Abstract
BackgroundQuantitative studies have demonstrated several factors predictive of readmissions to intensive care. Clinical decision tools, derived from these factors have failed to reduce readmission rates. The purpose of this study was to qualitatively explore the experiences and perceptions of physicians and nurses to gain more insight into intensive care readmissions.MethodsSemi-structured interviews of intensive care unit (ICU) and general medicine care providers explored work routines, understanding and perceptions of the discharge process, and readmissions to intensive care. Participants included ten providers from the ICU setting, including nurses (n = 5), consultant intensivists (n = 2), critical care fellows (n = 3) and 9 providers from the general medical setting, nurses (n = 4), consulting physicians (n = 2) and senior resident physicians (n = 3). Principles of grounded theory were used to analyze the interview transcripts.ResultsNine factors within four broad themes were identified: (1) patient factors – severity-of-illness and undefined goals of care; (2) process factors – communication, transitions of care; (3) provider factors – discharge decision-making, provider experience and comfort level; (4) organizational factors – resource constraints, institutional policies.ConclusionsSevere illness predisposes ICU patients to readmission, especially when goals of care were not adequately addressed. Communication, premature discharge, and other factors, mostly unrelated to the patient were also perceived by physicians and nurses to be associated with readmissions to intensive care. Quality improvement efforts that focus on modifying or improving aspects of non-patient factors may improve outcomes for patients at risk of ICU readmission.
Highlights
Quantitative studies have demonstrated several factors predictive of readmissions to intensive care
Using indepth interviews of patients and their care providers regarding the care they received on the general wards after intensive care unit (ICU) discharge, Russell described two themes relating to ICU readmissions – decreased resources on the general wards, and lack of communication between the ICU and ward staff [14]
A higher proportion of nurses than physicians cited factors relating to transitions of care (89% vs 60%) and discharge decisionmaking (89% vs. 70%)
Summary
Quantitative studies have demonstrated several factors predictive of readmissions to intensive care. Readmissions to the intensive care unit (ICU) are associated with increased cost of care and worse patient outcomes [1, 2], with predominant predisposing factors mostly related to the patient [3,4,5,6,7,8]. Nonpatient factors such as patient inflow volumes [9], ICU occupancy [10], and clinician decision-making practices [11], have been suggested. Elliot et al [15], conducted unstructured interviews of 21 nurses across the ICU, hospital wards and in educational and managerial positions and identified five contributory themes: premature discharge from ICU, delayed medical care at the ward level, heavy nursing workloads, lack of adequately qualified staff and highly demanding patients
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