Reengineering the Discharge of Elderly Patients from Intensive Care

The aim of this research was to better understand current intensive care unit (ICU) discharge practices.

Research Results

Findings: Data from this study indicate that most providers, patients and family members perceive the transition of care from ICU to hospital ward to be effective. However, there are clear opportunities for improvement that can be used to guide interventions: (1) engage ward nurses in the transfer process, (2) develop a written communication tool to ensure transfer of all important clinical information between providers, (3) develop a written communication tool to inform patients and family members of the care received and ongoing treatment plan and (4) develop a goals of care reconciliation tool to ensure that goals of care are reviewed at the time of patient transfer.

Impact of findings: We anticipate that an ICU discharge tool kit will reduce errors by improving communication, reduce readmission by improving continuity of care plans, and reduce ICU/hospital length of stay by initiating earlier discharge planning. Administrators or policy makers could use the knowledge generated through this work to improve the allocation of scarce resources, reduce unnecessary healthcare costs and improve elderly patient satisfaction with care. Ultimately, improving the ICU discharge process is important for optimizing the quality of care provided to elderly patients during these high-risk transitions. Furthermore, our findings aim to enhance patient/family care experience by empowering patients/family to facilitate their own continuity of care.

Publications, presentations and webinars

For more information on why this research matters, click the links below:

Policy        Families        Researchers

About the Project

The transition of patient care from the ICU to a hospital ward is a challenging time in healthcare delivery, often exposing patients to medical errors and adverse events. The critically ill frail elderly are at high risk of experiencing such an error or event.

The goal of this project was to describe the experiences and communication of stakeholders during patient transfer from ICU to hospital ward to identify opportunities to improve ICU discharge process and inform the development of an ICU discharge tool kit.

For more details on the project rationale, hypothesis, objectives and research plan, click here.

Project Team

Principal Investigators:

Henry Stelfox, BMSc, MD, PhD — University of Calgary

Sean Bagshaw, MD, MSc, FRCPC — University of Alberta

Peter Dodek, MD, MHSc — University of British Columbia

Alan Forster, MD, FRCPC, MSc — Ottawa Hospital Research Institute

Robert Fowler, MD, MSc — Sunnybrook Research Institute

François Lamontagne, MD, MSc — Université de Sherbrooke

Alexis Turgeon, MD, MSc — Université Laval

Co-Investigators:

Chaim Bell, PhD, MD — University of Toronto

Niall Ferguson, MSc, MD — University Health Network

William Ghali, MD, MPH, FRCPC — University of Calgary

Daniel Niven, MD — University of Calgary

Thomas Ricento, PhD — University of Calgary

Orla Smith, PhD candidate, MN, BScN — University of Toronto

Sharon Straus, MD, MSc, HBSc — University of Toronto

Deborah White, PhD, MN, BScN, RN — University of Calgary

Knowledge Users and Partners:

Paul Boucher — Alberta Health Services

Chris Doig — Alberta Health Services

Song Gao — Alberta Health Services

Janice Lo — University of British Columbia

Nancy Marlett — Alberta Health Services

Claudio Martin — Canadian Critical Care Society

Maire McAdams — B.C. Ministry of Health

Tom Noseworthy — University of Calgary

Dan Zuege — Alberta Health Services

David Zygun — Alberta Health Services 

Project Contact: Dr. Henry Stelfox — tstelfox@ucalgary.ca

CORE 2013-12

Key words: intensive care; critical care; elderly; quality of care; continuity of care; transitions of care; communication; chart review; surveys; interviews

Key Findings For Families

The aim of this research was to better understand current intensive care unit (ICU) discharge practices.

Project Contact: Dr. Henry Stelfox — tstelfox@ucalgary.ca

Key Findings for Families

The results of this study can help design a better transfer process from the ICU to other hospital units.

Most people involved with the care of the elderly in the ICU, and the patients, thought the transition from the ICU to other hospital units was good, but some areas for improvement were found: 

  • Make sure nurses are involved in the process 
  • A tool to make sure all important information is provided to doctors and nurses would be helpful 
  • A tool for doctors and nurses to make communication easier with patients and family members about the care received and ongoing treatment plan 
  • A tool to help talk about goals of care

Why This Matters

The transfer from the ICU to another hospital ward can result in more adverse events because they go to a unit with less intensive care and less resources. Moving from one unit to another can also result in loss of information about the care received during the ICU.

