Reducing readmissions to the intensive care unit

doi:10.1053/hl.1999.v28.a101055

Heart & Lung

Volume 28, Issue 5, September–October 1999, Pages 365-372

https://doi.org/10.1053/hl.1999.v28.a101055 Get rights and content

Abstract

Objective: To determine factors that contributed to readmissions to the intensive care unit (ICU) from the general wards. Design: Prospective, descriptive, qualitative, and quantitative. Setting: The Royal Melbourne Hospital, which is a large, metropolitan, university-affiliated tertiary hospital with specialist and general wards. The ICU is a 14-bed medical and surgical adult unit. Patients: 572 patients admitted to ICU between July 1 and December 31, 1993. Results: There were 639 admissions, with 67 (10.5%) being readmissions. This study showed that 63% of all readmissions came from the general wards. The study identified three main factors that contributed to readmissions from the ward: progression of the patient’s illness, postoperative care requirements, and inadequate follow-up care on the general wards. Identifying inadequate continuity of care on the general wards as a cause of readmissions to the ICU led to the appointment of an ICU follow-up nurse to facilitate the transition from the ICU to the general ward. Conclusion: Preliminary results indicate that the appointment of the follow-up nurse has not only reduced the rate of readmissions to the ICU but also decreased the acuity levels of those readmitted. (Heart Lung^® 1999;28:365-72)

Section snippets

BACKGROUND

The findings presented in this article are taken from a research project that followed up 639 admissions to the ICU at the Royal Melbourne Hospital between July 1 and December 31, 1993. This ICU is a general medical and surgical unit for adults in a large, metropolitan teaching hospital in Australia. It admits approximately 1300 patients per year. One of the aims of the research was to identify factors that contributed to the readmission rate to the ICU.

Several studies have shown the benefits

METHODS

This project received approval from the Royal Melbourne Hospital’s Board of Medical Research and its Ethics Committee. As a result, the researcher was given access to patients’ medical files and permission to contact patients 6 months after their discharge from the ICU. The researcher was also given permission to interview staff and care providers. It was agreed that patients would be identified with a numeric code; care providers would be identified by their relationship to the patients, for

RESULTS

In this study, there were 639 admissions. As 67 of these were readmissions, the readmission rate was 67/639 (10.5%); 46 patients were admitted to ICU twice, 7 patients were admitted 3 times, 1 patient was admitted 4 times, and 1 patient was admitted 5 times. This resulted in 55 patients requiring a second admission, with 9 of these patients requiring further admissions. The site of origin and categories of illness of these admissions and readmissions are represented in Tables I and II.

DISCUSSION

This research identified three main factors that contributed to readmissions from the ward: progression of the patient’s illness, postoperative care requirements, and inadequate follow-up care on the general wards. The inadequate follow-up care was evident in the narratives describing the transition to the general ward. Unlike the ICU, where the staff-to-patient ratio was greater than 1:1 and the access to life-saving treatments was often instantaneous, the nurses on general wards often cared

RECOMMENDATIONS

The main recommendation stemming from this research is to develop strategies to improve continuity of care for patients after their discharge from the ICU. One strategy tried at the Royal Melbourne Hospital is to employ a follow-up nurse. The role of the follow-up nurse is to strengthen the link between the specialized care patients receive in the ICU and their ongoing care. Although the role is to provide support and education to nurses on the wards, a follow-up nurse does not replace clinical

CONCLUSION

When patients are critically ill, they require access to sophisticated technology and skilled health care practitioners in the ICU. Most critically ill patients would die without such life-saving interventions. After close surveillance in the ICU with monitors and specialized medical and nursing care, patients in this study were then discharged to a general ward where there is a significant reduction in the provision of health care services. Unlike the ICU, the general wards were predominantly

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As for the acceptability of the program, most of the interventions were found acceptable and helpful by patients and families The provision of information by ICU nurses in preparation for the transition, the decrease of nursing surveillance and monitoring equipment before discharge and the introduction to the receiving team were particularly appreciated. These findings confirm the adequacy of recommendations that emerged from studies (Beard, 2005; Chaboyer et al., 2005; Leith, 1999; Odell, 2000; Russell, 1999a,b) on patients’ and families’ transition experience as well as of a recently developped grounded theory on ICU transitional care process (Häggström et al., 2012). This theory was created to address the gap that exists between the high technology ICU environment with its high staff ratio and different ward environments (Häggström et al., 2009).
Transfer from ICU to a general ward is recognized as a high-risk episode of care especially for patients with SCI.
To evaluate the feasibility and acceptability of a nursing intervention program developed to optimize the transition of SCI patients and their family from ICU to a trauma unit.
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Nine tetraplegic patients, 8 families and 8 health professionals participated in the study. Interventions pertaining to provision of information with regard to the functioning of the trauma unit and gradual decrease of ICU monitoring and nursing surveillance were found to be feasible. Other interventions, such as patients’, and families’, introduction to the receiving team and the use of a written report form were more difficult to apply. Patients and families considered the program very helpful and both greatly appreciated being informed about differences in the intensity of care between the two units. Health professionals also identified the provision of such information as facilitating the transition of care.
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In healthcare today, patients are often transferred rapidly and at an earlier stage, and are sicker than in the past (McKinney and Deeny, 2002). There exists a gap between the high-technology environment of the ICU with its high staff ratio and the different ward environment (Häggström et al., 2009) and research has shown that a transition from the ICU needs to be seriously planned and organised – both pre- and post-transfer (cf. Chaboyer et al., 2005b; Odell, 2000; Russell, 1999a,b). It is also of importance that compromised transitional care can result in serious complications and re-admissions to the ICU (Durbin and Kopel, 1993; Russell, 1999b).
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^*: From the School of Nursing at La Trobe University, Bundoora, Victoria, Australia.

^**: Reprint requests: Sarah Russell, BA, RN, PhD, La Trobe University, Bundoora, Victoria, Australia 3083.

^*: 0147-9563/99/$8.00 + 0 2/1/101055

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Reducing readmissions to the intensive care unit*,**,*

Abstract

Section snippets

BACKGROUND

METHODS

RESULTS

DISCUSSION

RECOMMENDATIONS

CONCLUSION

Injury

Reducing preventable deaths and containing costs: the expanding role of intensive care medicine

Med J Aust

Quality of life outcomes after intensive care: comparison with a community group

Intensive Care Med