Transfer out of intensive care: an evidence-based literature review

Case Report: Management of cerebral arterial gas embolism via transfer to an outpatient hyperbaric chamber

Gas embolisms can be caused by iatrogenic interventions, resulting in various manifestations. We present a patient who experienced loss of consciousness and simultaneous paralysis during a percutaneous needle biopsy of the lung. A CT scan of the head revealed a cerebral arterial gas embolism. Because the treating hospital did not have access to hyperbaric oxygen for immediate treatment, the patient was transferred to an outpatient wound care facility. There, the patient initially improved when treated with hyperbaric oxygen therapy but deteriorated with resumption of ambient pressure. Continued treatment occurred at another hospital where the patient's condition normalized. The initial transfer of the patient to another facility was notable because it was a transfer from a rural hospital, a higher-level facility, to an offsite wound care center with a hyperbaric chamber, a lower-level facility that could provide a higher level of care. This case report demonstrates the importance of immediate treatment of iatrogenic gas embolism with hyperbaric oxygen, which often is not available at many hospitals, and highlights the necessity to adapt to the transport of the patient from a higher-level facility to a lower-level facility when such transportation is necessary to provide effective and immediate care. This report is not recommending routinely transferring such patients to a lower level of care facility. However, when deemed clinically necessary and safe by bedside emergency physicians/critical care pulmonary physicians, it is a viable option. Explicit guidelines for transfers to lower-level facilities should be established to avoid delays in these situations.

Uncertainty experienced by the critical patient upon discharge to the general ward: Care proposals from the perspective of Mishel's theory

BACKGROUND

The process of discharging the critical patient to the ward (discharge from critical care to the general ward-DCCW) is often described as an experience involving uncertainty which may affect the patient's quality of life and ability to cope. Coping with uncertainty is an individual response not related to the course of the illness that is dependent on external and internal resources and the ability to utilize them. Mishel's theory of uncertainty identifies aspects of care that can shape the experience of uncertainty associated with the illness.

AIM

To understand the experiences of uncertainty of critical patients associated with discharge from the intensive care unit (ICU) to glean person-centred care strategies under such circumstances.

STUDY DESIGN

Qualitative study with a phenomenological approach. Between March 2017 and May 2018, 20 in-depth interviews were conducted on patients recently discharged from an ICU.

RESULTS

The patients have been organized according to the following pre-established categories of Mishel's theory: stimulus framework, structure providers and uncertainty assessment. Based on these results, suggestions for the care of the critical patient upon discharge from the ICU are made in each of these categories.

CONCLUSIONS

Applying Mishel's theoretical perspective to care for the critical patient during the process of discharge to the ward can help identify areas for intervention and improvement. To succeed, there is a need to promote a cultural change in ICUs, empower nurses and provide the necessary resources.

RELEVANCE TO CLINICAL PRACTICE

These findings are relevant and timely given the impact of the experience of critical patients discharge to the ward. Uncertainty management has been identified as an important element in the discharge experience of critically ill patients to the ward because, according to the informants' stories, it can make this transition a healthier process with less emotional impact.

Relatives' experiences of the transition from intensive care to home for acutely admitted intensive care patients-A qualitative study

BACKGROUND

Acute admission to an intensive care unit (ICU) can negatively affect quality of life for patients and their relatives. Relatives play an important caregiving role after the patient's admission. More knowledge and understanding of their needs are necessary as the patient transitions home.

AIM

This study aims to explore relatives' experiences of acutely admitted ICU patients' transition from the ICU to a general ward and then home.

STUDY DESIGN

A qualitative study with a phenomenological approach was conducted. Interviews were in-depth and featured open-ended questions. The interviews took place after the patients transitioned from ICU to home and were conducted online by videoconference. Data were analysed using Colaizzi's seven-step method.

