|HEALTHCARE QUALITY AND SAFETY
|Year : 2015 | Volume
| Issue : 1 | Page : 3-8
Advanced practitioner-driven critical care outreach to reduce intensive care unit readmission mortality
Niels Douglas Martin1, Michael A Pisa2, Tara Ann Collins2, Matthew P Robertson2, Corinna P Sicoutris2, Naveena Bushan2, Jason Saucier2, Amanda Martin2, Patrick M Reilly1, Meghan Lane-Fall3, Benjamin Kohl3
1 Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
2 Department of Advanced Practice, Hospital of the University of Pennsylvania, Philadelphia, USA
3 Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
|Date of Submission||02-Aug-2015|
|Date of Acceptance||23-Oct-2015|
|Date of Web Publication||29-Dec-2015|
Niels Douglas Martin
Medical Office Building Suite 120 (Trauma), 51 North 39th Street, Philadelphia, PA 19104
Source of Support: None, Conflict of Interest: None
Objectives: Intensive care unit (ICU) readmission is associated with poorer outcomes as compared to primary admissions. Recognizing new or recurrent critical care issues on the wards postICU discharge may improve outcomes, especially in those subsequently requiring readmission. Herein, we describe and evaluate a pilot surgical critical care outreach initiative to reduce mortality in patients ultimately requiring ICU readmission.
Methods: Each patient discharged from the ICU was visited within 48 h by a Critical Care Advanced practitioner who examined the patient, reviewed the chart, recent laboratory results, and orders, and then communicated any concerns to the primary service. Patient demographics, outreach issues identified, and severity of issues were recorded prospectively. Retrospectively, patient outcomes were assessed including the need and timing of any ICU readmission and mortality both before and after outreach implementation.
Results: Pre and postoutreach readmission rates were 2.41% (37/1534) versus 3.54% (54/1524), respectively (P = 0.07). Mortality rates before and after outreach were 5.08% (n = 78) versus 5.64% (n = 86) overall (P = 0.052) and 18.9% (n = 7) versus 9.25% (n = 5) for readmissions (P = 0.21), respectively.
Conclusions: Critical care outreach postICU discharge did not decrease readmission mortality in this pilot study. Further studies are required to evaluate its effects on not only readmission mortality but also readmission rates and timing along with the incident of subsequent ICU complications.
The following core competencies are addressed in this article: Patient care, Systems based practice, Communication.
Keywords: Advanced practitioners, critical care outreach, intensive care unit mortality, intensive care unit readmission
|How to cite this article:|
Martin ND, Pisa MA, Collins TA, Robertson MP, Sicoutris CP, Bushan N, Saucier J, Martin A, Reilly PM, Lane-Fall M, Kohl B. Advanced practitioner-driven critical care outreach to reduce intensive care unit readmission mortality. Int J Acad Med 2015;1:3-8
|How to cite this URL:|
Martin ND, Pisa MA, Collins TA, Robertson MP, Sicoutris CP, Bushan N, Saucier J, Martin A, Reilly PM, Lane-Fall M, Kohl B. Advanced practitioner-driven critical care outreach to reduce intensive care unit readmission mortality. Int J Acad Med [serial online] 2015 [cited 2019 Sep 23];1:3-8. Available from: http://www.ijam-web.org/text.asp?2015/1/1/3/172706
| Introduction|| |
The demand for inpatient critical care services has risen steadily over the past decades, even as in-patient hospital volume has decreased, especially in the United States., This has led to the restructuring of hospital beds to increase the availability of intensive care units (ICUs). Synonymously, ICU discharge has also hastened to generate additional capacity. This has imposed higher acuity and complexity on the hospital wards, especially during times of high ICU volume and has been associated with poorer outcomes.,,
In response to the increasing demand for critical care services and rising acuity on hospital wards, there has been growing interest in the development of rapid response teams, critical care consultations, and outreach services to help manage patients beyond the confines of the traditional ICU.,,,, Critical care outreach in different formats has been inconsistently found to be associated with decreased in-hospital complications and mortality.,,,
Metrics for ICU discharge efficacy in terms of patient outcome can be indirectly measured using readmission rates along with readmission outcome (mortality). The goals, therefore, of a critical care outreach program would be to reduce these measures in two ways. First, to preemptively intervene on a recognized issue before it requires ICU admission. Second, to expediently recognize an issue that does require readmission and allow readmission to occur in a way that minimizes its physiologic effect.
