Tools, Tips and Strategies for the Team

More patients are surviving acute, severe illness or injury because of increased technology and improvements in overall patient management. The clinical management of the critically ill is the priority, but the primary objective of care is to stabilize the patient and transition from the intensive care unit (ICU) to the next level of care, which may include a direct transfer to a post-acute provider or transfer to multiple units in the hospital.

The fragmentation affiliated with the movement of the critically ill through the continuum, the risk of complications, and complex care needs make transition management an extremely important part of the patient‘s treatment plan. Proactive discharge planning is often overlooked in the ICU, but is a major component of transition management. Discharge planning improves outcomes for patients, reduces costs, and decreases the length of stay. This article focuses on steps for effective discharge planning that moves the patient to the next level safely and efficiently.

Benefits of Clean Transitions

Discharge planning for critical care patients is challenging because their hospital course is unpredictable, post-acute care requires complex and expensive resources, and in many cases the clinical outcome, discharge date, and needs are not determined until later in the admission. Proactive discharge planning is essential for decreasing length of stay through early identification of post-hospital needs, for better resource utilization, for improving family and patient satisfaction, and for providing appropriate continuity of care. The best practice for successfully moving a critically ill patient throughout the continuum of care is management by a consistent multidisciplinary team led by a nurse case manager and social worker that develops and monitors effective transitional care strategies that meet the patient’s complex needs. Compromised transitions may lead to complications, adverse events, readmission to ICU, increased mortality rates, and increased costs.

Many post-acute care providers, such as long-term acute care units (LTACs), ventilator-weaning units and specialty rehabilitation units, can provide the necessary complex care once the patient is stable enough to leave ICU and are able to accept patients without a transfer to the floor. The discharge planning process is usually the same regardless or whether or not the patient leaves the hospital upon transfer from the ICU or after an extended stay on an inpatient unit. If the patient leaves early in the stay, the plan is implemented sooner. Early discharge may decrease fragmentation, because the ICU team who is familiar with the patient and has managed the care completes the discharge plan, rather than a secondary post-ICU team assuming the implementation of the discharge plan.

There are several barriers to discharge planning for the ICU patient, especially when early, direct transfer to a post-acute provider is the plan, because of family stressors, physician beliefs, patient acuity, financial constraints, and lack of appropriate post-acute care providers. Family members are often overwhelmed by the stress of an ICU admission and the unpredictable hospital course that may include multiple readmissions to the ICU. They may not be familiar with early discharges to post-acute care facilities and may be reluctant for the patient to leave the security of the hospital. Physicians may not agree with early transfers because they want to continue to manage the patient, they may fear not being appropriately notified of changes in patient status post-discharge, or because of negative experiences with a specific provider, concerns about readmissions or even fear of financial losses.

Funding resources may provide limited benefits, may be lost after a prolonged inpatient stay, or the patient may lack medical insurance. The number of post-acute care providers that provide services to complex patients may be limited, located a distance from the patient’s home, or may require expensive transportation due to distant location. Most ICU patients will require post-hospitalization placement or homecare services, thus proactive discharge planning that begins in the critical care unit will need to be implemented for a smooth transition to the next level of care.

Rorden and Taff’s (1990) definition of discharge planning begins with early assessment of anticipated patient needs; includes concerns for the patient’s total well-being; involves patient, family and caregivers in dynamic, interactive communication; places a priority on collaboration and coordination among healthcare professionals; results in mutually agreed upon decisions about the economic and clinical options for continuing care; and is based on thorough, up-to-date knowledge of available continuing care resources. It is a dynamic process that involves a variety of specific skills and requires all members of the healthcare team to work together in a coordinated method to achieve mutually agreed upon goals, and ultimately, continuity of care.