Nurse‐led discharge from high dependency unit

Abstract

High dependency care is a rapidly evolving area of critical care, with high patient turnover, which ultimately leads to high levels of pressure for beds. There is a growing trend emerging, recognizing the importance and value of nurse-led initiatives in delivering effective nursing care in acute care settings. One specific nurse-led initiative this author has developed is that of nurse-led discharge (NLD) from the high dependency unit (HDU), in order to optimize the utilization of critical care beds within the HDU. An audit of the current practice was undertaken, which ultimately led to the implementation of NLD. Early experiences indicate that HDU beds are now being used more effectively.

Towards a decision support tool for intensive care discharge: machine learning algorithm development using electronic health care data from MIMIC-III and Bristol, UK.

“…It would need to be sufficiently sensitive as to recommend high numbers of potential discharges, whilst providing enough specificity to retain clinician engagement. Here we have detailed the development of two machine learning algorithms intended for such a purpose, and demonstrated their performance improvement over a previously published set of criteria that were originally aimed at discharge automation [22]. At a threshold specificity of 0.7, the algorithm with best overall performance achieved mean sensitivities of 0.8909 and 0.9049 for the GICU and MIMIC cohorts respectively (table 7 in section D of the online supplementary file).…”

“…A range of different tools and methods have previously been proposed with the aim of improving ICU discharge practice. These tools range from criteria to evaluate discharge readiness [22,42], to guidelines for discharge planning and education [6]. Additionally, a number of risk models have been developed to predict adverse outcomes following ICU discharge [11][12][13]15,43].…”

“…If a patient meets all the criteria for a period of at least four hours, Knight states that they may be safely discharged by a nurse. The motivation behind developing these criteria was to facilitate discharge by nurses in cases where the decision was clear, and there is some evidence of improved bed allocation when using such a nurseled system [22,24,25]. In order to test the NLD criteria on historical patient data we codified the constraints (see online supplementary file section A) into 15 binary tests, which are defined in table 1.…”

“…The tool could also prompt clinicians to consider discharge decisions at other times of day, outside of normal rounds. In 2003 Knight proposed a set of nurse-led discharge criteria [22] with a similar aim -to expedite discharge from a high-dependency unit by allowing nurses to discharge patients who were clearly well enough to leave. These criteria represent a general and highly conservative set of constraints on physiology that characterise a patient as suitable for care on an acute ward (level 1 care).…”

Public hospital bed crisis: too few or too misused?

“…Hospital stay can be reduced by interventions, which hasten the time of discharge. 16 These include: (1) more systematic use of clinical guidelines and care pathways that decrease LOS without compromising safety 17 ; (2) regular multidisciplinary meetings using patient journey boards that focus team efforts on meeting a nominated date of discharge; (3) daily morning ward rounds by medical teams that take precedence over clinics or other discretionary activities; (4) nurse-led discharge whereby nurses are authorised, especially after-hours, to discharge patients who meet certain clinical criteria rather than wait for consultant rounds 18 ; (5) access to transit and discharge areas so beds can be vacated quickly; (6) timely access to comprehensive geriatric assessment teams, aged care and assessment teams, and other gate-keepers who determine patient eligibility for geriatric rehabilitation beds, residential care beds or transitional care packages; (7) same-day consultant responses for inter-speciality requests for advice on acute management; (8) prioritised access to urgent pathology and radiology services required for acute cases 19 ; and (9) routine assignment of medical teams to surgical patients at high risk of prolonged stay and perioperative complications. 20 (C) Better integration of inpatient care with post-discharge care.…”