The goals of this pilot study were, therefore, to evaluate the efficacy of an outreach program as measured by ICU readmission rates and ICU readmission mortality. We hypothesized that an outreach program would reduce both ICU readmissions and ICU readmission mortality.
| Methods|| |
This study was performed retrospectively using data from a prospectively entered performance improvement database maintained for our surgical ICU (SICU) population. This study was performed with the approval of our institutional review board. The setting is a 24-bed SICU at an urban, academic medical center.
Outreach began in August 2011. The preoutreach data were collected from December 2010 to July 2011 (7 months). The postoutreach data were collected from December 2011 to July 2012 (7 months) after a five months interval to allow for break-in of the outreach processes.
The outreach process: All patients discharged from the SICU and managed on the surgical floor wards were seen by the outreach team. Prior to ICU discharge, the transferring critical care advanced practice provider documented potential areas of concern on an outreach performance improvement data tool [Figure 1]. This tool objectified findings and optimized inter-rater reliability. Outreach was then performed within 48 h of ICU discharge. During the actual outreach encounter on the surgical wards, the advanced practice provider would review the discharge comments and then assess the patient, review the current chart, laboratory findings, and active orders. Concerning findings were communicated directly to the covering surgical ward service, and a note was also left on the chart. A surgical intensivist collaborated with the advanced practitioners during this process for any emergent issues or questions. Findings were also recorded on the outreach performance improvement data tool.
Patients were stratified by the need for readmission. They were then compared using the following independent variables namely, patient demographics, issues identified, severity of issues using a 5 point scale [Table 1], and mortality rate. Rating on the 5 point scale for a grade of severity was subjective on the part of the outreach team.
Statistical analysis was performed using SPSS version 20 (SPSS, Inc., 2011, Chicago, IL, USA). All data were subject to descriptive statistical analysis yielding frequency scores for categorical data and measures of central tendency (mean ± standard deviation) for continuous/interval data. Statistically significant differences between variables were then determined by conducting inferential statistical analysis using the Chi-square test for categorical variable comparisons and the Student's t-test for continuous/interval data comparisons. A P ≤ 0.05 was considered statistically significant.
| Results|| |
A total of 1107 outreach visits were conducted during the study period. Average SICU acute physiology and chronic health evaluation (APACHE)-II scores were similar pre and postoutreach 15.66 versus 15.43 (P = 0.398). Issues identified included electrolyte abnormalities (n = 71), pain (n = 44), pulmonary toilet (n = 30), and medication reconciliation (n = 23). In total, 391 issues were identified and assigned severity scores based on the scale noted in [Figure 1]; the majority scored Grade 1 [Figure 2]. There were differences in the distribution of issues among the grading levels. [Figure 3] displays the issues identified by frequency.
|Figure 2:Number of issues identified by Outreach by the severity grade of the issue|
Click here to view
Pre and postoutreach readmission rates were 2.41% (37/1534) versus 3.54% (54/1524), respectively (P = 0.07). Overall mortality rates before and after outreach were 5.08% (n = 78) versus 5.64% (n = 86) (P =0.052) and 18.9% (n = 7) versus 9.25% (n = 5) for readmissions (P = 0.21), respectively [Table 2]. Of note, 40 (74%) readmissions occurred prior to an outreach visit.
|Table 2: Pre and postoutreach outcome measures including rates of readmission, average APACHE-II score, and mortality|
Click here to view
| Discussion|| |
The concept of outreach focuses on improving the transition from ICU team to the ward team. Handoffs of this type have long been recognized as high-risk because of the potential for gaps in communication.,,,, We specifically focused our outreach program around our advanced practice staff, as their involvement as stakeholders in the design and implementation facilitated high compliance.
