCLUSIONS The study authors found that patients who had their discharge from the ICU delayed had an increased hospital LOS but a similar rate of hospital readmission.
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Affiliation(s)
- Murtaza Diwan
- Division of Critical Care, Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Graciela Mentz
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Matthew Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Milo Engoren
- Division of Critical Care, Department of Anesthesiology, University of Michigan, Ann Arbor, MI
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Hiller M, Wittmann M, Bracht H, Bakker J. Delphi study to derive expert consensus on a set of criteria to evaluate discharge readiness for adult ICU patients to be discharged to a general ward-European perspective. BMC Health Serv Res 2022; 22:773. [PMID: 35698122 PMCID: PMC9190161 DOI: 10.1186/s12913-022-08160-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 05/19/2022] [Indexed: 12/26/2023] Open
Abstract
Background/purpose Discharge decisions in Intensive Care Unit (ICU) patients are frequently taken under pressure to free up ICU beds. In the absence of established guidelines, the evaluation of discharge readiness commonly underlies subjective judgements. The challenge is to come to the right decision at the right time for the right patient. A premature care transition puts patients at risk of readmission to the ICU. Delayed discharge is a waste of resources and may result in over-treatment and suboptimal patient flow. More objective decision support is required to assess the individual patient’s discharge readiness but also the current care capabilities of the receiving unit. Methods In a modified online Delphi process, an international panel of 27 intensive care experts reached consensus on a set of 28 intensive care discharge criteria. An initial evidence-based proposal was developed further through the panelists’ edits, adding, comments and voting over a course of 5 rounds. Consensus was defined as achieved when ≥ 90% of the experts voted for a given option on the Likert scale or in a multiple-choice survey. Round 1 to 3 focused on inclusion and exclusion of the criteria based on the consensus threshold, where round 3 was a reiteration to establish stability. Round 4 and 5 focused on the exact phrasing, values, decision makers and evaluation time frames per criterion. Results Consensus was reached on a standard set of 28 ICU discharge criteria for adult ICU patients, that reflect the patient’s organ systems ((respiratory (7), cardiovascular (9), central nervous (1), and urogenital system (2)), pain (1), fluid loss and drainages (1), medication and nutrition (1), patient diagnosis, prognosis and preferences (2) and institution-specific criteria (4). All criteria have been specified in a binary decision metric (fit for ICU discharge vs. needs further intensive therapy/monitoring), with consented value calculation methods where applicable and a criterion importance rank with “mandatory to be met” flags and applicable exceptions. Conclusion For a timely identification of stable intensive care patients and safe and efficient care transitions, a standardized discharge readiness evaluation should be based on patient factors as well as organizational boundary conditions and involve multiple stakeholders. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08160-6.
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Affiliation(s)
- Maike Hiller
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands. .,Department of Hospital Patient Monitoring, Clinical Services, Philips Medizin Systeme Böblingen GmbH, Böblingen, Germany.
| | - Maria Wittmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Hendrik Bracht
- Central Emergency Medicine Services and Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Jan Bakker
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,New York University School of Medicine and Columbia University College of Physicians & Surgeons, New York, USA.,Department of Intensive Care, Pontificia Universidad Catolica de Chile, Santiago, Chile
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Ghorbanzadeh K, Ebadi A, Hosseini M, Maddah SSB, Khankeh H, Pishkhani MK, Adiban V. Factors Influencing the Decision-making of Healthcare Providers Regarding the Transition of Patients from the Intensive Care Unit to the General Ward in Iran: A Qualitative Study. Indian J Crit Care Med 2022; 26:568-573. [PMID: 35719458 PMCID: PMC9160623 DOI: 10.5005/jp-journals-10071-24211] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Kobra Ghorbanzadeh
- Department of Nursing, Khalkhal University of Medical Sciences, Khalkhal, Iran
| | - Abbas Ebadi
- Department of 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
- Mohammadali Hosseini, Department of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran, Phone: +09121488457, e-mail:
| | | | - Hamidreza Khankeh
- Department of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran; Department of Disaster and Emergency Medicine, Karolinska Institute, Stockholm, Sweden; Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden
| | | | - Vahid Adiban
- Department of Anesthesiology, School of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
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Acosta L, Soldevila N, Torner N, Martínez A, Ayneto X, Rius C, Jané M, Domínguez A. Influenza Vaccine Effectiveness in Preventing Severe Outcomes in Patients Hospitalized with Laboratory-Confirmed Influenza during the 2017-2018 Season. A Retrospective Cohort Study in Catalonia (Spain). Viruses 2021; 13:v13081465. [PMID: 34452337 PMCID: PMC8402781 DOI: 10.3390/v13081465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/19/2021] [Accepted: 07/22/2021] [Indexed: 11/16/2022] Open
Abstract
Seasonal influenza is a common cause of hospital admission, especially in older people and those with comorbidities. The objective of this study was to determine influenza vaccine effectiveness (VE) in preventing intensive care admissions and shortening the length of stay (LOS) in hospitalized laboratory-confirmed influenza cases (HLCI) in Catalonia (Spain). A retrospective cohort study was carried out during the 2017-2018 season in HLCI aged ≥18 years from 14 public hospitals. Differences in means and proportions were assessed using a t-test or a chi-square test as necessary and the differences were quantified using standardized effect measures: Cohen's d for quantitative and Cohen's w for categorical variables. Adjusted influenza vaccine effectiveness in preventing severity was estimated by multivariate logistic regression where the adjusted VE = (1 - adjusted odds ratio) · 100%; adjustment was also made using the propensity score. We analyzed 1414 HLCI aged ≥18 years; 465 (33%) were vaccinated, of whom 437 (94%) were aged ≥60 years, 269 (57.8%) were male and 295 (63.4%) were positive for influenza type B. ICU admission was required in 214 (15.1%) cases. There were 141/1118 (12.6%) ICU admissions in patients aged ≥60 years and 73/296 (24.7%) in those aged <60 years (p < 0.001). The mean LOS and ICU LOS did not differ significantly between vaccinated and unvaccinated patients. There were 52/465 (11.2%) ICU admissions in vaccinated cases vs. 162/949 (17.1%) in unvaccinated cases. Patients admitted to the ICU had a longer hospital LOS (mean: 22.4 [SD 20.3] days) than those who were not (mean: 11.1 [SD 14.4] days); p < 0.001. Overall, vaccination was associated with a lower risk of ICU admission. Taking virus types A and B together, the estimated adjusted VE in preventing ICU admission was 31% (95% CI 1-52; p = 0.04). When stratified by viral type, the aVE was 40% for type A (95% CI -11-68; p = 0.09) and 25% for type B (95% CI -18-52; p = 0.21). Annual influenza vaccination may prevent ICU admission in cases of HLCI. A non-significantly shorter mean hospital stay was observed in vaccinated cases. Our results support the need to increase vaccination uptake and public perception of the benefits of influenza vaccination in groups at a higher risk of hospitalization and severe outcomes.
