Copy of Copy of Summer Training Project - Sushma - Copy - Copy

7/30/2019 Copy of Copy of Summer Training Project - Sushma - Copy - Copy

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Summer Training Project onStreamlining the process of transfer from ICU to wards to

prevent re-admissions to ICUA quality improvement study

InFortis Memorial Research Institute (Gurgaon)

Submitted To Jamia Hamdard UniversityMBA (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


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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 wardsand assurance for prevention of return to ICU within 48 hours A quality improvementstudy. 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 ofDr. 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:


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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.DivyaGautam (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


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CONTENTS

Page No.

Acknowledgement

Declaration

Chapter 1.0 Executive summary 1-2

Chapter 2.0 Introduction &Literature review 3-10

Chapter 3.0 Objectives 11

Chapter 4.0 Research methodology 12-15

Chapter 5.0 Data Analysis 16-34

Chapter 6.0 Study findings 35-38

Chapter 7.0 Conclusion 39-40

Chapter 8.0 Limitations 41-42

References


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CHAPTER 1

EXECUTIVE SUMMARY


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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 & Mottois 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-2The 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.


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CHAPTER 2.0

INTRODUCTION AND REVIEW OF LITERATURE


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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


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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.


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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 toJames 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) ofJorvi 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 issuedto 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 members5. Post ICU visit3


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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


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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 theEvidences thatindicate 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
http://www.ncbi.nlm.nih.gov/pubmed?term=Wu%20CJ%5BAuthor%5D&cauthor=true&cauthor_uid=17300545http://www.ncbi.nlm.nih.gov/pubmed?term=St-Louis%20L%5BAuthor%5D&cauthor=true&cauthor_uid=22016020http://www.ncbi.nlm.nih.gov/pubmed?term=St-Louis%20L%5BAuthor%5D&cauthor=true&cauthor_uid=22016020http://www.ncbi.nlm.nih.gov/pubmed?term=Wu%20CJ%5BAuthor%5D&cauthor=true&cauthor_uid=17300545


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dataset of patients enabled the ability to statistically identify patients who presented as high-

risk due to respiratory-related complications. Patients with a cumulative risk score of 14 or

greater were identified as high-risk patients (p


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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


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OBJECTIVES OF THE STUDY

1. To determine the root causes of unplanned ICU re-admission byemploying Qualitative Method.

2. To Directly observe work flow and transition of care processesacross 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.


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CHAPTER 4.0RESEARCH METHODLOGY


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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.


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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 & Doctorsection.

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.


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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.


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CHAPTER 5.0

DATA ANALYSIS


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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.


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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 patientswho no longer needs ICU care. Transfers is considered when:

a. Patients physiological status has stabilised and the need for ICU monitoringand 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 nolonger 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 thatprovided 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 stableare 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 stablemay be shifted to general wards directly.

5. As far as possible, transfer from ICU should be completed before 7 pm. In case oftransfers 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 theconsultant himself/herself or a member of his/ her team.

2. Parent clinical unit/team is consulted prior to patient transfer and patientsclinical condition (including current and potential problems) is discussed.

3. Medical and nursing transfer summary must be completed by the critical careteam and this must accompany the patient to the receiving ward.


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4. Transfer form/document (see box below) must include clear medicalmanagement 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 thepatients 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 bedocumented along with any special instructions.

2. Care in the ward includes patient management as per the instructions mentionedin the transfer form.

3. Critical care team should be involved in early management of At risk patientsin 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.


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ANALYSIS POINTERS INCLINICAL EXCELLENCE SCORECARD FOR RETURN TO ICU

WITHIN 48 HOURS:

S.NO. ANALYSIS POINTERS ANALYSIS CUE/ TRIGGER CUE

1. Inappropriate step down due to

deviation from the transfer protocol

of ICU.

Refer to transfer criteria of critical care units for Inappropriate

monitoring of patients condition priorto 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

4. Early step down due to patient

financial constraints

Self explanatory

5. Communication gap One or more of the following in the patient file will indicatethe inadequacy in communication:

1. Inappropriate/incomplete inter-departmental transfernotes. Eg. Incomplete physician focus section.

2. Inappropriate intra-departmental handover3. Incomplete/missed documentation by healthcare

service provider.

6. Aggravation of pre-existing patient

risk factors despite a proper treatment

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.

7. Escalation of risk factors associated

with procedure despite a proper

treatment

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.

