Summer Training Project on Streamlining the process of transfer from ICU to wards to prevent re-admissions to ICU A quality improvement

study In Fortis Memorial Research Institute (Gurgaon)

Submitted To Jamia Hamdard University MBA (Health & Hospital Management) July 2013 Submitted by: Sushma Sinhmar (2012-2014) Under the supervision of Dr.Shibu John

Faculty of Management Studies & IT, Jamia Hamdard University Hamdard Nagar, New Delhi-11006

DECLARATION
I, Sushma Sinhmar, student of Jamia Hamdard University, New Delhi, hereby declare that I have completed my project, titled Streamlining the process of transfer from ICU to wards and assurance for prevention of return to ICU within 48 hours A quality improvement study. The information submitted herein is true and original to the best of my knowledge. The outcome and original research work was undertaken and carried out by me, under the guidance of Dr. Anita Arora (Head Quality & Microbiology) and Ms.Divya Gautam (Deputy Manager, Quality). It has not been submitted to any other University or Institute or published earlier.

Place: New Delhi Date:

ACKNOWLEDGEMENT
I owe a great many thanks to a great many people who helped me and supported me for completion of this project work. My deepest thanks to Dr.Anita Arora (Head Quality & Microbiology) and Ms.Divya Gautam (Deputy Manager, Quality) for guiding me throughout the study and provide me the necessary information to carry out this study. I express my thanks to the ICU teams, Floor Co-ordinators, Duty doctors, ICUs& Wards Team Leaders, Supervisors ,Nursing staff for their cooperation & contribution which was vital for the success of this project. Thanks and appreciation to the helpful people at Fortis Memorial Research Institute, Gurgaon for their support. I would also like to express my gratitude towards Dr Shibu John for his kind co-operation and encouragement at each step, which helped me in completion of this project.

Sushma Sinhmar

CONTENTS Page No. Acknowledgement Declaration Chapter 1.0 Executive summary Chapter 2.0 Introduction &Literature review Chapter 3.0 Objectives Chapter 4.0 Research methodology Chapter 5.0 Data Analysis Chapter 6.0 Study findings Chapter 7.0 Conclusion Chapter 8.0 Limitations References 1-2 3-10 11 12-15 16-34 35-38 39-40 41-42

CHAPTER 1 EXECUTIVE SUMMARY

Executive Summary:Fortis Memorial Research InstituteGurgaon is a 1000 bedded Multi- Super Specialty, Quaternary care hospital (in initial phase operating at 450 beds) with an enviable international faculty, reputed clinicians, including super-sub-specialists and specialty nurses, supported by cutting-edge technology. It is a premium referral hospital which endeavours to be the 'Mecca of Healthcare' for Asia Pacific and beyond. This Next Generation Hospital is built on the foundation of 'Trust' and rests on the four strong pillars Talent, Technology, Infrastructure and Service.

The FMRI- Vision is to be the ultimate healthcare destination - "Mecca of Medicine", Mission -to provide quaternary care to the community in a compassionate, dignified and distinctive manner & Motto is Best is the Least We Can Do". A Study was carried out carried out at 450 bedded (operational in its 1st phase) Fortis Memorial Research Institute-Hospital, with an objective of Prevention of return to ICU within 48 hours. The study was carried out in 3- Phases: The study was carried out as a result of: the number of unplanned Returns to ICU within 48 hours was high for the month of May 2013 and it remained the same in the month of June 2013. Phase-1 The first phase of study involved 10 days of Shadowing of Patients throughout the process of transfers from ICUs (medical, surgical, CTVS) to Wards. Identification and documentation of the various concerns (loop holes) observed throughout the whole process. Phase-2 The second phase of the study consisted of framing out the various strategies and implementing. The focus was confined to the various concerns and the aids which could help in eliminating the loop holes in order to reduce the number of unplanned returns to ICU within 48 hours. Phase-3 The third phase of the study done to actually see the effects of the interventions carried out in phase -2 of the study.

CHAPTER 2.0 INTRODUCTION AND REVIEW OF LITERATURE

Hospitals have experienced unprecedented growth in demand for services across a range of areas including critical care. Factors identified as driving the growing demand for intensive care include: a rise in chronic and complex illness an aging population more new treatment options through advances in medical technology.1 Wherein, the transfer of patients from the ICU is an everyday procedure. It is an accepted part of the ICUs routine work.4 Considering the whole transfer process from Intensive Care Unit
(ICU) to wards is complex, involving information exchange among ICU and ward staff in addition to transferring responsibility and accountability for care. Despite professional guidelines for managing ICU discharge processes, there are wide variations in practice. Discharges can be problematic, with issues such as bed-availability delays, inadequate skill mix on the receiving wards and resource limitations creating delays.3Whereas the earliest appropriate time of

transfer reduces excessive and unnecessary use of this expensive health care facility and improves the availability of beds for other critically ill patients requiring ICU admission.2

However, early discharge of ICU patients to general wards may expose them to inadequate levels of care. Moreover, early discharge may result in ICU readmission during the same hospitalisation with the possibility of a worsening of the patient's original disease process, increased morbidity and mortality rates, a longer length of stay and increased total costs. ICU readmission rates reported in the literature vary from 0.9% to 19% with mortality rates for readmitted patients ranging from 26% to 58%.2

Therefore, ICU transitional care is used and defined as care provided before, during and after the transfer of an ICU patient to another care unit that aims to ensure minimal disruption and optimal care for the patient. This care may be provided by ICU nurses, acute care nurses, physicians and other healthcare professionals. Discharge planning is a part of ICU transitional care. It is a part of the process that aims to provide continuity of care for the patients. The effects of a poorly coordinated discharge can lead to readmission to the ICU and also avoidable deaths. If the transfer for the individual patient is accompanied by scarce, inadequate or untimely knowledge or preparation, it may be perceived as a threat to security.4

JUSTIFICATION OF THE STUDY

Unplanned Return to ICU within 48 hours is a Critical Parameter of Medical Operating System for the Clinical Excellence Scorecard. The main focus is to minimise the unplanned returns to ICU within 48 hours, which is a matter of concern as a discontinuity in the continuity of care. Continuous care has to be provided after the Patient has been transferred from ICU to Wards, as many patients experience high anxiety, stress etc. during relocation from the intensive care unit to the wards. Thus, they require higher level of care for at least 48 hours , as compared to the patients who are already in the wards in order to prevent the returns to ICU. The present study was designed to minimise the unplanned returns to ICU within 48 hours by streamlining the transfer process.

