16 CRITICALCARENURSE Vol 25, No. 3, JUNE 2005 Wendy Chaboyer is a professor and the director of the Research Centre for Clinical Practice Innovation, Griffith University, Gold Coast, Australia. She is the past chair of the research advisory panel of the Australian College of Critical Care Nurses and a member of the editorial boards of the journals Australian Critical Care, Intensive and Critical Care Nursing, Nursing in Critical Care, and the Scandinavian Journal of Caring Sciences. Heather James is an associate lecturer, School of Nursing, Griffith University. She is currently completing a doctoral thesis on continuity of care for intensive care unit patients. Melissa Kendall is a research assistant in the Research Centre for Clinical Practice Innovation, Griffith University. She is also the research officer, Transitional Rehabilita- tion Program, Queensland Spinal Cord Injury Service, Brisbane, Australia. She is currently completing a doctoral thesis on rehabilitation psychology. T ransition is a “process or period in which something under- goes a change and passes from one state, stage, form, or activity to another.” 1 Ideally, healthcare transi- tions encompass safe and efficient movements of patients between dif- ferent sectors or levels of care within the healthcare system 2 and appear to be fundamental in achieving ben- eficial outcomes for patients. 3 Criti- cally ill patients in the intensive care unit (ICU) often experience multiple transitions as they move through different levels of care. The transfer of ICU patients to intermediate care units and subsequent ongoing pro- vision of care are a daily occurrence in acute care hospitals. In this article, we define ICU transitional care 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 continuity of care for the patient. This care may be provided by ICU nurses, acute care nurses, physicians, and other healthcare professionals. Compromised transitional care for ICU patients may result in compli- cations, including adverse events, 4-6 readmission to the ICU, 7,8 and increased rates of mortality. 5,7,9 The Transitional Care After the Intensive Care Unit Current Trends and Future Directions CoverArticle Authors * This article has been designated for CE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives: 1. Identify issues related to intensive care unit (ICU) transitional care 2. Describe the interventions to alleviate patient and family anxiety associated with transfer from the ICU 3. Discuss the role of the ICU liaison or discharge nurse Wendy Chaboyer, RN, PhD Heather James, RN, MN Melissa Kendall, BSc, Grad Dip Psych, MHumSrv To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809- 2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, [email protected]. CE Continuing Education by AACN on April 12, 2019 http://ccn.aacnjournals.org/ Downloaded from
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16 CRITICALCARENURSE Vol 25, No. 3, JUNE 2005
Wendy Chaboyer is a professor and the director of the Research Centre for Clinical Practice Innovation, Griffith University, Gold Coast, Australia. She is the past chair of theresearch advisory panel of the Australian College of Critical Care Nurses and a member ofthe editorial boards of the journals Australian Critical Care, Intensive and Critical CareNursing, Nursing in Critical Care, and the Scandinavian Journal of Caring Sciences.
Heather James is an associate lecturer, School of Nursing, Griffith University. She is currently completing a doctoral thesis on continuity of care for intensive care unit patients.
Melissa Kendall is a research assistant in the Research Centre for Clinical PracticeInnovation, Griffith University. She is also the research officer, Transitional Rehabilita-tion Program, Queensland Spinal Cord Injury Service, Brisbane, Australia. She is currently completing a doctoral thesis on rehabilitation psychology.
Transition is a “process orperiod in which something under-goes a change and passes from onestate, stage, form, or activity toanother.”1 Ideally, healthcare transi-tions encompass safe and efficientmovements of patients between dif-ferent sectors or levels of care withinthe healthcare system2 and appearto be fundamental in achieving ben-eficial outcomes for patients.3 Criti-cally ill patients in the intensive careunit (ICU) often experience multipletransitions as they move throughdifferent levels of care. The transferof ICU patients to intermediate careunits and subsequent ongoing pro-vision of care are a daily occurrencein acute care hospitals.
In this article, we define ICUtransitional care as care providedbefore, during, and after the transferof an ICU patient to another careunit that aims to ensure minimal
disruption and optimal continuityof care for the patient. This care maybe provided by ICU nurses, acutecare nurses, physicians, and otherhealthcare professionals.
