Ward-Based Care of Patients Following Discharge from Critical Care: a Mixed Methods Study

Background Historically, critical care research and policy focused on survival to intensive care unit (ICU) discharge. However, as critical care innovation has progressed, emphasis has shifted to the quality of survival beyond ICU discharge. There is significant focus on the long-term rehabilitation needs of patients who have required critical care, but very little evidence exists about the period between ICU and hospital discharge. Care during this time should be focused on recovery and rehabilitation, crucial in limiting the long-term morbidity associated with critical illness. Every year in the UK approximately 163,000 patients are admitted to an ICU. Despite patients being assessed as ready for discharge from ICU, having either recovered from the acute phase of critical illness or transitioned to end-of-life care, over 8,000 of the 139,000 discharged to a ward die before hospital discharge. Design This study aimed to explore the post-ICU in-hospital care period, answering the research question: What challenges and problems in care exist in the management of post-ICU ward patients? A convergent parallel exploratory mixed methods design was selected, integrating two methods: retrospective case record review (RCRR), including initial overview reviews and further in-depth analysis of the records of patients who death was judged probably avoidable, and survivors; and semi-structured interviews. The paper and electronic medical records of 300 patients discharged across three UK ICUs and who subsequently died before hospital discharge were reviewed using an established RCRR methodology. For twenty patients who died their death was judged as probably avoidable and subject to further in-depth review, together with the records of twenty survivors, for comparison. The 40 in-depth reviews examined problems in care delivery and underlying contributory human factors. In parallel, patients (n= 18), family members (n= 8) and staff (n= 30) (total n=56) were interviewed about their experiences of post-ICU ward care, with the aim of identifying challenges in care delivery and potential improvements. Results Primary data were integrated to develop an interdependent multi-layered description of post-ICU ward care, identifying challenges to care delivery at the patient, ward and organisational level. At the patient level, data were combined which revealed a clear picture of post-ICU patients as dependent, vulnerable and complex, contributing to the concept of post-ICU patients as other than general ward patients – having different care needs. These differences posed challenges to care delivery due to the constraints of workload, skill mix and leadership which were identified at the ward level and emphasised the otherness of post-ICU ward patients. Overarching characteristics at the organisational level, such as limitations in out-of-hours care provision, training and resources constrained the ability of the ward to meet the high demands of this complex group of patients. The characteristics identified at each level had the potential to impede continuity of care between ICU and the ward which had a profound impact on both patients and staff resulting in fear and anxiety. Critical Care Outreach Teams were identified as having a key role in supporting wards to manage patients transferred from ICU, although competing priorities can lead to limited capacity to offer comprehensive follow-up of post-ICU patients. Conclusion This study has critically examined the challenges faced by patients and staff following transfer from ICU to the ward. Post-ICU patients were demonstrated to be perceived as other than, or somehow different from, general ward patients, with the current system of care struggling to meet their needs. The findings of this study will inform the development of a complex intervention to improve care delivery for this complex, vulnerable patient cohort. This study was conducted prior to the 2020 COVID-19 pandemic, but offers insight into the current challenges in managing the significant increase in patients being discharged from ICU

Wearables for continuous patient monitoring on COVID-19 isolation wards

An ambulatory monitoring system for the continuous monitoring of heart rate, respiratory rate and oxygen saturation, using wearable devices was implemented at the start of the COVID-19 pandemic on selected isolation wards in a large UK hospital. We have retrospectively analysed the data and nurse observations from two groups of patients on these wards: those whose care was escalated so that they were admitted to the Intensive Care Unit (ICU); and those who were discharged home or to a non-isolation ward (stepping down). The computation of population averages for these two groups 24h prior to an ICU admission or prior to stepping down provides evidence for the value of wearable monitoring for the early identification of physiological deteriorations in COVID-19 patients. The continuous data from the finger-worn pulse oximeter reveals clinically significant changes between 2 and 3 hours ahead of the regular vital-sign observations by the nursing staff. We also show how a hybrid score based on six physiological parameters (calculated from a mixture of continuous and intermittent vital-sign data) can provide early warning of deterioration for high-risk patients

