Development and pilot implementation of a patient-oriented discharge summary for critically Ill patients

Critical illness among patients experiencing homelessness: a retrospective cohort study

PURPOSE

To understand the epidemiology and healthcare use of critically ill patients experiencing homelessness compared to critically ill patients with stable housing.

METHODS

This retrospective population-based cohort study included adults admitted to any ICU in Alberta, Canada, for a 3-year period. Administrative and clinical data from the hospital, ICU and emergency department were used to examine healthcare resource use (processes of care, ICU and hospital length of stay, hospital readmission and emergency room visits). Regression was used to quantify differences in healthcare use by housing status.

RESULTS

2.3% (n = 1086) of patients admitted to the ICU were experiencing homelessness; these patients were younger, more commonly admitted for medical reasons and had fewer comorbidities compared to those with stable housing. Processes of care in the ICU were mostly similar, but healthcare use after ICU was different; patients experiencing homelessness who survived their index hospitalization were more than twice as likely to have a visit to the emergency department (OR = 2.3 times, 95% CI 2.0-2.6, < 0.001) or be readmitted to hospital (OR = 2.1, 95% CI 1.8-2.4, p < 0.001) within 30 days, and stayed 10.1 days longer in hospital (95% CI 8.6-11.6, p < 0.001), compared with those who have stable housing.

CONCLUSIONS

Patients experiencing homelessness have different characteristics at ICU admission and have similar processes of care in ICU, but their subsequent use of healthcare resources was higher than patients with stable housing. These findings can inform strategies to prepare patients experiencing homelessness for discharge from the ICU to reduce healthcare resource use after critical illness.

A Multiple Baseline Trial of an Electronic ICU Discharge Summary Tool for Improving Quality of Care

OBJECTIVE

Effective communication between clinicians is essential for seamless discharge of patients between care settings. Yet, discharge summaries are commonly not available and incomplete. We implemented and evaluated a structured electronic health record-embedded electronic discharge (eDischarge) summary tool for patients discharged from the ICU to a hospital ward.

DESIGN

Multiple baseline trial with randomized and staggered implementation.

SETTING

Adult medical-surgical ICUs at four acute care hospitals serving a single Canadian city.

PATIENTS

Health records of patients 18 years old or older, in the ICU 24 hours or longer, and discharged from the ICU to an in-hospital patient ward between February 12, 2018, and June 30, 2019.

INTERVENTION

A structured electronic note (ICU eDischarge tool) with predefined fields (e.g., diagnosis) embedded in the hospital-wide electronic health information system.

MEASUREMENTS AND MAIN RESULTS

We compared the percent of timely (available at discharge) and complete (included goals of care designation, diagnosis, list of active issues, active medications) discharge summaries pre and post implementation using mixed effects logistic regression models. After implementing the ICU eDischarge tool, there was an immediate and sustained increase in the proportion of patients discharged from ICU with timely and complete discharge summaries from 10.8% (preimplementation period) to 71.1% (postimplementation period) (adjusted odds ratio, 32.43; 95% CI, 18.22-57.73). No significant changes were observed in rapid response activation, cardiopulmonary arrest, death in hospital, ICU readmission, and hospital length of stay following ICU discharge. Preventable (60.1 vs 5.7 per 1,000 d; p = 0.023), but not nonpreventable (27.3 vs 40.2 per 1,000d; p = 0.54), adverse events decreased post implementation. Clinicians perceived the eDischarge tool to produce a higher quality discharge process.

CONCLUSIONS

Implementation of an electronic tool was associated with more timely and complete discharge summaries for patients discharged from the ICU to a hospital ward.