Michelle Foster

Transfer out of intensive care: A qualitative exploration of patient and family perceptions

OBJECTIVE To examine perceptions of ICU transfer held by patients and their family members, focusing specifically on those aspects of transfer perceived as difficult and those perceived as helpful. DESIGN Descriptive qualitative case study design. SETTING General ICU of a large regional Australian teaching hospital. PATIENTS A total of 7 patients and 6 family members were purposefully recruited at one-month post-discharge from hospital. Participants were selected for their ability to recall ICU transfer, the involvement of family members and their ability to articulate their experiences. MAIN OUTCOME MEASURES Two focus groups (one for patients and one for families) were conducted in the hospital setting, aimed at capturing the individual and collective perceptions of transfer out of intensive care. RESULTS Four themes emerged from the data that reflected the complex and emotional nature of transfer out of intensive care. These themes included (1) a sense of sudden abandonment (2) pervasive feelings of vulnerability and helplessness, (3) a loss of importance and (4) ambivalence about the experience. CONCLUSIONS The need for ICU nurses, ward nurses and affiliated healthcare professionals to provide emotional support throughout ICU transfer is the most significant implication of the study. Strategies to provide this support must be developed, implemented and evaluated.

ICU nurses’ perceptions of discharge planning: a preliminary study

The role that intensive care unit (ICU) nurses could play in hospital discharge planning remains relatively unexplored. Using a case study, all ICU nurses in one hospital were surveyed about their perceptions of their role in the discharge process. Over 70% of the 58 nurses who responded thought that discharge planning was both appropriate in the ICU and not premature. However, several obstacles including patient acuity, time constraints and limited experience with this process were evident. While ICU nurses are aptly placed to manage discharge planning, they cannot be expected to undertake this important role without a systematic approach to its implementation.

Mortality rate comparison after switching from continuous to prolonged intermittent renal replacement for acute kidney injury in three intensive care units from different countries

BACKGROUND Prolonged intermittent renal replacement therapy (PIRRT) is a dialysis modality for critically ill patients that in theory combines the superior detoxification and haemodynamic stability of the continuous renal replacement therapy (CRRT) with the operational convenience, reduced haemorrhagic risk and low cost of conventional intermittent haemodialysis. However, the extent to which PIRRT should replace these other modalities is uncertain because comparative studies of mortality are lacking. We retrospectively examined the mortality data from three general intensive care units (ICUs) in different countries that have switched their predominant therapeutic approach from CRRT to PIRRT. We assessed whether this practice change was associated with a change in mortality rate. METHODS Data were analysed from ICUs in New Zealand, Australia and Italy. The study population comprised all patients requiring renal replacement therapy from 1 January 1995 to 31 December 2005 (n = 1347), the period of time spanning the change from CRRT to PIRRT in each unit. Poisson regression models were used to estimate the incident rate ratio (IRR) for death, comparing the periods before and after change to PIRRT in each unit. Estimates were adjusted for patient illness severity (APACHE II score) and for the underlying time trend in mortality rate over time. RESULTS The change from CRRT to PIRRT was not associated with any increase in mortality rate, with an adjusted IRR of 1.02 (0.61-1.71). The IRR was virtually identical in the three ICUs (P-value = 0.63 for the difference in the IRR between ICUs). CONCLUSIONS Switching from CRRT to PIRRT was not associated with a change in mortality rate. Pending the results of a randomized trial, our study provides evidence that PIRRT might be equivalent to CRRT in the general ICU patient.

Redesigning the ICU Nursing Discharge Process: A Quality Improvement Study

PURPOSE To evaluate the impact of a redesigned intensive care unit (ICU) nursing discharge process on ICU discharge delay, hospital mortality, and ICU readmission within 72 hours. METHODS A quality improvement study using a time series design and statistical process control analysis was conducted in one Australian general ICU. The primary outcome measure was hours of discharge delay per patient discharged alive per month, measured for 15 months prior to, and for 12 months after the redesigned process was implemented. The redesign process included appointing a change agent to facilitate process improvement, developing a patient handover sheet, requesting ward staff to nominate an estimated transfer time, and designing a daily ICU discharge alert sheet that included an expected date of discharge. RESULTS A total of 1,787 ICU discharges were included in this study, 1,001 in the 15 months before and 786 in the 12 months after the implementation of the new discharge processes. There was no difference in in-hospital mortality after discharge from ICU or ICU readmission within 72 hours during the study period. However, process improvement was demonstrated by a reduction in the average patient discharge delay time of 3.2 hours (from 4.6 hour baseline to 1.0 hours post-intervention). CONCLUSIONS Involving both ward and ICU staff in the redesign process may have contributed to a shared situational awareness of the problems, which led to more timely and effective ICU discharge processes. The use of a change agent, whose ongoing role involved follow-up of patients discharged from ICU, may have helped to embed the new process into practice.