Musculoskeletal impairments after critical illness: a protocol for a qualitative study of the experiences of patients, family and health care professionals

Background: Survivors of critical care are at risk of long-term disability from musculoskeletal (MSK) impairments. These can have a biopsychosocial impact on the patient and their families with a reduction in health-related quality of life, increased health care utilization, caregiving roles and associated psychological distress. Aims: To understand the experiences of patients living with MSK impairments following critical illness, and family and health care professionals supporting them, to inform the development of a future intervention to improve MSK health following critical illness. Study Design: A four-site qualitative case study approach will be taken, with each of the four hospital sites and associated community services representing a case site. We will conduct semi-structured interviews with 10–15 patients/family members and 10–15 health care professionals about their experiences of MSK impairment following critical illness. Interviews will be audio recorded, transcribed verbatim and analysed using reflexive thematic analysis within a descriptive phenomenological approach. Alongside interview data, analysis of publicly available policy documentation, patient-facing materials and information from service leads at the four sites will be conducted. Discourse analysis will be used for this case study documentation. Results: This protocol describes a qualitative study exploring the experiences of patients living with MSK impairments following critical illness, and the family and health care professionals supporting them. Relevance to Clinical Practice: Data analysis will illuminate their experiences and enable data richness to contribute to the qualitative body of evidence of intensive care unit (ICU) survivors. These findings will inform the development of a complex intervention for MSK rehabilitation after critical illness

Patient harm and institutional avoidability of out-of-hours discharge from intensive care: An analysis using mixed methods

© [2022] The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY). https://creativecommons.org/licenses/by/4.0/Objective: Out-of-hours discharge from ICU to the ward is associated with increased in-hospital mortality and ICU readmission. Little is known about why this occurs. We map the discharge process and describe the consequences of out-of-hours discharge to inform practice changes to reduce the impact of discharge at night. Design: This study was part of the REFLECT mixed methods study. We defined out-of-hours discharge as 16:00 - 07:59h. We undertook 20 in-depth case record reviews where in-hospital death after ICU discharge had been judged ‘probably avoidable’ in previous retrospective structured judgement reviews, and 20 where patients survived. We conducted semi-structured interviews with 55 patients, family members and staff with experience of ICU discharge processes. These, along with a stakeholder focus group, informed ICU discharge process mapping using the Human Factors-based Functional Analysis Resonance Method (FRAM). Setting: Three UK NHS hospitals, chosen to represent different hospital settings. Subjects: Patients discharged from ICU, their families and staff involved in their care. Interventions None. Measurements and Main Results: Out-of-hours discharge was common. Patients and staff described out-of-hours discharge as unsafe due to a reduction in staffing and skill mix at night. Patients discharged out-of-hours were commonly discharged prematurely, had inadequate handover, were physiologically unstable and did not have deterioration recognised or escalated appropriately. We identified five interdependent functions key to facilitating timely ICU discharge: multi-disciplinary team decision for discharge; patient prepared for discharge; bed meeting; bed manager allocation of beds; and ward bed made available. Conclusion: We identified significant limitations in out-of-hours care provision following overnight discharged from ICU. Transfer to the ward before 16:00 should be facilitated where possible. Our work highlights changes to help make day time discharge more likely. Where discharge after 16:00 is unavoidable, support systems should be implemented to ensure the safety of patients discharged from ICU at night.Peer reviewedFinal Published versio

‘Doing the best we can’: Registered Nurses' experiences and perceptions of patient safety in intensive care during COVID-19

