0
Original Research: Critical Care |

A Scoping Review of Patient Discharge From Intensive CarePatient Discharge From Intensive Care: Opportunities and Tools to Improve Care OPEN ACCESS

Henry T. Stelfox, MD, PhD; Dan Lane, MSc; Jamie M. Boyd, BA; Simon Taylor, BSc; Laure Perrier, MEd, MLIS; Sharon Straus, MD; David Zygun, MD; Danny J. Zuege, MD, FCCP
Author and Funding Information

From the Department of Critical Care Medicine (Drs Stelfox and Zuege and Mr Lane), and the Department of Medicine (Drs Stelfox and Zuege), University of Calgary and Alberta Health Services – Calgary Zone, Calgary, AB; the Department of Community Health Sciences (Dr Stelfox, Ms Boyd, and Mr Taylor), and the Institute for Public Health (Dr Stelfox), University of Calgary, Calgary, AB; the Li Ka Shing Knowledge Institute (Ms Perrier and Dr Straus), Saint Michael’s Hospital, Toronto, ON; the Department of Continuing Education and Professional Development (Ms Perrier), University of Toronto, Toronto, ON; the Department of Medicine (Dr Straus), Saint Michael’s Hospital, University of Toronto, Toronto, ON; the Division of Critical Care (Dr Zygun), University of Alberta, Edmonton, AB; and the Department of Critical Care Medicine (Dr Zygun), Alberta Health Services – Edmonton Zone Edmonton, AB, Canada.

CORRESPONDENCE TO: Henry T. Stelfox, MD, PhD, TRW Building, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada; e-mail: tstelfox@ucalgary.ca


FOR EDITORIAL COMMENT SEE PAGE 281

FUNDING/SUPPORT: This study was funded by a Knowledge Synthesis Grant from the Canadian Institutes of Health Research [Grant KRS124604]. Dr Stelfox is supported by a New Investigator Award from the Canadian Institutes of Health Research and a Population Health Investigator Award from Alberta Innovates Health Solutions. Dr Straus is funded by a Tier 1 Canada Research Chair. Dr Zygun is supported by a Clinical Investigator Award from Alberta Innovates Health Solutions.

This is an open access article distributed under the terms of the Creative Commons Attribution-Noncommercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted use, distribution, and reproduction to noncommercial entities, provided the original work is properly cited. Information for reuse by commercial entities is available online.


Chest. 2015;147(2):317-327. doi:10.1378/chest.13-2965
Text Size: A A A
Published online

BACKGROUND:  We conducted a scoping review to systematically review the literature reporting patient discharge from ICUs, identify facilitators and barriers to high-quality care, and describe tools developed to improve care.

METHODS:  We searched Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials. Data were extracted on the article type, study details for research articles, patient population, phase of care during discharge, and dimensions of health-care quality.

RESULTS:  From 8,154 unique publications we included 224 articles. Of these, 131 articles (58%) were original research, predominantly case series (23%) and cohort (16%) studies; 12% were narrative reviews; and 11% were guidelines/policies. Common themes included patient and family needs/experiences (29% of articles) and the importance of complete and accurate information (26%). Facilitators of high-quality care included provider-patient communication (30%), provider-provider communication (25%), and the use of guidelines/policies (29%). Patient and family anxiety (21%) and limited availability of ICU and ward resources (26%) were reported barriers to high-quality care. A total of 47 tools to facilitate patient discharge from the ICU were identified and focused on patient evaluation for discharge (29%), discharge planning and teaching (47%), and optimized discharge summaries (23%).

CONCLUSIONS:  Common themes, facilitators and barriers related to patient and family needs/experiences, communication, and the use of guidelines/policies to standardize patient discharge from ICU transcend the literature. Candidate tools to improve care are available; comparative evaluation is needed prior to broad implementation and could be tested through local quality-improvement programs.

Figures in this Article

A transition of care takes place each time a patient moves from one health-care provider or health-care setting to another. These involve transfer of accountability and responsibility for patient care and require communication of important patient data (eg, diagnoses, tests, treatments, goals of care) so that care plans can be continued in an uninterrupted manner.16

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,7 (2) transitioning from a resource-rich environment to one with fewer resources,810 (3) the number and complexity of providers (multiprofessional and interspecialty) involved,11,12 (4) a lack of standardized discharge procedures,7,13 and (5) a high frequency of verbal and written communication failures between providers14,15 and between providers and patients/families.16,17 There is a growing body of evidence that suggests transitions of care are vulnerable moments in health-care delivery associated with medical errors,18,19 adverse events,1,20 poor patient satisfaction with care,21 increased health-care costs,22 and increased mortality.23,24

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. The purpose of this scoping review was to systematically review the literature reporting patient discharge from ICU, identify facilitators and barriers to high-quality care during patient discharge from ICU, and describe strategies and tools that have been developed to improve patient discharge from ICU.