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Affiliation(s)
- Lesly Acosta
- Department of Statistics and Operations Research, Polytechnic University of Catalonia/BARCELONATECH, 08028 Barcelona, Spain;
| | - Nuria Soldevila
- CIBER Epidemiología Salud Pública, CIBERESP, PREVICET Program, 28029 Madrid, Spain; (N.S.); (A.M.); (C.R.); (M.J.); (A.D.)
- Department of Medicine, University of Barcelona, 08036 Barcelona, Spain
| | - Nuria Torner
- CIBER Epidemiología Salud Pública, CIBERESP, PREVICET Program, 28029 Madrid, Spain; (N.S.); (A.M.); (C.R.); (M.J.); (A.D.)
- Correspondence: ; Tel.: +34-934024566
| | - Ana Martínez
- CIBER Epidemiología Salud Pública, CIBERESP, PREVICET Program, 28029 Madrid, Spain; (N.S.); (A.M.); (C.R.); (M.J.); (A.D.)
- Public Health Agency of Catalonia, 08005 Barcelona, Spain;
| | - Xavier Ayneto
- Public Health Agency of Catalonia, 08005 Barcelona, Spain;
| | - Cristina Rius
- CIBER Epidemiología Salud Pública, CIBERESP, PREVICET Program, 28029 Madrid, Spain; (N.S.); (A.M.); (C.R.); (M.J.); (A.D.)
- Public Health Agency of Barcelona, 08024 Barcelona, Spain
| | - Mireia Jané
- CIBER Epidemiología Salud Pública, CIBERESP, PREVICET Program, 28029 Madrid, Spain; (N.S.); (A.M.); (C.R.); (M.J.); (A.D.)
- Department of Medicine, University of Barcelona, 08036 Barcelona, Spain
- Public Health Agency of Catalonia, 08005 Barcelona, Spain;
| | - Angela Domínguez
- CIBER Epidemiología Salud Pública, CIBERESP, PREVICET Program, 28029 Madrid, Spain; (N.S.); (A.M.); (C.R.); (M.J.); (A.D.)
- Department of Medicine, University of Barcelona, 08036 Barcelona, Spain
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Forster GM, Bihari S, Tiruvoipati R, Bailey M, Pilcher D. The Association between Discharge Delay from Intensive Care and Patient Outcomes. Am J Respir Crit Care Med 2020; 202:1399-1406. [PMID: 32649212 DOI: 10.1164/rccm.201912-2418oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Rationale: ICU discharge delay occurs when a patient is considered ready to be discharged but remains in the ICU. The effect of discharge delay on patient outcomes is uncertain.Objectives: To investigate the association between discharge delay and patient outcomes including hospital mortality, readmission to ICU, and length of hospital stay after ICU discharge.Methods: Data were accessed from the Australian and New Zealand Intensive Care Society Adult Patient Database between 2011 and 2019. Descriptive analyses and hierarchical logistic and Cox proportional hazards regression were used to examine association between discharge delay and adjusted outcomes. Patients were stratified and analyzed by categories of mortality risk at ICU admission.Measurements and Main Results: The study included 1,014,540 patients from 190 ICUs: 756,131 (75%) were discharged within 6 hours of being deemed ready, with 137,042 (13%) discharged in the next 6 hours; 17,656 (2%) were delayed 48-72 hours; 31,389 (3.1%) died in hospital; and 45,899 (4.5%) patients were readmitted to ICU. Risk-adjusted mortality declined with increasing discharge delay and was lowest at 48-72 hours (adjusted odds ratio, 0.87; 95% confidence interval, 0.79-0.94). The effect was seen in patients with predicted risk of death on admission to ICU of greater than 5% (adjusted odds ratio, 0.77; 95% confidence interval, 0.70-0.84). There was a progressive reduction in adjusted odds of readmission with increasing discharge delay.Conclusions: Increasing discharge delay in ICUs is associated with reduced likelihood of mortality and ICU readmission in high-risk patients. Consideration should be given to delay the discharge of patients with high risk of death on ICU admission.
