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Identifying intensive care unit discharge

planning tools: protocol for a scoping
review
Henry T Stelfox, Laure Perrier, Sharon E Straus, et al.

BMJ Open 2013 3:

doi: 10.1136/bmjopen-2013-002653

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Open Access Protocol

Identifying intensive care unit

discharge planning tools: protocol
for a scoping review
Henry T Stelfox,1,2,3,4 Laure Perrier,5,6 Sharon E Straus,5,7 William A Ghali,2,3,4
David Zygun,8,9 Paul Boiteau,1 Danny J Zuege1,2

To cite: Stelfox HT, Perrier L, ABSTRACT handoff, sign over, etc) is a common practice
Straus SE, et al. Identifying Background: Transitions of care between providers in acute care hospitals.1 During transfers of
intensive care unit discharge are vulnerable periods in healthcare delivery that
planning tools: protocol
patient care, crucial information on patient
expose patients to preventable errors and adverse conditions, tests undertaken and treatments
for a scoping review. BMJ
Open 2013;3:e002653.
events. Patient discharge from the intensive care unit received is transferred between providers, so
doi:10.1136/bmjopen-2013- (ICU) to a medical or surgical hospital ward is one of
that care plans can be effectively continued
002653 the most challenging and high risk transitions of care.
Approximately 1 in 12 patients discharged will be
by receiving providers. A handoff between
readmitted to ICU or die before leaving the hospital. healthcare providers is not only a process to
▸ Prepublication history and provide accurate and vital information
additional material for this
Many more patients are exposed to unnecessary
healthcare, adverse events and/or are disappointed regarding patients’ care, but also a transfer
paper are available online. To
view these files please visit with the quality of their care. Our objective is to of accountability and responsibility for
the journal online conduct a scoping review by systematically searching patient care.2–7 Healthcare organisations rec-
([Link] the literature to identify ICU discharge planning tools ognise the importance of transitions of care
bmjopen-2013-002653). and their supporting evidence-base including barriers and have proposed organisational practices
and facilitators to their use. to improve the effectiveness and coordin-
Received 30 January 2013
Methods and analysis: Systematic searching of the ation of communication among providers
Revised 7 March 2013
published health literature will be conducted to identify and recipients of care across the care
Accepted 11 March 2013
the existing ICU discharge planning tools and
continuum.3 8 9
This final article is available supporting evidence. Literature (research and
non-research) reporting on the tools used to facilitate
Unfortunately, the practice of provider
for use under the terms of
the Creative Commons decision making and/or communication at ICU handoff is often suboptimal because of com-
Attribution Non-Commercial discharge with patients of any age will be included. munication barriers6 10–12 and is a major
2.0 Licence; see Outcomes will include adverse events and provider and contributor to medical errors and adverse
[Link] patient/family-reported outcomes. Two investigators events.2 7 13–19 The Harvard Medical Practice
will independently review the abstracts (screen 1) to Study20 found that adverse events occur in
identify those meeting the inclusion criteria and then approximately 4% of patients discharged
independently assess the full text articles (screen 2) to from hospital, with three quarters of these
determine if they meet the inclusion criteria. Data adverse events resulting in patient disability
collection will include information on citations and (ranging from less than 1 month duration to
identified tools. A quality assessment will be performed
permanent). A similar Australian study
on original research studies. A descriptive summary
will be developed for each tool.
reported adverse events resulting in disability
Ethics and dissemination: Our scoping review will or increased length of stay for 17% of
synthesise the literature for ICU discharge planning tools patients admitted to hospital.21 In 2006, the
and identify the opportunities for knowledge to action and Joint Commission for Accreditation of
gaps in evidence where primary evidence is necessary. Health Care Organization ( JCAHO)
This will serve as the foundational element in a multistep reported that 63% of deaths related to
research programme to standardise and improve the medical error in its sentinel events database
quality of care provided to patients during ICU discharge. involved a breakdown in communication.22
Ethics approval is not required for this study. Most research on handoffs for in-hospital
patient transfers has focused on patient
For numbered affiliations see
end of article. transfers from the perspective of a single dis-
cipline, such as physician end-of-shift1 6 11 18 23
Correspondence to BACKGROUND or end-of-service2 16 17 24 handoffs. In con-
Dr Henry Thomas Stelfox; The transfer of responsibility for patient care trast, relatively little is known about the hand-
tstelfox@[Link] (synonyms include transition of care, offs between non-physician providers.10 25