The methods for article inclusion and data analyses were prespecified and performed as recommended by Arksey and O’Malley25 and refined by Levac and colleagues.26 We expanded the scope of a preexisting scoping review protocol27 to search for studies that described patient discharge from ICU to a hospital ward.

Search Strategy

Performing unrestricted searches in Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials identified relevant articles. Searches were performed on June 17, 2013, using a combination of the following terms: critical care, intensive care, discharge plan, transfer process, patient discharge, and patient transfer. Appropriate wildcards were used in all searches to account for plurals and variations in spelling, as advised by a librarian (L. P.). Bibliographies of retrieved articles were searched for additional relevant articles. The full Medline search strategy is available in an online appendix (e-Appendix 1). We also searched conference proceedings from the Canada Critical Care Forum, Society of Critical Care Medicine Congress, Australian and New Zealand Intensive Care Society Conference, European Society of Intensive Care Medicine Congress, American Thoracic Society Conference, and International Symposium on Intensive Care and Emergency Medicine from January 1, 2011, to June 17, 2013. Searches were performed with no language or publication restrictions.

Article Selection

We selected all articles that described the structure, process, or outcome of patient discharge from an ICU to a hospital ward. We included both research and nonresearch articles. Patient discharge from ICU was defined as the transfer of accountability and responsibility for patient care from the ICU to a hospital ward.6 We defined an ICU as a distinct hospital ward that is staffed by specialized health-care professionals and where immediate and continuous life-sustaining treatment (eg, invasive monitoring, vasoactive medications, invasive mechanical ventilation) is administered to hospitalized patients suffering from life-threatening conditions (eg, severe respiratory failure).8 Articles were excluded if they primarily described patient transfers between ICUs, patient discharge from ICU to home, or patient discharge from coronary care units, high-dependency units, or step-down units. We included articles regardless of the age (neonatal, pediatric, adult) or diagnoses (eg, medical, surgical, cardiovascular, trauma, burn, and so forth.) of the patients managed in the ICU. These conservative criteria were chosen because we wanted to optimize our chances to comprehensively identify the literature describing patient discharge from ICU.

Articles were assessed for inclusion through a two-stage process. In the first stage, two reviewers independently reviewed the titles and abstracts of publications identified through the search strategy and selected relevant articles. In the second stage, two reviewers independently reviewed the full texts of the remaining articles, selecting those that satisfied the inclusion criteria. Disagreements between reviewers were discussed, and a third reviewer was consulted if agreement could not be reached. Reviewers were not masked to author or journal name.

Data Extraction and Analysis

After a training exercise, two reviewers independently extracted data in duplicate using a standardized form. Extracted data included type of article, study details for research articles (purpose, design, sample size, measures, analysis), ICU specialty (medical, surgical, and so forth), patient population (adult, pediatric, neonate), and phase of care during ICU discharge (evaluation, planning, execution, postdischarge follow-up). In addition, articles were classified using a conceptual model of ICU discharge quality27 that incorporated dimensions of health-care quality proposed by Avedis Donabedian28,29 (structure—healthcare environment; process—method of giving/receiving care; outcome—consequences of care) and the Institute of Medicine30 (safe—free from harm; effective—uses best evidence; efficient—minimizes waste; timely—prompt; patient-centered—considers individual needs; equitable—benefits everyone equally). Although simple, this framework was designed to facilitate a comprehensive description of the quality of patient discharge.27

The data were independently analyzed by two team members according to validated guidelines for narrative synthesis of quantitative studies3134 and metasynthesis of qualitative studies.35 All articles were evaluated by identifying the key measures and themes presented. Factors reported (or hypothesized for non-original research articles) to be associated with the quality of care during patient discharge from ICU were grouped by theme and classified as patient, provider, or institution related. Owing to the heterogeneity of the data, articles, themes and factors were summarized as counts and proportions using the Statistical Package for Social Sciences (SPSS) version 20.0.1 (IBM).36 Quantitative studies were grouped according to outcomes measured. Methodologic and contextual factors (setting, population, phase of discharge) were evaluated to explain variability in study outcomes. Qualitative studies were evaluated by identifying the key outcomes and themes presented by each study. Nonresearch articles were evaluated by identifying the key themes. Analysis focused on identifying the overlap of key concepts between articles and refining them to identify core themes.

