Healthcare Provider Perceptions of Causes and Consequences of ICU Capacity Strain in a Large Publicly Funded Integrated Health Region: A Qualitative Study

Bagshaw, Sean M.; Opgenorth, Dawn; Potestio, Melissa L.; Hastings, Stephanie E.; Hepp, Shelanne; Gilfoyle, Elaine; McKinlay, David; Boucher, Paul; Meier, Michael; Leigh, Jeanna Parsons; Gibney, R. T. Noel; Zygun, David; Stelfox, Henry T.

doi:10.1097/ccm.0000000000002093

Cited by 51 publications

(44 citation statements)

References 48 publications

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“…Other factors included the perceived arrogance of ICU physicians, a feeling reported in other studies, the need to bargain to have a patient admitted to intensive care, and perceived shortcomings in completing tasks, including goals of care discussions on the ward. Perceived failure to engage in such discussions has been reported and may make the transition to a palliative care approach in acute hospitals more difficult . Collaborative decision making facilitates triage in “gray zones” and helps physicians take responsibility for life‐death decisions.…”

Section: Discussionmentioning

confidence: 99%

Admission to intensive care: A qualitative study of triage and its determinants

Escher

Cullati

Hudelson

et al. 2018

Health Services Research

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Objective To examine physicians’ decision making and its determinants about admission to intensive care. Data Sources/Study Setting ICU physicians (n = 12) and internists (n = 12) working in a Swiss tertiary care hospital. Study Design We conducted in‐depth interviews. Data Collection/Extraction Methods Interviews were analyzed using an inductive thematic approach. Principal Findings Admission decisions regarding seriously ill or elderly patients with comorbidities are complex. Nonmedical factors such as ICU beds availability, health care resources on the ward, information about patient preferences, and family behavior determine the decision. Code status and the quality of interaction between physicians are key determinants. The absence of code status or poor documentation of code status discussions makes decisions more difficult and laden emotionally, as physicians feel they are making a life‐death decision. Mutual respect and collaborative decision making facilitate the decision. Tensions arise due to ICU physicians’ postponing the decision because of lack of beds, ICU physicians’ dismissive attitudes, perceived shortcomings in the other physician's completion of expected tasks, and preconceptions about the other physician. Conclusions Systematic documentation of code status, and fostering collaboration between ICU physicians and internists would facilitate ICU admission decisions in complex clinical situations.

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Section: Discussionmentioning

confidence: 99%

Admission to intensive care: A qualitative study of triage and its determinants

Escher

Cullati

Hudelson

et al. 2018

Health Services Research

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“…The potential benefits include shortening hospital lengths of stay, reducing transitions of care, decreasing flow failure, and alleviating ICU capacity strain. 39 However, strategies are needed to make the discharge of patients directly home from the ICU more effective. Our data suggest that this practice varies widely across institutions and that most ICU clinicians likely have little experience with it.…”

Section: Research Original Investigationmentioning

confidence: 99%

Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit

et al. 2018

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IMPORTANCE The safety of discharging adult patients recovering from critical illness directly home from the intensive care unit (ICU) is unknown.OBJECTIVE To compare the health care utilization and clinical outcomes for ICU patients discharged directly home from the ICU with those of patients discharged home via the hospital ward. DESIGN, SETTING, AND PARTICIPANTSRetrospective population-based cohort study of adult patients admitted to the ICU of 9 medical-surgical hospitals from January 1, 2014, to January 1, 2016, with 1-year follow-up after hospital discharge. All adult ICU patients were discharged home alive from hospital, and the propensity score matched cohort (1:1) was based on patient characteristics, therapies received in the ICU, and hospital characteristics.EXPOSURES Patient disposition on discharge from the ICU: directly home vs home via the hospital ward. MAIN OUTCOMES AND MEASURESThe primary outcome was readmission to the hospital within 30 days of hospital discharge. The secondary outcomes were emergency department visit within 30 days and death within 1 year. RESULTS Among the 6732 patients included in the study, 2826 (42%) were female; median age, 56 years (interquartile range, 41-67 years); 922 (14%) were discharged directly home, with significant variation found between hospitals (range, 4.4%-44.0%). Compared with patients discharged home via the hospital ward, patients discharged directly home were younger (median age 47 vs 57 years; P < .001), more likely to be admitted with a diagnosis of overdose, substance withdrawal, seizures, or metabolic coma (32% [295] vs 10% [594]; P < .001), to have a lower severity of acute illness on ICU admission (median APACHE II score 15 vs 18; P < .001), and receive less than 48 hours of invasive mechanical ventilation (42% [389] vs 34% [1984]; P < .001). In the propensity score matched cohort (n = 1632), patients discharged directly home had similar length of ICU stay (median, 3.1 days vs 3.0 days; P = .42) but significantly shorter length of hospital stay (median, 3.3 days vs 9.2 days; P < .001) compared with patients discharged home via the hospital ward. There were no significant differences between patients discharged directly home or home via the hospital ward for readmission to the hospital (10% [n = 81] vs 11% [n = 92]; hazard ratio [HR], 0.88; 95% CI, 0.64-1.20) or emergency department visit (25% [n = 200] vs 26% [n = 212]; HR, 0.94; 95% CI, 0.81-1.09) within 30 days of hospital discharge. Four percent of patients in both groups died within 1 year of hospital discharge (n = 31 and n = 34 in the discharged directly home and discharged home via the hospital ward groups, respectively) (HR, 0.90; 95% CI, 0.60-1.35). CONCLUSIONS AND RELEVANCEThe discharge of select adult patients directly home from the ICU is common, and it is not associated with increased health care utilization or increased mortality.

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“…6,8 Multiple factors plague these processes, including variation in practices (both within and between hospitals), communication breakdowns, capacity strains, and limitations in available resources. 6,[8][9][10][11][12][13][14] Shortcomings in the delivery of care 9,15 for patients transferred from the ICU have been associated with higher healthcare costs and poor satisfaction with care. [16][17][18][19] Little is known about how hospital ward providers, who accept care of these patients, perceive current transfer practices nor which aspects of transfer they perceive as needing improvement.…”

Section: Introductionmentioning

confidence: 99%

Administrator Perspectives on ICU-to-Ward Transfers and Content Contained in Existing Transfer Tools: a Cross-sectional Survey

et al. 2018

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Healthcare Provider Perceptions of Causes and Consequences of ICU Capacity Strain in a Large Publicly Funded Integrated Health Region: A Qualitative Study

Abstract: Engagement with frontline critical care providers is essential for understanding their experiences and perspectives regarding strained capacity and for the development of sustainable strategies for improvement.

Cited by 51 publications

References 48 publications

Admission to intensive care: A qualitative study of triage and its determinants

Admission to intensive care: A qualitative study of triage and its determinants

Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit

Administrator Perspectives on ICU-to-Ward Transfers and Content Contained in Existing Transfer Tools: a Cross-sectional Survey

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