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Affiliation(s)
- Gareth Mitchell Forster
- Department of Intensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Shailesh Bihari
- Department of Intensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences and
| | - Michael Bailey
- The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Camberwell, Victoria, Australia; and
| | - David Pilcher
- The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Camberwell, Victoria, Australia; and
- Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran, Melbourne, Victoria, Australia
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Maley JH, Anesi GL. Watchful Waiting in the ICU? Considerations for the Allocation of ICU Resources. Am J Respir Crit Care Med 2020; 202:1332-1333. [PMID: 32755485 PMCID: PMC7667905 DOI: 10.1164/rccm.202007-2873ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Jason H Maley
- Division of Pulmonary and Critical Care Medicine Massachusetts General Hospital Boston, Massachusetts
- Center for Healthcare Delivery Science Beth Israel Deaconess Medical Center Boston, Massachusetts
| | - George L Anesi
- Division of Pulmonary, Allergy, and Critical Care
- Palliative and Advanced Illness Research (PAIR) Center University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania and
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia, Pennsylvania
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Bagshaw SM, Tran DT, Opgenorth D, Wang X, Zuege DJ, Ingolfsson A, Stelfox HT, Thanh NX. Assessment of Costs of Avoidable Delays in Intensive Care Unit Discharge. JAMA Netw Open 2020; 3:e2013913. [PMID: 32822492 PMCID: PMC7439109 DOI: 10.1001/jamanetworkopen.2020.13913] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
IMPORTANCE Delays in transfer for discharge-ready patients from the intensive care unit (ICU) are increasingly described and contribute to strained capacity. OBJECTIVE To describe the epidemiological features and health care costs attributable to potentially avoidable delays in ICU discharge in a large integrated health care system. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study was performed in 17 adult ICUs in Alberta, Canada, from June 19, 2012, to December 31, 2016. Participants were patients 15 years or older admitted to a study ICU during the study period. Data were analyzed from October 19, 2018, to May 20, 2020. EXPOSURES Avoidable time in the ICU, defined as the portion of total ICU patient-days accounted for by avoidable delay in ICU discharge (eg, waiting for a ward bed). MAIN OUTCOMES AND MEASURES The primary outcome was health care costs attributable to avoidable time in the ICU. Secondary outcomes were factors associated with avoidable time, in-hospital mortality, and measures of use of health care resources, including the number of hours in the ICU and the number of days of hospitalization. Multilevel mixed multivariable regression was used to assess associations between avoidable time and outcomes. RESULTS In total, 28 904 patients (mean [SD] age, 58.3 [16.8] years; 18 030 male [62.4%]) were included. Of these, 19 964 patients (69.1%) had avoidable time during their ICU admission. The median avoidable time per patient was 7.2 (interquartile range, 2.4-27.7) hours. In multivariable analysis, male sex (odds ratio [OR], 0.92; 95% CI, 0.87-0.98), comorbid hemiplegia or paraplegia (OR 1.47; 95% CI, 1.23-1.75), liver disease (OR 1.20; 95% CI, 1.04-1.37), admission Acute Physiology and Chronic Health Evaluation II score (OR, 1.03; 95% CI, 1.02-1.03), surgical status (OR, 0.90; 95% CI, 0.82-0.98), medium community hospital type (OR, 0.12; 95% CI, 0.04-0.32), and admission year (OR, 1.16; 95% CI, 1.13-1.19) were associated with avoidable time. The cumulative avoidable time was 19 373.9 days, with estimated attributable costs of CAD$34 323 522. Avoidable time accounted for 12.8% of total ICU bed-days and 6.4% of total ICU costs. Patients with avoidable time before ICU discharge showed higher unadjusted in-hospital mortality (1115 [5.6%] vs 392 [4.4%]; P < .001); however, in multivariable analysis, avoidable time was associated with reduced in-hospital mortality (adjusted hazard ratio, 0.74; 95% CI, 0.64-0.85). Results were similar in sensitivity analyses. CONCLUSIONS AND RELEVANCE In this study, potentially avoidable discharge delay occurred for most patients admitted to ICUs across a large integrated health system and translated into substantial associated health care costs.
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Affiliation(s)
- Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Canada
- School of Public Health, University of Alberta, Edmonton, Canada
| | - Dat T. Tran
- Institute of Health Economics, Edmonton, Alberta, Canada
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
| | - Dawn Opgenorth
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Xiaoming Wang
- Health Services Statistical and Analytic Methods, Alberta Health Services, Edmonton, Canada
| | - Danny J. Zuege
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Alberta Health Services, Calgary, Canada
| | | | - Henry T. Stelfox
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Alberta Health Services, Calgary, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nguyen X. Thanh
- School of Public Health, University of Alberta, Edmonton, Canada
- Strategic Clinical Networks, Alberta Health Services, Edmonton, Canada
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11
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Kennedy TK, Numa A. Factors associated with discharge delay and direct discharge home from paediatric intensive care. J Paediatr Child Health 2020; 56:1101-1107. [PMID: 32100413 DOI: 10.1111/jpc.14829] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 01/09/2020] [Accepted: 01/27/2020] [Indexed: 11/28/2022]
Abstract
AIM To examine the patient and hospital admission characteristics associated with direct discharge home from paediatric intensive care. METHODS This was a single-centre retrospective analysis of all admissions to a tertiary metropolitan general paediatric intensive care unit (ICU) surviving to discharge over a 10-year period between 1 January 2007 and 31 December 2016, divided into two epochs defined by changes in health service structure. Patient and admission characteristics were compared between groups discharged direct to home and discharged to ward across these two epochs. RESULTS There was a marked increase in the annual rate of direct discharge to home from ICU between the two epochs (3.7-9.5%, P < 0.0001). There was an inverse relationship between monthly ICU activity and rates of direct discharge to home. Patients discharged directly home were significantly more likely to experience delay to discharge (46.4 vs. 30.7%, P < 0.0001), for that delay to exceed 24 h and comprise a greater proportion of total ICU length of stay. Bronchiolitis accounted for an increasing proportion of admissions between epochs (7.0-15.1%) and was over-represented among patients discharged direct to home (up to 18.2%). CONCLUSIONS The high observed rate of direct discharge home is likely to have resulted from increased delays to discharge and changes to patient admission characteristics, attributable to organisational restructuring and possibly changing approaches to clinical management of bronchiolitis. It is imperative to now consider how we ensure that our systems support the proper use of intensive care resources.
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Affiliation(s)
- Tessa K Kennedy
- Children's Intensive Care Unit, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Numa
- Children's Intensive Care Unit, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
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Won MH, Son YJ. Development and psychometric evaluation of the Relocation Stress Syndrome Scale-Short Form for patients transferred from adult intensive care units to general wards. Intensive Crit Care Nurs 2020; 58:102800. [DOI: 10.1016/j.iccn.2020.102800] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 12/05/2019] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
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Ofoma UR, Montoya J, Saha D, Berger A, Kirchner HL, McIlwaine JK, Kethireddy S. Associations between hospital occupancy, intensive care unit transfer delay and hospital mortality. J Crit Care 2020; 58:48-55. [PMID: 32339974 DOI: 10.1016/j.jcrc.2020.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/26/2020] [Accepted: 04/14/2020] [Indexed: 11/18/2022]
Abstract
PURPOSE Hospital occupancy (HospOcc) pressures often lead to longer intensive care unit (ICU) stay after physician recognition of discharge readiness. We evaluated the relationships between HospOcc, extended ICU stay, and patient outcomes. MATERIALS AND METHODS 7-year retrospective cohort study of 8500 alive discharge encounters from 4 adult ICUs of a tertiary hospital. We estimated associations between i) HospOcc and ICU transfer delay; and ii) ICU transfer delay and hospital mortality. RESULTS Median (IQR) ICU transfer delay was 4.8 h (1.6-11.7), 1.4% (119) suffered in-hospital death, and 4% (341) were readmitted. HospOcc was non-linearly related with ICU transfer delay, with a spline knot at 80% (mean transfer delay 8.8 h [95% CI: 8.24, 9.38]). Higher HospOcc level above 80% was associated with longer transfer delays, (mean increase 5.4% per % HospOcc increase; 95% CI, 4.7 to 6.1; P < .001). Longer ICU transfer delay was associated with increasing odds of in-hospital death or ICU readmission (odds ratio 1.01 per hour; 95% CI 1.00 to 1.01; P = .04) but not with ICU readmission alone (OR 1.01 per hour; 95% CI 1.00 to 1.01, P = .14). CONCLUSIONS ICU transfer delay exponentially increased above a threshold hospital occupancy and may be associated with increased hospital mortality.