REVIEW OF LITERATURE
Intensive care units manage the sickest patients in a hospital. They provide time-critical care and treat patients often utilizing complex medical technology. Clinical staff are highly trained, with the ratio of nurses to patients much higher than on the wards.1 According to James and Kendall (2005), ICU transitional care is care provided before, during and after the transfer of an ICU patient to another care unit that aims to ensure minimal disruption and optimal continuity of care for the patient.3 Discharge from the intensive care unit (ICU) at the earliest appropriate time reduces excessive and unnecessary use of this expensive health care facility and improves the availability of beds for other critically ill patients requiring ICU admission. However, early discharge of ICU patients to general wards may expose them to inadequate levels of care. Moreover, early discharge may result in ICU readmission during the same hospitalization with the possibility of a worsening of the patient's original disease process, increased morbidity and mortality rates, a longer length of stay and increased total costs.2 An exploratory, qualitative pilot study was done by Polit and Hungler in 1995 involving one male and four female registered nurses from ward areas taking the most patient transfers from a general adult intensive care unit over an 18-month period (March 1997 to August 1998) to identify the difficulties faced by ward staff caring for patients transferred from intensive care.5 In 2009, Appelles Ohanga performed a qualitative study involving registered nurses from the five surgical ward (K3, K4, K5, K6, K7) of Jorvi hospital involving people who had a perspective on a particular research topic. The tool used was questionnaire, developed by the researcher specifically to collect data from the registered nurses working in the surgical wards. The development of the questionnaire was through literature searches and also discussing with the critical care unit nurses. An average of fifteen questionnaires was issued to each ward. The research period was two weeks for all the wards in June 2009. The study emerged with five themes. Communication was the most significant aspect in all the themes. 1. Information sharing 2. Timing of patient transfer 3. Documentation as a continuation of patient care 4. Intensive care patient family members 5. Post ICU visit3

Axel Kaben in 2008, investigated the incidence of, outcome from and possible risk factors for readmission to the surgical intensive care unit (ICU) at Friedrich Schiller University Hospital, Jena, Germany. The study involved all patients admitted to the post-operative ICU between September 2004 and July 2006. The results showed, of 3169 patients admitted to the ICU during the study period, 2852 were discharged to the hospital floor and these patients made up the study group (1828 male (64.1%), mean patient age 62 years). The readmission rate was 13.4% (n =381): 314 (82.4%) were readmitted once, 39 (10.2%) were readmitted twice and 28 (7.3%) were readmitted more than twice. The first readmission to the ICU occurred within a median of seven days (range 5 to 14 days). Patients who were readmitted to the ICU had a higher simplified acute physiology II score and sequential organ failure score on initial admission to the ICU than those who were not readmitted. In hospital mortality was significantly higher in patients readmitted to the ICU than in other patients.2

In August 2006, Malcolm Elliott, used the following databases to locate published data: Medline (1966-present), CINAHL (1982-present), Synergy, Science Direct, Proquest and Taylor & Francis. The search terms used were 'intensive or critical care', 'recidivism' 'patient follow- up', 'readmission' and 'bounce back'. Discipline-specific journals (e.g. American Journal of Critical Care, Heart & Lung, Intensive and Critical Care Nursing) were hand searched to find studies not catalogued in electronic databases. The worldwide web was also searched using three search engines (yahoo.com, scholar. google. com and askjeeves.com). Exclusion criteria included was non-research based articles, those not published in the English language and articles relating to the readmission of patients to hospital from the community. These search strategies identified a total of 20 studies specifically relating to the readmission of patients to ICU reviewed the published studies on readmissions to ICU with an aim to examine: 1. Determine the frequency of readmissions. 2. Identify the risk factors for readmission. 3. Determine the reasons for readmission or the common 'type' of patient readmitted. 4. Highlight areas for further research. The Research indicated that patients readmitted to ICU have mortality rates up to six times higher than those not readmitted and are eleven times more likely to die in hospital.6

Wu CJ et ol, 2007 reviewed the case studies of transferring ICU patients to general wards in order to identify the shortcomings of this process. The study revealed the Evidences that indicate that the poorly managed transfer of a patient from the intensive care unit (ICU) to the ward can lead to physical and psychological complications for the patient, and often require ICU readmission and re-hospitalization. Reviewing this patient transfer process to improve the quality of care would be a positive step towards enhancing patients' recovery and providing skills to staff.8

In 2011, St-Louis L et ol, studied to describe an innovative quality initiative to implement the clinical nurses specialist in medicine to facilitate the transition process between the intensive care unit and the medical wards, with a rationale of the study Safely transferring patients with complex health conditions from an area of high technology and increased monitoring, like the intensive care unit, to an area with lower nurse-to-patient ratio is an intricate process. The care of these patients, once transferred, also requires varying levels of expertise. As indicated in the nursing literature, this type of transition is often associated with high stress levels for the patient and family, as well as for the healthcare providers. To maximize patient safety and ensure optimal care for this patient population, well-defined mechanisms must be put in place. The outcomes of the study shows:on average, 150 patients are assessed each year by the CNS. Among these patients, 15% are considered at high risk for complications upon transfer to the unit and a systematic evaluation of patients by the CNS, before their transfer from the ICU to a medical unit, has been proven beneficial in ensuring a comprehensive patient care plan and patients and families have verbalized that this intervention is helpful. Staff members have indicated that this safety initiative is useful in planning patient transfers. The next step would be to formally measure patient, family, and staff satisfaction with this initiative.7

