Clinical Effectiveness of a Critical Care Nursing Outreach Service in Facilitating Discharge from the Intensive Care Unit

Teresa Ann Williams, RN, PhD, M Hlth Sci, Grad Dip Clin Epi, ICU Cert; Gavin Leslie, RN, PhD, ICU Cert, BAppSc(Nsg); Judith Finn, PhD, MEdStud, GradDipPH, BSc, DipAPPSc(Nsg), ICU Cert, RN, RM; Linda Brearley, RN, BEc, ICU Cer; , Mariyam Asthifa, RN, Ben Hay, RN; Karen Laurie, RN, ICU Cert; Tim Leen, RN; Keith O'Brien, RN; Michael Stuart, RN, BHlthSc(Nsg), ICU Cert; Michelle Watt, RN, BSci(Nsg), Grad Cert ICU

Disclosures

American Journal of Critical Care. 2010;19(5):e63-72. 

In This Article

Results

Of the total of 3001 patients discharged from the 3 ICUs during the study period, 1566 patients were in the 2007 "before intervention" cohort and 1435 patients were in the 2008 "after intervention" cohort. The characteristics of both cohorts are compared in Table 1. The cohorts from before and after the intervention were not significantly different. The mean age was 55 (SD, 19) years in the before group compared with 54 (SD, 19) years in the after group (t = –1.96, P = .05). The proportion of men was 65%, the same for both cohorts. From available data for 2762 patients, the mean APACHE II score was 16.8 (SD, 7.4) in the before group and 16.7 (SD, 7.2) in the after group (t = –0.37, P = .66).

Primary Outcome

The LOS for the ICU patients in the before cohort (median, 1.9 days; IQR, 1.0–4.0 days) was not significantly different (z = 0.57, P = .57) from that in the after cohort (median, 1.8 days; IQR, 0.9–4.8 days). The median LOS in the hospital from admission to the ICU until hospital discharge was 9.8 (IQR, 6.0–19.5) days in the before cohort and 10.1 (IQR, 5.9–20.6) days in the after cohort (z = 0.18, P = .86). After adjustment for patients' age and sex, the LOS after admission to the ICU did not differ significantly between the cohorts (95% CI, –0.096 to 0.041, P =.42).

Secondary Outcomes

Secondary outcomes were (1) number of ICU readmissions during the same hospital admission, (2) survival to hospital discharge, (3) day of week discharged from the ICU, (4) time of day discharged from the ICU, (5) activities of the outreach nurse, and (6) delay to discharge from the ICU.

Before the outreach service was implemented, 5.4% of patients were readmitted to the ICU during the same hospital admission, with 40% of the first readmissions within 48 hours of discharge from the ICU. After implementation of the outreach service, 5.6% of patients were readmitted to the ICU during the same hospital admission, with 33% of the first readmissions within 48 hours of discharge from the ICU. Readmission rates did not differ significantly between cohorts ( ). Although the proportion of later admissions was lower after the introduction of the critical care outreach service, this difference was not statistically significant ( ). Hospital mortality was similar between cohorts: 5.5% before the outreach service was implemented compared with 5.4% after the service was implemented ( ).

The day of discharge did vary between the 2 cohorts (
), as shown in Figure 1. Most patients were ready for discharge on weekdays and least often on Sundays in both cohorts, but discharges on Sundays decreased almost by half after the outreach service was implemented compared with before.

Figure 1.

Comparison of day of discharge before and after implementation of a critical care nursing outreach service.

The time of discharge did not differ significantly from before to after the introduction of the critical care outreach service ( ). The most common time for discharge was in the daytime (77% before and 78% after implementation of the outreach service). Further comparison showed that evening discharges were more frequent after than before the intervention; nighttime discharges were more frequent after (10%) than before (8%) the intervention (Figure 2).

Figure 2.

Comparison of time of discharge between before and after implementation of a critical care nursing outreach service.

Outreach Service

After the outreach service was implemented, 1435 patients were discharged from the ICU. The following results relate only to this postintervention cohort. Of these 1435 patients, the critical care outreach nurses visited 1198 patients before their discharge from the ICU (83% of patients admitted to the ICU during the study period). Some patients had more than 1 visit from the outreach nurses before their discharge, giving a total of 1459 visits.