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Affiliation(s)
- Uchenna R Ofoma
- Division of Critical Care Medicine, Washington University in St. Louis, St. Louis, MO, USA.
| | - Juan Montoya
- Division of General Internal Medicine, Geisinger Health System, Danville, PA, USA
| | - Debdoot Saha
- Division of Critical Care Medicine, Geisinger Health System, Danville, PA, USA
| | - Andrea Berger
- Department of Population Health Sciences, Geisinger Health System, Danville, PA, USA
| | - H Lester Kirchner
- Department of Population Health Sciences, Geisinger Health System, Danville, PA, USA
| | - John K McIlwaine
- Division of Critical Care Medicine, Geisinger Health System, Danville, PA, USA
| | - Shravan Kethireddy
- Department of Critical Care Medicine, Northeast Georgia Health System, Atlanta, GA, USA
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14
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Look Homeward, Intensivist. Crit Care Med 2019; 46:1015-1016. [PMID: 29762403 DOI: 10.1097/ccm.0000000000003140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Tran DT, Thanh NX, Opgenorth D, Wang X, Zuege D, Zygun DA, Stelfox HT, Bagshaw SM. Association between strained ICU capacity and healthcare costs in Canada: A population-based cohort study. J Crit Care 2019; 51:175-183. [PMID: 30852346 DOI: 10.1016/j.jcrc.2019.02.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 02/11/2019] [Accepted: 02/25/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Intensive care is resource intensive, with costs representing a substantial quantity of total hospitalization costs. Strained ICU capacity compromises care quality and adversely impacts outcomes; however, the association between strain and healthcare costs has not been explored. MATERIALS AND METHODS Population-based cohort study performed in 17 adult ICUs in Alberta, Canada. Data were captured on hospitalizations, ambulatory care, physician services and drug dispenses occurring 1-year before and 1-year after index ICU admission. Strain was defined as occupancy ≥90%; with 21 additional definitions evaluated. Patients were categorized as strain and non-strain admissions. Costs attributable to strain, were calculated as difference-in-difference costs using propensity-score matching. RESULTS 30,557 patients were included (strain: 11,830 [38.7%]; non-strain: 18,727 [61.3%]). At 1-year, strain admissions had adjusted-incremental per-patient cost of CA$9406 (95%CI, $5654-13,157) compared to non-strain admissions, due to hospitalization costs (CA$7930; 95%CI, $4553-11,307) and physician claims (CA$844; 95%CI, $430-1259). This equated to CA$111.3 million (95%CI, $66.9-155.6 million) in excess attributable costs. Strain portended longer hospitalization (3.3 days; 95%CI, 1.1-5.5); and more ambulatory visits (1.0; 95%CI, 0.1-2.0) and physician claims (9.5; 95%CI, 6.2-12.7). Incremental costs were robust across strain definitions. CONCLUSIONS Admissions to ICUs experiencing strain incur incremental costs, attributed to longer hospitalization and physician services.
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Affiliation(s)
- Dat T Tran
- Institute of Health Economics, Edmonton, Alberta, Canada
| | - Nguyen X Thanh
- Institute of Health Economics, Edmonton, Alberta, Canada; School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Dawn Opgenorth
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - Xiaoming Wang
- Research Facilitation, Analytics (DIMR), Alberta Health Services, Edmonton, Canada
| | - Danny Zuege
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - David A Zygun
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Henry T Stelfox
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada; Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sean M Bagshaw
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada.
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16
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Bose S, Johnson AEW, Moskowitz A, Celi LA, Raffa JD. Authors' Response to the Intensive Care Unit Discharge Delay and In-Hospital Mortality. J Intensive Care Med 2018:885066618816686. [PMID: 30526218 DOI: 10.1177/0885066618816686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Somnath Bose
- 1 Department of Anesthesia Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Alistair E W Johnson
- 2 Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Ari Moskowitz
- 3 Division of Pulmonary, Critical Care and Sleep Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Leo Anthony Celi
- 2 Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- 3 Division of Pulmonary, Critical Care and Sleep Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jesse D Raffa
- 2 Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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17
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Ofoma UR, Kethireddy S. Intensive Care Unit Discharge Delay and In-Hospital Mortality. J Intensive Care Med 2018:885066618816673. [PMID: 30514156 DOI: 10.1177/0885066618816673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Uchenna R Ofoma
- 1 Division of Critical Care Medicine, Geisinger Health System, Danville, PA, USA
| | - Shravan Kethireddy
- 2 Department of Critical Care Medicine, Northeast Georgia Health System, Gainesville, GA, USA
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18
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Bose S, Johnson AEW, Moskowitz A, Celi LA, Raffa JD. Impact of Intensive Care Unit Discharge Delays on Patient Outcomes: A Retrospective Cohort Study. J Intensive Care Med 2018; 34:924-929. [PMID: 30270722 DOI: 10.1177/0885066618800276] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Patients often overstay in intensive care units (ICU) after they are deemed discharge ready. The objective of this study was to examine the impact of such discharge delays (DD) on subsequent in-hospital morbidity and mortality. DESIGN Retrospective cohort study. SETTING Single tertiary academic medical center. PATIENTS Adult patients admitted to the medical ICU between 2005 and 2011. INTERVENTIONS For all patients, DD (ie, time between request for a ward bed and time of ICU discharge) was calculated. Discharge delays was dichotomized as long (≥24 hours) or short (<24 hours). Multivariable linear and logistic regressions were used to assess the association between dichotomized DD and post-ICU clinical outcomes. RESULTS Overall, 9673 discharges were included of which 10.4% patients had long DDs. In the fully adjusted model, a long delay was not associated with increased odds of death (adjusted odds ratio [aOR]: 0.99, 95% confidence interval [CI]: 0.74-1.31, P = .95) but was associated with a shorter log plus one of post-ICU discharge length of stay (LOS; regression coefficient: -0.13, 95% CI: -0.17 to -0.08, P < .001). Longer DD was not associated with more hospital-free days (HFD: a composite of post-ICU LOS and in-hospital mortality). Shorter DDs were associated with shorter LOS when LOS was measured from the time of ward bed request as opposed to the time of ICU discharge. CONCLUSIONS In this study, long DD was associated with a slight decrease in post-ICU LOS but longer LOS when measured from the point of ward bed request, suggesting a potential role for more aggressive discharge planning in the ICU for patients with long DDs. There was no association between long DD and subsequent mortality or HFD.