RESULTS

Twelve relatives of acutely admitted ICU patients were interviewed. Five main themes emerged: (1) mixed feelings, (2) sense of not being involved, (3) limited information provision, (4) lack of acknowledgement as a caregiver, and (5) an uncertain future perspective. Relatives experience major uncertainties during transitions and prefer to be actively involved in care and care decisions.

CONCLUSIONS

This study indicates that relatives of ICU patients experience a lack of guidance during the transitions from the ICU to a general ward and to home, or a follow-up facility. More focus is needed on the themes of mixed feelings, the sense of not being involved, limited information provision, lack of acknowledgement as a caregiver, and an uncertain future perspective. This increased focus might improve the guidance during these transitions.

RELEVANCE TO CLINICAL PRACTICE

The insights from this study may help to improve the care of patients and their relatives during the transitions.

Transfer anxiety in parents of children transferred from pediatric intensive care units to general wards in South Korea: a hybrid concept analysis

Purpose

This study aimed to analyze the concept of transfer anxiety in parents of children transferred from pediatric intensive care units to general wards.

Methods

The hybrid model by Schwarz-Barcott and Kim was used to analyze the characteristics of transfer anxiety in parents of children transferred from pediatric intensive care units to general wards.

Results

Transfer anxiety was defined by the following attributes: 1) stress concerning the adaptation process, 2) concern about the child’s condition worsening due to the parent’s caregiving, and 3) involuntary changes in daily life due to the treatment. Transfer anxiety has the following antecedents: 1) uncertainty; 2) a lack of knowledge about the illness, medical devices, and caregiving; and 3) a lack of social support. It resulted in 1) caregiver burden, 2) a decrease in the capacity for coping with caregiving, 3) delays in the child’s physical and psychological recovery, and 4) decreased quality of life.

Conclusion

It is necessary to develop an assessment scale that considers the attributes of transfer anxiety in parents of children transferred from pediatric intensive care units to general wards. Furthermore, an effective nursing intervention should be developed to reduce transfer anxiety.

Asking "Meaning Questions" in Evidence-Based Reviews and the Utility of Qualitative Findings in Practice

Evidence-based practice (EBP) systematic reviews are mostly conducted using etiology, diagnosis, therapy, prevention, and prognosis question format. "Meaning" or qualitative questions are very rarely used. The purpose of this article is to discuss qualitative findings' contribution to EBP through asking "meaning questions" in conducting systematic reviews and the utilization of the results to practice. Two EBP systematic review exemplars using meaning questions including the relevance and utilization of qualitative findings in health care decision-making, practice, and policy are presented. There is a need to instill an evidence-based mindset into systematic reviews that balance scientific knowledge gained through empirical research and evidence from qualitative studies. This is turn will increase awareness among clinicians and decision makers on the different ways in which qualitative evidence can be used and applied in practice.

A Novel Approach to ICU Survivor Care: A Population Health Quality Improvement Project

OBJECTIVES

Deliver a novel interdisciplinary care process for ICU survivor care and their primary family caregivers, and assess mortality, readmission rates, and economic impact compared with usual care.

DESIGN

Population health quality improvement comparative study with retrospective data analysis.

SETTING

A single tertiary care rural hospital with medical/surgical, neuroscience, trauma, and cardiac ICUs.

PATIENTS

ICU survivors.

INTERVENTIONS

Reorganization of existing post discharge health care delivery resources to form an ICU survivor clinic care process and compare this new process to post discharge usual care process.

