Background
Methods
Study design and setting
Individual and focus group interviews
Questionnaire
Data analysis
Results
Characteristics of the respondents
Individual interviews | Focus group interviews | |
---|---|---|
(n = 23) | (n = 25) | |
Job Title | ||
ICU physician (%) ICU nurse (%) Ward physician (%) Ward nurse (%) Policy maker a (%) Patient (%) | 5 (22) 5 (22) 3 (13) 5 (22) 3 (13) 2 (9) | 5 (20) 7 (28) 5 (20) 8 (32) 0 (0) 0 (0) |
Male (%) | 10 (43) | 8 (32) |
Hospital type | ||
General (%) Teaching (%) Academic (%) Not applicable b (%) | 6 (26) 4 (17) 10 (43) 3 (13) | 5 (20) 10 (40) 10 (40) 0 (0) |
Years clinical Experience in current specialty | ||
<5 years (%) 5–10 years (%) >10 years (%) Not applicable c (%) | 8 (35) 5 (22) 5 (22) 5 (22) | 5 (20) 7 (28) 13 (52) 0 (0) |
Respondents (n = 166) | |
---|---|
Gender | |
Male (%) Female (%) Missing (%) | 106 (63.9) 57 (34.3) 3 (1.8) |
Median Age (min-max)a
| 43 (31–64) |
Median years of experience (min-max)b
| 7 (0–34) |
Patient category | |
Adults (%) Adults and children (%) | 160 (96.4) 6 (3.6) |
Hospital type | |
General (%) Teaching (%) Academic (%) Missing (%) | 50 (30.1) 70 (42.2) 45 (27.1) 1 (0.6) |
ICU physician training hospital? | |
Yes (%) No (%) Missing (%) | 49 (29.5) 112 (67.5) 5 (3.0) |
Median number of ICU beds (min-max)a
| 16 (6–58) |
Perceived barriers and facilitators
Category | Subcategory | Factor | B | F |
---|---|---|---|---|
Intervention | Credibility | Lack of evidence [0,4,6] | ✓ | |
Utility | Lack of details in intervention description [B:1,F:1] | ✓ | ✓ | |
Advantage | Negative (B)/ positive (F) results experienced [B:6,F3] | ✓ | ✓ | |
(Not) used when (not) useful [B:4,F:3] | ✓ | ✓ | ||
(Not) used when there is (no) need [B:6,8,F:4,5,6,7,8] | ✓ | ✓ | ||
Observability | (No) positive results shown [B:8,F:7] | ✓ | ✓ | |
Feasibility | Does not work in practice [3,6,7] | ✓ | ||
Not always possible to execute [3,4] | ✓ | |||
Failed pilot test [8] | ✓ | |||
Form not user friendly [4] | ✓ | |||
Uniform policy is impossible [4] | ✓ | |||
Policy tailored to each general ward is not feasible [4] | ✓ | |||
Too many patients [7] | ✓ | |||
Implementation process | Accessibility | Intervention not converted into protocol [1] | ✓ | |
Protocol/policy available on intranet [1,2] | ✓ | |||
Clarity | Indistinct agreements surrounding intervention [4] | ✓ | ||
Support | Initiative from care professionals [4] | ✓ | ||
Creating support among healthcare professionals | ✓ | |||
Professional | Attitude | Opinion that intervention is no solution for structural problems [8] | ✓ | |
Opinion that formulating discharge criteria is (im)possible [B:1,F:1] | ✓ | ✓ | ||
Opinion that intervention is (not) useful [B:3,6,7,F:3,4] | ✓ | ✓ | ||
Negative attitude towards protocols or checklists [1,4] | ✓ | |||
Negative attitude towards new or more forms [0,4] | ✓ | |||
Negative attitude towards registration [0] | ✓ | |||
Opinion that ICU physician is involved until hospital discharge [4] | ✓ | |||
Knowledge | Guideline or intervention is unknown [1,7] | ✓ | ||
Physician has little knowledge about nursing discharge practices [3] | ✓ | |||
Awareness | Awareness of possible unsafe practices [0,5] | ✓ | ||
Behaviour | Change of routines necessary [0,4] | ✓ | ||
Skills | Lack of ICT skills [0,4] | ✓ | ||
Patient | Cognition | Communication impossible [5] | ✓ | |
Social | Leadership | Care professionals are not involved in decision making [0] | ✓ | |
Prioritization of problem/implementation of intervention [0,8] | ✓ | |||
Choices made in past [8] | ✓ | |||
Culture | (No) culture of feedback [0,4] | ✓ | ✓ | |
‘Ivory tower’-image of ICU [0] | ✓ | |||
Cultural differences between wards [4] | ✓ | |||
Collaboration | No multidisciplinary care [0] | ✓ | ||
No or too little structural consultation with ward [4] | ✓ | |||
Preconceived opinions against ICU professionals [0] | ✓ | |||
ICU nurse performs tasks in general wards [0] | ✓ | ✓ | ||
Organisational | Resources | Lack of man-hours/time [0,4,6,8] | ✓ | |
Ward physician is unavailable [4] | ✓ | |||
Ward equipment is not yet set up [4] | ✓ | |||
Lack of financial resources [8] | ✓ | |||
Structure | Large (B) or small (F) hospital [B:0,7,F:7] | ✓ | ✓ | |