Compromised transitional carefor ICU patients may result in compli-cations, including adverse events,4-6
readmission to the ICU,7,8 andincreased rates of mortality.5,7,9 The
Transitional CareAfter the IntensiveCare UnitCurrent Trends andFuture Directions
CoverArticle
Authors
* This article has been designated for CE credit.A closed-book, multiple-choice examinationfollows this article, which tests your knowledgeof the following objectives:
1. Identify issues related to intensive care unit (ICU) transitional care
2. Describe the interventions to alleviate patient and family anxiety associated with transfer from the ICU
3. Discuss the role of the ICU liaison or discharge nurse
knowledge gained by studying ICUpatients, who experience a numberof transitions, will provide insightand understanding of the processthese patients undergo and facili-tate improved clinical practicesthat may be applicable to othergroups of patients. In this article,we review current literature on tran-sitional care for ICU patients, with afocus on contemporary challenges,problematic clinical practices, andfuture research directions. Most ofthe literature on this topic reflectsthe experiences of ICUs located inthe United States, the United King-dom, and Australia.
Theoretical Perspectives on Transitions
The development of transitiontheories has been a focus of nursingand other disciplines. Althoughmanagement models tend to equatetransition with change, nursing the-ory offers broader perspectives forthe conceptualization of transition.For example, in describing thestrategies that organizations use toeffect change, McCarthy10 suggestedthat “transitional activities” aremerely strategies for change andthat in order to effectively ensurethat transition occurs smoothly, atransitional plan must be developed.This plan should be a “clear and tan-gible roadmap for change.”10(p5)
According to Meleis et al,11 how-ever, the essential properties of atransition include awareness, engage-ment, change and difference, timespan, and critical points and events.This conceptualization is clearlymuch broader than definitions oftransition as change alone. Previously,Schumacher and Meleis12 conducteda concept analysis and concluded
The physical and psychologicaleffects of the ICU experience con-tinue to affect many patients afterdischarge from the ICU.5,18 Many ofthe detrimental effects of the ICUare related to 3 factors: the nature ofcritical illness,4,19 the technologicalICU environment,19-21 and the modeof care in the ICU.22,23
Patients and their families mayexperience extreme anxiety as thepatients are prepared for transfer toother areas of the healthcare sys-tem.24,25 The ICU environment is syn-onymous with critical illness andlife-threatening events and naturallyevokes strong emotional reactions.Initially, patients and their familiesmay be overpowered and intimidatedby the pervasive nature of the ICU.Conversely, this same invasive, tech-nical environment often creates pos-itive feelings of reassurance, safety,and security.26,27 Patients and theirfamilies are reassured by the pres-ence of the complex technology and,most importantly, by the constantmonitoring and care provided bythe ICU staff.27 These 2 factors maycreate marked emotional problemsduring the first important transitioninto the intermediate care unit,
where patients and their familiesare separated from this security.
Although numerous practiceproblems exist in intermediate careunits during transitional care, insome instances, ICU patients aretransferred out of the ICU almost as
that transitions are processes thatoccur over time and that involvechange in identity, role, relationships,abilities, and behaviors.
These conceptualizations buildon the original definitions offeredby Chick and Meleis,13 who definedtransition as a passage or movementfrom one state, condition, or placeto another. Although a variety ofother theories may provide insightinto ICU transitions, the research11-13
of Meleis and colleagues appears tohave direct applicability to the tran-sitions faced by ICU patients.
Transition to an Intermediate Care Unit
Admission to an ICU is often abrief but extremely notable hospitalexperience for critically ill patients.Their stay in the ICU may have bothshort- and long-term effects on theiroverall recovery.14-17 These patientsmake several healthcare transitionswithin the healthcare setting duringtheir recovery. Two transitions thatmay have a marked impact are themoves from the ICU to an interme-diate care unit and then home. How-ever, like other hospital patients, ICUpatients may be transferred to other
hospitals, rehabilitation facilities,and nursing homes, all of whichrequire a time of transitional care.Each transition represents uniquechallenges for patients, their familymembers, and the healthcare profes-sionals involved in the patients’ care.
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The physical and psychological effects ofthe ICU experience continues to affect manypatients after discharge from the ICU.
