ITU Discharge Audit

Mark Smithies – Consultant Shabana Anwar – Advanced Trainee

Brian Johnston – AFP1 May 2013

Introduction

• Increased morbidity and mortality

• Complex process

• Exchange of information

• Foundation doctors role

To audit patient discharge from the Intensive Care Unit for compliance with National Institute for Health and Clinical

Excellence (NICE) CG50 guidelines: ‘Acutely ill patients in hospital: recognition of and response to acute illness of adults in hospital.’

CG50 – Critical care guidelines

Methodology

• 40 patients in audit

• Duration: 8 weeks

• February and March

• Survey of foundation doctors via eportfolio

Audit criterion One: Consultant to consultant referral For those patients admitted to a critical care area, the percentage of patients for whom there is evidence that the decision to admit was made by both the consultant caring for the patient on the ward and the consultant in critical care

YES NO

n (%) 37 (93%) 3 (7%)

Audit criterion two: Out of hours discharge

Transfer of patients from critical care areas to general wards: For those patients transferred from a critical care area back to a general ward, the percentage for whom this transfer occurred between 22.00 and 07.00.

YES NO NR

n (%) 4 (10%) 34 (85%) 2 (5%)

Audit criterion three: Formal verbal handover

Care on the general ward following transfer

Percentage of patients for whom there is a formal structured handover of care from critical care area staff to ward staff (including both medical and nursing staff), supported by a written plan.

YES NO

n (%) 29 (73%) 11 (22%)

Audit criterion four: Written management plan

Care on the general ward following transfer

Percentage of patients for whom there is a formal structured handover of care from critical care area staff to ward staff (including both medical and nursing staff), supported by a written plan.

YES NO

n (%) 27 (68%) 13 (32%)Are the discharge summaries easily accessible in the patients notes?

Do you find the discharge summaries useful?

Audit criterion 5

Care on the general ward following transfer Summary of the critical care stay, including diagnosis and treatment, monitoring and investigation plan

Agreed limitations of treatment

Physical and rehabilitation needs

Psychological and emotional needs

Specific communication or language needs.

Foundation year comments

A summary of relevant history and the admission, but particularly the specific needs which warranted ITU admission; how they have responded on the unit, and a plan for what to do if those problems recur and most specifically whether they are a candidate for re-admission to ITU

Levels of re-escalation (if applicable) + any discussions with family surrounding these +

DNACPR views/status.

When I've been handed over patients often important information has been missed out - its literally just "just to let you know they're being discharged"

These patients arriving on the ward from ITU tend to need more care than those on the ward for the first few days as the general ward staff ask more questions about their care and they are more concerned about small changes in obs etc even if still within normal limits

Improving handover process

• SBAR

• Generic Letters and Clinical Portal

• Quality control

• Conversion to ward documentation prior to discharge