Outreach has taken many different forms in other studies. Freitag and Carroll used an electronic medical charting system to frame handoff communication in a standardized fashion and were able to show improvements in measures of nursing sensitive indicators and patient satisfaction. Other efforts to smooth the transition from the ICU to the ward focus on human resource intensive processes that demonstrate varying efficacy. Butcher et al. used a more labor-intensive approach with proactive rounding by a pre-established rapid response team on patients discharged from their ICU. Interestingly, they found no significant effect on ICU readmission rate, ICU length of stay, or in-hospital mortality.
Our study found a trend toward decreased mortality in the readmission group. Although quality improvement processes such as outreach may make intuitive sense, they do not always have easily discernable statistically significant metrics. Eliott et al. published their results of an ICU nurse liaison program and also demonstrated trends toward improvement in ICU length of stay, hospital length of stay, and hospital and ICU mortality but similarly failed to demonstrate statistical significance. They were able to significantly reduce step-down unit length of stay. Interestingly, with this ICU nurse liaison program, the authors did note a significant increase in ICU readmission rate again with a trend toward improved mortality among the cohort of readmitted patients. We similarly found a trend in readmission rate with near-clinical significance.
The effects of outreach on readmission may be two-fold. Outreach may increase ICU readmissions because of more attention to the patient by the critical care team. However, on the contrary, outreach may decrease readmissions because outreach optimizes ward care. In actuality, both of these events are occurring together. The result of this is actually a higher acuity among these still ultimately readmitted. Chan et al. found a significantly higher mortality among patients readmitted to their ICU. Further, they found that among those who were readmitted earlier after initial discharge, mortality was lower than those admitted longer after initial discharge. The two main risk factors for mortality in their study were initial ICU length of stay and initial ICU APACHE-II score.
Nurse practitioner-led critical care outreach has been described previously. A group from New Zealand at a 750-bed tertiary care hospital with a paucity of critical care beds (1.5 beds per 100,000 population served) created an outreach program under similar auspices as our own. Their outreach was not for all discharges, but those so warranted by the discharging intensivist. Over their study period, there were 133 referrals accounting for 525 nurse practitioner visits. The most common interventions made were for analgesia and electrolyte repletion. Over their study period, they showed a reduction in ICU readmissions and a reduction of readmission length of stay. Our data showed similar findings in that over 1000 outreach visits, the majority of interventions were electrolyte abnormalities, pain, pulmonary toilet, and medication reconciliation issues.
The cost-effectiveness of outreach can certainly be questioned due to unclear efficacy. Several studies have demonstrated that implementing costly; large-scale initiatives may not always bring value., Our outreach program has been incorporated in a budget neutral way (no additional cost to the health system) by weaving in the responsibility of outreach into our preexisting advanced practice critical care program without the addition of staff. While long-term sustainability is yet to be seen, the value of the project to our institution may be an effective bargaining tool to increase advanced practice providers in the ICU moving forward.
The future of outreach will certainly be tailored based on the findings of this study. We found that the vast majority of outreach visits identified no outstanding critical care issue. Thus, the creation of a triage tool as to who should get an outreach visit is warranted. Identification of at-risk groups of postICU patients has been the focus of several studies.,,,,,,,,,,,,,, Pittard used a 7 point early warning score based on physiologic variables. Pirret used a subjective scoring system to realize a significant reduction in ICU readmissions. The type of outreach intervention can also be amended to be more streamlined. The majority of identified issues in our study was ranked low on our subjective severity of issue ranking scale as shown in [Figure 2]. Removing the more mundane interventions such as electrolyte replacement and pain control, which can be effectively performed by the ward team, could leave more time for critical interventions such as pulmonary toilet.
The benefits of outreach may be greater than the metrics discussed thus far. It can also act as a lead point for other initiatives focused on the high-risk patient. Ball et al. described an ongoing consult until the patient shows improvement or met specific physiologic criteria referred to as the resolution of early warning signs. We also theorize separate consultations can be spurred by outreach such as more aggressive respiratory therapy involvement on the ward.