Stelfox HT, Perrier L, Straus SE, et al. BMJ Open 2013;3:e002653. doi:10.1136/bmjopen-2013-002653 1
Identifying ICU discharge planning tools: protocol for a scoping review

Multidisciplinary handoffs though are required to opti- healthcare providers, most patients being assigned new
mally transition care and likely face relatively greater teams of physicians, nurses, pharmacists, therapists, etc.
communication hurdles owing to cultural differences, However, communication between providers discharging
work load challenges and differences in clinical focus patients from the ICU and providers admitting these
between specialties and disciplines, and thus may lead to patients to general care units has been documented to
greater potential for medical errors and adverse be infrequent, incomplete and of poor quality.30 40 An
events.10 12 25 observational study performed by our research team in
Numerous types of patient transfers and provider preparation for this protocol found direct verbal com-
handoffs occur every day.4 6 A transition of care occurs munication between ICU-discharging physicians and
each time a patient is referred to a specialist by their ward-admitting physicians to occur in only 15–25% of
family doctor, assigned a new nurse during hospital shift the ICU discharges.30 Optimal transfers of care require
change or discharged from hospital. Among these, effective communication between discharging and
patient transfers from the intensive care unit (ICU) to a admitting physicians that include direct communication
medical or surgical hospital ward are likely of particu- (in person or via telephone); concise, accurate,
larly high risk owing to the number, complexity and up-to-date discharge summaries; and physician notifica-
acuity of the medical conditions that characterise this tion at the time of transfer.3 30 However, communication
patient group26–29; the large ‘voltage’ drop in available during transfer is challenged by provider workloads,
resources when patients move from the ICU, where available resources and variations in clinical focus
medical care is intensive and resources are rich, to ward between specialties.10 12 25
environments, where patients typically receive much less Communication between physicians and patients/fam-
intensive monitoring and patient care26; the multitude ilies at the time of ICU discharge is also frequently sub-
of communication barriers that providers often face optimal with the same local observational study finding
during interspecialty and multidisciplinary handoffs30; 68% of patient/families reporting a desire for increased
the lack of standardisation in patient transfer processes opportunities to ask questions about the transfer.30 This
overall; and, in particular, the lack of standardised lack of information about the ICU transfer process
written and/or electronic tools to facilitate an optimal appears to be associated with patient and family
transfer process.28 anxiety.41–44Effective communication between providers
Patients admitted to the ICU are of the highest acuity and patients/families to provide early notification of an
requiring management with life support technologies upcoming transfer,30 present information on current
and aggressive interventions to sustain life and progress medical conditions and future plans prior to transfer
towards a clinically stabilised condition.28 Approximately would likely better manage expectations and reduce
1 in 10 patients admitted to an acute care facility is anxiety.
admitted to an ICU.31 Transition of care is extremely Standardising the process of patient discharge from
common with 90% of ICU patients being eventually dis- ICU could improve the safety, quality and efficiency of
charged to medical or surgical hospital wards.32 With care. Multiple interventions to improve ICU discharge
millions of hospitalisations in acute care facilities in have been developed (eg, transitional care units, ICU
most countries each year,31 hundreds of thousands of outreach, nursing liaison, etc),28 45–48 but there is no
patients will be admitted to ICU and experience challen- consensus on an ideal ICU discharge model to optimise
ging and high risk transfers to hospital wards. the quality of patient care28 and few organisations have
ICU discharge represents a large drop in the intensity implemented standardised guidelines or procedures for
of care with patients transitioning from a high acuity unit transitions of care.46 49 Government agencies,50 specialty
to a general care unit. ICUs are specially staffed, self- groups3 51 52 and the Institute for Healthcare
contained hospital units, dedicated to the management Improvement53 have all advocated standardising ICU dis-
and continuous monitoring of patients with life- charge structure and processes to improve continuity of
threatening illnesses.33 The medical support available to care, patient safety, patient and provider satisfaction and
patients in the ICU includes multidisciplinary teams of resource use.47 54
healthcare providers (ie, physicians, nurses, pharmacists The challenges of ICU discharge are well recog-
and therapists) that typically see each patient multiple nised.28 55 Very little is known about the quality of
times a day.34 35 In general, there is a nurse for every one patient care during ICU discharge. A comprehensive
or two patients and a physician for every 8 to 10 review of ICU discharge planning tools has not been
patients.36 37 In contrast, general medical and surgical previously completed. The scope and magnitude of
care units have fewer resources with a nurse for every tools to facilitate patient discharge from ICU has not
four to eight patients38 and physicians responsible for up been previously defined. For tools already developed, it
to as many as 65 patients during regular working hours is unclear how effectively these have been implemented
and 400 patients outside of regular working hours.39 and how they may have affected patient clinical out-
Other healthcare providers are often less available. comes and/or patient and family satisfaction with care.
When a patient is transferred from ICU to a general In response to these challenges, we will conduct a
care unit, typically there is a complete transition in scoping review to identify ICU discharge planning tools

