By Betty Tran, MD, MSc, Editor

Assistant Professor of Medicine, Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago

Dr. Tran reports no financial relationships relevant to this field of study.

SYNOPSIS: In this mostly qualitative study focused on patient and caregiver experiences after ICU discharge, researchers identified two major readmission contexts — medically unavoidable and complex health and psychosocial needs — as well as 10 patient-level and system-level themes that contributed to readmission primarily in the latter context.

SOURCE: Donaghy E, Salisbury L, Lone NI, et al. Unplanned early hospital readmission among critical care survivors: A mixed methods study of patients and carers. BMJ Qual Saf 2018;27:915-927.

In an era that has seen improvement in hospital mortality for ICU patients,1 there is a growing population of ICU survivors with post-intensive care syndrome (PICS). This syndrome includes disabilities in cognition, psychological health, and physical function. Additionally, family members of critically ill patients may experience symptoms of anxiety, depression, post-traumatic stress disorder, and lower quality of life (known as post-intensive care syndrome-family, or PICS-F).2 Given these issues, readmission to the acute hospital setting is common,3 although the exact determinants of readmission, especially from a patient and caregiver perspective, are poorly understood.

Donaghy et al chose a mixed methods approach to clarify contributors to unplanned hospital readmissions among ICU survivors across Scotland. Inclusion criteria included mechanical ventilation for > 48 hours and age > 18 years. The authors excluded organ transplant recipients, primary neurologic admissions, patients enrolled in palliative care, non-English speakers, and those lacking capacity or those who were too ill to participate. Investigators recruited 58 individuals (29 patients, 29 caregivers) to participate in semistructured interviews and to complete questionnaires (Functional Comorbidity Index for patients; Modified Caregiver Strain Index for caregivers) and a rating scale of the importance of nine previously identified factors important to readmission based on an a priori literature review. Separately, the investigators also conducted five focus groups comprised of a different set of 42 participants (20 patients, 22 caregivers) that aimed to provide independent validation for and refinement of their interview findings.

Based on their data, the researchers identified two major readmission contexts: “complex health and psychosocial needs” and “medically unavoidable.” In the former context, patients and caregivers believed several patient-level and system-level issues accumulated and interacted with pre-existing health and social issues to contribute to readmission. The five major patient-level themes that emerged included: multimorbidity and polypharmacy, problems with specialist equipment, psychological problems and alcohol/drug dependency, poor mobility, and fragile social support. The five major system-level themes included: poor preparation for hospital discharge (i.e., uncertain expectations for recovery, how to deal with common post-ICU problems), poor communication between acute and community-based care, inadequate psychological care, inadequate medication support (i.e., changes to treatment, inadequate explanation, poor communication with community services, delays in receiving new medications, and/or continuation of medications that should have been stopped), and lack of goal setting (i.e., lack of and/or unrealistic recovery goals, uncertainty in relation to participating in previously important activities).

For the complex health and psychosocial needs group, patients believed that timely anticipatory care, preparing them for what to expect at home, and early responses to address post-discharge needs could have prevented their readmissions. In contrast, the medically unavoidable group believed that few of the themes were present or contributed to their readmission. These patients tended to have better pre-existing health, stronger caregiver support, and lower reliance on health/social care services.

COMMENTARY

Other investigators have reported that pre-ICU health status is a significant driver for hospital readmission after an ICU stay.4-5 Researchers interested in this area find it difficult to determine whether these hospitalizations are avoidable. Although a pre-ICU health trajectory may not be entirely modifiable, Donaghy et al neatly identified and organized common themes from a patient and caregiver perspective that can serve as constructs for interventions aimed to improve quality of care and patient outcomes.

The patient-level and system-level themes presented could be used in multiple ways. Clinicians could use the themes to screen ICU patients prior to discharge who are at high risk for readmission. Further, these themes could help clinicians develop multifaceted anticipatory care plans to address the diverse needs of ICU patients. Care plans and pathways after discharge have been developed for other patient populations after admission for diagnoses such as myocardial infarction, stroke, or cancer; however, ICU follow-up poses a bigger challenge in its heterogeneity of patient diagnoses, PICS dysfunction, and complex care needs compared to “disease-focused” groups.

There may be more concrete solutions for some issues, such as problems with specialist equipment or medication support, compared to other issues, such as fragile social support and goal setting. Based on this study alone, we are unable to determine the relative importance of each factor and how patient and caregiver resilience or coping interacts with the issues presented. In addition, these themes may manifest differently depending on the patient population or healthcare system. Based on inductive analysis of a large sample of patients and caregivers, this study provides an organizational framework on which to focus efforts to develop complex healthcare interventions aimed at reducing readmission after critical illness.

REFERENCES

  1. Zimmerman JE, Kramer AA, Knaus WA. Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012. Crit Care 2013;17:R81.
  2. Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: An overview. J Transl Int Med 2017;5:90-92.
  3. Hua M, Gong MN, Brady J, Wunsch H. Early and late rehospitalizations for survivors of critical illness. Crit Care Med 2015;43:430-438.
  4. Jones TK, Fuchs BD, Small DS, et al. Post-acute care use and hospital readmission after sepsis. Ann Am Thorac Soc 2015;12:904-913.
  5. Liu VX, Escobar GJ, Chaudhary R, Prescott HC. Healthcare utilization and infection in the week prior to sepsis hospitalization. Crit Care Med 2018;46:513-516.