In December 2012, Grottenthaler et ol, studied early identification of high-risk patients through the use of an assessment checklist and risk score will predict and reduce ICU readmissions within 72 hours of discharge for respiratory-related complications using a qualitative study design. The research was a pilot study involving five adult ICUs with 165 patients . To validate accurate identification of high-risk patients, the ICU-designated Respiratory Care Practitioner (RCP) completed a Respiratory Bounce back Risk Score (RBRS) assessment checklist prior to each patient transfer out of the ICU. Statistical analysis was performed using a Statistical Package for Social Sciences (SPSS). A non-identifiable

dataset of patients enabled the ability to statistically identify patients who presented as highrisk due to respiratory-related complications. Patients with a cumulative risk score of 14 or greater were identified as high-risk patients (p<0.0001, Bonferroni corrected for multiple testing). High-risk patients were followed closely by the respiratory team and monitored to ensure optimal respiratory modalities were ordered and administered. Collaboration of the patient care plan was communicated amongst the multidisciplinary care team, all inclusively. The Initial outcomes of the data pre and post pilot demonstrated a reduction from 4 patients per month to 1.67 patients per month (57.5% decrease). The new practice of utilizing the JHBMC RBRS assessment checklist and risk score was hard-wired into standard practice and workflows. A full year of data (September 2011 to September 2012) indicated that we have sustained our gain with one year of outcomes data reflecting a 56.3% decrease compared to pre-RBRS.9

In 2012, Ofoma et ol performed a study at mayo college to determine and understand the root causes of ICU readmission by employing qualitative methods. Directly observe work flow and transition of care processes across specific ICUs. Map observed work flow and discharge process. Suggest a process model of ICU discharge for patients with high risk of re-admission that will include factors identified from our qualitative study. We performed direct observation of work flow and discharge processes in three intensive care units at Mayo Clinic Rochester. A full work day (7am - 7pm) was spent in each instance, with the field observer covertly embedding himself into the ICU rounding team. Using semi-structured recording instrument consisting of checklists and field notes, a record of observed activities, behaviours and interactions that relate to the discharge process was noted. Discharge processes were followed through until patients were evaluated on the general floors by the receiving services. We subsequently performed one-on-one semi-structured interviews using a purposive sample of ICU and general medical staff consisting of nurses, resident physicians, fellows or mid level practitioners and consultants. Interviews were recorded, transcribed and analyzed for common themes with the aid of Nvivo Software and illustrated using a Fishbone diagram. Observed and suggested workflow and discharge processes were mapped using Microsoft Visio. The outcomes of the study involved total of five discharge processes were observed during three work days of monitoring. A total of twenty four staff was interviewed, consisting of five nurses, two residents, two fellows and one consultant. Identified factors relating to

unexpected ICU readmission were classified into themes: Communication, Physician, Patient, Processes, Hospital & Staffing.10 Wendy Chaboyer, in 2008 performed a quality improvement study using a time-series design and statistical control analysis process in an Australian general ICU : To evaluate the impact of a redesigned intensive care unit (ICU) nursing discharge process on ICU discharge delay, hospital mortality and ICU readmission within 72 hours. A total of 1,787 ICU discharges were included in this study, 1,001 in the 15 months before and 786 in the 12 months after the implementation of the new discharge processes. . The redesign process included appointing a change agent to facilitate process improvement, developing a patient handover sheet, requesting ward staff to nominate an estimated transfer time and designing a daily ICU discharge alert sheet that included an expected date of discharge. The primary outcome measure was hours of discharge delay per patient discharged alive per month, measured for 15 months prior to, and for 12 months after the redesigned process was implemented. There was no difference in in-hospital mortality after discharge from ICU or ICU readmission within 72 hours during the study period. However, process improvement was demonstrated by a reduction in the average patient discharge delay time of 3.2 hours (from 4.6 hour baseline to 1.0 hours post-intervention).3

OBJECTIVES OF THE STUDY

1. To determine the root causes of unplanned ICU re-admission by employing Qualitative Method. 2. To Directly observe work flow and transition of care processes across specific ICUs. 3. To Map observed work flow and Transfer process. 4. To Design the corrective measures and recommendations to minimize Re-admissions to ICU. 5. To determine the effectiveness of the interventional programme undertaken by concerned stakeholders after circulation of Corrective measures recommendations.

CHAPTER 4.0 RESEARCH METHODLOGY

This chapter discusses in detail the research methodology selected in order to streamline the transfer process from ICU to Wards and assurance of prevention of unplanned returns to ICU within 48 hours.

4.1 Research design The Research approach used in this study was Retrospective, Observational, Descriptive & Interventional. The primary Research included observing & analysing the root cause for Unplanned return to ICU within 48 hours and data collection for the process of transfers from ICU to Wards. The secondary research included finding out the concerns in the process and planning interventions in order to reduce the number of unplanned returns to ICU within 48 hours and designing the recommendations, interventions & implementation. Third phase includes analysing the effectiveness of the interventions.

4.2 Study tools M.S excel was the tool used in the study for data collection and analysis. A Medical Operating System (MOS) checklist for prevention of return to ICU within 48 hours & Checklist for transfers of patient from ICU to Wards was used to record observations (observations were recorded in MS excel).

4.3 Methods of data collection A tri-phasic approach was used in the study. Primary data collection (Pre-intervention & Post-intervention) & initially secondary data (Retrospective) for last 3-months reviewed for Returns to ICU within 48 hours.

PRIMARY RESEARCH (Phase 1) Initially, retrospective study was done to evaluate the Returns to ICU within 48 hours to find the root causes of the re-admissions. In First phase included observations regarding the process of the transfers from ICUs to Wards was documented for 10 days, using a checklist prepared by the observer. The process flow of the transfers from ICU to Wards including the information flow to various areas and co-ordination among them was observed for ICU-2 (Surgical ICU), ICU-6 (CTVS-ICU) & ICU-7 (Medical ICU). The data collection was done using the Checklist for transfer process from ICU to wards.