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precipitously as they were admitted.Critical care beds are a finite resource,and the decision to transfer a patientto an intermediate care unit may bebased on which patient is nearest tobeing fit for transfer, and not neces-sarily at the optimal time for thatparticular patient.25,28-31 The effect ofan abrupt transition from the ICU iscompounded by the fact that staff inthe intermediate care unit may nothave the knowledge,25,30,32,33 theadvanced clinical skills,33 or thestaffing ratios30 necessary to providecomplex care for the transferredpatients. Goldfrad and Rowan31
suggest that the increasing trend totransfer ICU patients “after hours,”when staffing levels are reduced andthe number of experienced staff onduty is limited, further confoundseffective transitional care. Commu-nication breakdowns, lack of com-prehensive discharge planning, andrushed transfer processes furthercomplicate this first transition.34
Once transferred to an interme-diate care unit, ICU patients may bethe sickest patients on the new unitand may need close observation andconstant nursing care.33 Somepatients experience physical impair-ments, such as muscle weakness andneuropathies, and difficulties in eat-ing, swallowing, chewing, coughing,moving the upper extremities, toilet-ing, and mobilizing.35 Once in anintermediate care unit, patients mayexperience anxiety, panic attacks,and, in some instances, signs andsymptoms of acute posttraumaticdistress disorder.36-38 Patients mayalso withdraw emotionally or haveindications of depression, paranoia,and confusion.37 The patient-to-nurse ratio of the intermediate careunit does not always accommodate
the complex emotional and physicalneeds of these patients.39 Conse-quently, the patients may take muchlonger to achieve the goal of self-care status in this setting, furthercomplicating this initial transitionand affecting the next major transi-tion to home.
Some of the difficulties associatedwith transition into an intermediatecare unit are related to unrealisticexpectations of patients and patients’families. In many instances, both thepatient and the patient’s family areinadequately prepared for the markedreduction in staffing ratios.4,6,25,39 Thus,patients and their families may feelabandoned and insecure in the inter-mediate care unit, lacking confidencein both the medical and the nursingstaff.4,6,25,33,34 This apprehension andinsecurity most likely is heightenedfor patients who have been long-termadmissions to the ICU.
A study by Whittaker and Ball34
of nurses in 2 intermediate care unitsconfirmed that transitional care wasmarkedly compromised by the unre-alistic expectations of patients andpatients’ families. However, otherinfluencing factors have been identi-fied, including poor communicationwith a lack of clarity and uncoordi-nated hand-over processes,4 latenotification that a patient is beingtransferred and consequently aninadequate lead in preparation timein the intermediate care unit,6 andinsufficient resources in the newunit.4,6,34 This lack of liaison and com-munication between the ICU andintermediate care units has beenhighlighted as a major gap in thetransition process.34 Thus, in additionto the complex physical care ICUpatients may need in the intermedi-ate care unit and their potentially
unrealistic expectations for care, poorcommunication is another deterrentfor smooth transitional care.
Transition to HomeThe second major transition,
from the intermediate care unit tohome, may be as emotionally trau-matic as the transition from the ICUto the intermediate care unit.40 Themost important factor in this transi-tion may be the responsibility ofproviding care without the support,supervision, and assistance of thehealthcare system or friends and fam-ily.41 Many families take full responsi-bility for caring for former ICUpatients in the home environment.40,42
These families may feel unpreparedphysically or psychologically to copewith this major transition and conse-quently may experience apprehensionand anxiety. Conversely, overprotec-tive actions by family members mayfrustrate former ICU patients.36 Con-flicts between relatives and break-downs in relationships are commonduring this transitional phase ofrecovery.36,43,44
In many instances, patients andtheir families have just cause to strug-gle with convalescence in the homesetting. Many patients experience arange of ongoing physical and psy-chological problems that make thetransition to home particularly diffi-cult,15-17,45 and these problems maypersist for long periods. Althoughthese ongoing difficulties associatedwith physical and psychosocial recov-ery from critical illness occur irre-spective of the level of transitionalcare provided, the degree to which apatient has been educated, informed,and supported during transition andthe degree to which assistance wasprovided during that time are criti-
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cal to successful coping. In a studyby Jones and Griffiths,46 at an outpa-tient follow-up 8 weeks after dischargefrom the ICU, many patients weresurprised by how long it had taken toget back to normal. Patients reportedthat their mobility was restricted,especially in outdoor environments,where 44% could not manage steps.Furthermore, the patients oftenneeded physical aids such as walkingsticks and wheelchairs, and the needfor these aids was related to the lengthof time they spent in the ICU.
