Enhancing patient outcomes, hospital flow and resource utilization through timely care transitions in the ICU

Up to 25% of transitions from hospital ICUs are delayed^{1, 2}, and studies have shown that the lack of or late availability of general ward beds (when patients are actually physically stable enough for a transition) causes the majority of discharge delays^{3, 4}. Between 15-25% of ICU patient days are associated with waste⁵. This waste includes the opportunity cost of not being able to admit a new patient, the loss of income from surgery that was delayed due to a lack of beds, the cost of over-diagnosis and over-treatment and the cost of treating extended-stay related complications.

Delays in care transitions from the ICU are not only an economic problem; they may also put patients at risk,^6,7 including risks of medical error, over-treatment and ICU related complications, such as healthcare-associated infections (HAI)⁸ and delirium.⁹

Solving the problem of inefficient ICU care transitions begins with understanding its scope in your institution. To create a baseline against which to assess improvements, my research suggests establishing metrics in three areas: patient flow, resource utilization and patient outcome.

These performance metrics acknowledge that ICU care transitions are highly interwoven with transitions in other departments. For example, if there are delays in discharging patients from the general ward, there may not be beds available for patients ready to leave the ICU. If the ICU is full, surgeries may have to be delayed until an ICU bed is available, and patients presenting to the ED may face ICU admission delay and further physiologic deterioration10. In order to implement any change, all involved stakeholders need to understand the baseline situation and current effects on their performance related to suboptimal care transitions. Therefore, parameters to measure improvement need to be meaningful to the stakeholders of the different departments that would contribute to enhancing patient transitions.

One major contributor to care transition delays is a lack of a standardized discharge readiness evaluation of the patient as well as of the receiving unit. In the absence of objective and clearly defined discharge criteria, transition decisions may be based on a variety of factors: the risk comfort-level of staff, the financial incentive of either keeping patients in higher acuity settings or releasing early, capacity strain and the need to free a bed or the lack of a bed in a lower acuity unit, concern over litigation and even patient preference and available palliative care pathways.

A holistic discharge readiness evaluation should be multi faceted and consider patient, process, provider, organizational and social factors.