The various parameters which were looked into were as follows: MOS- Checklist for Prevention of Return to ICU within 48 hours:-

Audit to be done after 24 hours of transfer of patient from ICU to Wards 1. Transfer from ICU is signed/authorized by the responsible ICU Consultant. (Check the transfer sheet/progress notes for instructions by critical care consultant.) 2. Treating Consultant/Team has been consulted and the same has been documented. (If the intensivist is ordering transfer for another consultants patient-verify that the information given to the treating team is documented in progress notes). 3. Transfer form is complete (Doctors as well Nurse Section). (Check the in-house transfer form for completion and correct documentation including legible name and signature). 4. Taking over/patient receiving documentation is complete- Nurse & Doctor section. 5. Care instructions for next 24 hours are documented. (Check the progress notes/transfer form for care instructions apart from medications). 6. Suctioning frequency is mentioned (for tracheotomised patients). (Check for written instructions for those who are transferred in with ETT/TT). 7. Instructions for care of drains have been documented (if applicable). (Check for written instructions for those patients who are transferred in with drains including intercostal drain). 8. Care instructions are carried out in the ward. (Compare progress notes with transfer instructions).

Checklist for transfers of patient from ICU to Wards:Shadowing of patient throughout the process of transfer from ICU to Wards 1. Interpreter requirement and availability. 2. Written orders from Consultant team & Critical care team. 3. Room Availability delays.

4. Co-ordination among ICU- supervisor & Ward Team Leader. 5. In-house transfer summary sheet complete (Doctor Section). 6. In-house transfer summary sheet complete (Nurse Section). 7. Patient profile explanation by ICU nurse to ward nurse. 8. Transfer book complete. 9. Co-ordination b/w assigned Nurse and Team Leader. 10. Co-ordination b/w Team Leader and Duty Doctor. 11. Co-ordination b/w Duty Doctor and Consultant Team.

Phase-2 The second phase of the study included planning of the interventions for the concerns through the process of transfers from ICU to Wards. Implementation of interventional plans using various quality improvement interventions, in order to streamline the process of transfers and prevent the unplanned returns to ICU within 48 hours involving the following: ICU-2,ICU-6, ICU-7, Nightingale ward (1st floor), 2nd floor and 3rd floor (Insignia) areas.

SECONDARY RESEARCH Third phase of the research was done to determine the effectiveness of the interventions carried out in the phase-2. In this phase again patients were shadowed and the transfer process parameters were evaluated for its compliance.

CHAPTER 5.0 DATA ANALYSIS

Data analysis
The outcome indicators for Prevention of unplanned returns to ICU within 48 hours in Clinical excellence scorecard is the number of patients returning to ICU (within 48 hours of transfers) divided by the number of patients transferred out from ICU * 100.

Calculation of Returns to ICU (within 48 hours of transfers):-

Returns to ICU Rate: No. Of cases returning to ICU within 48 hours * 100 No. Of patients shifted out from ICU in a month

The number of patients transferred out from ICU & number of patients returning to ICU includes the total number of transfers from all ICUs in a month & returns in the month from all ICUs.

The data collected was represented in percentage.

Exclusion Criteria:- ICU-1, & ICU-9 is not included in the study as ICU-1 (recovery area) has post-operative patient & patients only stay for few hours and ICU-9 is the paediatric surgery ICU and the number of patients transferred from OT are very few (1-2 patients). ICU-5 is not functional yet so, not included in the study.

FINDINGS FOR FIRST PHASE OF THE STUDY: STANDARD PROTOCOL FOR MOS PARAMETER PREVENTION OF RETURN TO ICU WITHIN 48 HOURS.

PROTOCOL PRE-TRANSFER PROCESS:

1. Status of patients admitted in ICU is monitored continuously to identify patients who no longer needs ICU care. Transfers is considered when: a. Patients physiological status has stabilised and the need for ICU monitoring and care is no longer necessary. Parameters to be considered for this decision are listed below for guidance purpose (Box at end of text). b. Patients physiological status has deteriorated and active interventions are no longer planned, and transfer to a lower level of care is appropriate. 2. A patient who does not require intensive care but needs more care than that provided in a general ward is shifted to HDU. Such patients require more frequent monitoring of vital signs &/ or nursing interventions. 3. Patients with ICU status of more than 7 days and who are hemodynamically stable are shifted to HDU before considering shifting to general wards with monitoring facilities and higher patient-nurse ratios. 4. Patients with ICU stay of less than 7 days and who are hemodynamically stable may be shifted to general wards directly. 5. As far as possible, transfer from ICU should be completed before 7 pm. In case of transfers being considered after 7 pm or if delay has occurred despite transfer instructions issued earlier in the day, a re-approval from the ICU consultant as well as parent clinical unit/team is obtained.

TRANSFER PROCESS 1. Transfer must be approved by responsible ICU consultant and signed by the consultant himself/herself or a member of his/ her team. 2. Parent clinical unit/team is consulted prior to patient transfer and patients clinical condition (including current and potential problems) is discussed. 3. Medical and nursing transfer summary must be completed by the critical care team and this must accompany the patient to the receiving ward.

4. Transfer form/document (see box below) must include clear medical management plan for next 24 hours. Special care of At risk patients (eg. Patients with tracheostomy, GCS lower than 9 etc.). 5. If patient is on Insulin, parent units are informed of the insulin protocol. 6. Other care teams involved (like Physiotherapy, Dieticians etc.) should be informed of transfer. 7. Treatment limitation/non-escalation directives must be discussed with the patients attendants and with parent clinical unit. The same must be documented.

POST ICU TRANSFER 1. Patient condition at the time of receiving the patient (in the ward) should be documented along with any special instructions. 2. Care in the ward includes patient management as per the instructions mentioned in the transfer form. 3. Critical care team should be involved in early management of At risk patients in order to minimise chances of unplanned return to ICU.

OBJECTIVE PARAMETERS BEFORE TRANSFER FROM ICU: VITAL SIGNS: Pulse > 40 or < 120 beats/minute Systolic arterial pressure > 80 mmHg Mean arterial pressure > 70 mmHg Diastolic arterial pressure < 100 mmHg Respiratory rate < 30 breaths/minute

LABORATORY VALUES (NEWLY DISCOVERED) Serum sodium > 130 mEq/L or < 150 mEq/L Serum potassium > 3.5 mEq/L or < 5.5 mEq/L PaO2 > 60 mmHg pH > 7.2 or < 7.5 Serum glucose < 200 mg/dl Serum calcium < 10 mg/dl Toxic level of drug or other chemical substances have cleared.