In another study,17 patients’ nor-mal daily activities were affected evena year after discharge from the ICU,and patients’ level of pain was higherand their overall health status waslower than population norms forpatients with chronic diseases. Arecent systematic review16 of out-come measures used in ICUs high-lighted the range of physical andpsychosocial consequences relevantto ICU survivors. Table 1 is a sum-mary of the range of physical and
nightmares and hallucinations longafter they have been discharged tohome. Table 2 lists other psychologi-cal disturbances that may occur.
Despite the wide range of diffi-culties that occur during transition,the degree to which these difficultiesrepresent a normal recovery remains
Jones36 sug-gests that at 2months, psycho-logically,patients feel theneed to reviewtheir time in theICU becausethey often donot rememberor appreciatethe graveness oftheir episode ofillness. They areoften frustrated with their slowrecovery, are irritable anddepressed, and may have a sense ofhopelessness. Jones36 further assertsthat although many patients reporthaving little memory of their ICUexperience, they also experienceongoing sleep disturbances such as
unclear. Indeed, not all patientsexperience difficulties in transition,and for some, the experience maybe a positive one, providing tangibleevidence of recovery and improve-ment.18,25 Therefore, although diffi-culties faced during healthcaretransition may be a common experi-ence, the experience is by no meansa universal one.
Furthermore, the contribution oftransitional care to the experience ofthese difficulties remains unclear.Empirical comparisons of outcomesacross populations that differ intransitional care are lacking. Regard-less of the underlying causes of theseexperiences, however, the difficultiesexperienced during transition maypose significant challenges topatients and their families. Health-care providers must strive toimprove the quality of services pro-vided to patients and improve theoverall healthcare experience foreach patient.
Shifting FocusThe accumulation of evidence
clearly indicates that difficultiesassociated with transitions for ICUpatients may have marked short- andlong-term implications. This situationmay be exacerbated when transitionalcare is inadequate or inappropriate.It is therefore imperative to identifythose patients most at risk for diffi-culties during transition and todevelop more effective transitionalcare strategies in the ICU context.25
In other healthcare contexts, coordi-nated systems of transitional care,such as formal discharge planning,have been associated with improvedoutcomes for patients,57,58 reducedcosts,59,60 and decreased duration ofhospital stay.2,58,61,62 The majority of
these systems have been designed toaddress discharge difficulties similarto those identified in ICU patients.The benefit of adapting this clinicalknowledge to the ICU environmentis obvious. Conversely, the specificknowledge gained through ICUpatients’ multiple transitions mayprovide more detailed insight andunderstanding for more generalizedclinical application.
Despite the existence of transi-tional care models2,4,57-62 and the inte-gral nature of discharge planning inother contexts, specific transitionalcare practices in ICUs are the excep-tion rather than the norm.3,8,63 Severalreasons have been suggested for thislack of implementation. Coakley etal39 found, through a series of casestudies, that ICU staff often lackawareness about the needs and out-comes of their patients after discharge,and White44 reported that ICU nursesrarely receive detailed feedback onpatients’ outcomes after the patients’discharge from the ICU. This lack ofinformative feedback and limitedunderstanding of patients’ needsafter discharge further hamper thedevelopment of effective dischargeplanning. The lack of policy standardsand staff education for dischargeplanning is evident.3,63,64 Consequently,ICU discharge planning may be rela-tively fragmented and informal.64
Current Strategies for ICU Transitional Care
A range of clinical interventionshave been implemented to reducethe impact and potential complica-tions associated with transitionalcare for ICU patients. In essence, 4major interventions or “changestrategies” have emerged in transi-tional care after the ICU. These are
changes in ICU practice in dischargeplanning, the use of ICU liaison ordischarge nurses, step-down orhigh-dependency units, and outpa-tient follow-up clinics. The firststrategy is an initiative to improvedischarge planning practices andpatients’ preparation for dischargefrom the ICU. The next 2 strategiesare primarily targeted at the transi-tion from the ICU to the intermedi-ate care unit, and the fourth is morespecifically targeted at the transitionfrom hospital to community.