The literature search identified 8,153 unique articles. Review of titles and abstracts led to the retrieval of 669 potentially relevant full-text articles. We identified 224 full text articles written in five languages (English, Portuguese, Spanish, Dutch, Korean) for inclusion in the review (Fig 1). The most common reason for excluding articles after full-text review was that the primary focus was not on patient discharge from ICU to a hospital ward. Interrater agreement for selection of articles during full-text review was good (κ = 0.672; 95% CI, 0.616-0.728).37

Figure Jump LinkFigure 1 –  Selection of articles for review.Grahic Jump Location
Description of the Articles

Table 1 summarizes the characteristics of the articles. Most articles were original research studies (n = 131, 58%) that used case series (n = 51, 23%), cohort (n = 35, 16%), or cross-sectional (n = 29, 13%) designs. The nonoriginal research articles (n = 93, 42%) consisted of narrative reviews (n = 26, 12%), guideline/policy documents (n = 25, 11%), opinion pieces (n = 23, 10%), and editorials (n = 19, 8%). Most articles originated from authors in the United States (n = 100, 45%), Europe (n = 57, 25%), or Australia (n = 40, 18%) and were published since 1999 (n = 152, 68%). The majority of articles reported on the discharge of adult patients (n = 126, 56%), with a minority focused on neonatal (n = 72, 32%) or pediatric patients (n = 12, 5%). The specialty focuses of the ICUs (eg, medical) were reported for a majority (n = 132, 59%) of articles. A referenced bibliography of the articles included in the review with a description of the patient population, phase of care during ICU discharge, quality-of-care dimensions, themes, facilitators and barriers to high-quality care, and tools to improve patient discharge from ICU is included in e-Appendix 2.

Table Graphic Jump Location
TABLE 1 ]  Characteristics of the Articles Included in the Review

Data are given as No. (%).

Patient Care and Quality Frameworks

The articles covered four phases of patient care during discharge from ICU, including evaluation of patient readiness for discharge (n = 43, 19%), planning for discharge (n = 65, 29%), execution of discharge (n = 122, 54%), and postdischarge follow-up (n = 63, 28%). The articles reflected all three dimensions of the framework of Donabedian28,29 for health-care quality: structure (n = 111, 50%), process (n = 71, 32%), and outcome (n = 65, 29%). The majority of articles focused on the Institute of Medicine’s quality-of-care dimensions of patient-centeredness (n = 88, 39%), effectiveness (n = 78, 35%), and safety (n = 57, 25%) of care during ICU discharge. Fewer articles focused on the efficiency (n = 30, 13%), timeliness (n = 20, 9%), or equality (n = 2, 1%) of care during patient discharge. The number of articles focused on the different phases of care and the different dimensions of quality of care varied by patient population (Table 2). For example, relatively fewer articles on adult patients focused on patient-centered care than articles on pediatric or neonatal patients (29% vs 42% vs 60%).

Table Graphic Jump Location
TABLE 2 ]  Distribution of Articles According to Phase of Care During Discharge From ICU and Quality of Care Frameworks

Data are given as No. (%). Responses not mutually exclusive.

Description of Discharge Themes

Table 3 summarizes the main themes of the articles included in this study. The most common themes were patient and family needs and experiences (n = 65, 29%); availability of complete and accurate discharge information (n = 59, 26%); discharge education for patients and families (n = 56, 25%); planning discharge (n = 49, 22%); standardizing the discharge process (n = 48, 21%); and the outcomes of patient discharge, including adverse events, ICU readmission, and death (n = 41, 18%). A small minority of articles focused on discharge education for providers (n = 14, 6%), medication reconciliation (n = 4, 2%), and patient autonomy (n = 3, 1%).

Table Graphic Jump Location
TABLE 3 ]  Discharge Themes of the Articles Included in the Review

Data are given as No. (%). Responses not mutually exclusive.

Facilitators and Barriers to High-Quality Care During Patient Discharge

Table 4 summarizes patient, provider, and institutional factors that may act as facilitators and/or barriers to high-quality care during patient discharge from ICU. Thirty factors were identified, many of which could act as either facilitators or barriers depending on how framed (ie, positive vs negative context) and are summarized as presented in the literature. The most common facilitators related to patients and their families included provider-patient communication (n = 68, 30%), discharge education for patients and families (n = 66, 29%), and family support for the patient (n = 65, 29%). Patient and family anxiety about discharge (n = 48, 21%) was the most commonly reported barrier, whereas patient demographic and clinical characteristics (n = 92, 41%) were identified as both facilitators and barriers to discharge. Facilitators related to providers included provider-provider verbal (n = 57, 25%) and written (n = 26, 12%) communication, the use of transition-of-care services (eg, outreach teams and liaison nurses; n = 51, 23%), collaboration between hospital units (n = 30, 13%), and the experience and knowledge (n = 31, 14%) and clinical judgment (n = 21, 9%) of providers. Conversely, provider workload (n = 12, 5%) and provider anxiety (n = 5, 2%) were barriers identified in a small number of articles. Facilitators related to institutional factors included the use of guidelines and policies (n = 64, 29%), education and training of ICU and ward providers (n = 34, 15%), implementation of best practices (n = 34, 15%), and the use of tools to facilitate discharge (n = 25, 11%). The availability of limited resources both in the ICU and receiving hospital wards (n = 58, 26%) was identified as a barrier and the time of discharge (day of week or time of day; n = 33, 15%) as both a facilitator and barrier.

