A Multiple Baseline Trial of an Electronic ICU Discharge Summary Tool for Improving Quality of Care

 

by Stelfox, Henry T.; Brundin-Mather, Rebecca; Soo, Andrea; Whalen-Browne, Liam; Kashyap, Devika; Sauro, Khara M.; Bagshaw, Sean M.; Fiest, Kirsten M.; Taljaard, Monica; Parsons Leigh, Jeanna 

 

Critical Care Medicine: August 16, 2022 - Volume - Issue - 10.1097

 

Objective: 

Effective communication between clinicians is essential for seamless discharge of patients between care settings. Yet, discharge summaries are commonly not available and incomplete. We implemented and evaluated a structured electronic health record–embedded electronic discharge (eDischarge) summary tool for patients discharged from the ICU to a hospital ward.

Design: 

Multiple baseline trial with randomized and staggered implementation.

Setting: 

Adult medical-surgical ICUs at four acute care hospitals serving a single Canadian city.

Patients: 

Health records of patients 18 years old or older, in the ICU 24 hours or longer, and discharged from the ICU to an in-hospital patient ward between February 12, 2018, and June 30, 2019.

Intervention: 

A structured electronic note (ICU eDischarge tool) with predefined fields (e.g., diagnosis) embedded in the hospital-wide electronic health information system.

MEASUREMENTS AND MAIN RESULTS 

: We compared the percent of timely (available at discharge) and complete (included goals of care designation, diagnosis, list of active issues, active medications) discharge summaries pre and post implementation using mixed effects logistic regression models. After implementing the ICU eDischarge tool, there was an immediate and sustained increase in the proportion of patients discharged from ICU with timely and complete discharge summaries from 10.8% (preimplementation period) to 71.1% (postimplementation period) (adjusted odds ratio, 32.43; 95% CI, 18.22–57.73). No significant changes were observed in rapid response activation, cardiopulmonary arrest, death in hospital, ICU readmission, and hospital length of stay following ICU discharge. Preventable (60.1 vs 5.7 per 1,000 d; p = 0.023), but not nonpreventable (27.3 vs 40.2 per 1,000d; p = 0.54), adverse events decreased post implementation. Clinicians perceived the eDischarge tool to produce a higher quality discharge process.

Conclusions: 

Implementation of an electronic tool was associated with more timely and complete discharge summaries for patients discharged from the ICU to a hospital ward.

 

 

Emergency Department to ICU Time Is Associated With Hospital Mortality: A Registry Analysis of 14,788 Patients From Six University Hospitals in The Netherlands*

Emergency Department to ICU Time Is Associated With Hospital Mortality: A Registry Analysis of 14,788 Patients From Six University Hospitals in The Netherlands*

Groenland, Carline N. L.; Termorshuizen, Fabian; Rietdijk, Wim J. R.; van den Brule, Judith; Dongelmans, Dave A.; de Jonge, Evert; de Lange, Dylan W.; de Smet, Anne Marie G. A.; de Keizer, Nicolette F.; Weigel, Joachim D.; Jewbali, Lucia S. D.; Boersma, Eric; den Uil, Corstiaan A.

Critical Care Medicine: November 2019 - Volume 47 - Issue 11 - p 1564-1571

Objectives: Prolonged emergency department to ICU waiting time may delay intensive care treatment, which could negatively affect patient outcomes. The aim of this study was to investigate whether emergency department to ICU time is associated with hospital mortality.

Design, Setting, and Patients: We conducted a retrospective observational cohort study using data from the Dutch quality registry National Intensive Care Evaluation. Adult patients admitted to the ICU directly from the emergency department in six university hospitals, between 2009 and 2016, were included. Using a logistic regression model, we investigated the crude and adjusted (for disease severity; Acute Physiology and Chronic Health Evaluation IV probability) odds ratios of emergency department to ICU time on mortality. In addition, we assessed whether the Acute Physiology and Chronic Health Evaluation IV probability modified the effect of emergency department to ICU time on mortality. Secondary outcomes were ICU, 30-day, and 90-day mortality.

Interventions: None.

