ICU Transfer Best Practices

The Role of Stepdown Beds in Hospital Care

Source: American Journal of Respiratory and Critical Care Medicine (2014)

Abstract: Stepdown beds provide an intermediate level of care for patients with requirements somewhere between that of the general ward and the intensive care unit. Models of care include incorporation of stepdown beds into intensive care units, stand-alone units, or incorporation of beds into standard wards. Stepdown beds may be used to provide a higher level of care for patients deteriorating on a ward (“step-up”), a lower level of care for patients transitioning out of intensive care (“stepdown”) or a lateral transfer of care from a recovery room for postoperative patients. These units are one possible strategy to improve critical care cost-effectiveness and patient flow without compromising quality, but these potential benefits remain primarily theoretical as few patient-level studies provide concrete evidence.

This journal article highlights topics such as patient selection for Stepdown unit care, the location of Stepdown beds, unit staffing, and patient outcomes related to Stepdown unit care.

 

When to Introduce a Step Down Unit

Source: Columbia University (2013)

Abstract: There is an ongoing debate in the medical community as to whether and how SDUs should be used. On one hand, an SDU alleviates ICU congestion by providing a safe environment for post-ICU patients before they are stable enough to be transferred to the general wards. On the other hand, an SDU can take capacity away from the already over-congested ICU. In this work, we propose a queueing model of patient flow through the ICU and SDU in order to determine when an SDU is needed and what size it should be.

 

Opportunities to Improve Transfer from ICU to Hospital Ward

Source: BMJ Open (2015)

Abstract: The transfer of patient care between the intensive care unit (ICU) and the hospital ward is associated with increased risk of medical error and adverse events. This study will describe patient transfer from ICU to hospital ward by documenting (1) patient, family and provider experiences related to ICU transfer, (2) communication between stakeholders involved in ICU transfer, (3) adverse events that follow ICU transfer and (4) opportunities to improve ICU to hospital ward transfer.

This journal article highlights topics such as communication breakdown during transfer, multiprofessional transfer, and resource limitations.

 

An Innovative Approach to the ICU to Ward Transition of Care

Source: Society of Hospital Medicine (2015)

Abstract: Transfers from the ICU to the medical ward pose a number of unique risks to patients recovering from critical illness. Several studies have identified communication breakdown among physicians and nurses at the time of transfer as a key vulnerability. This dilemma is particularly challenging in the context of tertiary institutions with high levels of patient acuity and complexity. Unfortunately, no studies are available to provide guidance as to the optimal transfer mechanism in this setting. To describe an innovative reorganization of the transfer process at Wake Forest Baptist Health. Our aim was to collaboratively involve transferring physicians, nurse managers, and hospital bed logistics personnel in a proactive multi-disciplinary daily handoff process.

 

Intrafacility Transport Guidelines

Source: Critical Care Nurse (2015)

Abstract: Adult critical care patients in an academic medical center experienced adverse events during intrafacility transport resulting from lack of preparation. An intervention was needed to help keep patients safe during intrafacility transport. Reported adverse outcomes for patients include alterations in vital signs, changes in intracranial pressure, variations in partial pressure of oxygen in brain tissue, agitation, hypoxia, deep vein thrombosis, pneumothorax, ventilator-associated pneumonia, atelectasis, and alterations in blood glucose levels. Equipment-related events are also frequently reported. Examples include equipment failure, disconnected or tangled tubes and wires, and depleted oxygen supply.

How to Inform Your ICU Discharge/Transfer Strategy

Source: The American College of Chest Physicians (2015)

Abstract: The discharge of patients from the ICU to a hospital ward is a challenging transition of care, attributable to (1) caring for patients with the highest acuity of illness in the hospital, (2) transitioning from a resource-rich environment to one with fewer resources, (3) the number and complexity of providers (multiprofessional and interspecialty) involved, (4) a lack of standardized discharge procedures, and (5) a high frequency of verbal and written communication failures between providers, and between providers and patients/families. There is a growing body of evidence that suggests transitions of care are vulnerable moments in health-care delivery associated with medical errors, adverse events, poor patient satisfaction with care, increased health-care costs, and increased mortality.

To improve patient discharge from ICU, we need to understand current discharge practices and opportunities for improvement. At present, there is no comprehensive summary of the literature describing patient discharge from ICU. This suggests that there is unlikely to be a simple universal solution (eg, single discharge checklist) to address the challenges of patient discharge from ICU. Rather, meaningful improvement is most likely to occur with a series of interrelated interventions to “reengineer” the structure and process of patient discharge from ICU.

TABLE 6. Literature-Derived Candidate Elements to Inform an ICU Discharge Strategy

• Structures to facilitate patient discharge
• Guidelines or policies to apply and standardize best practices
• Triage models to identify patients with greatest need for ICU care
• Education programs to train providers
• Processes of patient discharge
• Risk stratification to evaluate patient readiness for discharge from ICU
• Plan for discharge
• Inform patient and family of discharge planning
• Identify receiving team and discharge location
• Activate patient family and support systems
• Introduce patient and family to receiving team if not previously acquainted
• Educate patient and family about care received, care planned, discharge process, and discharge location
• Reconcile medications
• Reconcile patient goals of care
• Summarize patient medical problems/care and communicate to receiving team
• Execute discharge
• Determine best day of week and best time of day for discharge
• Discharge patient when ready—minimize delays once ready to discharge
• Verbally communicate handoff between providers
• Complete checklist to ensure all necessary steps performed
• Follow up patient post-discharge
• Outcomes of patient discharge
• Measure outcomes
• Patient, family, and provider anxiety
• Adverse events
• Medical emergency team activation/rescue
• Readmission to ICU
• Mortality
• Patient, family, and provider satisfaction

This suggests that one potential strategy to improve patient discharge from ICU is to initiate discharge planning early in patients’ ICU stay and potentially overlap the care provided to patients by critical care medicine providers and hospital ward providers both before and after patients leave ICU. This may be particularly important for patients who do not have hospital ward providers engaged in their care throughout their ICU stay. Overlapping provider care, although conceptually attractive, would necessitate effective communication (a frequently reported challenge during discharge) and careful management of the transfer of accountability and responsibility for patient care. Discharge planning tools can help standardize the multistep, multidimensional ICU discharge process and ensure that all essential steps are completed before patients leave the ICU. In addition, they provide an opportunity to engage patients and their families in the discharge process (eg, patient/family information), enhance continuity of care, and potentially reduce transfer anxiety, while improving the patient care experience.