Aims: To explore registered nurses' experiences of patient safety in intensive care during COVID-19. Design: A qualitative interview study informed by constructivism. Method: Semi-structured interviews were conducted and audio-recorded with 19 registered nurses who worked in intensive care during COVID-19 between May and July 2021. Interviews were transcribed verbatim and thematically analysed utilizing framework. Results: Two key themes were identified. ‘On a war footing’—an unprecedented situation which describes the situation nurses faced, and the actions are taken to prepare for the safe delivery of care. ‘Doing the best we can’—Safe Delivery of Care which describes the ramifications of the actions taken on short- and long-term patient safety including organization of care, missed and suboptimal care and communication. Both themes were embedded in the landscape of Staff Well-being and Peer Support. Conclusion: Nurses reported an increase in patient safety risks which they attributed to the dilution of skill mix and fragmentation of care. Nurses demonstrated an understanding of the holistic and long-term impacts on patient safety and recovery from critical illness. Impact: This study explored the perceived impact of COVID-19 on patient safety in intensive care from a nursing perspective. Dilution of skill mix, where specialist critical care registered nurses were diluted with registered nurses with no critical care experience, and the fragmentation of care was perceived to lead to reduced quality of care and increased adverse events and risk of harm which were not consistently formally reported. Furthermore, nurses demonstrated a holistic and long-term appreciation of patient safety. These findings should be considered as part of future nursing workforce modelling and patient safety strategies by intensive care leaders and managers. No public or patient contribution to this study. The study aims and objectives were developed in collaboration with health care professionals

Investigating the impact of physical activity interventions on delirium outcomes in intensive care unit patients: A systematic review and meta-analysis

Background. To investigate the impact of physical activity interventions, including early mobilisation, on delirium outcomes in critically ill patients. Methods. Electronic database literature searches were conducted, and studies were selected based on pre-specified eligibility criteria. Cochrane Risk of Bias-2 and Risk Of Bias In Non-randomised Studies-of Interventions quality assessment tools were utilised. Grading of Recommendations, Assessment, Development and Evaluations was used to assess levels of evidence for delirium outcomes. The study was prospectively registered on PROSPERO (CRD42020210872). Results. Twelve studies were included; ten randomised controlled trials one observational case-matched study and one before-after quality improvement study. Only five of the included randomised controlled trial studies were judged to be at low risk of bias, with all others, including both non-randomised controlled trials deemed to be at high or moderate risk. The pooled relative risk for incidence was 0.85 (0.62–1.17) which was not statistically significant in favour of physical activity interventions. Narrative synthesis for effect on duration of delirium found favour towards physical activity interventions reducing delirium duration with median differences ranging from 0 to 2 days in three comparative studies. Studies comparing varying intervention intensities showed positive outcomes in favour of greater intensity. Overall levels of evidence were low quality. Conclusions. Currently there is insufficient evidence to recommend physical activity as a stand-alone intervention to reduce delirium in Intensive Care Units. Physical activity intervention intensity may impact on delirium outcomes, but a lack of high-quality studies limits the current evidence base

Using a novel ambulatory monitoring system to support patient safety on an acute infectious disease ward during an unfolding pandemic

Aim: To gain staff feedback on the implementation and impact of a novel ambulatory monitoring system to support coronavirus patient management on an isolation ward. Design: Qualitative service evaluation. Methods: Semi-structured interviews were conducted with 15 multidisciplinary isolation ward staff in the United Kingdom between July 2020 and May 2021. Interviews were audio-recorded, transcribed and analysed using thematic analysis. Findings: Adopting Innovation to Assist Patient Safety was identified as the overriding theme. Three interlinked sub-themes represent facets of how the system supported patient safety. Patient Selection was developed throughout the pandemic, as clinical staff became more confident in choosing which patients would benefit most. Trust In the System described how nurses coped with discrepancies between the ambulatory system and ward observation machines. Finally, Resource Management examined how, once trust was built, staff perceived the ambulatory system assisted with caseload management. This supported efficient personal protective equipment resource use by reducing the number of isolation room entries. Despite these reported benefits, face-to-face contact was still highly valued, despite the risk of coronavirus exposure. Conclusion: Hospital wards should consider using ambulatory monitoring systems to support caseload management and patient safety. Patients in isolation rooms or at high risk of deterioration may particularly benefit from this additional monitoring. However, these systems should be seen as an adjunct to nursing care, not a replacement. Implications for the Profession and/or Patient Care: Nurses valued ambulatory monitoring as a means of ensuring the safety of patients at risk of deterioration and prioritizing their workload. Impact: The findings of this research will be useful to all those developing or considering implementation of ambulatory monitoring systems in hospital wards. Reporting Method: This manuscript follows the Consolidated criteria for Reporting Qualitative Research (COREQ) guidelines with inclusion of relevant SQUIRE guidelines for reporting quality improvement. Patient or Public Contribution: No Patient or Public Contribution

