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Improving transitions of care from ICU/HDU to ward settings

Improving transitions of care from ICU/HDU to ward settings


GOALS:
To improve transitions of care to a ward setting for our most at-risk ICU/HDU patients in order to:

  • reduce readmission rates to ICU/HDU
  • reduce delays in patient discharge
  • reduce the number of out-of-hours discharges

Why?

  • Patients who are in our Intensive Care / High Dependency Unit (ICU/ HDU) at North Shore Hospital are, by definition, some of the sickest patients in the hospital. Because of this the ICU/HDU is equipped with better technology and higher staff ratios than a general ward environment.
  • Transition of these patients to the ward is a high-risk process which can expose our vulnerable patients to preventable adverse events.

What did we find?

  • Literature reviews of best evidence-based practiced determined that a safe transition of care involves coordination, optimal timing, participation and a multidisciplinary-team (MDT) approach
  • We reviewed other ICU/HDUs around New Zealand and found that many had more structured processes for discharging ‘long-term’ ICU/HDU patients
  • Surveys of ward staff about their experience with taking over patients from ICU/HDU identified that there were issues around handover and timing of transitions of care
  • Feedback from a small group of patients and family members about their discharge experiences showed that some found the transition scary - “Leaving ICU/HDU was frightening

What did we do?

  1. Definition of long-term / vulnerable patient
    We developed a criteria for ‘long-term’ ICU/HDU patients:
    72 hours ventilated or any patient with ICU/HDU length of stay (or expected LOS) of 7 days or more
  2. Multidiscplinary team compositionInitiated weekly multi-disciplinary team meetings
    We implemented weekly multi-disciplinary team (MDT) meetings in September 2014 with the purpose of reviewing and planning the transition of care for our identified long-term patients
  3. Pre-discharge visits by Critical Care Outreach Team
    All patients meeting the ‘long-term’ criteria are visited by the Critical Care Outreach Team (CCOT) prior to discharge to:
    • introduce the CCOT’s follow-up service
    • provide information and reassurance about ward transfer and answer any questions about the ward environment
    • emphasise progress made in patient’s care / treatment
    • discuss ongoing care requirements with the bedside nurse
  4. Combined nursing and medical discharge document
    We developed a discharge / transfer form for ICU/HDU to combine nursing and medical information in order to improve our discharge processes.

We also identified the following key performance indicators to monitor how we are doing and to identify improvements from these changes in practice:

  • Readmission rate
  • Delayed discharge
  • Out-of-hours discharge

Did we make a difference?

Feedback from staff on our new process for improving transitions of care from ICU/HDU to the ward setting has been overwhelmingly positive, with all stakeholders agreeing that this is making a positive difference to our most at-risk patients.

Process outcomes

  • We have a consistent process to identify long-term / vulnerable patients and all of those identified receive reviews at MDT meetings and CCOT pre-discharge visits
  • We have increased MDT referrals and collaboration
  • We have improved the handover process

Feedback from ward staff

Staff outcomes

  • Staff have a greater awareness and ownership of discharge process
  • There is improved communication and collaboration
  • We have improved the ability to provide holistic care during the ward transition period

Feedback from ICU/HDU staff

Patient outcomes

  • There have been no patient adverse events reported since practice changes implemented
  • We have increased the provision of “Going to the ward” information leaflet to patients / family members

Where to from here?

  • Obtain patient feedback about their experience of transition to identify improvements from our practice changes
  • Continue to monitor our key performance indicators

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