Table Graphic Jump Location
TABLE 4 ]  Facilitators and Barriers to High-Quality Care During Patient Discharge From ICU

Data are given as No. (%). Responses not mutually exclusive.

a 

Facilitators and barriers to high-quality care during patient discharge from ICU.

Tools to Facilitate Patient Discharge

Table 5 summarizes candidate tools to facilitate patient discharge from ICU (individual tools listed in e-Appendix 2). A total of 47 tools focused on patient evaluation for discharge (n = 14, 29%), discharge planning and teaching (n = 22, 47%), and optimized discharge summaries (n = 11, 25%) were identified. Evaluation tools included those evaluating readiness for discharge (n = 11, 23%) and triage of patients for discharge based on continued need for ICU care (n = 3, 6%). Discharge planning tools included guidelines or checklists (n = 11, 23%), transfer brochures (n = 6, 13%), patient/family educational tools (n = 4, 8%), and questionnaires (n = 1, 2%) to identify patient and family discharge needs to better prepare them for discharge. Most original research studies were single-center evaluations of tool implementation and did not provide comparative evaluations to other tools.

Table Graphic Jump Location
TABLE 5 ]  Tools to Facilitate Patient Discharge from ICU

Data are given as No. (%).

In this review, we identified 224 articles that describe the practices and challenges of discharging patients from ICU. We identified 15 discharge themes and 30 patient, provider, and institutional factors that may act as facilitators and barriers to high-quality care during patient discharge from the ICU. Common themes among the articles included the importance of complete and accurate information to facilitate continuity of care, patient and family needs and experiences, and the role for educating patients and families about the discharge process. Potential facilitators and barriers to high-quality care during patient discharge included effective communication (both provider-patient and provider-provider) and the use of guidelines and policies to standardize practice. We identified 47 candidate tools to facilitate patient discharge by evaluating patient readiness for discharge, optimally planning discharge, and ensuring effective communication through discharge summaries.

Our results highlight potential areas to improve patient discharge from ICU. Patient discharge from ICU is clearly complex, as emphasized by the large number of themes, facilitators and barriers, and tools identified. Furthermore, although there are likely common challenges to patient discharge from ICU, population- and institution-specific factors are also likely important. 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. The discharge themes, factors, and tools identified from the literature provide candidate elements to inform a multipronged ICU discharge strategy that can be tailored to local needs and contexts (Table 6).

Table Graphic Jump Location
TABLE 6 ]  Literature-Derived Candidate Elements to Inform an ICU Discharge Strategy
a 

Published tools available (see e-Appendix 2).

b 

Ten or more original research publications available for systematic review (see e-Appendix 2).

Patient discharge from ICU represents a continuum composed of multiple sequential steps. We identified articles that described the evaluation of patient readiness for discharge, planning for discharge, execution of discharge, and postdischarge follow-up. 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. Nevertheless, successful examples of overlapping coordinated care for critically ill patients during discharge from ICU have been described.3840

There are areas of richness in the literature that can inform efforts to improve patient discharge from ICU. Notably, we identified many articles that focused on the availability of complete and accurate discharge information, patient and family needs and experiences, discharge education for patients and families, planning for discharge, and standardizing the discharge process. These areas provide an opportunity for systematic reviews to more specifically and comparatively inform discharge improvement. Conversely, we identified few articles that focused on discharge education for providers, medication reconciliation, and patient autonomy, suggesting a need for more empirical research in these domains. Institutions and providers can use the available data to target common themes that transcend the literature. For example, communication practices (both provider-patient and provider-provider) during patient discharge appear to be important areas for improvement that could be evaluated with audits and potentially standardized with protocols to ensure accuracy and completeness of information exchange.

One important observation from our review is that a large number of tools that target different phases of the discharge process and different dimensions of health-care quality have been developed to facilitate patient discharge from ICU. For example, tools to evaluate patient “readiness for discharge” can provide decision support by incorporating patient-specific data into a predictive model to estimate individualized risk of adverse events (eg, ICU readmission) and guide discharge decision-making (eg, identify patients that may benefit from additional transition resources).41 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.42 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.43 Finally, patient discharge summaries are an important communication tool that can present and prioritize patient information in a standardized fashion and highlight competing issues requiring attention.44 Although there is a need to comparatively evaluate these tools to identify those most effective in improving patient discharge, many have been individually studied, appear promising (e-Appendix 2), and could be locally implemented and evaluated through quality-improvement initiatives pending further studies. For example, there are multiple tools to evaluate patient “readiness for discharge” that could be selected based on published operating characteristics and locally available data.41