MEASUREMENTS AND MAIN RESULTS

Demographic data, Acute Physiology and Chronic Health Evaluation IV scores, and Charlson Comorbidity Index scores were extracted from the electronic health record. Additional data was extracted from the care manager database. Economic data were extracted from the Geisinger Health Plan database and analyzed by a health economist. During 13-month period analyzed, patients in the ICU survivor care had reduced mortality compared with usual care, as determined by the Kaplan-Meier method (ICU survivor care 0.89 vs usual care 0.71; log-rank p = 0.0108) and risk-adjusted stabilized inverse probability of treatment weighting (hazard ratio, 0.157; 95% CI, 0.058-0.427). Readmission for ICU survivor care versus usual care: at 30 days (10.4% vs 26.3%; stabilized inverse probability of treatment weighting hazard ratio, 0.539; 95% CI, 0.224-1.297) and at 60 days (16.7% vs 34.7%; stabilized inverse probability of treatment weighting hazard ratio, 0.525; 95% CI, 0.240-1.145). Financial data analysis indicates estimated annual cost savings to Geisinger Health Plan ranges from $247,052 to $424,846 during the time period analyzed.

CONCLUSIONS

Our ICU survivor care process results in decreased mortality and a net annual cost savings to the insurer compared with usual care processes. There was no statistically significant difference in readmission rates.

A qualitative study portraying nurses' perspectives on transitional care between intensive care units and hospitals wards

INTRODUCTION

The transition process from the intensive care unit (ICU) to hospital ward may impact the illness trajectory and compromise the continuity of safe care for ICU survivors. ICU and ward nurses are involved with the transition and are responsible for the quality of the transitional care.

AIM

The aim was to explore ICU and ward nurses' views on assignments in relation to patients' transition between ICU and hospital ward.

METHODS

We conducted a qualitative study with 20 semi-structured interviews with ICU nurses and ward nurses and analysed data by content analysis.

SETTING

A university hospital with 690 beds and an 11-bed mixed medical/surgical ICU.

FINDINGS

The overarching themes were (1) 'Ritual of hand over' with the categories: (a) 'Ready, able and willing', (b) 'Transfer of responsibility' and (c) 'Nice to know versus need to know' and (2) 'From lifesaving care to rehabilitative care' with the categories: (a) 'Complex care needs persist', (b) 'Fight or flight mode' and (c) '"Weaning" the family'. Nurses were highly focused on the ritual of the actual handover of the patient and discussed readiness as an indicator of quality and the feeling of passing on the responsibility. Nurses had different opinions on what useful knowledge was and thus necessary to communicate during handover. Although patients' complex care needs may not have been resolved when exiting the ICU, ward nurses had to receive patients in a setting where nurses were mostly comfortable within their own specialty - this was worrying for both type of nurses. Patients could enter the ward very exhausted and weak or in 'fight mode' and demand rehabilitation at a pace the ward was not capable of delivering. ICU nurses encouraged families to be demanding after the ICU stay, and ward nurses asked them to trust them and steep back.

Challenges of the patient transition process from the intensive care unit: a qualitative study

Background

The transition of patients from the intensive care unit (ICU) to the general ward is challenging. This study aimed to explain the challenges that patients face during the transition process.

Methods

In this qualitative research of conventional content analysis, data collection was conducted between February 2018 and July 2019 in educational hospitals. After obtaining informed consent, purposive sampling was performed with 22 nurses, intensive care physicians, anesthesiologists, and patients and their families using in-depth semi-structured interviews until data saturation.

Results

The content analysis yielded three main themes in the challenges patients face during the transition process from the ICU: mixed feelings regarding transition (happiness/hope, worry/uncertainty, abandonment); care break (different atmosphere, the difference between the program and the quality of care, assigning care to the patient and family, and care culture and beliefs); and search for support and information (ineffective communication, self-care capacity of patient and family, ineffective and disrupted training, and weak follow-up programs), which inflicts care shock in the patients.

Conclusions

The results showed that patients and their families were in a state of care shock during the ICU transition process and were sometimes disconcerted. It is necessary to design and implement care models according to the needs and challenges patients face during the transition period from ICU (patient-centered), based on the evidence available, and after considering the field of medicine and the accessibility of care in the country. The transition process can be improved and enhanced by obtaining knowledge about ICU care and related challenges as well as organizing a learning environment.