2 Stelfox HT, Perrier L, Straus SE, et al. BMJ Open 2013;3:e002653. doi:10.1136/bmjopen-2013-002653
 Identifying ICU discharge planning tools: protocol for a scoping review

and the supporting evidence base for these tools includ- responsibility for patient care from the ICU to a hospital
ing barriers and facilitators to their use. ward. Tools are defined as structural devices (eg, proto-
cols, reminders, order sets, bundles, checklists, forms
and decision aids) designed to aid healthcare providers
METHODS AND ANALYSIS or patients/families with decision making and/or
Conceptual model communication.64
Our scoping review will adopt the model of system The specific objectives of the scoping review are
theory first introduced in 1966 by Avedis 1. To complete a systematic search of the literature to
Donabedian.56 57 In Donabedian’s framework, the three identify existing ICU discharge planning tools and
components of healthcare quality are structure, process evaluate the evidence base in support of the tools
and outcome. The structure is the environment in which (including impact on patient outcomes).
healthcare is provided and includes material and health 2. To map the ICU discharge planning tools and the
resources, operational factors and organisational charac- supporting evidence to our conceptual framework to
teristics of the healthcare facility. The process is the identify gaps in the evidence where primary evidence
method by which healthcare is provided and includes or systematic reviews are required.
the giving and receiving of care by the providers and 3. To evaluate the tools according to their relevance to
healthcare system. The outcome is the consequence of knowledge users (importance, feasibility, usability and
healthcare and includes the health status of patients. We scientific acceptability).
will examine structural devices (tools) used to facilitate 4. To describe barriers and facilitators to the implemen-
ICU discharge and evaluate their association with pro- tation and utilisation of ICU discharge planning
cesses and outcomes of care for patients discharged from tools.
ICU (figure 1).
In addition, we will incorporate the Institute of
Medicine’s (IOM’s) six aims for the 21st Century Health Eligibility criteria
Care System into our research. ICU discharge tools Research studies (no methodological restrictions—case
should foster safe, effective, efficient, timely, equitable series, cohort, cross-sectional, non-randomised con-
and patient-centered discharge from ICU. We have trolled, consensus method, case–control and rando-
developed a conceptual model for our scoping review mised controlled) and non-research study designs
that merges the Donabedian model and the IOM’s six (editorial, guideline, letter to the editor and narrative
aims (table 1). We recognise that our conceptual model review) are eligible. We will include studies with all
is a relatively basic and simple representation of ICU dis- human patients discharged from any ICU regardless of
charge, but no other simple validated framework exists subspecialty (eg, medical, neuroscience, etc). There is
and we have successfully used a variation of this model no restriction on age, as tools identified for neonatal
to develop quality indicators for injury care.58–61 and paediatric patients may provide relevant information
for the discharge of adult patients (and vice versa).
Objectives Eligible studies must include an electronic or paper
This is a protocol for a scoping review to identify ICU tool (including guidelines, protocols, questionnaires,
discharge planning tools and the supporting evidence checklist, etc) intended to facilitate discharge from ICU
base for these tools including barriers and facilitators to (regardless of discharge destination) either by providing
their use. Methods for inclusion and analysis of articles decision support for healthcare providers and/or
and reporting of their results will be performed as patients/families to determine readiness for discharge
recommended by Arksey and O’Malley62 and refined by or aid in guiding the process of patient discharge. A
Levac et al.63 comparison group is not required as we will be looking
We define an ICU as a distinct hospital ward that is for studies that describe the development, implementa-
staffed by specialised healthcare professionals and where tion or evaluation of a tool. If evaluation studies are
immediate and continuous life-sustaining treatment (eg, identified, details on the comparison group will be
invasive monitoring, vasoactive medications and invasive assessed including patients, type of ICU (eg, medical,
mechanical ventilation) is administered to hospitalised neuroscience, etc) and discharge destination (eg, high
patients suffering from life-threatening conditions (eg, dependency step down unit, hospital ward, etc).
severe respiratory failure).36 Patient’s discharge from Outcome measures will include (1) any severe adverse
ICU is defined as the transfer of accountability and events post-ICU discharge (eg, ICU readmission and
hospital mortality), (2) any provider reported outcomes
(eg, quality of communication and satisfaction) or (3)
any patient/family reported outcomes (eg, quality of
information, engagement and satisfaction).
Studies will be excluded if they include patient dis-
Figure 1 Conceptual evidence-based intensive care unit charges predominantly from coronary care units, high
discharge planning tool. dependency units and step-down units.