This study has several limitations. It was a single-institution, retrospective study. Our main study outcome was mortality that may have been affected by the new cohort of patients requiring readmission after outreach. Outreach may have prevented some readmissions by improving ward care, leaving behind a more sick cohort to be readmitted and thus, with a higher chance of mortality. In addition, we found several trends that may have reached statistical significance if we had more power; in particular, here is the mortality rate of the readmitted group. Further studies are needed to elucidate the significance of these elements, perhaps with a more select group of ICU discharged patients. Finally, this study did not directly compare the issues identified on outreach with the causes of the actual readmissions.
| Conclusion|| |
In this study, critical care outreach postICU discharge did not significantly decrease readmission mortality. Further studies are needed to evaluate its effects on not only readmission mortality but also readmission rate and timing of readmission. The timing of the outreach visits themselves should also be considered in future iterations. Although we performed outreach within 48 h, the great majority of our readmissions occurred prior to our outreach visit. Further work is needed to look at discharge patterns and optimal timing of outreach, as well as high-yield groups of patients, who may benefit more greatly by outreach.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985-2000: an analysis of bed numbers, use, and costs. Crit Care Med 2004;32:1254-9.
Halpern NA, Pastores SM. Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med 2010;38:65-71.
Chrusch CA, Olafson KP, McMillan PM, Roberts DE, Gray PR. High occupancy increases the risk of early death or readmission after transfer from intensive care. Crit Care Med 2009;37:2753-8.
Simchen E, Sprung CL, Galai N, Zitser-Gurevich Y, Bar-Lavi Y, Gurman G, et al.
Survival of critically ill patients hospitalized in and out of intensive care units under paucity of intensive care unit beds. Crit Care Med 2004;32:1654-61.
Kramer AA, Higgins TL, Zimmerman JE. The association between ICU readmission rate and patient outcomes. Crit Care Med 2013;41:24-33.
Hillman K. Critical care without walls. Curr Opin Crit Care 2002;8:594-9.
Butcher BW, Vittinghoff E, Maselli J, Auerbach AD. Impact of proactive rounding by a rapid response team on patient outcomes at an academic medical center. J Hosp Med 2013;8:7-12.
Eliott SJ, Ernest D, Doric AG, Page KN, Worrall-Carter LJ, Thalib L, et al.
The impact of an ICU liaison nurse service on patient outcomes. Crit Care Resusc 2008;10:296-300.
Pittard AJ. Out of our reach? Assessing the impact of introducing a critical care outreach service. Anaesthesia 2003;58:882-5.
Pirret AM. The role and effectiveness of a nurse practitioner led critical care outreach service. Intensive Crit Care Nurs 2008;24:375-82.
McGaughey J, Alderdice F, Fowler R, Kapila A, Mayhew A, Moutray M. Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database Syst Rev 2007;(3):CD005529.
Esmonde L, McDonnell A, Ball C, Waskett C, Morgan R, Rashidian A, et al.
Investigating the effectiveness of critical care outreach services: a systematic review. Intensive Care Med 2006;32:1713-21.
Hillman K, Chen J, Cretikos M, Bellomo R, Brown D, Doig G, et al.
Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet 2005;365:2091-7.
Priestley G, Watson W, Rashidian A, Mozley C, Russell D, Wilson J, et al.
Introducing critical care outreach: a ward-randomised trial of phased introduction in a general hospital. Intensive Care Med 2004;30:1398-404.
Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ 2000;320:791-4.
Freitag M, Carroll VS. Handoff communication: using failure modes and effects analysis to improve the transition in care process. Qual Manag Health Care 2011;20:103-9.
Maughan BC, Lei L, Cydulka RK. ED handoffs: observed practices and communication errors. Am J Emerg Med 2011;29:502-11.
Nagpal K, Vats A, Ahmed K, Smith AB, Sevdalis N, Jonannsson H, et al.
A systematic quantitative assessment of risks associated with poor communication in surgical care. Arch Surg 2010;145:582-8.
Raduma-Tomàs MA, Flin R, Yule S, Williams D. Doctors' handovers in hospitals: a literature review. BMJ Qual Saf 2011;20:128-33.