Predischarge Visits

Fourteen percent of the patients who received a predischarge visit required 2 or more visits (range, 1–7 visits). The time taken for visits conducted before the patient's discharge from the ICU ranged from 2 to 260 (median, 15; IQR, 15–30) minutes. Issues most often encountered were respiratory (70% of visits), related to catheters (52% of visits), gastrointestinal (52% of visits), renal (48% of visits), and cardiovascular (45% of visits). Up to 14 types of referrals, 1115 in total, were made for 456 patients at these predischarge visits. The 5 most common referrals were to the ICU team (52%), a physiotherapist (23%), a dietitian (19%), a specialty team, (19%) and a speech pathologist (16%).

Care Needs on Discharge from the ICU

From a total of 1435 patients discharged from the ICU after implementation of the outreach service, just more than half (56%) had no requirements for special accommodation on discharge from the ICU. For the others, accommodation needs included 1:1 nursing care (29 discharges, 2%), isolation/single rooms (70 discharges, 5%), 1:1 nursing care and isolation (5 discharges, 0.3%), high-dependency unit (335 discharges, 23%), coronary care unit (28 discharges, 2%), and other requirements related to nursing staffing (135 discharges, 9.4%). Thirteen discharged patients (1%) required other care requirements (eg, patient care assistant to guard patient, burns room, larger 2-bed room for bariatric patient). Three percent of patients had some order restricting resuscitation (do not resuscitate in 23 patients [2%], no cardiopulmonary resuscitation/MET activation/escalation of treatment in 16 patients [1%]) before discharge from the ICU. Most discharged patients had vascular catheters (93%): 66% of discharged patients had central catheters, and 83% required some form of respiratory therapy, including tracheostomy in 9%. Urinary catheters (84%) also were common, 43% of patients had concerns associated with intravenous fluids, and 81% had issues related to fluid balance that required monitoring in the general care area. Thirty-three percent of patients had cardiovascular intervention: cardiac monitoring, drains, pacing, and/or vasoactive infusions. Confusion or delirium was present in 11% of patients.

Postdischarge Review

Most patients (89%) from the cohort after the outreach service was implemented were reviewed while in the general care area after their discharge from the ICU. Of the 3721 reviews conducted among 1285 patients discharged from the ICU, 93% were considered routine. The number of reviews performed by the critical outreach team ranged from 1 to 49 visits (median, 1; IQR, 1–3). The mean time spent for each review was 18 (SD, 16.9) minutes but ranged from 4 to 450 minutes. At the Royal Perth Hospital, most patients were discharged to postsurgical care areas, but most reviews were conducted in medical care areas. The reviews by the critical care outreach nurses were conducted primarily for reasons related to the patient (95%) but education (n = 251), clinical issues (n=218), advice (n=121), equipment (n=119), staff in the general care area (n = 94), adverse events (n = 90), and relatives (n = 32) were also the primary or secondary reason(s) for conducting the review.

Interventions (categorized as manipulation of existing therapy, recommending a practice change, education, or referral) were related to respiratory (18%), gastrointestinal (13%), catheter (7%), renal (6%), psychiatric/psychological (6%), electrolyte (5.5%), cardiac (5%), neurological (3%), pain management (4%), wound care (3.5%), activities of daily living (3%), hematological, metabolic (3%), micro-biological (2%), and musculoskeletal (2%) issues.

Patients (n = 173) were referred to specialist services on 1026 occasions. For patients who had a referral, the median number of referrals was 2 (IQR, 1–3) but as many as 38 referrals per patient were made. Most referrals were to the patient's specialty team (Table 2).

Delays in Discharge

Of 1261 discharged patients for whom data on when they were deemed suitable for discharge were available, 36% of patients had their discharge from the ICU delayed by more than 8 hours. Among these patients, no bed being available or a delay in a bed becoming available were the most common reasons for the delay, accounting for 45% of discharge delays. Medical concerns accounted for 21% of delays in discharge; no reason was given for 27% of delays. Other reasons were staff shortages (4%), skill mix issues (2%), and lack of suitable accommodation (1%). The distribution pattern of the day the patient was deemed suitable for discharge from the ICU differed significantly ( ) between patients whose discharge was delayed and patients whose discharge was not delayed. Delayed discharges occurred most often on Mondays and Sundays. Patients whose discharge was delayed were more likely to be discharged after hours than were patients whose discharge was not delayed ( ).

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