Factors Influencing the Decision-making of Healthcare Providers Regarding the Transition of Patients from the Intensive Care Unit to the General Ward in Iran: A Qualitative Study

Waiting to be discharged from intensive care units: Key factors shaping patient and family experiences

OBJECTIVES

To explore the factors that facilitate and hinder intensive care unit (ICU) discharge processes related to patients and their family members.

METHODS

This was a qualitative exploratory study conducted in three regional adult ICUs in Queensland, Australia. Data were collected through semi-structured interviews with patients and their family members (or patient representatives) in addition to daily reflections based on direct observation. A deductive content analysis was undertaken using the Structure, Process, and Outcomes framework, followed by an inductive approach to generate themes.

RESULTS

A total of 16 participants participated in interviews, involving 14 patients, one family member, and one patient representative. Four themes included a desire to be involved, being kept informed, uncertainty in waiting, and the discharge rush. Participants spoke about the desire to be involved in their care and discharge transition. There was a prevailing tension among patients about being kept informed. Although participants remarked that staff communication was reassuring, supportive, and comforting, they noted that timelines for discharge were often unclear, causing hesitation in the discharge process and minimal information before a sudden transfer. Uncertainty in waiting was frequently mentioned by the participants and also reflected in the daily reflections. This uncertainty led to consequences, such as discharge against medical advice and after-hours discharge rush.

CONCLUSION

The findings of this study support existing literature that underlines the importance of patient and family involvement in care, effective communication, and coordination during the discharge processes. After-hours discharge rush should be avoided for the safety of the patients and others on the wards.

IMPLICATIONS FOR CLINICAL PRACTICE

Gaining an understanding of patient and family perspectives on the ICU discharge processes can guide clinicians in developing strategies to improve the continuity and quality of care and therefore enhance patient safety during ICU discharge.

Who gets the bed: Factors influencing the intensive care exit block: A qualitative study

BACKGROUND

Patient flow problems, including discharge delay and after-hours discharge, have been a consistently major issue, especially for intensive care units (ICUs). Evidence suggests that discharge delay and after-hours discharge are associated with increased ICU and hospital length of stay, leading to worsened patient outcomes and increased healthcare costs. They can also increase ICU readmission and post-ICU mortality. The factors influencing discharge processes are not well elucidated.

OBJECTIVE

This study aimed to explore the barriers and facilitators to the ICU patient discharge processes in adult ICUs.

METHODS

This qualitative exploratory multisite observational study was conducted in three regional adult ICUs in Queensland, Australia. We used staff interviews, fieldnotes, and document analysis as data collection techniques. Data analysis commenced with a deductive content analysis using the Structure, Process, and Outcomes framework. Following this, an inductive process was taken using the Theoretical Domains Framework.

FINDINGS

We conducted 59 staff interviews and analysed the discharge documents across three sites. Four domains, including context and resources, beliefs about consequences, social/professional role and identity, and behaviour regulation, were strongly related to the factors that influenced the discharge processes. The findings revealed barriers to discharge, including finding the right bed, disconnected and ineffective information systems, ineffective communication and coordination within and across teams and departments, and uncertainty and inconsistency in discharge decision making. Facilitators included clarity on professional roles in ICU discharge, effective communication within the ICU team, and context specific strategies to support the discharge processes.

CONCLUSIONS

The findings provide an in-depth understanding of the barriers and facilitators to the ICU discharge processes. Multifaceted strategies should be considered to facilitate and manage ICU discharge safely and efficiently, including the use of clearer discharge criteria and guidelines, digital systems that aid communication and coordination, and early planning of ICU patient discharge.

Nurses' perception of uncertainty in clinical decision-making: A qualitative study

Background

Uncertainty is a common challenge for nurses in clinical decision-making, which can compromise patient care quality and safety. To address this issue, it is essential to understand how nurses perceive and cope with uncertainty in their practice.

Aim

This study aimed to explore nurses' perceptions of uncertainty in clinical decision-making using a qualitative approach.

Methods

This study was conducted with a qualitative approach and conventional content analysis in 2020. Participants consisted of 17 nurses from different wards of teaching hospitals in Northwestern Iran, recruited using the purposive sampling method. Data were collected through semi-structured interviews and analyzed simultaneously with data collection (June to December 2020). The data were analyzed using the content analysis approach suggested by Wildemuth. Data were managed with MAXQDA10 software. The analysis revealed four main themes and ten subthemes that described the nurses' experiences of uncertainty in clinical decision-making.

Results

The main themes were: difficult choice, difficult situation, insufficient judgment, and emotional burden.

Conclusions

The study participants defined uncertainty in clinical decision-making as a difficult choice that occurs in difficult situations, which influenced their clinical judgment and emotional well-being. These findings provide valuable insights for developing interventions to help nurses manage uncertainty and improve their decision-making skills and safety.

Pediatricians' Perspectives on Introducing Transitional Care into Handover Between Pediatric Intensive Care Units and General Wards

Background

Despite the availability of a considerable number of studies on transitional care, few qualitative studies have synthesized physicians' perspectives on PICU-to-ward transition to develop a comprehensive transitional care curriculum. The aim of this study is to explore physicians' perceptions and management of the transition of critically ill children from the PICU to the general ward, with the aim of providing an evidence-based curriculum.

Methods

A qualitative study was conducted between July and August 2022. The study involved semi-structured interviews with 11 participants, and data analysis was carried out using NVivo 12.0 software through thematic analysis method.

Results

Based on the data analysis, three main themes were identified: recognition of professional roles during transition, difficulties during implementation transitional care and suggestions for improving transitional care.

Conclusion

The insights of doctors can be valuable in improving transitional care for critically ill children during PICU-to-Ward transition and in developing relevant curricula. It is essential to introduce standardized clinical pathways and strengthen curricula on critical elements, including communication and follow-up.

The Effect of Clinical Decision Support Systems on Patients, Nurses, and Work Environment in ICUs: A Systematic Review

This study aimed to examine the impact of clinical decision support systems on patient outcomes, working environment outcomes, and decision-making processes in nursing. The authors conducted a systematic literature review to obtain evidence on studies about clinical decision support systems and the practices of ICU nurses. For this purpose, the authors searched 10 electronic databases, including PubMed, CINAHL, Web of Science, Scopus, Cochrane Library, Ovid MEDLINE, Science Direct, Tr-Dizin, Harman, and DergiPark. Search terms included "clinical decision support systems," "decision making," "intensive care," "nurse/nursing," "patient outcome," and "working environment" to identify relevant studies published during the period from the year 2007 to October 2022. Our search yielded 619 articles, of which 39 met the inclusion criteria. A higher percentage of studies compared with others were descriptive (20%), conducted through a qualitative (18%), and carried out in the United States (41%). According to the results of the narrative analysis, the authors identified three main themes: "patient care outcomes," "work environment outcomes," and the "decision-making process in nursing." Clinical decision support systems, which target practices of ICU nurses and patient care outcomes, have positive effects on outcomes and show promise in improving the quality of care; however, available studies are limited.