About This Study

  • This study included 451 patients from 10 ICUs across Canada
  • Information was collected from patients, family members and health care providers
  • Information was collected using surveys, interviews and health record reviews

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Policy

The aim of this research was to better understand current intensive care unit (ICU) discharge practices.

Project Contact: Dr. Henry Stelfox — tstelfox@ucalgary.ca

Key Findings for Policy

While the transition of care from ICU to hospital ward was perceived to be effective, clear opportunities for improvement were identified: 

  • Engage ward nurses in the transfer process 
  • Develop a written communication tool to ensure transfer of key clinical information between providers 
  • Develop a written communication tool to facilitate communication with patients and family members about the care received and ongoing treatment plan 
  • Develop a reconciliation tool to ensure that goals of care are reviewed at the time of patient transfer

The recommendations highlighted in this study could improve safety and quality of care during the transfer of the elderly from the ICU to hospital wards.

  • Lack of ward nurse involvement in the ICU to hospital transfer may mean that patients are sometimes transferred into the care of providers who are not comfortable caring for them or do not have the resources or time to care for them
  • Tools to document patient information so that it is available at the point of care could improve communication during patient transfer from ICU to hospital ward
  • Improving communication with patients and/or family members about goals of care can improve engagement of patients in decision making around their health care resulting in improved quality of care

Why This Study was Needed

The transfer between the ICU to hospital ward is a vulnerable period and may increase risk of adverse events. Patients who are transferred from ICU to hospital experience a drop in intensive care, fewer resources to care for patients in the hospital ward and increased risk that information about their care will not be accurately transferred in a timely manner during the ICU to hospital ward transfer process.

Study Summary

This was a mixed method prospective observational study of ICU to hospital ward transfer practices for 451 patients in 10 ICUs across Canada. Data were collected from patients, family members and health care providers using surveys (n=451), interviews (n=31) and health record reviews (n=451).

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Researchers

The aim of this research was to better understand current intensive care unit (ICU) discharge practices.

Project Contact: Dr. Henry Stelfox — tstelfox@ucalgary.ca

Key Findings for Researchers

While the transition of care from ICU to hospital ward was perceived to be effective, clear opportunities for improvement were identified: 

  • Engage ward nurses in the transfer process 
  • Develop a written communication tool to ensure transfer of key clinical information between providers 
  • Develop a written communication tool to facilitate communication with patients and family members about the care received and ongoing treatment plan 
  • Develop a reconciliation tool to ensure that goals of care are reviewed at the time of patient transfer

Key criteria could improve the discharge of the elderly from the ICU.

  • Lack of ward nurse involvement in the ICU to hospital transfer may mean that patients are sometimes transferred into the care of providers who are not comfortable caring for them or do not have the resources or time to care for them
  • Tools to document patient information so that it is available at the point of care could improve communication during patient transfer from ICU to hospital ward
  • Improving communication with patients and/or family members about goals of care can improve engagement of patients in decision making around their health care resulting in improved quality of care

Why This Study was Needed

The transfer between the ICU to hospital ward is a vulnerable period in health care delivery and may increase risk of adverse events. Patients who are transferred from ICU to hospital experience a drop in intensive care, fewer resources to care for patients in the hospital ward and increased risk that information about their care will not be accurately transferred in a timely manner during the ICU to hospital ward transfer process.

Study Summary

This was a mixed method prospective observational study of ICU to hospital ward transfer practices for 451 patients in 10 ICUs across Canada. Data were collected from patients, family members and health care providers using surveys (n=451), interviews (n=31) and health record reviews (n=451).

Future Research

  • A tool to facilitate written and face-to-face communication between stakeholders involved in the transfer of patients from ICU to hospital ward needs to be developed. 
  • Evaluation of the effectiveness of these tools for improving the transfer of information and how it impacts patient care needs to be conducted. 

Back to CORE 2013-12 Project Page

Publications

The aim of this research was to better understand current intensive care unit (ICU) discharge practices.

