Improving critical care discharge summaries: a collaborative quality improvement project using PDSA

Abstract

Around 110,000 people spend time in critical care units in England and Wales each year. The transition of care from the intensive care unit to the general ward exposes patients to potential harms from changes in healthcare providers and environment. Nurses working on general wards report anxiety and uncertainty when receiving patients from critical care.An innovative form of enhanced capability critical care outreach called ‘iMobile’ is being provided at King's College Hospital (KCH). Part of the remit of iMobile is to review patients who have been transferred from critical care to general wards. The iMobile team wished to improve the quality of critical care discharge summaries.A collaborative evidence-based quality improvement project was therefore undertaken by the iMobile team at KCH in conjunction with researchers from King's Improvement Science (KIS). Plan, Do, Study, Act (PDSA) methodology was used. Three PDSA cycles were undertaken.Methods adopted comprised: a scoping literature review to identify relevant guidelines and research evidence to inform all aspects of the quality improvement project; a process mapping exercise; informal focus groups / interviews with staff; patient story-telling work with people who had experienced critical care and subsequent discharge to a general ward; and regular audits of the quality of both medical and nursing critical care discharge summaries.The following behaviour change interventions were adopted, taking into account evidence of effectiveness from published systematic reviews and considering the local context: regular audit and feedback of the quality of discharge summaries, feedback of patient experience, and championing and education delivered by local opinion leaders.The audit results were mixed across the trajectory of the project, demonstrating the difficulty of sustaining positive change. This was particularly important as critical care bed occupancy and through-put fluctuates which then impacts on work-load, with new cohorts of staff regularly passing through critical care. In addition to presenting the results of this quality improvement project, we also reflect on the lessons learned and make suggestions for future projects.

The nature and extent of service user involvement in critical care research and quality improvement: A scoping review of the literature

“…In some cases, there was an attempt to follow standard research procedures to recruit people for involvement. For example, Goulding et al () describe how they approached patients during their critical care follow up clinic appointment. Locock et al () also report using a purposive sampling technique.…”

“…The review questions emerged from local work with critical care service users and service providers (Bench, Cornish, & Xyrichis, ; Bench, Day, & Griffiths, ; Goulding et al, ). These experiences identified a current lack of understanding around how best to involve former patients and their families and concerns regarding the impact of not doing it right.…”

Intensive care discharge summaries for general practice staff: a focus group study

“…Work to improve ICU to ward discharge summaries demonstrates some progress 33. A single ongoing document where all members of the multidisciplinary team can add information at each transition point might help achieve aspirations for streamlined care 13 , 27 , 31.…”

Improving the efficacy of elderly patients' hospital discharge through multi-professional safety briefings and behavioural change

“…Completing eDANs promptly is more challenging to sustain in an acute hospital environment such as a Medical Admissions Unit due to the nature of the ward; there is often a very high turnover of patients, a significant proportion of whom may be acutely unwell. A similar challenge was described in a recent quality improvement project on the ICU at Kings College Hospital [ 3 ]. On the Medical Admissions Unit for Older People at LTHT there are approximately 20-50 discharges each week and also a new team of junior doctors rotating through weekly.…”