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Affiliation(s)
- Somnath Bose
- Department of Anesthesia Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Alistair E W Johnson
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Ari Moskowitz
- Division of Pulmonary, Critical Care and Sleep Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Leo Anthony Celi
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jesse D Raffa
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
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Perspectives on strained intensive care unit capacity: A survey of critical care professionals. PLoS One 2018; 13:e0201524. [PMID: 30133479 PMCID: PMC6104911 DOI: 10.1371/journal.pone.0201524] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 06/18/2018] [Indexed: 01/09/2023] Open
Abstract
Background Strained intensive care unit (ICU) capacity represents a supply-demand mismatch in ICU care. Limited data have explored health care worker (HCW) perceptions of strain. Methods Cross-sectional survey of HCW across 16 Alberta ICUs. A web-based questionnaire captured data on demographics, strain definition, and sources, impact and strategies for management. Results 658 HCW responded (33%; 95%CI, 32–36%), of which 452 were nurses (69%), 128 allied health (19%), 45 physicians (7%) and 33 administrators (5%). Participants (agreed/strongly agreed: 94%) reported that strain was best defined as “a time-varying imbalance between the supply of available beds, staff and/or resources and the demand to provide high-quality care for patients who may become or who are critically ill”; while some recommended defining “high-quality care”, integrating “safety”, and families in the definition. Participants reported significant contributors to strain were: “inability to discharge ICU patients due to lack of available ward beds” (97%); “increases in the volume” (89%); and “acuity and complexity of patients requiring ICU support” (88%). Strain was perceived to “increase stress levels in health care providers” (98%); and “burnout in health care providers” (96%). The highest ranked strategies were: “have more consistent and better goals-of-care conversations with patients/families outside of ICU” (95%); and “increase non-acute care beds” (92%). Interpretation Strain is perceived as common. HCW believe precipitants represent a mix of patient-related and operational factors. Strain is thought to have negative implications for quality of care, HCW well-being and workplace environment. Most indicated strategies “outside” of ICU settings were priorities for managing strain.
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González de Molina Ortiz FJ, Gordo Vidal F, Estella García A, Morrondo Valdeolmillos P, Fernández Ortega JF, Caballero López J, Pérez Villares PV, Ballesteros Sanz MA, de Haro López C, Sanchez-Izquierdo Riera JA, Serrano Lázaro A, Fuset Cabanes MP, Terceros Almanza LJ, Nuvials Casals X, Baldirà Martínez de Irujo J. "Do not do" recommendations of the working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of critically ill patients. Med Intensiva 2018; 42:425-443. [PMID: 29789183 DOI: 10.1016/j.medin.2018.04.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/24/2018] [Accepted: 04/02/2018] [Indexed: 02/06/2023]
Abstract
The project "Commitment to Quality of Scientific Societies", promoted since 2013 by the Spanish Ministry of Health, seeks to reduce unnecessary health interventions that have not proven effective, have little or doubtful effectiveness, or are not cost-effective. The objective is to establish the "do not do" recommendations for the management of critically ill patients. A panel of experts from the 13 working groups (WGs) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2000 to 2017 was extracted. The clinical evidence was discussed and summarized by the experts in the course of consensus finding of each WG, and was finally approved by the WGs after an extensive internal review process carried out during the first semester of 2017. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and aim to reduce those treatments or procedures that do not add value to the care process; avoid the exposure of critical patients to potential risks; and improve the adequacy of health resources.
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Affiliation(s)
- F J González de Molina Ortiz
- Servicio de Medicina Intensiva, Hospital Universitario Mutua Terrassa, Barcelona, España; Servicio de Medicina Intensiva, Hospital Universitario Quirón Dexeus, Barcelona, España.
| | - F Gordo Vidal
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, España
| | - A Estella García
- Servicio de Medicina Intensiva, Hospital del SAS de Jerez, Jerez, Cádiz, España
| | - P Morrondo Valdeolmillos
- Servicio de Medicina Intensiva, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - J F Fernández Ortega
- Servicio de Medicina Intensiva, Complejo Hospitalario Carlos Haya, Málaga, España
| | - J Caballero López
- Servicio de Medicina Intensiva, Hospital Universitario Arnau de Vilanova, Lleida, España
| | - P V Pérez Villares
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, España
| | - M A Ballesteros Sanz
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - C de Haro López
- Servicio de Medicina Intensiva, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, España
| | | | - A Serrano Lázaro
- Servicio de Medicina Intensiva, Hospital Clínico Universitario, Valencia, España
| | - M P Fuset Cabanes
- Servicio de Medicina Intensiva, Hospital Universitari i Politècnic la Fe, Valencia, España
| | - L J Terceros Almanza
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - X Nuvials Casals
- Servicio de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Barcelona, España
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Ofoma UR, Dong Y, Gajic O, Pickering BW. A qualitative exploration of the discharge process and factors predisposing to readmissions to the intensive care unit. BMC Health Serv Res 2018; 18:6. [PMID: 29304857 PMCID: PMC5755430 DOI: 10.1186/s12913-017-2821-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 12/28/2017] [Indexed: 11/24/2022] Open
Abstract
Background Quantitative studies have demonstrated several factors predictive of readmissions to intensive care. Clinical decision tools, derived from these factors have failed to reduce readmission rates. The purpose of this study was to qualitatively explore the experiences and perceptions of physicians and nurses to gain more insight into intensive care readmissions. Methods Semi-structured interviews of intensive care unit (ICU) and general medicine care providers explored work routines, understanding and perceptions of the discharge process, and readmissions to intensive care. Participants included ten providers from the ICU setting, including nurses (n = 5), consultant intensivists (n = 2), critical care fellows (n = 3) and 9 providers from the general medical setting, nurses (n = 4), consulting physicians (n = 2) and senior resident physicians (n = 3). Principles of grounded theory were used to analyze the interview transcripts. Results Nine factors within four broad themes were identified: (1) patient factors – severity-of-illness and undefined goals of care; (2) process factors – communication, transitions of care; (3) provider factors – discharge decision-making, provider experience and comfort level; (4) organizational factors – resource constraints, institutional policies. Conclusions Severe illness predisposes ICU patients to readmission, especially when goals of care were not adequately addressed. Communication, premature discharge, and other factors, mostly unrelated to the patient were also perceived by physicians and nurses to be associated with readmissions to intensive care. Quality improvement efforts that focus on modifying or improving aspects of non-patient factors may improve outcomes for patients at risk of ICU readmission. Electronic supplementary material The online version of this article (10.1186/s12913-017-2821-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Uchenna R Ofoma
- Division of Critical Care Medicine, Geisinger Medical Center, 100 North Academy Avenue, Danville, PA, 17822, USA.