There are limitations to this review. First, our search may not have been exhaustive, despite the search of multiple databases using unrestricted and comprehensive search strategies with no language restrictions, designed by a librarian. Nevertheless, it is unlikely that we missed major themes regarding patient discharge from ICU, important facilitators and barriers to high-quality care, and promising tools to improve patient discharge from ICU. Second, it is difficult to extract accurate and complete data from all publications even with the assistance of predefined data abstraction tools. Some articles do not disclose all materials or methods used. Some articles report results that are unclear or difficult to interpret. Classification of articles according to quality-of-care dimensions, themes, and facilitators and barriers is partially subjective even when performed in duplicate by independent reviewers. Third, we conducted a scoping review, which by definition is designed to provide a systematic high-level mapping of the literature to inform research,45 quality-improvement initiatives,46 funding agency priorities,47 and policy agendas48 but provides limited detail of individual factors, interventions, and associated outcomes.25,26 Nevertheless, such mapping exercises are needed to identify areas of richness in the literature to be targeted for separate systematic reviews to synthesize this more detailed data, areas with few studies to be targeted for more empirical research, and both opportunities and tools for improvement to be targeted for local quality-improvement initiatives. Our scoping review identified more than a dozen candidate elements for an ICU discharge strategy (Table 6) that have sufficient literature for researchers to conduct individual systematic reviews and 47 tools that could be implemented and evaluated through quality-improvement initiatives.

The Institute of Medicine has highlighted that health-care quality suffers because “inadequate health-care delivery systems” fail to coordinate patient care across the care continuum.30 We identified a large body of literature that describes current discharge practices and the challenges of discharging patients from the ICU. Our results should promote future research in three areas. First, systematic reviews are warranted to explore whether areas with existing richness of literature (eg, availability of complete and accurate discharge information, patient and family needs and experiences, standardizing the discharge process) can inform practices to improve the quality of ICU discharge. Second, empirical research is needed to fill important and somewhat surprising knowledge gaps (eg, medication reconciliation). Third, research is needed to evaluate the impact of efforts to improve patient discharge from ICU on important patient outcomes. Candidate elements for an ICU discharge strategy are available (Table 6); additional evaluation is needed prior to broad implementation, but many elements could be tested through local quality-improvement programs. Reengineering patient discharge from ICU by developing and evaluating a multipronged evidence-informed ICU discharge strategy will help ensure that the right patient is discharged at the right time with the right plan using a standardized process to optimize patient outcomes and facilitate seamless care across the health-care continuum.

Author contributions: As principal investigator, H. T. S. had full access to all the study data and assumes responsibility for the integrity of the data and the accuracy of the analysis. H. T. S., D. L., J. M. B., S. T., L. P., S. S., D. Z., and D. J. Z. contributed to the study’s conception, design, and interpretation; L. P. was responsible for searching the literature; D. L., J. M. B., and S. T. were responsible for screening abstracts, selecting manuscripts for full text review, and performing the analysis; and H. T. S., D. L., J. M. B., S. T., L. P., S. S., D. Z., and D. J. Z. assisted in the successive revisions of the final manuscript and read and approved the final manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: Funding sources had no role in the design of the protocol, and we are unaware of any conflicts of interest.

Other contributions: We thank Jessalyn Holodinsky BSc, for helping with data collection.

Additional information: The e-Appendixes can be found in the Supplemental Materials section of the online article.

Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121(11):866-872. [CrossRef] [PubMed]
 
Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004;141(7):533-536. [CrossRef] [PubMed]
 
Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care. 2004;16(2):125-132. [CrossRef] [PubMed]
 
Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094-1099. [CrossRef] [PubMed]
 
Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14(6):401-407. [CrossRef] [PubMed]
 
How safe are Canadian health organizations? 2011 report on required organizational practices. Accreditation Canada website. http://www.accreditation.ca/sites/default/files/report-on-rops-en.pdf. Accessed September 15, 2014.
 
Watts R, Pierson J, Gardner H. Coordination of the discharge process planning in critical care. J Clin Nurs. 2007;16(1):194-202. [CrossRef] [PubMed]
 
Simchen E, Sprung C, Galai N, et al. Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds. Crit Care Med. 2004;32(8):1654-1661. [CrossRef] [PubMed]
 
Ward NS, Read R, Afessa B, Kahn JM. Perceived effects of attending physician workload in academic medical intensive care units: a national survey of training program directors. Crit Care Med. 2012;40(2):400-405. [CrossRef] [PubMed]
 
Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987-1993. [CrossRef] [PubMed]
 
Apker J, Mallak LA, Gibson SC. Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007;14(10):884-894. [PubMed]
 
Riesenberg LA, Leitzsch J, Massucci JL, et al. Residents’ and attending physicians’ handoffs: a systematic review of the literature. Acad Med. 2009;84(12):1775-1787. [CrossRef] [PubMed]
 
Heidegger CP, Treggiari MM, Romand JA; Swiss ICU Network. A nationwide survey of intensive care unit discharge practices. Intensive Care Med. 2005;31(12):1676-1682. [CrossRef] [PubMed]
 