Measurements and Main Results: A total of 14,788 patients were included. The median emergency department to ICU time was 2.0 hours (interquartile range, 1.3–3.3 hr). Emergency department to ICU time was correlated to adjusted hospital mortality (p < 0.002), in particular in patients with the highest Acute Physiology and Chronic Health Evaluation IV probability and long emergency department to ICU time quintiles: odds ratio, 1.29; 95% CI, 1.02–1.64 (2.4–3.7 hr) and odds ratio, 1.54; 95% CI, 1.11–2.14 (> 3.7 hr), both compared with the reference category (< 1.2 hr). For 30-day and 90-day mortality, we found similar results. However, emergency department to ICU time was not correlated to adjusted ICU mortality (p = 0.20).

Conclusions: Prolonged emergency department to ICU time (> 2.4 hr) is associated with increased hospital mortality after ICU admission, mainly driven by patients who had a higher Acute Physiology and Chronic Health Evaluation IV probability. We hereby provide evidence that rapid admission of the most critically ill patients to the ICU might reduce hospital mortality.

Evaluation of Medication Errors at the Transition of Care From an ICU to Non-ICU Location

Evaluation of Medication Errors at the Transition of Care From an ICU to Non-ICU Location

 by Tully, Andrea P.; Hammond, Drayton A.; Li, Chenghui; Jarrell, Andrew S.; Kruer, Rachel M.

Critical Care Medicine: April 2019 - Volume 47 - Issue 4 - p 543–549

Objectives: To determine the point prevalence of medication errors at the time of transition of care from an ICU to non-ICU location and assess error types and risk factors for medication errors during transition of care. 

Design: This was a multicenter, retrospective, 7-day point prevalence study. 

Setting: Fifty-eight ICUs within 34 institutions in the United States and two in the Netherlands. Patients: Nine-hundred eighty-five patients transferred from an ICU to non-ICU location. Interventions: None. 

Measurements and Main Results: Of 985 patients transferred, 450 (45.7%) had a medication error occur during transition of care. Among patients with a medication error, an average of 1.88 errors per patient (SD, 1.30; range, 1–9) occurred. The most common types of errors were continuation of medication with ICU-only indication (28.4%), untreated condition (19.4%), and pharmacotherapy without indication (11.9%). Seventy-five percent of errors reached the patient but did not cause harm. The occurrence of errors varied by type and size of institution and ICU. Renal replacement therapy during ICU stay and number of medications ordered following transfer were identified as factors associated with occurrence of error (odds ratio, 2.93; 95% CI, 1.42–6.05; odds ratio 1.08, 95% CI, 1.02–1.14, respectively). Orders for anti-infective (odds ratio, 1.66; 95% CI, 1.19–2.32), hematologic agents (1.75; 95% CI, 1.17–2.62), and IV fluids, electrolytes, or diuretics (odds ratio, 1.73; 95% CI, 1.21–2.48) at transition of care were associated with an increased odds of error. Factors associated with decreased odds of error included daily patient care rounds in the ICU (odds ratio, 0.15; 95% CI, 0.07–0.34) and orders discontinued and rewritten at the time of transfer from the ICU (odds ratio, 0.36; 95% CI, 0.17–0.73). 

Conclusions: Nearly half of patients experienced medication errors at the time of transition of care from an ICU to non-ICU location. Most errors reached the patient but did not cause harm. This study identified risk factors upon which risk mitigation strategies should be focused.

Transferring the critically ill patient

Transferring the critically ill patient: Are we there yet? Critical Care, 2015, 19: 62.

Droogh, J.M., et al.

http://ccforum.com/content/19/1/62

During the past few decades the numbers of ICUs and beds has increased significantly, but so too has the demand for intensive care. Currently large, and increasing, numbers of critically ill patients require transfer between critical care units. Inter-unit transfer poses significant risks to critically ill patients, particularly those requiring multiple organ support. While the safety and quality of inter-unit and hospital transfers appear to have improved over the years, the effectiveness of specific measures to improve safety have not been confirmed by randomized controlled trials. It is generally accepted that critically ill patients should be transferred by specialized retrieval teams, but the composition, training and assessment of these teams is still a matter of debate. Since it is likely that the numbers and complexity of these transfers will increase in the near future, further studies are warranted.

Risk management during inter-hospital transfer of critically ill patients: making the journey safe

From Publisher From Free Medical Journals . com (/2000 - /Embargo: 1 year)

From Proquest NHS (09/2003 - 11/2003)

From UK PubMed Central (/2001 - 07/2005)
Page: 502 - 505
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