Discharge Planning in the ICUIncreasing awareness of the
transitional difficulties faced byICU patients has resulted in practicechanges within the ICU beforepatients are discharged from theunit.8,25,33,34,43,44,65 These changes haveprimarily centered on improved dis-charge planning practices and thepreparation of patients for the tran-sition to an intermediate care unit.Specific strategies have includededucation and in-service training onpatients’ needs after discharge,44 theintroduction of information book-lets,65 earlier weaning from bothspecialized ICU equipment66 andone-to-one nursing care,6,67 dischargeplanning that begins at the time ofadmission with appropriate careplans,66 and structured protocols foreducating patients.66-68
In a review of ICU-based inter-ventions to alleviate anxiety associ-ated with transfer from the ICU inpatients and their families, Leith24
outlined interventions such as pre-senting the ICU as temporary, inform-ing patients and their families oftransfer plans in advance, involvingpatients’ families in planning fortransfer, planning for daytime trans-
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fer, promoting transfer as a sign ofprogress, encouraging patients toask questions, encouraging patients’autonomy, and keeping patients up-to-date on their medical progress.Many of these practices have beenwidely adopted within ICUs eventhough evidence of their effectivenessis largely anecdotal. Their continueduse may be justified on the basis ofthese anecdotal reports and on thebasis that the practices are unlikelyto do any harm and are relatively cost-effective. However, an evidence basefor their use is essential and shouldbe a focus for future research studies.
ICU Liaison or Discharge NursesThe development of a specialist
role, that of an ICU discharge or liaison nurse, has been forminggradually during the past severalyears.4,33,69,70 A primary role of an ICUliaison nurse is to provide practicaland emotional support for patientsand their families during patients’
transition to an intermediate careunit.33 A secondary role typicallyincludes providing clinical supportand resources to staff in the interme-diate care unit who manage the careof patients transferred from the ICU.69
Use of an ICU liaison or dis-charge nurse generally requires inte-grating the services of a singlequalified ICU nurse and supportservices from the ICU medical con-
of the role is a focus on a preventiverather than a remedial approach totransitional care. In this instance,use of ICU liaison nurses may ensurecontinuity of care within the health-care system.39 Because continuity ofcare is one of the most frequentlycited difficulties experienced by ICUpatients,8,14,24,25,63 the potential advan-tages of having a single person followup with patients through to dischargehome are obvious.
The most important reasons forthe lack of widespread acceptanceand use of ICU liaison nurses arerelated to the incomplete body ofevidence supporting the effectivenessof these specialists and the focus oncost containment, particularly in theshort-term. Evaluations of the role ofICU liaison or discharge nurses havebeen limited to date and largelydescriptive, citing the frequency ofspecific services provided, the occur-rence of adverse outcomes, and sat-isfaction surveys.33,69,70 Perhaps thestrongest evidence for the role wasoutlined by Russell,33 who foundthat the introduction of an ICU liai-son nurse decreased readmissionsby 8.5% and decreased the severityof illness in the patients who werereadmitted.
The cost of using ICU liaison ordischarge nurses has received littleattention. In addition, because ofthe broader healthcare focus oncontaining costs, particularly thoserelated to staffing,71,72 acceptance ofthese specialists may be perceived asrisky for administrators, especiallybecause of the limited evidence forthe overall cost of using such special-ists as well as the cost-effectiveness ofdoing so. Broader evaluations of theuse of ICU liaison or discharge nursesin multiple sites are needed.
sultants. Carr30 suggests that the liai-son nurse who visits the intermedi-ate care unit should have ICUexperience; compared with nurseswith no ICU experience, nurses whohave cared for patients in the ICUmay better understand the experi-ences of patients and patients’ fami-lies of being in the ICU and thereactions to being transferred to anintermediate care unit. The scope ofpractice, qualifications, and jobtitles of these specialist nurses haveyet to be standardized, althoughdescriptions provided by Russell33
are an important contribution todefining the role of ICU liaisonnurses.