Note: If any parameter is out of range, a special note should be made by the ICU team.

ANALYSIS POINTERS INCLINICAL EXCELLENCE SCORECARD FOR RETURN TO ICU WITHIN 48 HOURS:

S.NO. 1.

ANALYSIS POINTERS Inappropriate step down due to deviation from the transfer protocol of ICU.

ANALYSIS CUE/ TRIGGER CUE Refer to transfer criteria of critical care units for Inappropriate monitoring of patients condition prior to shifting to ward.

2.

Inappropriate care planning in the ward by healthcare providers.

One or more of the following in the patient file will indicate the appropriateness of care plan: 1. Gross variation in vitals not addressed in time. 2. Care plan not documented based on assessment. 3. Critical investigation reports not addressed in time. 4. Inadequate monitoring on prescribed intervals.

3.

Early step down Due to high occupancy

Self explanatory Staff/ specialist interviews may also be reflective Self explanatory

4.

Early step down due to patient financial constraints

5.

Communication gap

One or more of the following in the patient file will indicate the inadequacy in communication: 1. Inappropriate/incomplete inter-departmental transfer notes. Eg. Incomplete physician focus section. 2. Inappropriate intra-departmental handover 3. Incomplete/missed documentation by healthcare service provider.

6.

Aggravation of pre-existing patient

This explanation is to be supported by appropriate

risk factors despite a proper treatment documentation of risk factors & the factors that have led to this aggravation of pre-existing ailment in the patient file. 7. Escalation of risk factors associated with procedure despite a proper treatment 8. Any other (Please specify) This explanation is to be supported by appropriate documentation of risk factors & the factors that have led to this aggravation of pre-existing ailment in the patient file. Explanations to be included

Transfer process from ICU to wards:Written orders from consultant team + critical care team Discussion with Patient/ relatives in Room decision.

Information flow from ICU to IPD for availability of room(E-mail)

Delay Conveyed to ICU-supervisor

Conveyed to ICU-supervisor and ward Team Leader(E-mail)

Information flow from ICU-supervisor to Ward Team Leader Regarding Transfer ( E-mail) In-house transfer summary sheet completion + Pharmacy clearance

Transfer of patient with assigned ICU-nurse & GDA

Patient received by assigned nurse in ward

Patient progress explanation by ICU-nurse to ward nurse + received sign. by ward nurse on In-house transfer summary sheet & Transfer book.

TL informed about patient receival by assigned ward nurse

TL informs duty doctor

Duty doctor informs consultant team

TABLE-1 NO. OF UNPLANNED RETURNS TO ICU WITHIN 48 HOURS IN MONTH OF MAY , JUNE & JULY

TIME PERIOD

MAY
ICU-2 ICU-6 ICU-7 ICU-2

JUNE
ICU-6 ICU-7
ICU-2

JULY(27th)
ICU-6 ICU-7

AREAS

Total Number Of Patients Transferred From ICU Total number of returns to ICU within 48 hours

52

49

48

61

53

47

51

46

53

Calculation of Returns to ICU (within 48 hours of transfers):Returns to ICU Rate: No. Of cases returning to ICU within 48 hours * 100 No. Of patients shifted out from ICU in a month

NUMBER OF UNPLANNED RETURNS TO ICU IN MONTH OF MAY 2013:

Unplanned Returns to ICU Within 48 hours (May)

2%

98%

Total no. of patients transferred from ICU's to wards Unplanned returns to ICU within 48 hours

No. Of Unplanned Returns To ICU In Month Of June

No. Of Unplanned Returns to ICU in Month of July

1.86%

0.67%

98.14 %

99.33 %
Total no. of patients transferred from ICU's to wards Unplanned returns to ICU within 48 hours

Total no. of patients transferred from ICU's to wards Unplanned returns to ICU within 48 hours

COMPARISION : RETURN TO ICU IN THE MONTH OF MAY, JUNE & JULY:

120 100 80 60 40 20 2 0
MAY JUNE JULY

98

98.14

99.33

1.86

0.67

Total no. of patients transferred from ICU's to wards Unplanned returns to ICU within 48 hours

Table-2 Pre-intervention -Transfer process from ICU to wards (% compliance):

Parameters Interpreter required and available (sample size-2) Written orders from consultant & critical care team Room availability (Delays) Co-ordination b/w ICU-supervisor & ward TL Co-ordination b/w Assigned ward nurse & TL Co-ordination b/w TL and Duty doctor In house transfer summary sheet complete (doctors part) In house transfer summary sheet complete (nurses part) Patient progress explained by ICU-nurse to ward nurse verbally ICU-transfer book complete Patient first seen by duty doctor/consultant team (delays)

% Present 50 93

% Absent 50 7

86 86 64 64 57

14 14 36 36 43

21

79

100

93 64

7 36

Note: The number of patients shadowed during the whole process of transfer from from 10th June to 20th June 2013.

ICU to wards

were 14 patients, each consuming approximately 3 hours and the time period of shadowing was

% Compliance of Transfer process from ICU to Wards

Sample size - 14 (Complete shadowing of patients:10th -20th June)

120 100 100 93 93 86 80 64 60 64 64 57 43 40 36 36 36 21 20 7 0 0 7 14 14 50 50 86 79

% Present

% Absent

The graphical presentation of the percentage compliance of the transfer process from ICU to wards is depicted above with the various parameters against which the compliance rate was checked and the documented to take the corrective actions to enhance the compliance rate.

CONCERNS ASSOCIATED WITH THE TRANSFER PROCESS FROM ICU TO WARDS

1. Unavailability of Interpreter (international patients), affecting the delivery of care needed by the patient during the whole process, which takes around an hour. The nurse is not able to understand the needs of the patient due to language barrier. 2. Incomplete In-house transfer summary sheet : Nurses part: Eg. Patient wound details (Type of dressing, Frequency of change etc.), Drain details (Type, color etc.), Handover details etc. Doctor-s part: Analgesia details etc. 3. In-efficient management by team leader (Ward Nurse) as associated with the assigning of patient to the nurse before the patient reaches the room, which contributes to the delays in transfer process. 4. Delays in the rounds by the duty doctor/consultant team due to the communication gap between the Assigned nurse and team leader regarding the time of patient transferred to the room and hence contributing to the incoordination between team leader and duty doctor . 5. Delays in the transfer process excluding the delays due to inefficient management by team leader includes: In-efficiency & in-appropriate prioritization of work by the assigned nurse for the patient and hence contributing to the delays in the transfer process. The delays , as the assigned nurse is busy with the other patient for which he/she has been assigned earlier. 6. Critical care daily progress notes incomplete. Eg. Patient plan for the day, current problems, vital system status etc.