Stelfox HT, Perrier L, Straus SE, et al. BMJ Open 2013;3:e002653. doi:10.1136/bmjopen-2013-002653 3
Identifying ICU discharge planning tools: protocol for a scoping review

Table 1 Conceptual model of ICU discharge*

IOM aims Structure (discharge tool) Process Outcome
Safe Risk stratification Patient to right ward ↓ ICU readmission
Effective Medication reconciliation Right medications ↓ Adverse event
Efficient Information for providers Providers informed ↓ Duplication of tests
Timely Risk stratification Discharged when ready ↓ Length of stay
Patient-centered Information for patients Patients engaged ↑ Patient satisfaction
Equitable Checklist Equal access ↓ Inequalities
*Table populated with sample tool components and consequent processes and outcomes.
ICU, intensive care unit; IOM, Institute of Medicine.

Search strategy Data items and data collection process

We will search the following electronic databases: The data collection instruments will include information
MEDLINE (OVID interface, 1946 onwards), EMBASE on both citations and identified tools. We will document
(OVID interface, 1947 onwards), CINAHL (EBSCO the type of citation (eg, original research), country,
interface, 1981 onwards) and the Cochrane Library setting (eg, subspecialty of unit), study design, study
(current issue). Bibliographies of the retrieved articles population, recruitment and sampling, diagnostic cri-
will be searched for additional relevant articles. We will teria, reference standard, blinding, statistical methods
also search conference proceedings from the past and outcomes. For each tool, we will document the
5 years, including the Canadian Critical Care name, purpose (eg, patient evaluation for discharge,
Conference, Society of Critical Care Medicine, planning patient discharge, etc), components (single
Australian and New Zealand Intensive Care Society component vs multicomponent), how it is applied (eg,
Conference, European Society of Intensive Care electronic) and the timing of activation (eg, discharge
Medicine Conference, American Thoracic Society planning vs discharge execution). If available, we will
Conference, and International Symposium on Intensive record any measurement properties documented (sensi-
Care and Emergency Medicine. Experts in the field, tivity/specificity), reported impact on processes (eg,
identified from the references of included studies will medication reconciliation) and outcomes (eg, patient
be contacted to determine whether they are aware of readmission to ICU) of care for patients, families and
any additional studies. providers and barriers and facilitators identified to use
An experienced information specialist (LP) will of the tool (eg, organisational culture). The data collec-
conduct the literature searches. It will be performed tion instrument and reviewer training will be sequen-
with no year or language restrictions and will use combi- tially revised until reliable data abstraction can be
nations and synonyms of the following search terms: demonstrated (estimated κ≥0.8).66 Differences in
intensive care, critical care, discharge plan, patient trans- coding between the two reviewers will be resolved by dis-
fer and patient discharge. Appropriate wildcards will be cussion and a third reviewer will be consulted if an
used to account for plurals and variations in spelling. A agreement cannot be reached. Original research studies
draft literature search is available in online supplemen- will have the quality of their methodology assessed using
tary additional file 1. the framework of Caldwell et al67 for evaluating both
quantitative and qualitative study designs. Three clinical
decision-makers (DZ, PB and DJZ) will independently
Study selection process judge the relevance of each tool for decision-making
Two investigators will independently review the retrieved according to four dimensions derived from the Strategic
abstracts (screen 1) to identify those that meet the inclu- Framework Board in the USA68: (1) targets important
sion criteria. The full text of those articles deemed rele- improvements in the continuity of patient care, (2) feas-
vant by either reviewer will be obtained. Two ible to implement, (3) easy to use and (4) strength of
investigators will independently assess the full text arti- scientific evidence (using the GRADE criteria).69
cles (screen 2) to determine if they meet the inclusion
criteria. Two investigators will discuss disagreements on Analysis
inclusion and a third investigator will resolve disagree- Quantitative and qualitative analyses will be performed.
ments if needed. Bibliographic details will be down- The articles and tools will be categorised according to
loaded to EndNote.65 The study selection process will be their respective criteria. Agreement on data abstraction
pilot tested using 50 citations from the literature search. and article classification will be assessed with Cohen
The inclusion and exclusion criteria will be serially clari- κ-reliability coefficients.66 A comprehensive list of tools
fied and reviewer training sequentially revised until reli- will be developed and summarised using simple numer-
able study selection can be demonstrated (estimated ical counts. We will present the distribution of tools
κ≥0.6).66 according to the cells of our conceptual model along

4 Stelfox HT, Perrier L, Straus SE, et al. BMJ Open 2013;3:e002653. doi:10.1136/bmjopen-2013-002653
 Identifying ICU discharge planning tools: protocol for a scoping review

