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Abstract

Introduction: Readmission to the Intensive Care Unit (ICU) is associated with worse outcomes and increased cost. Discharge processes are often fraught with errors and providers are poor judges of the risk of readmission. The implementation of a previously validated scoring tool [1] for predicting the probability of readmission in our medical ICU had an impact on provider discharge planning but not on the overall readmission rates. This suggests that ICU readmission may be associated with poor discharge and transition processes, factors that are not measurable by quantitative means. Hypothesis: 1.To determine and understand the root causes of ICU readmission by employing qualitative methods 2. Directly observe work flow and transition of care processes across specific ICUs3. Map observed work flow and discharge process4.Suggest a process model of ICU discharge for patients with high risk of readmission, that will include factors identified from our qualitative study. Methods: We performed direct observation of work flow and discharge processes in three intensive care units at Mayo Clinic Rochester. A full work day (7am – 7pm) was spent in each instance, with the field observer covertly embedding himself into the ICU rounding team.Using semi-structured recording instrument consisting of checklists and field notes, a record of observed activities, behaviors and interactions that relate to the discharge process was noted. Discharge processes were followed through until patients were evaluated on the general floors by the receiving services.We subsequently performed one-on-one semi-structured interviews using a purposive sample of ICU and general medical staff consisting of nurses, resident physicians, fellows or midlevel practitioners and consultants. Interviews were recorded, transcribed and analyzed for common themes with the aid of Nvivo Software and illustrated using a Fishbone diagram.Observed and suggested workflow and discharge processes were mapped using Microsoft Visio. Results: •Total of five (5) discharge processes were observed during three work days of monitoring•A total of twentyfour (24) staff were interviewed, consisting of 5 nurses, two residents, two fellows and one consultant •Identified factors relating to unexpected ICU readmission were classified into themes: Communication, Physician, Patient, Processes, Hospital & Staffing•Results illustrated using Fishbone Diagram•Processes Mapped using Microsoft Visio. Suggested process map incorporated factors relating to Communication and Processes themes. Conclusions: ICU readmissions may be associated with poor discharge and transition processes, These factors are best elucidated by qualitative methodologies. Adopting a system approach and engaging different stake holders is necessary to address these complex issues. Addressing the issues relating to transitions of care may possibly reduce unexpected readmissions to the ICU