Best nursing review paperA literature review of organisational, individual and teamwork factors contributing to the ICU discharge process
Introduction
Improving patient safety and patient outcomes has emerged as a priority for hospitals in the last 20 years. The US Institute of Medicine's (IOM) report to Congress “To err is human” provided a coherent set of directions that set the agenda for patient safety worldwide.1 The IOM defines healthcare quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”.2 The IOM definition suggests a broad approach to measuring healthcare quality in terms of data-desired outcomes and related processes of care. The IOM's six aims of health care, safe, effective, patient-centred, timely, efficient, and equitable,2 provides an direction for improving patient safety and the quality of health care. It is against this context that a literature review of the ICU discharge process was conducted.
The intensive care unit (ICU) is an essential component of most large hospitals in the modern healthcare system, providing critically ill patients with high quality care. In addition, patients undergoing major surgery often require ICU admission postoperatively. In Australia in 2004–2005, elective surgery accounted for 31.4% of ICU admissions and emergency cases accounted for 46.3% of ICU admissions.3
Intensive care resources are limited and expensive commodities. In 2002–2003, one study found that the average cost of an ICU bed in Australia was A$2670 per day and the total stay per patient was A$9852.4 Australia has significantly fewer ICU resources than other western countries.5 In 2002, the available ICU beds per 100,000 population was 25 in Germany, 24 in USA, 11 in Switzerland, and 10 in The Netherlands.5 In contrast, Martin et al.3 reported that in 2004–2005, there were only 6.1 ICU beds per 100,000 populations in privately and publicly funded institutions in Australia. Using the number of beds per population to argue shortage of beds is debatable, because research shows that patient acuity is lower in countries with more ICU beds. This may indicate that some ICU resources might be more optimally utilised.6 However, a lack of beds relative to population and the high cost suggests that optimal use of the existing ICU beds is imperative in coping with the increasing demand for ICU beds in Australia.
It would appear that optimal bed flow is critical to ensure high quality of care under current ICU capacities, given that ICUs are often under forward pressure from areas such as Emergency Department (ED) or Operating Theatre (OT) for beds7. Discharging patients is one way to relieve this pressure but clearly the risk of premature discharge8 must be managed. At the same time, lack of beds in other parts of the hospital can also cause discharge delays. One study identified that 46% of unsuccessful discharges from ICU were due to a lack of ward beds or disagreement over admitting services in the wards, and one in six discharges were unsuccessful on the first attempt.9 Often patients cannot be admitted into ICU because it is full, which may be because the ICU beds have been taken by patients waiting for ward beds, a situation referred to as discharge delay, “bed-block” or outflow limitation.10, 11 On occasion, a patient maybe discharged prematurely to the ward because a sicker patient from ED or OT needs the ICU bed.
Discharging an ICU patient is a complex, multidisciplinary process, involving collaboration among physicians, nurses, managers, ward clerks, and support systems, both in ICU and across other hospital departments. Effective teamwork and coordination among staff can optimise the ICU patient discharge process and patient outcomes. The following section discusses the conceptual framework for this literature review.
The ICU patient discharge process may begin with a patient's admission to ICU when some of the discharge paperwork is started, and does not finish until the patient is transferred to the ward. Many factors can potentially cause problems. In the last two decades there has been increasing interest in researching factors that may contribute to patient outcomes in hospitals.12, 13, 14, 15 In the 1990s, Reason13, 16 identified that adverse events in complex healthcare systems may result from either active or latent failures. Active failures in a hospital setting are usually “committed” by the person closest to the patient, and this can lead to immediate adverse patient events. Latent failures, in contrast, refer to less apparent failures of organisation or design that contributed to the occurrence of errors.17 Latent failures often arise from management decisions that determine working conditions. Although active failures are much easier to identity than latent failures, identifying the latter could have a much larger effect on improving the working environment and patient safety.
Following this work, Vincent14 and Pronovost et al.15 identified a framework of six factors that may contribute to adverse events in clinical practice. The factors included: (i) patient factors, including clinical conditions, language, and social factors; (ii) task factors, including availability or use of protocols, test results, and accuracy of test results; (iii) individual factors, including knowledge, skills, competence, fatigue, failure to follow established protocols/procedures, motivation and attitude, and physical, mental health; (iv) teamwork factors, including verbal or written communication during handover, routine care and crisis, supervision and seeking help, and team structure and leadership; (v) working conditions, including staffing levels, skills mix, workload, availability or maintenance of equipment, and administrative and managerial support; and (vi) organisational and management factors, including financial resources, time pressures, and physical environment.
Based on these earlier frameworks, in this literature review, factors contributing to the ICU patient discharge process were grouped into four broad domains: organisational factors, individual factors, teamwork factors and patient factors (see Fig. 1). Working conditions, organisational and management factors together were considered as organisational factors. The aim of this literature review was to critically analyse current literature related to factors that influence the ICU patient discharge process. It examined how organisational factors, individual factors and teamwork factors influence the ICU patient discharge. Patient factors, a widely well-researched topic,18, 19 were excluded to limit the review to a manageable length.
Section snippets
Methods
Databases including CINAHL, MEDLINE, PROQUEST, SCIENCE DIRECT were searched using key terms such as ICU discharge, discharge process, discharge policies, ICU guidelines and policies, discharge decision-making, ICU and organisational factors, ICU and human factors, and ICU patient transfer. Web search and the “snow-balling” search of reference lists of articles were also used to locate relevant literature.
On the basis of this literature, the “ICU patient discharge process conceptual framework”
Results
Among the included articles, 10 articles were on organisational factors including four reports, policies and guidelines, and oranisational interventions regarding ICU discharge (see Table 1), five were on individual factors (see Table 2), and six were on teamwork factors (see Table 3).
Discussion
The ICU patient discharge process often starts from ICU admission when the planning of care is initiated, and does not conclude until the patients have been transferred out to wards, and the responsibility, accountability, and management of the patient has been completely handed over to the ward staff. This process can involve health professionals from many disciplines, including ICU specialist physicians and nurses, ward physicians and nurses, managers from different departments, ward clerks,
Recommendations and conclusion
Intensive care patient discharge is influenced by organisational factors, individual factors and teamwork factors. Organisational interventions are effective in reducing ICU discharge delay and shortening patient hospital stay. However, from the current literature, gaps exist. In order to provide evidence for best clinical practice in critical care, more rigorous research is needed to discover how organisational factors, such as discharge guidelines and policies, individual factors, such as
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