'Doing the best we can': Registered nurses' experiences and perceptions of patient safety in intensive care during COVID-19

Aims: To explore registered nurses' experiences of patient safety in intensive care during COVID-19.Design: A qualitative interview study informed by constructivism. Method: Semi-    structured interviews were conducted and audio- recorded with 19 registered nurses who worked in intensive care during COVID-19 between May and July 2021. Interviews were transcribed verbatim and thematically analysed utilizing framework. Results: Two key themes were identified. ‘On a war footing’—an unprecedented situation which describes the situation nurses faced, and the actions are taken to prepare for the safe delivery of care. ‘Doing the best we can’—Safe Delivery of Care which describes the ramifications of the actions taken on short-  and long-term patient safety including organization of care, missed and suboptimal care and communication. Both themes were embedded in the landscape of Staff Well-being and Peer  Support. Conclusion: Nurses reported an increase in patient safety risks which they attributed to the dilution of skill mix and fragmentation of care. Nurses demonstrated an under-standing of the holistic and long-term impacts on patient safety and recovery from critical illness. Impact: This study explored the perceived impact of COVID-19 on patient safety in intensive care from a nursing perspective. Dilution of skill mix, where specialist critical care registered nurses were diluted with registered nurses with no critical care experience, and the fragmentation of care was perceived to lead to reduced quality of care and increased adverse events and risk of harm which were not consistently formally reported. Furthermore, nurses demonstrated a holistic and long-term appreciation of patient safety. These findings should be considered as part of future nursing work-force modelling and patient safety strategies by intensive care leaders and managers. No public or patient contribution to this study. The study aims and objectives were developed in collaboration with health care professionals

Using a novel ambulatory monitoring system to support patient safety on an acute infectious disease ward during an unfolding pandemic

Aim. To gain staff feedback on the implementation and impact of a novel ambulatory monitoring system to support coronavirus patient management on an isolation ward. Design. Qualitative service evaluation. Methods. Semi-structured interviews were conducted with 15 multidisciplinary isolation ward staff in the United Kingdom between July 2020 and May 2021. Interviews were audio-recorded, transcribed and analysed using thematic analysis. Findings. Adopting Innovation to Assist Patient Safety was identified as the overriding theme. Three interlinked sub-themes represent facets of how the system supported patient safety. Patient Selection was developed throughout the pandemic, as clinical staff became more confident in choosing which patients would benefit most. Trust In the System described how nurses coped with discrepancies between the ambulatory system and ward observation machines. Finally, Resource Management examined how, once trust was built, staff perceived the ambulatory system assisted with caseload management. This supported efficient personal protective equipment resource use by reducing the number of isolation room entries. Despite these reported benefits, face-to-face contact was still highly valued, despite the risk of coronavirus exposure. Conclusion. Hospital wards should consider using ambulatory monitoring systems to support caseload management and patient safety. Patients in isolation rooms or at high risk of deterioration may particularly benefit from this additional monitoring. However, these systems should be seen as an adjunct to nursing care, not a replacement. Implications for the Profession and/or Patient Care. Nurses valued ambulatory monitoring as a means of ensuring the safety of patients at risk of deterioration and prioritizing their workload. Impact. The findings of this research will be useful to all those developing or considering implementation of ambulatory monitoring systems in hospital wards. Reporting Method. This manuscript follows the Consolidated criteria for Reporting Qualitative Research (COREQ) guidelines with inclusion of relevant SQUIRE guidelines for reporting quality improvement. Patient or Public Contribution. No Patient or Public Contribution