ruj 30, 2022 by Philips
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Enhancing patient outcomes, hospital flow and resource utilization through timely care transitions in the ICU

Healthcare professions carry a patient

Up to 25% of transitions from hospital ICUs are delayed1, 2, and studies have shown that the lack of or late availability of general ward beds (when patients are actually physically stable enough for a transition) causes the majority of discharge delays3, 4. Between 15-25% of ICU patient days are associated with waste5. This waste includes the opportunity cost of not being able to admit a new patient, the loss of income from surgery that was delayed due to a lack of beds, the cost of over-diagnosis and over-treatment and the cost of treating extended-stay related complications.

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Delays in care transitions from the ICU are not only an economic problem; they may also put patients at risk,6,7 including risks of medical error, over-treatment and ICU related complications, such as healthcare-associated infections (HAI)8 and delirium.9

Measuring the scope of the problem      

Solving the problem of inefficient ICU care transitions begins with understanding its scope in your institution. To create a baseline against which to assess improvements, my research suggests establishing metrics in three areas: patient flow, resource utilization and patient outcome.

 

These performance metrics acknowledge that ICU care transitions are highly interwoven with transitions in other departments. For example, if there are delays in discharging patients from the general ward, there may not be beds available for patients ready to leave the ICU. If the ICU is full, surgeries may have to be delayed until an ICU bed is available, and patients presenting to the ED may face ICU admission delay and further physiologic deterioration10. In order to implement any change, all involved stakeholders need to understand the baseline situation and current effects on their performance related to suboptimal care transitions. Therefore, parameters to measure improvement need to be meaningful to the stakeholders of the different departments that would contribute to enhancing patient transitions.

  • Patient flow can be assessed by measuring the number of rejected admissions from the ED or ICU due to capacity strain, the time from entering the ED to ICU admission and the time between a discharge decision and actual discharge. Understanding the peak hours for admission and discharge helps to determine where bottlenecks are likely. In addition, looking at readmission rates within 48 hours post-discharge provides a good indication of the quality of the current discharge process.

  • Resource utilization can be calculated by measuring capacity rates and lengths-of-stay in the ICU and general ward. Calculating nursing workload scores and nurse/patient ratios will uncover capacity strain and indicate where bottlenecks may occur. Costs associated with discharge delay should be quantified, as well as costs of avoidable complications and missed revenues, such as cancelled or delayed surgeries and not being able to treat other more acute patients.

  • Patient outcome measurements include acuity scores at admission and discharge, any change in ICU / hospital mortality, the occurrence of ICU-related complications and avoidable adverse events.

Patient in hospital room

The need for standardized discharge evaluations and criteria

One major contributor to care transition delays is a lack of a standardized discharge readiness evaluation of the patient as well as of the receiving unit. In the absence of objective and clearly defined discharge criteria, transition decisions may be based on a variety of factors: the risk comfort-level of staff, the financial incentive of either keeping patients in higher acuity settings or releasing early, capacity strain and the need to free a bed or the lack of a bed in a lower acuity unit, concern over litigation and even patient preference and available palliative care pathways.

 

A holistic discharge readiness evaluation should be multi faceted and consider patient, process, provider, organizational and social factors.

  1. Patient factors: Current patient status, the severity-of-illness level, the patient’s frailty and physiological reserve, age, co-morbidities and prognosis, and the goals of care

  2. Process factors: Communication channels, given transitions of care support and protocols and policies

  3. Provider factors: Provider experience, comfort level and the involved decision stakeholders

  4. Organizational factors: Available staffing, beds and technology, institutional policies, and hospital economic factors

  5. Social factors: Patient preferences and culture, the definition of futility of further intensive care, withholding vs. withdrawing care decisions, the balance of costs and patient outcome measured in quality of life, and the overall system costs

Healthcare profession carries patient with wheelchair

Progress toward a standardized discharge readiness assessment

Based on these factors, our research group aimed to develop a standardized and objective ICU discharge criteria list for adult patients to be used in any type of ICU. Using a modified Delphi process over five rounds of consensus voting yielded 28 criteria. These reflect on the patient’s organ systems, pain, fluid loss and drainages, medication and nutrition, patient diagnosis, prognosis and preferences, and institution-specific criteria11. We are testing these criteria now in clinical practice, to assess utility and the impact of its use on patient flow, outcome and resource utilization improvement. Our goal is to support acute care transitions by helping Intensive Care teams apply a standardized and objective assessment that identifies which patients can be safely discharged to the next lower level of care and which require further stabilization.

  1. Edenharter G, Gartner D, Heim M, Martin J, Pfeiffer U, Vogt F, Braun K, Pforringer D: Delay of transfer from the intensive care unit: a prospective observational analysis on economic effects of delayed in-house transfer. Eur J Med Res 2019, 24(1):30.
  2. Johnson DW, Schmidt UH, Bittner EA, Christensen B, Levi R, Pino RM: Delay of transfer from the intensive care unit: a prospective observational study of incidence, causes, and financial impact. Crit Care 2013, 17(4):R128.
  3. Rutherford PA, Anderson A, Kotagal UR, Luther K, Provost LP, Ryckman FC, Taylor J: Achieving hospital-wide patient flow (second edition) The right care, in the right place, at the right time. In: IHI White Paper. Edited by Improvement IfH. Boston Massachusetts: Institute for Healthcare Improvement; 2020: 72.
  4. Williams TA, Leslie GD, Brearley L, Leen T, O'Brien K: Discharge delay, room for improvement? Aust Crit Care 2010, 23:141 - 149.
  5. Almoosa, K. F., et al. Applying the New Institute for Healthcare Improvement Inpatient Waste Tool to Identify "Waste" in the Intensive Care Unit. J Healthc Qual 2016; 38(5): e29-38.
  6. McWilliams C, Lawson DJ, Santos-Rodriguez R, Gilchrist ID, Champneys A, Gould TH, Thomas MJ, Bourdeaux CP: Towards a decision support tool for intensive care discharge: machine learning algorithm development using electronic healthcare data from MIMIC III and Bristol, UK. BMJ Open 2019, 9(e025925).
  7. Howell MD. Managing ICU throughput and understanding ICU census. Curr Opin Crit Care  2011;17:626–33.
  8. European Centre for Disease Prevention and Control. Annual Epidemiological Report 2016 – Healthcare-associated infections acquired in intensive care units.
    [Internet]. Stockholm: ECDC; 2016 [cited 2022 September 01].
  9. Tiruvoipati R, Botha J, Fletcher J, Gangopadhyay H, Majumdar M, Vij S, et al. Intensive care discharge delay is associated with increased hospital length of stay: A multicentre prospective observational study.  PLoS ONE 2017; 12(7): e0181827.
  10. Cardoso L, Grion C, Matsuo T, Anami E, Kauss I, Seko L, Bonametti A: Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study. Crit Care 2011, 15(R28):8.
  11. 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):14.

Access the paper detailing the Delphi study on objective ICU discharge criteria here.

Parameters to measure improvement need to be meaningful to the stakeholders of the different departments that would contribute to enhancing patient transitions.

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