with binomial 95% CIs as well as detailed tabulations by including the annual meetings of the Canadian Critical
type of article (original research and non-research) and Care Trials Group, and International Symposium of
study design. We will examine the purpose and compo- Intensive Care and Emergency Medicine among others.
nents of the tools from each study as well as the reported Our scoping review results have the potential to influ-
measurement properties (eg, sensitivity/specificity of ence the care of many patients. We will synthesise the lit-
risk stratification tools) and reported processes (eg, hos- erature for ICU discharge planning tools and identify
pital length of stay) and outcomes (eg, readmission to the opportunities for knowledge to action and gaps in
ICU) of care. A descriptive summary of each tool’s evidence where primary evidence is necessary. ICUs are
purpose, components, conceptual model classification, specialised units that have been widely implemented
measurement properties and relevance to knowledge around the world to care for the sickest patients in the
users will be developed. healthcare system.55 Discharge from ICU is a high risk
Qualitative studies will be evaluated by identifying the process because vulnerable patients move from a
key outcomes and themes presented by each study (eg, resource rich environment to a relatively resource poor
reported barriers and facilitators to discharge tool util- environment using a process that is non-standardised,
isation), preserving the meaning from their original inefficient and characterised by poor communication
source and tabulating them within the review. and frequent adverse events.29 30 40 45 46 71 72 To
Translation of key concepts from all studies will be per- improve patient care, we need evidence-based tools to
formed to identify novel concepts not explored by indi- standardise and improve the quality of care provided to
vidual studies. Analysis will focus on identifying the patients during ICU discharge. Our results will help in
overlap of key concepts between studies. Finally, the implementing an evidence-based ICU discharge plan-
translated concepts will be synthesised and refined to ning tool to ensure that discharge from the ICU is safe,
identify core themes.70 effective, efficient, timely, equitable and patient-centered
Using the above categorisation scheme, we will be able so that the right patient is discharged at the right time
to provide a scoping review of what research is available using a process that improves patient care and reduces
in the area of ICU discharge planning tools and the evi- the risk of adverse events and hospital mortality while
dence base supporting available tools. From this, we will facilitating patients’ care journeys.
identify where there is a need for a systematic review of
the literature (eg, there may be sufficient literature on Author affiliations
1
validated risk stratification techniques) and where gaps Department of Critical Care Medicine, University of Calgary and Alberta
in the literature exist and primary prospective studies Health Services—Calgary Zone, Calgary, Alberta, Canada
2
Department of Medicine, University of Calgary and Alberta Health Services—