Family-Centered Care During the COVID-19 Era

Family support is more, not less, important during crisis. However, during the COVID-19 pandemic, maintaining public safety necessitates restricting the physical presence of families for hospitalized patients. In response, health systems must rapidly adapt family-centric procedures and tools to circumvent restrictions on physical presence. Strategies for maintaining family integrity must acknowledge clinicians' limited time and attention to devote to learning new skills. Internet-based solutions can facilitate the routine, predictable, and structured communication, which is central to family-centered care. But the reliance on technology may compromise patient privacy and exacerbate racial, socioeconomic, and geographic disparities for populations that lack access to reliable internet access, devices, or technological literacy. We provide a toolbox of strategies for supporting family-centered inpatient care during physical distancing responsive to the current clinical climate. Innovations in the implementation of family involvement during hospitalizations may lead to long-term progress in the delivery of family-centered care.

Inter-facility transfers for advanced critical care services: Impacts on rural families

AIMS AND OBJECTIVES

The aim of this article is to provide an integrative review of rural family members' experiences of a relative's inter-facility transfer to an urban tertiary care centre for advanced critical care services.

BACKGROUND

Although there is an increasing awareness of the negative consequences of a relative's critical illness for family members, there has been limited research conducted on the impacts of this experience for families of patients in rural settings who require an inter-facility transfer for advanced services.

SEARCH STRATEGY

The search strategy for this review was framed by the study purpose, research question, and a conceptual structure of key constructs. Databases and reference lists were electronically and manually searched.

INCLUSION AND EXCLUSION CRITERIA

Articles were included if they were research articles, available in English, and focused on family members' experiences of inter-facility transfer during critical illness. Articles focusing on critical care transfers within a single urban setting, elective transfers undertaken for patient or family preference, transfers not associated with critical illness, and systematic or scoping reviews were excluded.

CONCLUSION

Stress and anxiety are central to the rural family members' experience of this phenomenon. These constructs are influenced by modifiable factors, including the actions of health care providers, the financial burden associated with the transfer, the family members' physical proximity to the patient, and their access to information and support networks. Further research is required to explore potential short- and long-term consequences of this experience and the experience of family members who are left behind and to develop and test interventions to support families.

RELEVANCE TO CLINICAL PRACTICE

This review highlights the concern that health care providers frequently misunderstand the needs of family members who are experiencing this phenomenon. Through a better understanding of this phenomenon, health care providers will be better positioned to effectively support these individuals during this unique experience.

Posttraumatic Stress Syndrome: What Is It?

Readily defined as symptoms consistent with posttraumatic stress disorder (PTSD), but that occur earlier than 30 days after experiencing the traumatic event, posttraumatic stress syndrome (PTSS) is now acknowledged to be a serious health issue. Even so, PTSS often goes unrecognized until an official diagnosis of PTSD is made. Screening tools such as the PTSS-14 have proven reliable in identifying people with PTSS who are at risk of developing PTSD. Through early recognition, providers may be able to intervene, thus alleviating or reducing the effects of a traumatic experience.

Mentoring the next generation of neuroscience nurses: a pilot study of mentor engagement within an academic-service partnership

Resulting from a system-wide launch of an academic-service partnership that united a research-intensive School of Nursing and a tertiary healthcare system, neuroscience nurses used a team-based approach in mentoring undergraduate nursing students in neuroscience nursing. They linked their team approach to the Institute of Medicine's Future of Nursing report and American Association of Neuroscience Nurses' (2012) strategic plan to prepare neuroscience nurses for the future. Using case reports containing both the mentors' and students' perspective, we showcase sophomore nursing students' development in neuroscience nursing with focus on their developing skills in competency, leadership, and collaboration. Results from this implementation phase include improved reliability in performing undergraduate neurological assessments; developing competency in collaborating with the health team using a culturally sensitive approach; beginning leadership in managing a patient with seizures; and collaborating with families in patient-family-focused care. Evaluation of the effectiveness of this mentored approach to clinical undergraduate nursing education will focus on confidence building for students and mentors.