ICU is ‘separated’ from hospital by architectural barriers [0] | ✓ | |||
High turnover of physicians [3] | ✓ | |||
ICT infrastructure | (No) hospital wide electronic patient file [B:4,F:4,5] | ✓ | ✓ | |
No check, no summary as a result of one electronic patient file [4] | ✓ | |||
Electronic patient file unclear/not user-friendly [5] | ✓ | |||
Intervention is connected to electronic patient file [5] | ✓ | ✓ | ||
Policy | Confusion about which physician is responsible for patient [4] | ✓ | ||
Society | Financial support | No compensation by insurance company [0,6,8] | ✓ | |
Cuts are made to minimise expenditures [8] | ✓ | |||
Confusion about financing structures [0,8] | ✓ | |||
Financial incentives | Production is central [0] | ✓ | ||
Regulations | Production instead of quality is performance measure [0] | ✓ | ||
Variation in quality of step down beds due to a lack of policy [8] | ✓ | |||
Other hospitals | Competition [7] | ✓ | ✓ | |
Professional associations | Discussion whether ICU tasks can and should be performed in general wards by ICU professionals [0] | ✓ | ||
Discussion about the reallocation of ICU tasks to general ward professionals [6] | ✓ |
Intervention-related factors
“In some cases, the patient is ready for discharge early in the morning. If there is room in the receiving ward, the patient will leave a few hours later. Planning the discharge 24 h in advance is not necessary in these cases.” (ICU physician – individual interview)
“That depends of course on when an ICU physician thinks a patient is not yet recovered enough to go to the general ward. There are no real criteria for that, for when a patient is ready for discharge. So it depends on what an ICU physician thinks whether or not a patient is discharged at that moment.” (ICU nurse – individual interview)
Professional-related factors
“These are things that you have memorised, because you have to work with them every day. You don’t need a list for that.” (ICU physician – individual interviews)
Social factors
“The ICU still remains a little bit of an island within the hospital. Whenever I have to call the ICU, I think: ‘I hope I have my story straight..’.” (Ward nurse – individual interview)
Patient-related factor
Organisation-related factors
“It is bothersome, I think, to figure out who is the physician on the ward. I think that a face-to-face handover would be an improvement, but it costs a lot of time to call six physicians before you’ve got the right one.” (ICU physician – individual interview)
Society-related factors
“Health insurers should be realistic and make it possible to claim the costs of medium care facilities. At the moment we have no income from the medium care, and that is ridicules.” (ICU manager – individual interview)
Implementation-related factors
“The general ward worries whether the patient eats enough, whether he tries to stand and walk. We incorporate this in our handover, because they ask about it. But these points are not part of the standard discharge list. This could possibly be improved.” (ICU nurse – individual interview)
Ranking
Category | Subcategory | Statement | Agree (%) | Disagree (%) | NAa (%) |
---|---|---|---|---|---|
P | Attitude | I think that having a checklist to structure the verbal handover is useful.c
| 153 (92.2) | 7 (4.2) | 6 (3.6) |
P | Attitude | I think that there is room to improve the communication between ICU and general ward.c, g
| 145 (87.3) | 19 (11.4) | 2 (1.2) |
I | Resources | I experience enough demand from the ward to implement/sustain the consulting ICU nurse position. | 138 (83.1) | 20 (12.0) | 8 (4.8) |
O | ICT infrastructure | I think that when making an up-to-date medication overview at ICU discharge a electronic patient file is indispensable. d
| 130 (78.3) | 32 (19.3) | 4 (2.4) |
I | Utility | I think that there are differences between intensivists in when they deem a patient ready for ICU discharge, because there are no specific ICU discharge criteria. | 128 (77.1) | 32 (19.3) | 6 (3.6) |
S | Collaboration | I do sometimes overestimate the possibilities in a general ward.e
| 124 (74.7) | 38 (22.9) | 4 (2.4) |
S | Leadership | I think that improving the ICU discharge process deserves more attention from the management.e, f