To be effective, ICU liaison nursesmust develop their roles in collabo-ration with the intermediate careunit staff. Staff members in the inter-mediate care unit must not feel threat-ened by this specialty role, but ratherperceive it as a collaborative ventureto improve care for patients and
patients’ families. ICU liaison nursesmust be able to train and supportstaff in the intermediate care unit indeveloping critical care skills relevantfor transferred patients and empowerthe staff members to manage transi-tional care with confidence andcompetence.69,70
The major advantages of using anICU liaison nurse are practical andeconomic, because the major thrust
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termed high-dependency units, playan important role in bridging thegap between the level of supportavailable in the ICU and that avail-able in an intermediate care unit.73,74
Although their primary purpose wasnot to provide transitional care anddischarge planning for ICU patients,step-down units do, to some degree,address some of the transitionalissues experienced by patients andpatients’ families on discharge fromthe ICU and may be used more exten-sively than ICU liaison or dischargenurses in some countries.75,76 Althoughstaffing patterns vary widely inter-nationally and patients’ acuity andillness severity mediate nurses’ work-loads, step-down units typically pro-vide an intermediate level of care; inAustralia, the ratio of registered nursesto patients is slightly less than the 1:1ratio often provided in ICUs buthigher than the ratio typically asso-ciated with intermediate care units.73
Step-down units may be staffed byregistered nurses with past ICUexperience77 but may also be staffedby nurses without ICU experiencewho may be interested in nursingpatients who have more complexcare needs than patients in a inter-mediate care unit do.
Although use of step-down unitscan reduce the rate of unplannedreadmission to an ICU,75,78,79 the pri-mary function of these units appearsto be related to decreasing ICU uti-lization76,78 by allowing ICU patientsto be discharged sooner than waspreviously possible while still pro-viding better nurse-to-patient ratiosthan intermediate care units and ahigher level of critical care expertise.However, in a review of step-down
units, Keenan et al80 questioned theevidence for the cost-effectiveness ofthe units, suggesting that more rig-orous trials are required. Althoughevaluation of step-down units hasbeen reported,75,78,81 the researcherstypically focused on physical andmedical outcomes, with some evalu-ation of economic impact.80 Thisapproach does not encompass thescope of patients’ potential transi-tional difficulties and the impact ofstep-down units on everyone involvedin transitional care.
Outpatient ClinicsAs ICU patients leave the acute
healthcare sector and are dischargedhome, their ongoing health needshave traditionally been ignoredwithin the context of their ICU sta-tus.40,45 Current initiatives for transi-tional care take into account theneed for and importance of follow-upcare for these patients after dischargeto home. Outpatient clinics areanother health service initiative inthe provision of transitional care forICU survivors.45,50, 55,56,82 These clinicsmay be led by either physicians83 ornurses.50,55 Additionally, ICU dischargenurses are involved in some follow-up clinics.55,56 The clinics operate in amanner similar to that of the outpa-tient departments for other specialtydisciplines. The primary objectiveis assessment of the physical, func-tional, and psychosocial changesassociated with recovery from acritical illness after discharge tohome. Staff at follow-up clinics alsoprovide appropriate referral optionsfor patients experiencing ongoingdifficulties.56
Another successful initiative is ahelp-line service that provides accessto specialist healthcare advice for
patients and their families outsidenormal outpatient clinic hours.55
The introduction of this ICU outreachservice indicates a recognition of thespecific and unique difficulties expe-rienced by patients who have beenin an ICU.
Although ICU outpatient follow-up clinics have been evaluated,40,45,82
the evaluations have tended to bedescriptive, centering on the typesof patients who attend, the problemsthat emerge during the visit, and thetreatments provided, including thenumber of referrals to other health-care providers. The cost-effectivenessof follow-up clinics has not beenreported in the literature, and stud-ies in which objective measurementswere used to determine the impactof the clinics on patients’ recoveryare in their infancy. Without rigor-ous analysis to measure end points,the exact benefit of follow-up clinicscannot be determined. In an envi-ronment of tight healthcare fiscalpolicy, empirical evidence mustindicate the overall cost benefit ofthe clinics to patients, patients’ fam-ilies, and the wider community. Fur-thermore, empirical evidence isrequired to support initiatives thatspan the variety of transitions ICUpatients are likely to experience.