| | - Yue Dong
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
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Healthcare Provider Perceptions of Causes and Consequences of ICU Capacity Strain in a Large Publicly Funded Integrated Health Region: A Qualitative Study. Crit Care Med 2017; 45:e347-e356. [PMID: 27635769 DOI: 10.1097/ccm.0000000000002093] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Discrepancy in the supply-demand relationship for critical care services precipitates a strain on ICU capacity. Strain can lead to suboptimal quality of care and burnout among providers and contribute to inefficient health resource utilization. We engaged interprofessional healthcare providers to explore their perceptions of the sources, impact, and strategies to manage capacity strain. DESIGN Qualitative study using a conventional thematic analysis. SETTING Nine ICUs across Alberta, Canada. SUBJECTS Nineteen focus groups (n = 122 participants). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Participants' perspectives on strain on ICU capacity and its perceived impact on providers, families, and patient care were explored. Participants defined "capacity strain" as a discrepancy between the availability of ICU beds, providers, and ICU resources (supply) and the need to admit and provide care for critically ill patients (demand). Four interrelated themes of contributors to strain were characterized (each with subthemes): patient/family related, provider related, resource related, and health system related. Patient/family-related subthemes were "increasing patient complexity/acuity," along with patient-provider communication issues ("paucity of advance care planning and goals-of-care designation," "mismatches between patient/family and provider expectations," and "timeliness of end-of-life care planning"). Provider-related factor subthemes were nursing workforce related ("nurse attrition," "inexperienced workforce," "limited mentoring opportunities," and "high patient-to-nurse ratios") and physician related ("frequent turnover/handover" and "variations in care plan"). Resource-related subthemes were "reduced service capability after hours" and "physical bed shortages." Health system-related subthemes were "variable ICU utilization," "preferential "bed" priority for other services," and "high ward bed occupancy." Participants perceived that strain had negative implications for patients ("reduced quality and safety of care" and "disrupted opportunities for patient- and family-centered care"), providers ("increased workload," "moral distress," and "burnout"), and the health system ("unnecessary, excessive, and inefficient resource utilization"). CONCLUSIONS Engagement with frontline critical care providers is essential for understanding their experiences and perspectives regarding strained capacity and for the development of sustainable strategies for improvement.
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Bose E, Chen L, Clermont G, Dubrawski A, Pinsky MR, Ren D, Hoffman LA, Hravnak M. Risk for Cardiorespiratory Instability Following Transfer to a Monitored Step-Down Unit. Respir Care 2017; 62:415-422. [PMID: 28119497 DOI: 10.4187/respcare.05001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Hospitalized patients who develop at least one instance of cardiorespiratory instability (CRI) have poorer outcomes. We sought to describe the admission characteristics, drivers, and time to onset of initial CRI events in monitored step-down unit (SDU) patients. METHODS Admission characteristics and continuous monitoring data (frequency 1/20 Hz) were recorded in 307 subjects. Vital sign deviations beyond local instability trigger threshold criteria, with a tolerance of 40 s and cumulative duration of 4 of 5 min, were classified as CRI events. The CRI driver was defined as the first vital sign to cross a threshold and meet persistence criteria. Time to onset of initial CRI was the number of days from SDU admission to initial CRI, and duration was length of the initial CRI epoch. RESULTS Subjects transferred to the SDU from units with higher monitoring capability were more likely to develop CRI (CRI n = 133 [44%] vs no CRI n = 174 [31%] P = .042). Time to onset varied according to the CRI driver. Subjects with at least one CRI event had a longer hospital stay (CRI 11.3 ± 10.2 d vs no CRI 7.8 ± 9.2 d, P < .001) and SDU stay (CRI 6.1 ± 4.9 d vs no CRI 3.5 ± 2.9 d, P < .001). First events were more often due to SpO2 , whereas breathing frequency was the most common driver of all CRI. CONCLUSIONS Initial CRI most commonly occurred due to SpO2 and was associated with prolonged SDU and hospital stay. Findings suggest the need for clinicians to more closely monitor SDU patients transferred from an ICU and parameters (SpO2 , breathing frequency) that more commonly precede CRI events.
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Affiliation(s)
- Eliezer Bose
- School of Nursing, University of Texas, Austin, Texas.
| | - Lujie Chen
- Auton Laboratory, Robotics Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | | | - Artur Dubrawski
- Auton Laboratory, Robotics Institute, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | | | - Dianxu Ren
- Department of Health and Community Systems, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leslie A Hoffman
- Department of Acute/Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
| | - Marilyn Hravnak
- Department of Acute/Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania
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24
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High-Cost Patients: Hot-Spotters Don't Explain the Half of It. J Gen Intern Med 2017; 32:28-34. [PMID: 27480529 PMCID: PMC5215147 DOI: 10.1007/s11606-016-3790-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 05/17/2016] [Accepted: 06/14/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Understanding resource utilization patterns among high-cost patients may inform cost reduction strategies. OBJECTIVE To identify patterns of high-cost healthcare utilization and associated clinical diagnoses and to quantify the significance of hot-spotters among high-cost users. DESIGN Retrospective analysis of high-cost patients in 2012 using data from electronic medical records, internal cost accounting, and the Centers for Medicare and Medicaid Services. K-medoids cluster analysis was performed on utilization measures of the highest-cost decile of patients. Clusters were compared using clinical diagnoses. We defined "hot-spotters" as those in the highest-cost decile with ≥4 hospitalizations or ED visits during the study period. PARTICIPANTS AND EXPOSURE A total of 14,855 Medicare Fee-for-service beneficiaries identified by the Medicare Quality Resource and Use Report as having received 100 % of inpatient care and ≥90 % of primary care services at Cleveland Clinic Health System (CCHS) in Northeast Ohio. The highest-cost decile was selected from this population. MAIN MEASURES Healthcare utilization and diagnoses. KEY RESULTS The highest-cost decile of patients (n = 1486) accounted for 60 % of total costs. We identified five patient clusters: "Ambulatory," with 0 admissions; "Surgical," with a median of 2 surgeries; "Critically Ill," with a median of 4 ICU days; "Frequent Care," with a median of 2 admissions, 3 ED visits, and 29 outpatient visits; and "Mixed Utilization," with 1 median admission and 1 ED visit. Cancer diagnoses were prevalent in the Ambulatory group, care complications in the Surgical group, cardiac diseases in the Critically Ill group, and psychiatric disorders in the Frequent Care group. Most hot-spotters (55 %) were in the "frequent care" cluster. Overall, hot-spotters represented 9 % of the high-cost population and accounted for 19 % of their overall costs. CONCLUSIONS High-cost patients are heterogeneous; most are not so-called "hot-spotters" with frequent admissions. Effective interventions to reduce costs will require a more multi-faceted approach to the high-cost population.