Li P, Stelfox HT, Ghali WA. A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers. Am J Med. 2011;124(9):860-867. [CrossRef] [PubMed]
 
Lin F, Chaboyer W, Wallis M. A literature review of organisational, individual and teamwork factors contributing to the ICU discharge process. Aust Crit Care. 2009;22(1):29-43. [CrossRef] [PubMed]
 
Forsberg A, Lindgren E, Engström ÃS. Being transferred from an intensive care unit to a ward: Searching for the known in the unknown. Int J Nurs Pract. 2011;17(2):110-116. [CrossRef]
 
Field K, Prinjha S, Rowan K. ‘One patient amongst many’: a qualitative analysis of intensive care unit patients’ experiences of transferring to the general ward. Crit Care. 2008;12(1):R21. [CrossRef] [PubMed]
 
Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168(16):1755-1760. [CrossRef] [PubMed]
 
Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011;306(8):840-847. [CrossRef] [PubMed]
 
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-167. [CrossRef] [PubMed]
 
Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med. 1994;120(12):999-1006. [CrossRef] [PubMed]
 
Improving transitions of care. National Transitions of Care Coalition website. http://www.ntocc.org/Portals/0/PDF/Resources/PolicyPaper.pdf. Accessed October 10, 2012.
 
Kramer AA, Higgins TL, Zimmerman JE. The association between ICU readmission rate and patient outcomes. Crit Care Med. 2013;41(1):24-33. [CrossRef] [PubMed]
 
Daly K, Beale R, Chang RW. Reduction in mortality after inappropriate early discharge from intensive care unit: logistic regression triage model. BMJ. 2001;322(7297):1274-1276. [CrossRef] [PubMed]
 
Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005;8(1):19-32. [CrossRef]
 
Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69. [CrossRef] [PubMed]
 
Stelfox HT, Perrier L, Straus SE, et al. Identifying intensive care unit discharge planning tools: protocol for a scoping review. BMJ Open. 2013;3(4):e002653. [CrossRef] [PubMed]
 
Donabedian A. The Definition of Quality and Approaches to Its Assessment. Ann Arbor, MI: Health Administration Press; 1980.
 
Donabedian A. Evaluating the quality of medical care. 1966. Milbank Q. 2005;83(4):691-729. [CrossRef] [PubMed]
 
Institute of Medicine Committee on the Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. [PubMed] [PubMed]
 
Rodgers M, Sowden A, Petticrew M, et al. Testing methodological guidance on the conduct of narrative synthesis in systematic reviews: effectiveness of interventions to promote smoke alarm ownership and function. Evaluation. 2009;15(1):49-73. [CrossRef]
 
Arai L, Britten N, Popay J, et al. Testing methodological developments in the conduct of narrative synthesis: a demonstration review of research on the implementation of smoke alarm interventions. Evidence & Policy. 2007;3(3):361-383.
 
Hurwitz B, Greenhalgn T, Skultans V. Meta-narrative mapping: a new approach to the systematic review of complex evidence.. InGreenhalgh T., ed. Narrative Research in Health and Illness. Malden, MA: Blackwell Publishing Ltd; 2008:349-381.
 
Rodgers M, Sowden A, Petticrew M, et al. Testing methodological guidance on the conduct of narrative synthesis in systematic reviews: effectiveness of interventions to promote smoke alarm ownership and function. Evaluation. 2009;15(1):49-73.
 
Walsh D, Downe S. Meta-synthesis method for qualitative research: a literature review. J Adv Nurs. 2005;50(2):204-211.
 
SPSS Inc. IBM SPSS Statistics, Version 20.0.1. New York, NY: IBM; 2011.
 
Orwin RG. Evaluating coding decisions.. In:Cooper H, Hedges LV., eds. The Handbook of Research Synthesis. New York, NY: Russell Sage Foundation; 1994.
 
Haines S, Crocker C, Leducq M. Providing continuity of care for patients transferred from ICU. Prof Nurse. 2001;17(1):17-21.
 
Häggström M, Asplund K, Kristiansen L. How can nurses facilitate patient’s transitions from intensive care? A grounded theory of nursing. Intensive Crit Care Nurs. 2012;28(4):224-233.
 
Niven DJ, Bastos JF, Stelfox HT. Critical care transition programs and the risk of readmission or death after discharge from an ICU: a systematic review and meta-analysis. Crit Care Med. 2014;42(1):179-187.
 
Hosein FS, Bobrovitz N, Berthelot S, Zygun D, Ghali WA, Stelfox HT. A systematic review of tools for predicting severe adverse events following patient discharge from intensive care units. Crit Care. 2013;17(3):R102.
 
Gawande A. The Checklist Manifesto: How to Get Things Right. New York, NY: Henry Holt and Company, LLC; 2010.
 
Rao JK, Anderson LA, Inui TS, Frankel RM. Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care. 2007;45(4):340-349.
 
Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-841.
 
Stelfox HT, Bobranska-Artiuch B, Nathens A, Straus SE. Quality indicators for evaluating trauma care: a scoping review. Arch Surg. 2010;145(3):286-295.
 
White DE, Straus SE, Stelfox HT, et al. What is the value and impact of quality and safety teams? A scoping review. Implement Sci. 2011;6:97.
 
A guide to knowledge synthesis. Canadian Institutes of Health Research website. http://www.cihr-irsc.gc.ca/e/41382.html. Accessed June 26, 2014.
 
Bryden A, Petticrew M, Mays N, Eastmure E, Knai C. Voluntary agreements between government and business - a scoping review of the literature with specific reference to the Public Health Responsibility Deal. Health Policy. 2013;110(2-3):186-197.
 

Figures

Figure Jump LinkFigure 1 –  Selection of articles for review.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Characteristics of the Articles Included in the Review

Data are given as No. (%).

Table Graphic Jump Location
TABLE 2 ]  Distribution of Articles According to Phase of Care During Discharge From ICU and Quality of Care Frameworks

Data are given as No. (%). Responses not mutually exclusive.

Table Graphic Jump Location
TABLE 3 ]  Discharge Themes of the Articles Included in the Review

Data are given as No. (%). Responses not mutually exclusive.

Table Graphic Jump Location
TABLE 4 ]  Facilitators and Barriers to High-Quality Care During Patient Discharge From ICU

Data are given as No. (%). Responses not mutually exclusive.

a 

Facilitators and barriers to high-quality care during patient discharge from ICU.

Table Graphic Jump Location
TABLE 5 ]  Tools to Facilitate Patient Discharge from ICU

Data are given as No. (%).

Table Graphic Jump Location
TABLE 6 ]  Literature-Derived Candidate Elements to Inform an ICU Discharge Strategy
a 

Published tools available (see e-Appendix 2).

b 

Ten or more original research publications available for systematic review (see e-Appendix 2).

References

Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121(11):866-872. [CrossRef] [PubMed]
 
Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004;141(7):533-536. [CrossRef] [PubMed]
 
Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care. 2004;16(2):125-132. [CrossRef] [PubMed]
 
Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094-1099. [CrossRef] [PubMed]
 
Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14(6):401-407. [CrossRef] [PubMed]
 
How safe are Canadian health organizations? 2011 report on required organizational practices. Accreditation Canada website. http://www.accreditation.ca/sites/default/files/report-on-rops-en.pdf. Accessed September 15, 2014.
 
Watts R, Pierson J, Gardner H. Coordination of the discharge process planning in critical care. J Clin Nurs. 2007;16(1):194-202. [CrossRef] [PubMed]
 
Simchen E, Sprung C, Galai N, et al. Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds. Crit Care Med. 2004;32(8):1654-1661. [CrossRef] [PubMed]
 
Ward NS, Read R, Afessa B, Kahn JM. Perceived effects of attending physician workload in academic medical intensive care units: a national survey of training program directors. Crit Care Med. 2012;40(2):400-405. [CrossRef] [PubMed]
 
Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987-1993. [CrossRef] [PubMed]
 
Apker J, Mallak LA, Gibson SC. Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety. Acad Emerg Med. 2007;14(10):884-894. [PubMed]
 
Riesenberg LA, Leitzsch J, Massucci JL, et al. Residents’ and attending physicians’ handoffs: a systematic review of the literature. Acad Med. 2009;84(12):1775-1787. [CrossRef] [PubMed]
 
Heidegger CP, Treggiari MM, Romand JA; Swiss ICU Network. A nationwide survey of intensive care unit discharge practices. Intensive Care Med. 2005;31(12):1676-1682. [CrossRef] [PubMed]
 
Li P, Stelfox HT, Ghali WA. A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers. Am J Med. 2011;124(9):860-867. [CrossRef] [PubMed]
 
Lin F, Chaboyer W, Wallis M. A literature review of organisational, individual and teamwork factors contributing to the ICU discharge process. Aust Crit Care. 2009;22(1):29-43. [CrossRef] [PubMed]
 
Forsberg A, Lindgren E, Engström ÃS. Being transferred from an intensive care unit to a ward: Searching for the known in the unknown. Int J Nurs Pract. 2011;17(2):110-116. [CrossRef]
 
Field K, Prinjha S, Rowan K. ‘One patient amongst many’: a qualitative analysis of intensive care unit patients’ experiences of transferring to the general ward. Crit Care. 2008;12(1):R21. [CrossRef] [PubMed]
 
Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168(16):1755-1760. [CrossRef] [PubMed]
 
Bell CM, Brener SS, Gunraj N, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011;306(8):840-847. [CrossRef] [PubMed]
 
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-167. [CrossRef] [PubMed]
 
Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med. 1994;120(12):999-1006. [CrossRef] [PubMed]
 
Improving transitions of care. National Transitions of Care Coalition website. http://www.ntocc.org/Portals/0/PDF/Resources/PolicyPaper.pdf. Accessed October 10, 2012.
 