Because of the varied purposesof interventions and because differ-ent interventions focus on differenttransitions experienced by ICUpatients, a number of models foroutpatient clinics may emerge. Forexample, the combination of usingan ICU liaison or discharge nurseand a follow-up clinic may be a morecomprehensive and holistic methodof transitional care than either ini-tiative alone. These possibilitiesrequire much greater investigation
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to highlight their potential value toICU patients.
Implications for ICU NursingCumulatively, a growing body
of literature supports the need fortransitional care for ICU patients.Because of their inherent understand-ing of the complex needs of ICUpatients, ICU nursing staff are in anideal position to take steps to improvetransitional care. Although a reviewof the literature highlights the multi-dimensional and multidisciplinarynature of transitional care and thelikelihood that practices and servicesbeyond the realms of ICU nurses areneeded, individual nurses and indi-vidual ICUs can adopt practices thatwould be important contributionsto providing transitional care. Table3 outlines potential avenues for ICUnurses to contribute to the provisionof transitional care. Not all of thesesuggestions can be implemented inthe short-term because of the inade-quate level of resources at the unitlevel. Nevertheless, these suggestions
has prompted researchers to developtransitional care strategies that mayimprove the short- and long-termphysical and psychosocial outcomesfor patients who have been criticallyill. The future in the field of transi-tional care after the ICU lies in pro-moting a shift in the provision ofhospital care and in developing astrong evidence base through rigor-ous research and evaluation. Theknowledge gained from this highlytransitional group of patients mayprovide much deeper understand-ing of the complex issues associatedwith transitional care, which may beadaptable for a broader range ofpatients, in diverse clinical settings.
References1. Encarta World English Dictionary. North
American ed. Bloomsbury Publishing/Microsoft Corp; 2005. Available at: www.dictionary.msn.com. Accessed March 2,2005.
2. Naylor MD. A decade of transitional careresearch with vulnerable adults. J CardiovascNurs. April 2000;14:1-14.
3. Griffiths RD, Jones C. Why is ICU follow-upneeded? In: Griffiths RD, Jones C, eds.Intensive Care Aftercare. Boston, Mass: Butterworth-Heinemann Health; 2002:1-4.
4. Hall-Smith J, Ball C, Coakley J. Follow-upservices and the development of a clinical
may be useful for ICU nurses andICU management to consider inquality improvement initiatives.
ConclusionAlthough many ICU patients
have complex discharge planningneeds, traditionally ICUs have notfocused on this aspect of transitionalcare,14,24,63 with a notable paucity ofresearch in this area. Russell33 sug-gests that the philosophical under-pinnings of intensive care mayaccount for this discrepancy. Thefocus in the ICU is on sustaining lifeduring the episode of critical illnessand not necessarily on the “life afterlife support.”33 As allocation ofhealthcare resources continues totighten, this philosophical stancemust evolve to reflect the fluidity ofcare boundaries. Discharge plan-ning must anticipate care beyondthe walls of the ICU.
The recognition of challenges inthe transitional care of patients aftertheir discharge from the ICU, orfrom any healthcare environment,
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System level
ICU discharge or liaison nurses
ICU follow-up clinics
Use of step-down and intermediate care units
Development of an evidence base and research agendas related totransitional care
Improvement in the resources of intermediate care units
Improvement in staff-to-patient ratios in intermediate care units
Improvement in access to community resources
In-service training for staff of intermediate care units and establishment of standardized transfer teaching programs
Development of protocols or mechanisms for feedback from ICUpatients
Table 3 Transitional care strategies for intensive care units (ICUs) to advocate or implement at the individual and systemlevel
Individual level
Early discharge planning with the development of standardized discharge policies and care plans
Education of patients about discharge, with repetition of informationand promotion of realistic expectations
Steps to encourage patients’ independence, with early weaningfrom equipment and one-to-one nursing care
Steps to ensure direct handover, with appropriate and adequatewritten documentation, of ICU patients to staff in an intermediatecare unit
Daytime discharge with adequate warning to the intermediate careunit
Steps to involve patients’ families in the discharge process and toencourage questions from patients and patients’ family members
Development of written resourcesVisits by ICU personnel to patients in the intermediate care unit
after discharge from the ICUImprovement in knowledge of the resources of intermediate care
units and the communityEfforts to improve reciprocal communication with staff in the
intermediate care unit
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CE Test Test ID C053: Transitional Care After the Intensive Care Unit: Current Trends and Future DirectionsLearning objectives: 1. Identify issues related to intensive care unit (ICU) transitional care 2. Describe the interventions to alleviate patient and familyanxiety associated with transfer from the ICU 3. Discuss the role of the ICU liaison or discharge nurse
Program evaluationYes No
Objective 1 was met ❑ ❑Objective 2 was met ❑ ❑Objective 3 was met ❑ ❑Content was relevant to my
nursing practice ❑ ❑My expectations were met ❑ ❑This method of CE is effective
for this content ❑ ❑The level of difficulty of this test was:
❑ easy ❑ medium ❑ difficultTo complete this program,
it took me hours/minutes.