FISH BONE ANAYSIS

Fish Bone Analysis was done for the various concerns associated with the transfer process as a quality defect prevention, to identify potential factors causing returns to ICU. Each cause or reason for imperfection is a source of variation.

Physician Delays
Duty Doctor busy in care of other patients Communication Gap between Duty doctor and Team Leader (Nurse) Communication gap between assigned nurse(ward) and Team Leader Casual approach of assigned nurse Consultant team busy in OT/OPD/other patients

Communication
In-house transfer summary sheet incomplete Nurse Unaware for details to be filled in certain columns . Lack of training Casual approach of Doctors Casual approach of Nurses

Interpreter unavailability Phone switched off Nurse unaware of protocol for Instant call for Interpreter Lack of training

Unplanned returns to ICU

Formulation of roaster not done for planned transfers Unavailability of Room Delay in discharge process Delay in room preparation Inefficient management of house-keeping staff Nurse not assigned prior to patient arrival Inefficient management by Team Leader Assigned nurse busy with other patient Inefficient time-management Inappropriate prioritization Inefficient utilization of GDAs Incomplete Instructions to GDAs

Team Leader unaware of planned transfers information sent a day before the transfer. Lack of Training

Casual approach of Management

Casual approach of GDAs

Transfer Delays

Inefficient Management

S . No. Observations
1 2
Interpreter unavailability

Recommendations
Training on whom to esclate the call, in case interpreter is not available

Responsibilities
Nursing supervisor.

Inefficient use of GDA's(GDA waits till the nurse completes the handover). Casual attitude of GDA to be looked in.

After transporting the patient to ward , GDA shall go ICU-Nursing supervisor back to ICU

Delay in Room availability

Delay in discharge process

Billing

Delay in preparation of room for next patient (Ward) Supervisor - House Keeping

4 5 6

Team Leaders (3rd &4th floor) Unaware about planned transfers information a day before

TL to infromed and trained about the planned step Nursing supervisors. down intimation mail.

Circulation of information to Nightingale ward by ICU- ICU - Nursing Supervisor Unavailability of information of planned transfers from ICU to supervisor. nightingale ward, prior evening At time of patient being received in wards- no nurse available to Nursing roaster to could be be prepared as per the list Floor TL take hand over of planned step down from ICU - to assign poper number of nurses. Team Leaders to be more proactive in assigning duties Floor TL for patient received from ICU Casual approach of nursing staff (ICU &Wards) in completing the details of transfer form Doctor's not completing the transfer form Delays in rounds by Duty doctor/Consultant team ICU-nursing staff to be trained- how to fill the in transfer summary sheet. Training and orientation for doctors - completing form details Flow of information from assigned nurse to ward-team Staff Nurse leader needs to be focussed. Team leaders should be accountable for informing duty doctor about arrival of patient to ward (team leader busy). Team Leaders & nursing supervisors Nursing Educator

7 8

DESIGNING OF INTERVENTIONS
1. The interventions which were required to be taken for the implementation of the corrective actions were designed according to the concerns associated with the transfer process.

UNAVAILABILITY OF INTERPRETER Step-1: Discussion with the floor managers of 1st (Nightingale ward), 3rd floor (Insignia ward) & 4th floor regarding the protocol for the instant call for Interpreter. The discussion concluded the existence of protocol for the instant call for interpreter. Whereas, the nursing staff of all the floors were unaware of the protocol. Step-2 : Nursing supervisors & team leaders of 1st, 3rd & 4th floor informed regarding the unawareness among nursing staff. Step-3: Acknowledgement of nursing staff about the protocol for instant call for interpreter by the nursing supervisors of the respective floors.

IN-EFFICIENT MANAGEMENT BY THE TEAM LEADER (NURSE) Planned transfers Step-1 Discussion with the ICU-supervisors of ICU-2, ICU-6 & ICU-7 about the circulation of list of planned transfers to the ward a day before (evening). The discussion concluded with the information that circulation of the list of planned transfers is sent to nursing stations of 1st, 3rd & 4th floors. Whereas,the team leader found unaware of this information flow. Step-2 Nursing supervisors of all floors informed regarding the unawareness among team leaders. Step-3 Education of team leaders by the nursing supervisors of respective floors about the information flow that happens a day before the patient is to be transferred. Team leaders taught about the formulation of the roasters for assigning the nursing staff for the patients to be transferred the next day. This would streamline the process of transfers and minimise the delays.

Unplanned transfers Step-1 Discussion with team leaders of 1st, 3rd & 4th floor regarding the pattern followed for the assigning of nurse for the unplanned transfers. The discussion concluded that nurse is not assigned prior to the patient arrival from the ICU & it was done when the patient has arrived. Step-2 Nursing supervisor informed about approach of the team leaders.

Step-3 Education of the team leaders by the nursing supervisors of the respective floors regarding the prior planning the nurse to be assigned, as co-ordination among ICU-supervisor and Ward team leader exist before the patient is transferred to the ward. This prior assignment of the nurse for the patient transferring from ICU, minimize the transfer delays and reduce the panic among the nursing staff Hence, smooth workflow can be seen. IN HOUSE TRANSFER SUMMARY SHEET INCOMPLETE: NURSES PART: Step-1 Evidence based information provided to the Nursing supervisors of ICU-2, ICU-6 & ICU-7 for the areas in In-house transfer summary sheet to be focused for deficiencies and lack of knowledge among nursing staff about the details to be filled in certain columns. Step-2 ICU- nursing staff educated about the deficiencies by the ICU-supervisors of the respective ICUs. Step-3 Individually pointing out the errors in the ICUs by the observer and correcting the nursing staff for the deficiencies or errors made. DOCTORS PART: Step-1 Informing the Doctors (Critical care team) regarding the deficient areas in the In-house transfer summary sheet in doctors part. Such as Analgesia details etc.

