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Editorials |

The Complexities of ICU DischargeComplexities of ICU Discharge FREE TO VIEW

May Hua, MD; Hannah Wunsch, MD
Author and Funding Information

From the Department of Anesthesiology (Drs Hua and Wunsch), Columbia University; the Department of Critical Care Medicine (Dr Wunsch), Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Department of Anesthesia (Dr Wunsch), University of Toronto, Toronto, ON, Canada.

CORRESPONDENCE TO: Hannah Wunsch, MD, Department of Critical Care Medicine, Sunnybrook Hospital, 2075 Bayview Ave, Rm D1.08, Toronto, ON, M4N 3M5, Canada; e-mail: hannah.wunsch@sunnybrook.ca


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.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(2):281-282. doi:10.1378/chest.14-2377
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The triage of patients for admission to ICUs is a topic of intense focus by researchers and clinicians.1 But the process of discharging a patient from the ICU also involves multiple parties and steps, starting with the decision of whether a patient is ready for discharge, progressing to discharge planning and actual discharge, and ending with follow-up after discharge.2,3 Because of the complexity of care requirements for critically ill patients, and the fact that this discharge transition occurs from a resource-rich to a relatively resource-poor environment, discharge from the ICU represents a potentially vulnerable time for patients. The decision to discharge may be premature, transfer itself may create medical errors, and patients and families may experience fear or dissatisfaction with care.4,5 A scoping review by Stelfox and colleagues3 in this issue of CHEST (see page 317) provides an impressive overview of the discharge process for a patient from the ICU to the hospital ward, highlights the many facets of the issue, and catalogs tools that have been previously reported to facilitate this process.

The primary goal of a scoping review is to “map the literature,” or to delineate the extent of existing literature on a given topic.6 The scoping review differs from the systematic review in several important ways. The systematic review investigates a focused question, performs some assessment of the quality of included studies, and aims to synthesize the literature to answer the initial question. In contrast, a scoping review is intentionally nonspecific and broad, with the goal of identifying all relevant themes regardless of the quality of the literature. The scoping review exposes areas of richness as well as gaps in the literature7 and is often performed as a precursor to a systematic review. Results of a scoping review are not intended to be conclusive; rather they are meant to be stimulating, highlighting questions for future research.7

Stelfox and colleagues3 identified 15 themes in the literature regarding patient discharge from the ICU and > 10 specific areas that may be appropriate for individual systematic reviews. The most common themes included issues such as “patient and family needs and experiences during discharge,” “availability of complete and accurate discharge information,” and “discharge education for patients and families,” whereas “continuity of patient care” and “medication reconciliation” were among the least common. The authors also isolated 30 barriers and facilitators to high-quality care during patient discharge, stemming from patient/family, provider, and organizational domains, and found a remarkable 47 different tools that have been created to aid the process of patient discharge from the ICU. Last, they synthesized some of these elements into an overall strategy and framework for approaching patient discharge from the ICU.

This scoping review clearly succeeds in providing a comprehensive mapping of a large and diverse literature and pinpoints multiple areas in need of further investigation. Notably, several of the most common themes emphasized the needs of the patient and family. In the current environment where there is a heavy focus on personalization of medicine, the literature of patient discharge from the ICU appears to already be appropriately patient centered. However, there were somewhat surprising gaps (that the authors themselves highlighted) related to patient safety. As medication reconciliation is an important tool for reducing adverse drug events,8 and lapses in continuity of care have been associated with increased adverse events,9 these aspects of the ICU discharge process likely deserve further attention. One other issue that is understudied (and not discussed in this review) is the question of what level of care is provided for the patients when they leave the ICU; the decision-making regarding readiness for discharge, the hand-off process, and the patient and family experience may be markedly different if the transition is to a step-down bed vs a general ward bed, with potentially a different nurse and/or physician staffing in each.

A caveat to interpreting the results is that the scoping review does not provide an assessment of whether the body of work on a particular theme is adequate. Because there is no formal assessment of the quality of included studies, themes that are common in the literature have not necessarily been addressed in a methodologically rigorous fashion and may require additional research. Furthermore, while this type of review is helpful for providing an overarching perspective on a topic, details regarding the particulars of each theme are not provided. Thus, as the authors suggest, multiple systematic reviews targeting specific facets of the ICU discharge process are needed to truly delineate gaps in knowledge and direct future research.

To improve the process of ICU discharge, the authors propose that particular elements of such a multipronged strategy may be tested in local quality improvement programs and provide several candidate outcomes for such studies. In practice, this is a challenging task. The review compiled an overwhelming number (n = 47) of different tools for potential implementation, and the question of which tools should be prioritized for further study is unanswered. In addition, properly conducting these types of trials will likely require complex study design (eg, cluster randomization). As an example, a recent systematic review determined that ICU readmissions may be reduced by the use of a critical-care transition program. But the conclusions stopped short of recommending such programs, as all included studies had methodologic limitations because of the use of a before-and-after study design.10 Furthermore, disentangling whether interventions truly affect the outcome of a process with many moving parts can be difficult, as multifaceted interventions have not always been successful in other domains of ICU care.11

Once ICU caregivers have made the determination that a patient is ready for discharge, they may tend to adopt the mindset of the catchphrase “my work here is done.” The efforts of Stelfox and colleagues4 emphasize the importance of vigilance during this transition by highlighting its complexity. This collation of research on the topic may help us take the first steps toward tackling the improvement of this fraught process.

References

Sprung CL, Geber D, Eidelman LA, et al. Evaluation of triage decisions for intensive care admission. Crit Care Med. 1999;27(6):1073-1079. [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]
 
Stelfox HT, Lane D, Boyd JM, et al. A scoping review of patient discharge from intensive care: opportunities and tools to improve care. Chest. 2015;147(2):317-327.
 
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]
 
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]
 
Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009;26(2):91-108. [CrossRef] [PubMed]
 
Armstrong R, Hall BJ, Doyle J, Waters E. Cochrane Update. ‘Scoping the scope’ of a Cochrane review. J Public Health (Oxf). 2011;33(1):147-150. [CrossRef] [PubMed]
 
Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-1069. [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]
 
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. [CrossRef] [PubMed]
 
Curtis JR, Nielsen EL, Treece PD, et al. Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial. Am J Respir Crit Care Med. 2011;183(3):348-355. [CrossRef] [PubMed]
 

Figures

Tables

References

Sprung CL, Geber D, Eidelman LA, et al. Evaluation of triage decisions for intensive care admission. Crit Care Med. 1999;27(6):1073-1079. [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]
 
Stelfox HT, Lane D, Boyd JM, et al. A scoping review of patient discharge from intensive care: opportunities and tools to improve care. Chest. 2015;147(2):317-327.
 
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]
 
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]
 
Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009;26(2):91-108. [CrossRef] [PubMed]
 
Armstrong R, Hall BJ, Doyle J, Waters E. Cochrane Update. ‘Scoping the scope’ of a Cochrane review. J Public Health (Oxf). 2011;33(1):147-150. [CrossRef] [PubMed]
 
Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057-1069. [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]
 
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. [CrossRef] [PubMed]
 
Curtis JR, Nielsen EL, Treece PD, et al. Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: a randomized trial. Am J Respir Crit Care Med. 2011;183(3):348-355. [CrossRef] [PubMed]
 
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