Test answers: Mark only one box for your answer to each question. You may photocopy this form.
1. Compromised transitional care for intensive care unit (ICU) patients may result in which of the following?a. Delayed healingb. Readmission to the ICUc. Increased morbidityd. Distrust of nursing staff
2. Which of the following is not a detrimental ef fect of the ICU?a. Nature of the critical illnessb. Technological ICU environmentc. Mode of ICU cared. Physical layout of the ICU
3. Patients and their families may feel abandoned and insecure in the intermediate care unit because of which of the following?a. Early transfer from the ICUb. Absence of complex technologyc. Marked reduction in staffing ratiosd. Insufficient resources in the new unit
4. Which of the following is a major gap in the transition process between the ICU and intermediate care units?a. Lack of communicationb. Complex patient needsc. Precipitous transfer from the ICUd. Reduced nurse-patient ratios
5. Which is the most important factor that patients and their families fear in the transition from the intermediate care unit to home?a. Inadequate financial supportb. Family role reversalc. Inability to cope with convalescenced. Increased mortality
6. Which of the following is not a physical or psychosocial limitation that can occur after discharge from the ICU?a. Hair lossb. Weight gainc. Posttraumatic stress disorderd. Reduced confidence
7. Which of the following has been associated with improved outcomes for patients, reduced costs, and decreased length of stay?a. Formal discharge planningb. Early weaning from specialized ICU equipmentc. In-service on patients’ discharge needsd. Structured care protocols
8. Which of the following is not a major intervention in transitional care after the ICU?a. Changes in ICU discharge planning practicesb. Use of ICU liaison or discharge nursesc. Step-down unitsd. Home healthcare visits
9. Which of the following ICU-based interventions may alleviate anxiety associated with transfer from the ICU? a. Advanced notification of transferb. Planning for evening transferc. Families assisting in patient cared. Meeting the intermediate care nurse
10. Which of the following is a primary role of the ICU liaison nurse?a. Coordinate discharge planningb. Provide support for intermediate care unit staffc. Provide support for patients and their familiesd. Communication of transfer needs to intermediate care unit
11. To be effective, ICU liaison nurses must develop their role in collaboration with which of the following members of the healthcare team?a. Intensivistsb. Case managersc. ICU staffd. Intermediate care unit staff
12. One research study found that the introduction of an ICU liaison nursedecreased readmissions by what percentage?a. 5%b. 8.5%c. 12%d. 15.5%
Mail this entire page to:AACN
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Test ID: C053 Form expires: June 1, 2007. Contact hours: 2.0 Fee: $12 Passing score: 9 correct (75%) Category: A Test writer: John P. Harper, RN, MSN, BC
9. ❑a❑b❑c❑d
8. ❑a❑b❑c❑d
7. ❑a❑b❑c❑d
6. ❑a❑b❑c❑d
5. ❑a❑b❑c❑d
4. ❑a❑b❑c❑d
3. ❑a❑b❑c❑d
2. ❑a❑b❑c❑d
1. ❑a❑b❑c❑d
12. ❑a❑b❑c❑d
11. ❑a❑b❑c❑d
10. ❑a❑b❑c❑d
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