DELAYS IN ROUNDS BY THE DUTY DOCTOR/CONSULTANT TEAM Step-1 Delays in rounds by the duty doctor/ consultant team were captured using the patient file (progress notes of the patient). Step-2 Information regarding the delays conveyed to team leader & nursing supervisor of the floor by the observer. The factors contributing to delays included the casual attitude of the team leader and communication gap between assigned nurse and team leader about the arrival of the patient. Step-3 Nursing supervisors educated the team leader for the continuity of information flow to the duty doctor and team leaders educated nursing staff of the respective floor for maintaining the flow of information .

DELAYS IN TRANSFER PROCESS Step-1 Detection of the delays in the transfer process by the observer and contributing factors. Step-2 Nursing supervisor informed about the delays and the factors contributing as nursing staff inefficiency & in-appropriate prioritization of the work by the assigned nurse for the patient.

Step-3 Education of the nursing staff regarding the prioritization of the work & increasing their efficiency by eliminating wasteful processes. 2. Circulation of the results of the pre-intervention transfer process with details of the deficiencies and areas of concerns and focus points in the various departments as follows: ICU-2 incharge ICU-6 incharge ICU-7 incharge Nursing supervisors of 1st, 3rd & 4th floor.

3. Presentation of the results of the pre-intervention in the monthly meeting of the quality department focusing the deficient areas and the focus areas. 4. Doctors (ICU-incharges) feedback for any changes in the In-house transfer summary sheet and additions were recommended for the next prints of the In-house transfer summary sheet. The Recommendations were: 1. Drug details 2. Advisory orders by doctors (Critical care team & Consultant team) 3. Dietary advisory column for doctors.

INTERVENTIONAL LAYOUT OF THE CONCERNS

Orientation of TL by Nursing supervisors about the planned step down intimation mails sent a day prior. ICU-supervisors informed about circulation of information (mail) to Nightingale ward (1st floor) about the planned stepdowns a day prior to transfer. Teamleaders oriented about nursing roasters to be made a day prior for planned step downs and team leaders to be In-efficient more pro-active in assigning management causing delay's duties.

Training of nursing staff (wards) by nursing supervisor to escalate the call, in case interpreter is not available.

Unavailability of interpreter

in transfer process).

Training of nurses in order to improve flow of information from assigned nurse to team leader (ward). Orientation of Team leaders by nursing supervisor to be accountable for informing duty doctor about arrival of patient to ward.

Delays in rounds by duty doctors and consultants

Incomplete "In house transfer summary sheet E

ICU-nursing staff trainedhow to fill the in transfer summary sheet by Nursing- educator. Training and orientation for doctors - completing form details.

Suggestion:
1. Suggestion for Improvement in In-house transfer summary sheet was given by the observer , in order to capture the transfer time taken from the ICU to the handover given to the ward nurse. So, inclusion of the TIME at which patient is received by the ward nurse. Presently , the summary sheet captures only the time of transferring ICU-nurse.

Table-3 Post-intervention -Transfer process from ICU to wards (% compliance): Parameters Written orders from consultant & critical care team Room availability (Delays) Co-ordination b/w ICU-supervisor & ward TL Co-ordination b/w Assigned ward nurse & TL Co-ordination b/w TL and Duty doctor In house transfer summary sheet complete (doctors part) In house transfer summary sheet complete (nurses part) Patient progress explained by ICU-nurse to ward nurse verbally ICU-transfer book complete Patient first seen by duty doctor/consultant team (delays) 100 87 0 13 100 0 67 33 93 93 60 80 80 7 7 40 20 20 % Present 100 % Absent 0

Note: The post intervention phase was from 17th July to 25th July. Wherein, again the patients were shadowed during the transfer process and documented for the compliance rate. The post-intervention shadowing was done to check the effectiveness of the interventions.

% Compliance Transfer process from ICU to wards (Post Intervention):

Sample size 15 (Complete shadowing of patients: 17th-25th July)

120 100 100 100 100 93 93 87 80 80 67 60 60 40 40 20 20 7 0 0 0 0 7 13 20 33 80

% Present

% Absent

The graphical presentation of the percentage compliance of the transfer process from ICU to wardspost-intervention is depicted above with the various parameters against which the compliance rate was checked.

Table-4: Comparison Pre & post intervention:

Parameters Written orders from consultant & critical care team Room availability (Delays) Co-ordination b/w ICU-supervisor & ward TL Co-ordination b/w Assigned ward nurse & TL Co-ordination b/w TL and Duty doctor In house transfer summary sheet complete (doctors part) In house transfer summary sheet complete (nurses part) Patient progress explained by ICU-nurse to ward nurse verbally ICU-transfer book complete Patient first seen by duty doctor/consultant team (delays) % Pre-compliance 93 86 86 64 64 57 21 100 93 64 % post compliance 100 93 93 60 80 80 67 100 100 87

% Compliance pre and post intervention:

120 100 100 100 80 60 40 20 0 21 100 100 93 93 93 86 93 86 64 60 64 64 57 87 80 80 67

Sample size-14 Sample size-15

% Compliance Pre- intervention

% Compliance Post-intervention

CHAPTER 6.0 STUDY FINDINGS

FINDINGS OF THE FIRST PHASE: I. The primary research carried out was for the purpose of extracting the concerns associated with the transfer process from ICU to wards. II. III. The concerns associated were documented & discussed with the concerned departments. The primary data collected during the shadowing of the patients was checked for the compliance, considering the various parameters, prepared as checklist in the process of the transfer of patients from ICU to wards.