Principal Investigators

Henry Stelfox, BMSc, MD, PhD — University of Calgary

Sean Bagshaw, MD, MSc, FRCPC — University of Alberta

Peter Dodek, MD, MHSc — University of British Columbia

Alan Forster, MD, FRCPC, MSc — Ottawa Hospital Research Institute

Robert Fowler, MD, MSc — Sunnybrook Research Institute

François Lamontagne, MD, MSc — Université de Sherbrooke

Alexis Turgeon, MD, MSc — Université Laval

Publications

de Grood C, Parsons Leigh J, Bagshaw SM, Dodek PM, Fowler RA, Forster AJ, Boyd JM and Stelfox HT. Patient, family and provider experiences with transfers from intensive care unit to hospital ward: a multicentre qualitative study. CMAJ June 04, 2018 190 (22) E669-E676; DOI: https://doi.org/10.1503/cmaj.170588

Stelfox HT, Leigh JP, Dodek PM, Turgeon AF, Forster AJ, Lamontagne F, Fowler RA, SooA, Bagshaw SM. A multi-center prospective cohort study of patient transfers from the intensive care unit to the hospital ward. Intensive Care Med. 2017 Aug 29. doi: 10.1007/s00134-017-4910-1. [Epub ahead of print]

Stelfox, H.T., Bastos, J., Niven, D., Bagshaw, S.M., Turin, T.C., Gao, S. (March 2016). Critical care transition programs and the risk of readmission or death after discharge from ICU. Intensive Care Med 42, 401-410pp. Doi: 10.1097/CCM.0b013e3182a272c0.

Buchner, D., Bagshaw, S.M., Dodek, P., Fowler, R., Lamontagne, F., Turgeon, A., Potestio, M., Stelfox, H.T. (January 2015). Perspective cohort study protocol to describe the transfer of patients from intensive care units to hospital wards. BMJ Open 2015 5: doi: 10.1136/bmjopen-2015.

Azevedo, L.C., de Souza, I.A., Zygun, D.A., Stelfox, H.T., Bagshaw, S.M. (September 2015). Association Between Nighttime Discharge from the Intensive Care Unit and Hospital Mortality: A Multi-Center Retrospective Cohort Study. BMC Health Serv Res 15, 378-pp. Doi: 10.1186/s12913-015-1044-4.

Presentations

ICU Multidisciplinary Transfer Study summary and presentation of preliminary results (Denise Buchner), Adult Provincial Clinical Development and optimization Committee, Alberta Health Services. August 18, 2015.

Overview of the ICU discharge Tool – Multi-Center Observational Study (Denise Buchner), Critical Care Strategic Clinical Network monthly core committee meeting. May 21, 2015.

Development of an ICU transition questionnaire: Evaluating the transfer process from ICU, ward, and patient/family stakeholder perspectives (Simon Taylor), Trauma Association of Canada Annual Meeting. Calgary, Alberta. April, 2015.

Development of an ICU transition questionnaire: Evaluating the transfer process from ICU, ward, and patient/family stakeholder perspectives (Simon Taylor), 12th Annual Critical Care Conference. Whistler, British Columbia. February 2015. 

Development of an ICU transition questionnaire: Evaluating the transfer process from ICU, ward, and patient/family stakeholder perspectives (Simon Taylor), Alberta Society of Intensive Care Physicians (ASICP) Education Meeting. Lake Louise, Alberta. January 2015.

Webinars

Translating Science into Better Patient Care in the ICU — Tom Stelfox

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Rationale

The aim of this research was to better understand current intensive care unit (ICU) discharge practices.

Principal Investigators

Henry Stelfox, BMSc, MD, PhD — University of Calgary

Sean Bagshaw, MD, MSc, FRCPC — University of Alberta

Peter Dodek, MD, MHSc — University of British Columbia

Alan Forster, MD, FRCPC, MSc — Ottawa Hospital Research Institute

Robert Fowler, MD, MSc — Sunnybrook Research Institute

François Lamontagne, MD, MSc — Université de Sherbrooke

Alexis Turgeon, MD, MSc — Université Laval

Rationale: At this time there is not a standard procedure for discharging patients from ICU to ward. The complexity of the problem requires a comprehensive, multi-disciplinary and partnership-based approach.

Hypothesis: Understanding communication between ICU providers, ward providers, patients, and families is a foundational step in the development of an evidence informed ICU discharge tool kit that can improve the quality of care provided to patients during ICU to ward transitions.

Objectives: We propose to describe the experiences and communication of stakeholders during patient transfer from ICU to hospital ward to identify opportunities to improve ICU discharge process and inform the development of an ICU discharge tool kit.

Research plan: A two-pronged approach: (1) Conduct a prospective, multi-centre Canadian cohort study to describe the ICU process (Descriptive Phase) and (2) Begin development of an ICU discharge tool kit prototype through synthesis of identified needs, opportunities and existing discharge tools.

Back to CORE 2013-12 Project Page