Kramer AA, Higgins TL, Zimmerman JE. The association between ICU readmission rate and patient outcomes. Crit Care Med. 2013;41(1):24-33. [CrossRef] [PubMed]
 
Daly K, Beale R, Chang RW. Reduction in mortality after inappropriate early discharge from intensive care unit: logistic regression triage model. BMJ. 2001;322(7297):1274-1276. [CrossRef] [PubMed]
 
Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology. 2005;8(1):19-32. [CrossRef]
 
Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5:69. [CrossRef] [PubMed]
 
Stelfox HT, Perrier L, Straus SE, et al. Identifying intensive care unit discharge planning tools: protocol for a scoping review. BMJ Open. 2013;3(4):e002653. [CrossRef] [PubMed]
 
Donabedian A. The Definition of Quality and Approaches to Its Assessment. Ann Arbor, MI: Health Administration Press; 1980.
 
Donabedian A. Evaluating the quality of medical care. 1966. Milbank Q. 2005;83(4):691-729. [CrossRef] [PubMed]
 
Institute of Medicine Committee on the Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. [PubMed] [PubMed]
 
Rodgers M, Sowden A, Petticrew M, et al. Testing methodological guidance on the conduct of narrative synthesis in systematic reviews: effectiveness of interventions to promote smoke alarm ownership and function. Evaluation. 2009;15(1):49-73. [CrossRef]
 
Arai L, Britten N, Popay J, et al. Testing methodological developments in the conduct of narrative synthesis: a demonstration review of research on the implementation of smoke alarm interventions. Evidence & Policy. 2007;3(3):361-383.
 
Hurwitz B, Greenhalgn T, Skultans V. Meta-narrative mapping: a new approach to the systematic review of complex evidence.. InGreenhalgh T., ed. Narrative Research in Health and Illness. Malden, MA: Blackwell Publishing Ltd; 2008:349-381.
 
Rodgers M, Sowden A, Petticrew M, et al. Testing methodological guidance on the conduct of narrative synthesis in systematic reviews: effectiveness of interventions to promote smoke alarm ownership and function. Evaluation. 2009;15(1):49-73.
 
Walsh D, Downe S. Meta-synthesis method for qualitative research: a literature review. J Adv Nurs. 2005;50(2):204-211.
 
SPSS Inc. IBM SPSS Statistics, Version 20.0.1. New York, NY: IBM; 2011.
 
Orwin RG. Evaluating coding decisions.. In:Cooper H, Hedges LV., eds. The Handbook of Research Synthesis. New York, NY: Russell Sage Foundation; 1994.
 
Haines S, Crocker C, Leducq M. Providing continuity of care for patients transferred from ICU. Prof Nurse. 2001;17(1):17-21.
 
Häggström M, Asplund K, Kristiansen L. How can nurses facilitate patient’s transitions from intensive care? A grounded theory of nursing. Intensive Crit Care Nurs. 2012;28(4):224-233.
 
Niven DJ, Bastos JF, Stelfox HT. Critical care transition programs and the risk of readmission or death after discharge from an ICU: a systematic review and meta-analysis. Crit Care Med. 2014;42(1):179-187.
 
Hosein FS, Bobrovitz N, Berthelot S, Zygun D, Ghali WA, Stelfox HT. A systematic review of tools for predicting severe adverse events following patient discharge from intensive care units. Crit Care. 2013;17(3):R102.
 
Gawande A. The Checklist Manifesto: How to Get Things Right. New York, NY: Henry Holt and Company, LLC; 2010.
 
Rao JK, Anderson LA, Inui TS, Frankel RM. Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care. 2007;45(4):340-349.
 
Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-841.
 
Stelfox HT, Bobranska-Artiuch B, Nathens A, Straus SE. Quality indicators for evaluating trauma care: a scoping review. Arch Surg. 2010;145(3):286-295.
 
White DE, Straus SE, Stelfox HT, et al. What is the value and impact of quality and safety teams? A scoping review. Implement Sci. 2011;6:97.
 
A guide to knowledge synthesis. Canadian Institutes of Health Research website. http://www.cihr-irsc.gc.ca/e/41382.html. Accessed June 26, 2014.
 
Bryden A, Petticrew M, Mays N, Eastmure E, Knai C. Voluntary agreements between government and business - a scoping review of the literature with specific reference to the Public Health Responsibility Deal. Health Policy. 2013;110(2-3):186-197.
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Supporting Data

Online Supplement

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
Physiotherapy in Intensive Care*: Towards an Evidence-Based Practice
PubMed Articles
Guidelines
Treatment of acute exacerbation of asthma.
Finnish Medical Society Duodecim | 1/25/2008
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543