8. Any other (Please specify) Explanations to be included


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Transfer process from ICU to wards:-

Written orders from consultant team + critical care team

Discussion with Patient/ relatives inRoom 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


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TABLE-1

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

TIME PERIODMAY JUNE JULY(27th)

AREAS ICU-2 ICU-6 ICU-7 ICU-2 ICU-6 ICU-7 ICU-2 ICU-6 ICU-7

Total Number Of Patients

Transferred From ICU

52 49 48 61 53 47 51 46 53

Total number of returns to

ICU within 48 hours

0 1 2 2 0 1 0 1 0

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:

98%

2%

Unplanned Returns to ICU Within 48

hours (May)

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


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No. Of Unplanned Returns To ICU In Month Of June No. Of Unplanned Returns to ICU in Month of July

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

98.14

%

1.86%

Total no. of patients transferred from

ICU's to wardsUnplanned returns to ICU within 48

hours

99.33

%

0.67%

Total no. of patients transferred

from ICU's to wards

Unplanned returns to ICU within 48

hours

98 98.14 99.33

2 1.86 0.670

20

40

60

80

100

120

MAY JUNE JULY

Total no. of patients transferred from ICU's to wards

Unplanned returns to ICU within 48 hours


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Table-2

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

Parameters % Present % Absent

Interpreter required and available (sample size-2) 50 50

Written orders from consultant & critical care

team

93 7

Room availability (Delays) 86 14

Co-ordination b/w ICU-supervisor & ward TL 86 14

Co-ordination b/w Assigned ward nurse & TL 64 36

Co-ordination b/w TL and Duty doctor 64 36

In house transfer summary sheet complete

(doctors part)

57 43


(nurses part)

21 79

Patient progress explained by ICU-nurse to ward

nurse verbally

100 0

ICU-transfer book complete 93 7

Patient first seen by duty doctor/consultant team

(delays)

64 36

Note: The number of patients shadowed during the whole process of transfer from ICU to wards

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

from 10th June to 20th June 2013.


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% Compliance of Transfer process from ICU to Wards

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

-20th

June)

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.

100

93 93

86 86

64 64 64

57

50

21

0

7 7

14 14

36 36 36

43

50

79

0

20

40

60

80

100

120

% Present % Absent


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CONCERNS ASSOCIATED WITH THE TRANSFER PROCESS FROM ICU TO

WARDS

1. Unavailability of Interpreter (international patients), affecting the delivery ofcare 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) asassociated withthe 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 thecommunication gap between the Assigned nurse and team leader regarding thetime of patient transferred to the room and hence contributing to the inco-

ordination between team leader and duty doctor .

5. Delays in the transfer process excluding the delays due to inefficientmanagement 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 assignednurse 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.


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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.

Unplanned returns

to ICU

Communication

Transfer Delays

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

Inefficient Management

Inefficient utilization of GDAs

Incomplete Instructions to GDAs

Casual approach of

Management

Casual approach of GDAs

Physician DelaysDuty Doctor busy in care of other

patients

Communication Gap between Duty

doctor and Team Leader (Nurse)

Communication gap

between assigned

nurse(ward) and Team

LeaderCasual approach of

assigned nurse

Consultant team busy in

OT/OPD/other patients

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

Team Leader

unaware of

planned transfers

information sent a

day before the

transfer.

Lack of

Training

Formulation of roaster

not done for planned

transfers


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S . No. Observations Recommendations Responsibilities

1 Interpreter unavailabilityTraining on whom to esclate the call, in case

interpreter is not available Nursing supervisor.

2

Inefficient use of GDA's(GDA waits till the nurse completes the

handover).

After transporting the patient to ward , GDA shall go

back to ICU

ICU-Nursing supervisor

Casual attitude of GDA to be looked in.

3 Delay in Room availability Delay in discharge process Billing

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

Keeping

4Team Leaders (3rd &4th floor) Unaware about planned

transfers information a day before

TL to infromed and trained about the planned step

down intimation mail.

Nursing supervisors.

5Unavailability of information of planned transfers from ICU to

nightingale ward, prior evening

Circulation of information to Nightingale ward by ICU-

supervisor.

ICU - Nursing Supervisor

6 At time of patient being received in wards- no nurse available totake hand over

Nursing roaster to could be be prepared as per the list

of planned step down from ICU - to assign poper

number of nurses.

Floor TL

Team Leaders to be more proactive in assigning duties

for patient received from ICU

Floor TL

7 Casual approach of nursing staff (ICU &Wards) in completingthe details of transfer form

ICU-nursing staff to be trained- how to fill the in

transfer summary sheet.

Nursing Educator

8Doctor's not completing the transfer form

Training and orientation for doctors - completing form

details

9 Delays in rounds by Duty doctor/Consultant team Flow of information from assigned nurse to ward-teamleader needs to be focussed.