% COMPLIANCE OF THE VARIOUS PARAMETERS (PRE-INTERVENTION)

Parameters Interpreter required and available (sample size-2) Written orders from consultant & critical care team Room availability (Delays) Co-ordination b/w ICU-supervisor & ward TL Co-ordination b/w Assigned ward nurse & TL Co-ordination b/w TL and Duty doctor In house transfer summary sheet complete (doctors part) In house transfer summary sheet complete (nurses part) Patient progress explained by ICU-nurse to ward nurse verbally ICU-transfer book complete Patient first seen by duty doctor/consultant team (delays)

% Present 50 93

% Absent 50 7

86 86 64 64 57

14 14 36 36 43

21

79

100

93 64

7 36

FINDINGS FOR SECOND PHASE: I. The second phase of the study involved the discussions with the concerned departments and designing of the interventions. II. III. The designed interventions were circulated to the various concerned departments. Implementation of the interventions for the concerns by the nursing supervisors of ICU-2,ICU6,ICU-7,1st floor, 3rd floor & 4th floor and the researcher. IV. The concerns were addressed as follows:

Training of nursing staff (wards) by nursing supervisor to escalate the call, in case interpreter is not available.

Unavailability of interpreter

Orientation of TL by Nursing supervisors about the planned step down intimation mails sent a day prior. ICU-supervisors informed about circulation of information (mail) to Nightingale ward (1st floor) about the planned stepdowns a day prior to transfer. Teamleaders oriented about nursing roasters to be made a day prior for planned step downs and team leaders to be In-efficient management more pro-active in assigning causing delay's duties.

in transfer process).

Training of nurses in order to improve flow of information from assigned nurse to team leader (ward). Orientation of Team leaders by nursing supervisor to be accountable for informing duty doctor about arrival of patient to ward.

Delays in rounds by duty doctors and consultants

Incomplete "In house transfer summary sheet E

ICU-nursing staff trainedhow to fill the in transfer summary sheet by Nursing- educator.

Training and orientation for doctors - completing form details.

FINDINGS OF THE THIRD PHASE: I. The third phase of the study was done to review the effects of the interventions implemented to improve the compliance rate. II. The data collection in the third phase involved the shadowing of patients and documentation of the various parameters for their compliance.

% COMPLIANCE OF THE VARIOUS PARAMETERS (POST-INTERVENTION)

Parameters Written orders from consultant & critical care team Room availability (Delays) Co-ordination b/w ICU-supervisor & ward TL Co-ordination b/w Assigned ward nurse & TL Co-ordination b/w TL and Duty doctor In house transfer summary sheet complete (doctors part) In house transfer summary sheet complete (nurses part) Patient progress explained by ICU-nurse to ward nurse verbally ICU-transfer book complete Patient first seen by duty doctor/consultant team (delays)

% Present 100

% Absent 0

93 93 60 80 80

7 7 40 20 20

67

33

100

100 87

0 13

CHAPTER 7.0 CONCLUSION

The study showed that there is an established process flow for the transfer of patients from ICU to wards to smoothen the transfers. Whereas, some concerns were identified in the process by the observer. The retrospective study of the Unplanned Returns to ICU Within 48 hours showed a trend where in the 2 months i.e. May & June the returns to ICU remained same with 3 cases. Whereas, in the month of July the number of unplanned returns to ICU dropped down to 1 case. The transfer process from ICU to Wards in the Phase-1 of the study included the data collection of pre-interventional phase in order to check for the compliance in the process. After the compliance rate was calculated and the concerns associated with the process were documented. The second phase of the study included the Designing of interventions for the concerns associated with the transfer process and implementation of the designed interventions by the nursing supervisor. The concerns were addressed by the observer to nursing supervisor. The compliance results against various parameters were circulated to the ICU-2 incharge, ICU-6-incharge, ICU-7-incharge, nursing supervisors of 1st, 3rd & 4th floor. The third phase of the study was done to check the effectiveness of the interventions taken in the second phase of the study. In this phase the various parameters of the transfer process were checked for its compliance rate.

The comparison of the results of pre-intervention and post-intervention showed that the interventional programme played an effective role where it shows a marked improvement in the compliance rate of every parameter under the study. Therefore, contributing to streamline the transfer process from ICU to wards. The effectiveness of the interventions contributed to the reduction in the Unplanned returns to ICU Within 48 hours, which was reduced to 1case in the month of July to 3 cases in the month of MAY & JUNE.

CHAPTER 8.0 LIMITATIONS

Sample size was small. ICU-1 & ICU-9 were not involved in the study. There was a time-constraint. Indirect involvement of observer in the interventional programme.

Suggestion:
The study can be isolated to the specific ICUs as Medical, Surgical and CTVS as than results can be compared for any difference in the outcomes in the work flow with more accuracy as needs vary among all the ICUs.

REFERENCES

1. A framework for the intensive care unit liaison nurse in Victorian health services. (Victorian Government Department of Health, Melbourne, Victoria.) 2. Readmission to a surgical intensive care unit: incidence, outcome and risk factors. (Axel Kaben1, Fabiano Corra1, Konrad Reinhart1, Utz Settmacher2, Jan Gummert3, Rolf Kalff4 and Yasser Sakr1)(2008). 3. Transition of patient from the intensive care unit to the ward environment. A ward nursing perspective (Appelles ohanga)(2009). 4. Struggle with a gap between intensive care units and general wards. (MARIE HAGGSTROM PhD student, KENNETH ASPLUND Professor &LISBETH KRISTIANSEN PhD)(2009). 5. Providing continuity of care for patients transferred from ICU. (Susan Haines, BSc (Hons), RN.)(2001). 6. Re-admission to intensive care : a review of literature. (Malcolm Elliott . RN BN MN)(2006). 7. A clinical nurse specialist intervention to facilitate safe transfer from ICU. (St-Louis L, Brault D.)(2011). 8. Reconsidering the transfer of patients from the intensive care unit to the ward: a case study approach. ( Wu CJ, Coyer F.)(2007). 9. 106: Reducing ICU admissions. (Grottenthaler, Cheri; Reese, Carroll)(2012). 10. 800: Designing An Effective Intensive Care Unit Discharge Process Towards Reducing Unexpected Readmissions; Qualitative Methodologies That Elucidate Quality Gaps (Ofoma, Uchenna; Dong, Yue; Gajic, Ognjen; Pickering, Brian; Joseph, Christopher)(2012).