| 121 (72.9) | 40 (24.1) | 5 (3.0) |
O | Resources | I think that implementing improvement interventions takes a lot of energy and time. | 117 (70.5) | 46 (27.7) | 3 (1.8) |
I | Utility | I think it is desirable to set more specific ICU discharge criteria. | 115 (69.3) | 48 (28.9) | 3 (1.8) |
I | Feasibility | I think that planning the discharge of an ICU patient 24 h in advance is not feasible in daily practice, because the time between the decision to discharge and actual handover is often less than 24 h.d
| 109 (65.7) | 54 (32.5) | 3 (1.8) |
O | Resources | A major reason for not performing a verbal handover between physicians is the fact that the ward physician is often not available. | 108 (65.1) | 50 (30.1) | 8 (4.8) |
S | Culture | In my experience ward professional do give feedback when the handover to the general ward was suboptimal, | 92 (55.4) | 68 (41.0) | 6 (3.6) |
O | Resources | I think that a lack of financial resources is a barrier for implementing improvement interventions. | 82 (49.4) | 79 (47.6) | 5 (3.0) |
O | Resources | In my opinion it is organisationally impossible to make step down facilities.d
| 82 (49.4) | 70 (42.2) | 14 (8.4) |
O | Resources | I think that because of an insufficient nursing staff it is not feasible to monitor post-ICU patient on the wards. b
| 76 (45.8) | 83 (50.0) | 7 (4.2) |
Sy | Professional associations | I think that relocating ICU tasks to the wards by a consulting ICU nurse is not desirable. c
| 65 (39.2) | 100 (60.2) | 1 (0.6) |
I | Credibility | I think the ICU discharge criteria as described in the NVIC guideline are sufficiently based on scientific evidence. | 62 (37.3) | 79 (47.6) | 25 (15.1) |
I | Utility | I think that the ICU discharge criteria as described in the NVIC guideline are unclear. | 58 (34.9) | 91 (54.8) | 17 (10.2) |
P | Attitude | I think that intensivists should be involved in care for ICU patients until they are discharged from the hospital. | 43 (25.9) | 123 (74.1) | 0 (0.0) |
I | Credibility | If there is no scientific evidence for an intervention, I think that this intervention should not be implemented into daily practice. | 42 (25.3) | 123 (74.1) | 1 (0.6) |
O | Structure | I think that the size of my hospital makes it more difficult to improve the ICU discharge process.c, e, f, g
| 42 (25.3) | 115 (69.3) | 9 (5.4) |
O | Resources | I think the current nursing staff is not sufficient for introducing a consulting ICU nurse position. | 41 (24.7) | 117 (70.5) | 8 (4.8) |
IP | Accessibility | I’ve never seen written ICU discharge criteria in our ICU.c, d
| 39 (23.5) | 124 (74.7) | 3 (1.8) |
I | Feasibility | I think that performing structured handover takes a lot of time. | 34 (20.5) | 130 (78.3) | 2 (1.2) |
I | Credibility | Because little is known about causes of ICU readmissions, we can’t do anything about this problem. | 31 (18.7) | 134 (80.7) | 1 (0.6) |
I | Utility | I think it is impossible to set more specific ICU discharge criteria. | 30 (18.1) | 124 (74.7) | 12 (7.2) |
P | Attitude | I think that the sickest patient should be the priority of the intensivist. Patients who are almost ready for ICU discharge are of less importance.f
| 21 (12.7) | 143 (86.1) | 2 (1.2) |
Subgroup analyses
Discussion
Main findings and related literature
Strengths and limitations
Implications for practice
Implications for research
Conclusion
Key messages
-
To decrease practice variation, it is necessary for ICU and general ward to agree on discharge criteria and the ICU discharge process in general.
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An important aspect to consider when evaluating whether or not a patient can be safely discharged is the current capacity of the general ward; characteristics such as number and skill mix of ward staff, and care burden of other patients already on the general ward need to be taken into account.
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To effectively improve the ICU discharge process, improving handover communication, formulating specific discharge criteria, stimulating a culture of feedback, and preventing overestimation of the general ward are important.