Staff Nurse

Team leaders should be accountable for informing

duty doctor about arrival of patient to ward (team

leader busy).

Team Leaders &

nursing supervisors


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DESIGNING OF INTERVENTIONS

1. The interventions which were required to be taken for the implementation of the corrective actionswere 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 theprotocol 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 1 st, 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.


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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 in-

efficiency & in-appropriate prioritization of the work by the assigned nurse for the patient.


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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 andareas 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 departmentfocusing the deficient areas and the focus areas.

4. Doctors (ICU-incharges) feedback for any changes in the In-house transfer summary sheet andadditions were recommended for the next prints of the In-house transfer summary sheet.

The Recommendations were:

1. Drug details2. Advisory orders by doctors (Critical care team & Consultant team)3. Dietary advisory column for doctors.

INTERVENTIONAL LAYOUT OF THE CONCERNS

E

Training of nursing staff

(wards) by nursing

supervisor to escalate the

call, in case interpreter is

not available.

Unavailabilityof interpreter

In-efficientmanagement

causing delay'sin transferprocess).

Incomplete "Inhouse transfer

summary sheet

Delays in roundsby duty doctorsand consultants

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.

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 step-

downs 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

more pro-active in assigning

duties.

ICU-nursing staff trained-

how to fill the in transfer

summary sheet by

Nursing- educator.

Training and orientation

for doctors - completing

form details.


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Suggestion:

1. Suggestion for Improvement in In-house transfer summary sheet was given by the observer , inorder 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):


Written orders from consultant & critical careteam

100 0





In house transfer summary sheet complete(doctors part)

80 20


(nurses part)

67 33


nurse verbally

100 0

ICU-transfer book complete 100 0Patient first seen by duty doctor/consultant team

(delays)

87 13

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.


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Table-4: Comparison Pre & post intervention:

Parameters % Pre-compliance % post compliance

Written orders from consultant & critical care team 93 100





In house transfer summary sheet complete (doctors part) 57 80

In house transfer summary sheet complete (nurses part) 21 67

Patient progress explained by ICU-nurse to ward nurse verbally 100 100


Patient first seen by duty doctor/consultant team (delays) 64 87

% Compliance pre and post intervention:

100

93 93

8686

64

6464

57

21

100

100

100 93

93

60

80

87

80

67

0

20

40

60

80

100

120

% Compliance Pre- intervention % Compliance Post-intervention

Sample size-14

Sample size-15


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CHAPTER 6.0

STUDY FINDINGS


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FINDINGS OF THE FIRST PHASE:

I. The primary research carried out was for the purpose of extracting the concerns associated withthe transfer process from ICU to wards.

II. The concerns associated were documented & discussed with the concerned departments.III. 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)


Interpreter required and available (sample size-2) 50 50


team

93 7






(doctors part)

57 43


(nurses part)

21 79


nurse verbally

100 0



(delays)

64 36


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FINDINGS FOR SECOND PHASE:

I. The second phase of the study involved the discussions with the concerned departments anddesigning of the interventions.

II. The designed interventions were circulated to the various concerned departments.III. Implementation of the interventions for the concerns by the nursing supervisors of ICU-2,ICU-

6,ICU-7,1st floor, 3rd floor & 4th floor and the researcher.

IV. The concerns were addressed as follows:

E

Training of nursing staff(wards) by nursing

supervisor to escalate thecall, in case interpreter isnot available.

Unavailabilityof interpreter

In-efficientmanagement

causing delay'sin transferprocess).

Incomplete "Inhouse transfer

summary sheet

Delays in roundsby duty doctorsand consultants

Training of nurses in order

to improve flow of

information from assigned

nurse to team leader (ward).

Orientation of Team leadersby nursing supervisor to be

accountable for informing

duty doctor about arrival of

patient to ward.

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 step-downs 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

more pro-active in assigning

duties.

ICU-nursing staff trained-

how to fill the in transfer

summary sheet by

Nursing- educator.

Training and orientationfor doctors - completing

form details.


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FINDINGS OF THE THIRD PHASE:

I. The third phase of the study was done to review the effects of the interventions implemented toimprove the compliance rate.

II. The data collection in the third phase involved the shadowing of patients and documentation of thevarious parameters for their compliance.

% COMPLIANCE OF THE VARIOUS PARAMETERS (POST-INTERVENTION)



team

100 0






(doctors part)

80 20


(nurses part)

67 33


nurse verbally

100 0



(delays)

87 13


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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.


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CHAPTER 8.0

LIMITATIONS


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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 canbe compared for any difference in the outcomes in the work flow with more accuracy as needs varyamong all the ICUs.


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