Patients who received ICU care experience problems that need to be resolved before they are discharged. These can include delirium, debility, and dysphagia, researchers say.1
Investigators studied the period before patients were discharged to identify gaps in their care, says Eileen Kim, MD, assistant professor in the division of hospital medicine at Hofstra/Northwell in Manhasset, NY. They found after patients were transitioned from the ICU to hospital beds, many still experienced persistent delirium, functional decline, and dysphagia. Hospital practices, including bed rest and dietary restrictions, led to these syndromes, worsening these conditions.
This post-acute ICU syndrome (PICS) affected a large proportion of ICU patients. For instance, up to 80% of ICU patients experience delirium while in the ICU. Researchers found nearly one-quarter of patients transferred out of ICU received constant observation, physical restraints, and/or antipsychotic medications, all of which suggest persistent delirium after they were transitioned to acute medical care units.
This suggests a gap in care. PICS patients need treatment of their syndrome before they are discharged.
Specific Care Needed
Once patients leave the ICU, they need care specific for their health issues, but their care typically is the same as other hospitalized patients. For instance, a patient with problems related to an ICU stay is treated similarly to patients admitted for pneumonia. The nursing ratio is the same, which creates a gap in care.
“Think about the patients who spend four days in the ICU, but 10 days on the medical ward,” Kim says. “We thought there must be a gap and unmet need of ICU patients on the medical ward.”
Nurses and case managers can be a solution to this problem. “Nurses and case managers have their own communication and may have a better appreciation of care complexity for ICU survivors,” Kim explains. “For case management — essential in transition from hospital to home — these patients may have interim skill needs.”
They may need additional help at home with physical therapy and activities of daily living. “The case management is essential in communication with patient and family, and communication could start in the ICU,” Kim says. “The syndrome of delirium, functional decline, and dysphagia is so common that all patients may need speech and swallowing examination on discharge.”
This first study was a needs assessment to find out what was happening on the floor. Investigators also are working on a second study, surveying nurses, nurse practitioners, and others who receive ICU survivors to study their perceptions.
“Now that we know there is a care gap, our next step is to see what is the perception of the receiver,” Kim explains. “Our goal is to improve the quality of care for ICU survivors.”
Kim and colleagues also want to build evidence-based guidelines, like bundles, protocols, and curricula that nurses and case managers can use to improve quality of care and minimize poor outcomes associated with the ICU stay.
Gaps in Care Fuel Readmissions
From a health system’s perspective, the gap in care for ICU survivors results in higher ICU readmission rates. “Twenty-five percent of patients still had an indwelling bladder catheter, and that was associated with higher ICU readmission rates,” Kim notes.
This suggests patients would benefit from a bladder scan. The results would make it clear whether the catheter should be removed. “In our hospital, when people come out of the ICU with a Foley catheter, we initially start with a bladder scan to make sure they don’t retain too much urine,” Kim explains. “We take out the Foley and give them eight hours.”
Nurses can help patients cope with becoming ambulatory to quicken their need to urinate without a catheter. After eight hours, they can perform another bladder scan to see if the patient is retaining or not producing urine.
“If they’re retaining too much urine in the bladder, then we do a straight catheterization, putting in a little catheter and draining whatever is in the bladder to relieve the pressure and to make sure urine is coming out of the body,” Kim says. “This is temporary, and the risk of infection is much less than an indwelling catheter, especially for elderly men who may have prostate problems.”
When patients still struggle to urinate after several trials, and the bladder scan suggests urine standing in the bladder, the Foley catheter can be reinserted. “This requires a lot of communication and protocols with the nursing staff,” Kim says. “Nursing has to do the bladder scan, straight catheterization, put in an active order, and start medications. It takes a multidisciplinary effort to reduce complications.”
Nurse case managers and social workers also are needed to help patients and family members cope with the fear of going home with a Foley catheter, if necessary. “Case managers and social workers can play a major role, saying, ‘Even though we do keep you on a Foley and catheter bag, when you are ready for discharge, we can connect a leg bag to wear next to your thigh,’” Kim explains. Patients can go out in public with the thigh bag without anyone noticing.
Case managers also can reassure patients that after a few weeks, the Foley catheter likely will be removed. “Case managers can give hope to patients and family members,” Kim says.
Another role for case managers is to help patients and families with expectations. Family members may not have noticed the patient’s cognitive decline before the hospitalization. From the clinician’s perspective, the hospitalization worsened an underlying condition and caused a rapid decline.
“There are some cases where ICU survivors go through so much and get transient delirium,” Kim adds. “In those cases, case managers can set expectations for family members.”
For example, case managers can introduce the idea of sending the patient to the rehabilitation unit after ICU, she says. Rehab can serve as a bridge before the patient is discharged.
“A lot of family members have guilt of sending their loved ones to rehab; they feel pressured to bring them home because they love them so much,” Kim explains. “Case managers can introduce the idea that rehab is not neglecting, but is only a bridge until they get out of acute illness.”
Case managers also can introduce the idea of palliative care, hospice care, or home visits to families of patients with worsened dementia.
- Kim E, Kast C, Afroz-Hossain A, et al. Bridging the gap between the intensive care unit and the acute medical care unit. Am J Crit Care 2021;30:193-200.