Clark CJ, Sindell SL, Koehler RP. Template for success: using a resident-designed sign-out template in the handover of patient care. J Surg Educ 2011;68:52-7.
Chan KS, Tan CK, Fang CS, Tsai CL, Hou CC, Cheng KC, et al.
Readmission to the intensive care unit: an indicator that reflects the potential risks of morbidity and mortality of surgical patients in the intensive care unit. Surg Today 2009;39:295-9.
Landefeld CS, Shojania KG, Auerbach AD. Should we use large scale healthcare interventions without clear evidence that benefits outweigh costs and harms? No. BMJ 2008;336:1277.
Crump B. Should we use large scale healthcare interventions without clear evidence that benefits outweigh costs and harms? Yes. BMJ 2008;336:1276.
Badawi O, Breslow MJ. Readmissions and death after ICU discharge: development and validation of two predictive models. PLoS One 2012;7:e48758.
Brown SE, Ratcliffe SJ, Kahn JM, Halpern SD. The epidemiology of intensive care unit readmissions in the United States. Am J Respir Crit Care Med 2012;185:955-64.
Fernandez R, Serrano JM, Umaran I, Abizanda R, Carrillo A, Lopez-Pueyo MJ, et al.
Ward mortality after ICU discharge: a multicenter validation of the Sabadell score. Intensive Care Med 2010;36:1196-201.
Gajic O, Malinchoc M, Comfere TB, Harris MR, Achouiti A, Yilmaz M, et al.
The Stability and workload index for transfer score predicts unplanned intensive care unit patient readmission: initial development and validation. Crit Care Med 2008;36:676-82.
Hanane T, Keegan MT, Seferian EG, Gajic O, Afessa B. The association between nighttime transfer from the intensive care unit and patient outcome. Crit Care Med 2008;36:2232-7.
Ho KM, Dobb GJ, Lee KY, Finn J, Knuiman M, Webb SA. The effect of comorbidities on risk of intensive care readmission during the same hospitalization: a linked data cohort study. J Crit Care 2009;24:101-7.
Lai JI, Lin HY, Lai YC, Lin PC, Chang SC, Tang GJ. Readmission to the intensive care unit: a population-based approach. J Formos Med Assoc 2012;111:504-9.
Lee HF, Lin SC, Lu CL, Chen CF, Yen M. Revised acute physiology and chronic health evaluation score as a predictor of neurosurgery intensive care unit readmission: a case-controlled study. J Crit Care 2010;25:294-9.
Lissauer ME, Diaz JJ, Narayan M, Shah PK, Hanna NN. Surgical intensive care unit admission variables predict subsequent readmission. Am Surg 2013;79:583-8.
Ouanes I, Schwebel C, Français A, Bruel C, Philippart F, Vesin A, et al.
A model to predict short-term death or readmission after intensive care unit discharge. J Crit Care 2012;27:422.e1-9.
Pilcher DV, Duke GJ, George C, Bailey MJ, Hart G. After-hours discharge from intensive care increases the risk of readmission and death. Anaesth Intensive Care 2007;35:477-85.
Renton J, Pilcher DV, Santamaria JD, Stow P, Bailey M, Hart G, et al.
Factors associated with increased risk of readmission to intensive care in Australia. Intensive Care Med 2011;37:1800-8.
Rosenberg AL, Hofer TP, Hayward RA, Strachan C, Watts CM. Who bounces back? Physiologic and other predictors of intensive care unit readmission. Crit Care Med 2001;29:511-8.
Kastrup M, Powollik R, Balzer F, Röber S, Ahlborn R, von Dossow-Hanfstingl V, et al.
Predictive ability of the stability and workload index for transfer score to predict unplanned readmissions after ICU discharge. Crit Care Med 2013;41:1608-15.
Cook DA. Readmission models revisited: strong evidence for the general and weak evidence for the specific. Crit Care Med 2013;41:1803-5.
Ball C, Kirkby M, Williams S. Effect of the critical care outreach team on patient survival to discharge from hospital and readmission to critical care: non-randomised population based study. BMJ 2003;327:1014.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]