ICU Transitions: Patients, Families, and Staff

Patients in the ICU face a number of health transitions from the time they enter the hospital until they are discharged. A transition is defined as a “process or period in which something undergoes a change and passes from one state, stage, form, or activity to another” (Encarta World Dictionary, 1999). While transitions may involve new roles, such as becoming a mother or starting a new job, health transitions are complex and multidimensional. This is especially so in the transition from being a regular patient to becoming a critically ill one or being a regular family member to being a family member of an ICU patient. Such transitions require the rapid incorporation of new knowledge, possible behavioral adjustments, and a change in a person’s definition of “self.” Assisting patients and their families in coping with health transitions has long been part of the nursing role (Image. 1994;26:119). Recent studies have focused on the ‘patient journey’ through the continuum of care. (Ben-Tovim et al. Med J Aust. 2008;188[suppl 6]:S14).

There is limited research on patients’ transitions into the ICU, perhaps because such admissions are often unplanned. Once patients are in the ICU, however, they, and their family members, have a profound need to “feel safe.” They need to overcome the ICU-engendered anxiety, depression, fear, and high stress levels (acute stress disorder, posttraumatic stress disorder, and posttraumatic stress reaction) (McAdam and Puntillo. Am J Crit Care. 2009;18[3]:200). Research has also shown that the ICU environment is so unexpected and difficult that families are affected both socially and economically (Agard and Harder. Intensive Crit Care Nurs. 2007;23[3]:170). The key to accomplishing this safe feeling is the close observation, vigilant care, and personal interaction provided by the ICU nurse (Hupcey. J Nurs Scholarship. 2000;32[4]:361).

Similarly, transfer out of the ICU has been identified as a particularly stressful time for both patients and families. Common themes have emerged from interviews with patients and families about the ICU transfer to the hospital ward. These include feelings of sudden abandonment, vulnerability and helplessness, unimportance; and ambivalence about the entirety of the ICU experience (Chaboyer et al. Aust Crit Care. 2005; 18[4]:138). “Transfer anxiety” and “relocation stress” are two terms that have been coined to capture this experience. Caregivers of chronically ill patients report a high level of lifestyle restrictions and stress, especially if their loved ones never returned home or regained their preadmission health status after ICU discharge (Choi et al. Am J Crit Care. 2011;20[1]:12). Therefore, supporting the caregivers is an important task for health professionals during ICU and hospital discharge transitions.

In addition to psychological issues, recent evidence suggests that patients are at particular risk for adverse events (ie, patient injury as a result of health-care change and not the underlying condition) following transfer out of ICU. In a cohort study of 300 consecutive patients, a total of 147 adverse events were identified in patients in the 72 h after transfer from the ICU (Chaboyer et al. Am J Crit Care. 2008;17[3]:255). Others have shown that 52% of adverse events experienced by patients in the 72 h following ICU transfer were potentially preventable (McLaughlin et al. Anaesth Intensive Care. 2007;35[4]:486). Additionally, post-ICU mortality may be related to the time of day of ICU discharge, with increased mortality associated with after-hours ICU discharge (Lin et al. Aust Crit Care. 2009;22[1]:29), although this relationship is not universally accepted.

From the health service perspective, this body of work complements two recent patient safety initiatives, clinical handover and recognizing and responding to the deteriorating patient. Clinical handover (or hand-offs) is much more than the transfer of information; it also involves transferring responsibility and accountability for patient care (The OSSIE Guide to Clinical Handover Improvement. Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2010). Recent campaigns, such as the World Health Organization’s “High 5s,” have raised awareness of the risks associated with poor clinical handover. Miscommunication during handover poses a major risk for adverse events (Bomba and Prakash. Aust Health Rev. 2005;29[1]:68; Joint Commission’s Perspectives on Patient Safety. 2005;5[2]:1-2) and can lead to discontinuity of care (van Walraven et al. J Gen Internal Med. 2004;19[6]:624). One European study showed that 28% of medical ICU transfer reports contained at least one critical or serious error (Perren et al. Intensive Care Med. 2008;34[11]:2054). The second patient safety initiative, recognizing and responding to the deteriorating patient, has its foundation in Australian research that identified clinical signs and symptoms that were exhibited by patients in the hours prior to cardiac arrest (Franklin and Matthew. Crit Care Med. 1994; 22[2]:244; Harrison. Resuscitation. 2006;71[3]:327). Yet, these warning signs go unnoticed. Clinical staff may not have the knowledge and skills to safely identify and care for acutely ill ward patients at risk of serious deterioration (Cioffi. Heart Lung. 2000;29[4]:262).

Health service providers and researchers have responded to both the physical and psychosocial risks associated with ICU transfer in a number of ways. Critical Care Outreach Teams (CCOT) in the United Kingdom and ICU Liaison Nurses (LN) in Australia are but two examples. These nurse-led services focus on following-up patients discharged from the ICU, in addition to assisting the ward staff in caring for patients with complex needs or who are at risk of deterioration. Such nursing teams provide psychosocial and practical support to the patient and family in addition to physical support to the patient.

The next major transition ICU patients face is their transition out of the hospital. A recent review of long-term complications of critical care identified that physical, psychiatric, and cognitive complications can last for 5 to 15 years (Desai et al. Crit Care Med. 2011;39[2]:371). These limitations are pulmonary, neuromuscular, and physical in nature, whereas others reflect depression, anxiety, post-traumatic stress disorder, and delirium. Deficits in most quality of life domains have also been consistently identified and have resulted in hospital and outpatient initiatives. For example, avoidance of medications, such as corticosteroids and neuromuscular blocking agents, and glycemic control have been advocated to address critical care illness neuromyopathy. Early mobility and rehabilitation in the ICU and its continuation throughout the recovery period have also been suggested to promote better physical functioning and prevent muscle atrophy, as has limiting deep sedation. Lighter sedation or daily sedation interruption have also been advocated to limit psychiatric complications. But, as Desai and colleagues note (Crit Care Med. 2011;39[2]:371), the evidence for most of these initiatives is only beginning to emerge.

Health-care professionals may benefit from using the “theory of illness representations” (Leventhal et al. Handbook of Health Psychology. Mahwah, NJ: Lawrence Erlbaum Associates Publishers; 2001) when helping patients and families adjust to these transitions. Illness representations are reflections of how people develop and use their own interpretation of their illness conditions. Both cognitive and emotional representations are used to determine individuals’ illness-related behaviors in response to health threats and their adjustments and coping with these changes. In numerous patient populations, illness representations have been associated with quality of life and functional outcomes. Application of this theory may assist health professionals in gaining an understanding of their patients’ illness perceptions and develop more accurate perceptions, if required. Techniques, such as cognitive behavioral therapy, can be used to reshape erroneous perceptions.

As more patients are being admitted to the ICU and also surviving their ICU experiences, it seems important to continue investigating not only their recovery but also their transitions and how we can help patients and their families in this endeavor. And, if we really want to understand the patient and family journeys, then we will have to undertake this research with their collaboration, extending their right to participate in their care to their right to be active members of the research team. Ultimately, this paradigm shift reflects the simple idea leaders in patient safety have been advocating—“If it’s about me, not without me.”

Professor Wendy Chaboyer, RN, PhD
Director, NHMRC Centre of Research
Excellence in Nursing Interventions for
Hospitalised Patients;
and Frances Lin, RN, PhD Candidate
Griffith University, Gold Coast,
Qld, Australia