The effect of music on discomfort experienced by intensive care unit patients during turning: A randomized cross-over study

Research consistently demonstrates that intensive care unit (ICU) patients experience pain, discomfort and anxiety despite analgesic and sedative use. The most painful procedure reported by critically ill patients is being turned. Music diminishes anxiety and discomfort in some populations; however, its effect on critically ill patients remains unknown. This research aimed to identify the effect of music on discomfort experienced by ICU patients during turning using a single blind randomized cross-over design. Seventeen post-operative ICU patients were recruited and treatment order randomized. Discomfort and anxiety were measured 15 min before and immediately after two turning procedures. Findings indicated that listening to music 15 min before and during turning did not significantly reduce discomfort or anxiety. Pain management might effectively be addressing discomfort and anxiety experienced during turning. Given previous studies have identified turning as painful, current results are promising and it might be useful to determine if this is widespread.

Relocating an intensive care unit: An exploratory qualitative study

BACKGROUND As new hospitals are built to replace old and ageing facilities, intensive care units are being constructed with single patient rooms rather than open plan environments. While single rooms may limit hospital infections and promote patient privacy, their effect on patient safety and work processes in the intensive care unit requires greater understanding. Strategies to manage changes to a different physical environment are also unknown. OBJECTIVES This study aimed to identify challenges and issues as perceived by staff related to relocating to a geographically and structurally new intensive care unit. METHODS This exploratory ethnographic study, underpinned by Donabedians structure, process and outcome framework, was conducted in an Australian tertiary hospital intensive care unit. A total of 55 participants including nurses, doctors, allied health professionals, and support staff participated in the study. We conducted 12 semi-structured focus group and eight individual interviews, and reviewed the hospitals documents specific to the relocation. After sorting the data deductively into structure, process and outcome domains, the data were then analysed inductively to identify themes. FINDINGS Three themes emerged: understanding of the relocation plan, preparing for the uncertainties and vulnerabilities of a new work environment, and acknowledging the need for change and engaging in the relocation process. DISCUSSION AND CONCLUSIONS A systematic change management strategy, dedicated change leadership and expertise, and an effective communication strategy are important factors to be considered in managing ICU relocation. Uncertainty and staff anxiety related to the relocation must be considered and supports put in place for a smooth transition. Work processes and model of care that are suited to the new single room environment should be developed, and patient safety issues in the single room setting should be considered and monitored. Future studies on managing multidisciplinary work processes during intensive care unit relocation will add to the learnings we report here.

Snake bite--an occupational hazard?

Snake bite envenomation demands a high level of knowledge and skill on the part of the critical care nurse. The following paper examines a case study of one patient who presented on two separate occasions, with snake bites from a taipan and then, 6 months later, from a death adder. Snake venom contains a variety of complex substances which do vary between the snake species; therefore, the different forms of envenomation require different modalities of treatment. This paper seeks to examine the different management required for each specific episode of envenomation. It compares the characteristics of the two snakes and examines the different effects of envenomation in both cases.

Redesigning the ICU nursing discharge process: a quality improvement study

Introduction: The ICU discharge process is complex. Despite professional guidelines for managing ICU discharge processes, there are wide variations in practice. Objectives: To evaluate the impact of a redesigned ICU nursing discharge process on ICU discharge delay, hospital mortality and ICU readmission within 72 h. Methods: After ethics approval, a quality improvement study using a time series design and statistical process control analysis was conducted in one Australian general ICU. The primary outcome measure was hours of discharge delay per patient discharged alive per month, measured 15 months prior to and 12 months after the redesigned process was implemented. The redesign process included developing a patient handover sheet, requesting ward staff to nominate an estimated transfer time, a daily ICU discharge alert sheet and an expected date of discharge to be recorded in the ICU notes. Results: A total of 1787 ICU discharges were included in this study, 1001 in the 15 months before and 786 in the 12 months after the implementation of the new discharge processes. There was no difference in hospital mortality or ICU readmission within 72 h during the study period. However, process improvement was demonstrated by a reduction in the average patient discharge delay time of 3.2 h (from 4.6 h baseline to 1.0 h post-intervention). Conclusions: Involving both ward and ICU staff in the redesign process may have contributed to a shared situational awareness of the problems, which led to more timely and effective ICU discharge processes.