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Abstract
NHS England is to introduce a new Commissioning for Quality and Innovation to reduce delayed discharges from adult critical care to ward-level care. A delayed discharge is greater than 4 h, this occurred in 64.2% of patients in the critical care minimum data set database from Intensive Care National Audit & Research Centre from the last five years; 46.3% were delayed between 4 and 24 h and 17.9% were delayed more than 24 h. For those who had a delay in their discharge of greater than 24 h, the data suggests that "sicker" patients ultimately do better, since there was a reduction in expected mortality of 5892 patients to an actual mortality of 5201 patients over the five years. More in depth analysis of this data is necessary to try to identify which patients are more likely to benefit from extending their critical care stay once the need for organ support has abated. The current Commissioning for Quality and Innovation offers a slightly perverse incentive against this cohort of patients.
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Affiliation(s)
- Stephen Gilligan
- Department of Anaesthesia, Royal Blackburn Teaching Hospital, Blackburn, UK
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26
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Mahmoudian-Dehkordi A, Sadat S. Sustaining critical care: using evidence-based simulation to evaluate ICU management policies. Health Care Manag Sci 2016; 20:532-547. [PMID: 27216611 DOI: 10.1007/s10729-016-9369-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 05/10/2016] [Indexed: 10/21/2022]
Abstract
Intensive Care Units (ICU) are costly yet critical hospital departments that should be available to care for patients needing highly specialized critical care. Shortage of ICU beds in many regions of the world and the constant fire-fighting to make these beds available through various ICU management policies motivated this study. The paper discusses the application of a generic system dynamics model of emergency patient flow in a typical hospital, populated with empirical evidence found in the medical and hospital administration literature, to explore the dynamics of intended and unintended consequences of such ICU management policies under a natural disaster crisis scenario. ICU management policies that can be implemented by a single hospital on short notice, namely premature transfer from ICU, boarding in ward, and general ward admission control, along with their possible combinations, are modeled and their impact on managerial and health outcome measures are investigated. The main insight out of the study is that the general ward admission control policy outperforms the rest of ICU management policies under such crisis scenarios with regards to reducing total mortality, which is counter intuitive for hospital administrators as this policy is not very effective at alleviating the symptoms of the problem, namely high ED and ICU occupancy rates that are closely monitored by hospital management particularly in times of crisis. A multivariate sensitivity analysis on parameters with diverse range of values in the literature found the superiority of the general ward admission control to hold true in every scenario.
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Affiliation(s)
| | - Somayeh Sadat
- Health Systems Engineering Program, Faculty of Industrial and Systems Engineering, Tarbiat Modares University, Tehran, Iran.
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27
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Zhou G, Ho KM. Procalcitonin concentrations as a predictor of unexpected readmission and mortality after intensive care unit discharge: A retrospective cohort study. J Crit Care 2016; 33:240-4. [PMID: 27020769 DOI: 10.1016/j.jcrc.2016.02.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 01/20/2016] [Accepted: 02/07/2016] [Indexed: 10/22/2022]
Abstract
Procalcitonin (PCT) has been used to guide treatment in critically ill patients with sepsis, but whether PCT at intensive care unit (ICU) discharge can stratify risks of post-ICU readmission or mortality is unknown. This cohort study compared the ability of PCT with C-reactive protein (CRP) in predicting unexpected adverse post-ICU events. Of the 1877 patients admitted to the multidisciplinary ICU between 1 April 2012 and 31 March 2014, 1653 (88.1%) were discharged without treatment limitations. A total of 71 (4.3%) were readmitted and 18 patients (1%) died unexpectedly after ICU discharge during the same hospitalization. Both PCT (0.6 vs 0.4 μg/L, P = .002) and a high CRP concentration >100 mg/L (58% vs 41%, P = .004) at ICU discharge were associated with an increased risk of adverse post-ICU events in the univariate analyses; however, the ability of PCT to discriminate between patients with and without adverse post-ICU outcomes was limited (area under the receiver operating characteristic curve = 0.61; 95% confidence interval, 0.55-0.66). In the multivariable analysis, only a high CRP concentration (odds ratio, 1.92; 95% confidence interval, 1.12-3.11; P = .008) was associated with an increased adverse post-ICU events. Elevated PCT concentration at ICU discharge was inadequate in its predictive ability to guide ICU discharge.
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Affiliation(s)
- George Zhou
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, WA 6000, Australia.
| | - Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, WA 6000, Australia; School of Population Health, University of Western Australia, Perth, WA 6000, Australia; School of Veterinary and Life Sciences, Murdoch University, Perth, 6150, Australia
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An Integrative Literature Review of Organisational Factors Associated with Admission and Discharge Delays in Critical Care. BIOMED RESEARCH INTERNATIONAL 2015; 2015:868653. [PMID: 26558286 PMCID: PMC4629003 DOI: 10.1155/2015/868653] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 07/16/2015] [Accepted: 07/26/2015] [Indexed: 12/03/2022]
Abstract
The literature shows that delayed admission to the intensive care unit (ICU) and discharge delays from the ICU are associated with increased adverse events and higher costs. Identifying factors related to delays will provide information to practice improvements, which contribute to better patient outcomes. The aim of this integrative review was to explore the incidence of patients' admission and discharge delays in critical care and to identify organisational factors associated with these delays. Seven studies were included. The major findings are as follows: (1) explanatory research about discharge delays is scarce and one study on admission delays was found, (2) delays are a common problem mostly due to organisational factors, occurring in 38% of admissions and 22–67% of discharges, and (3) redesigning care processes by improving information management and coordination between units and interdisciplinary teams could reduce discharge delays. In conclusion, patient outcomes can be improved through efficient and safe care processes. More exploratory research is needed to identify factors that contribute to admission and discharge delays to provide evidence for clinical practice improvements. Shortening delays requires an interdisciplinary and multifaceted approach to the whole patient flow process. Conclusions should be made with caution due to the limited number of articles included in this review.