are needed. Calgary Zone, Calgary, Alberta, Canada
3
Department of Community Health Sciences, University of Calgary, Calgary,
Alberta, Canada
4
ETHICS AND DISSEMINATION Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
5
Li Ka Shing Knowledge Institute, Saint Michael’s Hospital, Toronto, Canada
This scoping review is the first step in a major empiric 6
Continuing Education & Professional Development, Faculty of Medicine,
work to measure and improve ICU discharge processes University of Toronto, Toronto, Canada
(focused on adult patients). It will identify the funda- 7
Department of Medicine, Saint Michael’s Hospital, University of Toronto,
mental information needed to implement an ICU dis- Toronto, Canada
8
charge planning tool. This review will identify existing Division of Critical Care, University of Alberta, Edmonton, Alberta, Canada
9
Department of Critical Care Medicine, Alberta Health Services—Edmonton
tools to facilitate ICU discharge, the supporting evi-
Zone, Edmonton, Alberta, Canada
dence base as well as facilitators and barriers to imple-
mentation. All data will be obtained from publicly Acknowledgements We thank Stephanie Todd and Jamie Boyd for their help
available materials, and therefore this study will not in formatting the manuscript.
require ethics approval. Contributors HTS, LP, SES, WAG, DZ, PB, DJZ contributed to concept and
Our knowledge translation strategy will involve, among design of the study, edited the protocol and obtained funding. HTS drafted
other approaches, a workshop to be held in conjunction the protocol. All authors read and approved the final protocol.
with the annual January Canadian Critical Care Trials Funding The project is supported by a Synthesis Grant (KRS124604) from
Group meeting that will bring together key target audi- the Canadian Institutes of Health Research.
ences across disciplines for our research. By engaging Competing interests HTS is supported by a New Investigator Award from the
multidisciplinary stakeholders, we will enhance linkages Canadian Institutes of Health Research and a Population Health Investigator
necessary for dissemination of our results. We will Award from Alberta Innovates Health Solutions. SES is funded by a Tier 1
engage stakeholders in a discussion of the results and Canada Research Chair. WAG is funded by a Senior Health Scholar
Award from Alberta Innovates Health Solutions. DZ is supported by a
develop and prioritise a research agenda for the imple-
Clinical Investigator Award from Alberta Innovates. Funding sources had no
mentation of a standardised ICU discharge planning role in the design of the protocol and we are unaware of any conflicts of
tool. We will publish in health services research and interest.
discipline-based journals. In addition, we will encourage Provenance and peer review Not commissioned; externally peer reviewed.
presentation of findings at health services research con-
ferences at national and international meetings Data sharing statement No additional data are available.

Stelfox HT, Perrier L, Straus SE, et al. BMJ Open 2013;3:e002653. doi:10.1136/bmjopen-2013-002653 5
 Identifying ICU discharge planning tools: protocol for a scoping review

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