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A Practical, Global Perspective on Using Administrative Data to Conduct Intensive Care Unit Research. Ann Am Thorac Soc 2015; 12:1373-86. [DOI: 10.1513/annalsats.201503-136fr] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Olafson K, Ramsey C, Yogendran M, Fransoo R, Chrusch C, Forget E, Garland A. Surge capacity: analysis of census fluctuations to estimate the number of intensive care unit beds needed. Health Serv Res 2014; 50:237-52. [PMID: 25040848 DOI: 10.1111/1475-6773.12209] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To compare methods of characterizing intensive care unit (ICU) bed use and estimate the number of beds needed. STUDY SETTING Three geographic regions in the Canadian province of Manitoba. STUDY DESIGN Retrospective analysis of population-based data from April 1, 2000, to March 31, 2007. METHODS We compared three methods to estimate ICU bed requirements. Method 1 analyzed yearly patient-days. Methods 2 and 3 analyzed day-to-day fluctuations in patient census; these differed by whether each hospital needed to independently fulfill its own demand or this resource was shared across hospitals. PRINCIPAL FINDINGS Three main findings were as follows: (1) estimates based on yearly average usage generally underestimated the number of beds needed compared to analysis of fluctuations in census, especially in the smaller regions where underestimation ranged 25-58 percent; (2) 4-29 percent fewer beds were needed if it was acceptable for demand to exceed supply 18 days/year, versus 4 days/year; and (3) 13-36 percent fewer beds were needed if hospitals within a region could effectively share ICU beds. CONCLUSIONS Compared to using yearly averages, analyzing day-to-day fluctuations in patient census gives a more accurate picture of ICU bed use. Failing to provide adequate "surge capacity" can lead to demand that frequently and severely exceeds supply.
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Affiliation(s)
- Kendiss Olafson
- Section of Critical Care, Department of Medicine, University of Manitoba, Winnipeg, MB
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31
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Organizing safe transitions from intensive care. Nurs Res Pract 2014; 2014:175314. [PMID: 24782924 PMCID: PMC3982467 DOI: 10.1155/2014/175314] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 02/13/2014] [Accepted: 02/13/2014] [Indexed: 02/06/2023] Open
Abstract
Background. Organizing and performing patient transfers in the continuum of care is part of the work of nurses and other staff of a multiprofessional healthcare team. An understanding of discharge practices is needed in order to ultimate patients' transfers from high technological intensive care units (ICU) to general wards. Aim. To describe, as experienced by intensive care and general ward staff, what strategies could be used when organizing patient's care before, during, and after transfer from intensive care. Method. Interviews of 15 participants were conducted, audio-taped, transcribed verbatim, and analyzed using qualitative content analysis. Results. The results showed that the categories secure, encourage, and collaborate are strategies used in the three phases of the ICU transitional care process. The main category; a safe, interactive rehabilitation process, illustrated how all strategies were characterized by an intention to create and maintain safety during the process. A three-way interaction was described: between staff and patient/families, between team members and involved units, and between patient/family and environment. Discussion/Conclusions. The findings highlight that ICU transitional care implies critical care rehabilitation. Discharge procedures need to be safe and structured and involve collaboration, encouraging support, optimal timing, early mobilization, and a multidiscipline approach.
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Blot S, Afonso E, Labeau S. Insights and advances in multidisciplinary critical care: a review of recent research. Am J Crit Care 2014; 23:70-80. [PMID: 24382619 DOI: 10.4037/ajcc2014403] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The intensive care unit is a work environment where superior dedication is pivotal to optimize patients' outcomes. As this demanding commitment is multidisciplinary in nature, it requires special qualities of health care workers and organizations. Thus research in the field covers a broad spectrum of activities necessary to deliver cutting-edge care. However, given the abundance of research articles and education activities available, it is difficult for modern critical care clinicians to keep up with the latest progress and innovations in the field. This article broadly summarizes new developments in multidisciplinary intensive care, providing elementary information about advanced insights in the field by briefly describing selected articles bundled in specific topics. Issues considered include cardiovascular care, monitoring, mechanical ventilation, infection and sepsis, nutrition, education, patient safety, pain assessment and control, delirium, mental health, ethics, and outcomes research.
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Affiliation(s)
- Stijn Blot
- Stijn Blot is a professor in the Department of Internal Medicine, Faculty of Medicine and Health Science, Ghent University, Belgium. Elsa Afonso is a research nurse and clinical trial coordinator, CIBERES, Barcelona, Spain. Sonia Labeau is a lecturer in the Faculty of Education, Health and Social Work, University College Ghent, Belgium
| | - Elsa Afonso
- Stijn Blot is a professor in the Department of Internal Medicine, Faculty of Medicine and Health Science, Ghent University, Belgium. Elsa Afonso is a research nurse and clinical trial coordinator, CIBERES, Barcelona, Spain. Sonia Labeau is a lecturer in the Faculty of Education, Health and Social Work, University College Ghent, Belgium
| | - Sonia Labeau
- Stijn Blot is a professor in the Department of Internal Medicine, Faculty of Medicine and Health Science, Ghent University, Belgium. Elsa Afonso is a research nurse and clinical trial coordinator, CIBERES, Barcelona, Spain. Sonia Labeau is a lecturer in the Faculty of Education, Health and Social Work, University College Ghent, Belgium
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33
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Garland A. Response. Am J Crit Care 2013; 22:464. [PMID: 24186813 DOI: 10.4037/ajcc2013593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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34
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Baggs J. Multidisciplinary decision making needed for patient transfers. Am J Crit Care 2013; 22:464. [PMID: 24186812 DOI: 10.4037/ajcc2013116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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