From ITU to the Ward

TRANSITIONAL CARE
 Session Aims

 Discuss the purpose of transitional care

 Revision of ICU care levels

 Looking after the level two patient

 The level one patient/getting ready for the ward

 Safe discharge planning

 What is Transitional Care?

 Care provided before, during and after the transfer of

an ICU patient to another care unit

 Aims to ensure minimal disruption and optimal care

for the patient

 To plan and perform safe discharge planning

 Prevention of readmission to ICU

 Why have Transitional Care?

For the benefit of the:

 Patient

 Relatives

 ICU

 Receiving Ward
 Nursing Concerns

 Too Much Documentation

 The Need for Assessment?

 Frequency of Observations
 Levels of care in an ITU

Level 3 Level 2

 Receiving advanced  Pre-operative

respiratory support optimisation
 Extended post-
operative care
 Receiving a minimum
 Stepping down from
of two organ support level 3 care
(not respiratory and
 Receiving single organ
CVS) support (not advanced
respiratory)
 Levels of Care in an ITU

Level 1 Level 0

 Recently discharged  Needs that can be met

from a higher level of through normal ward
care care
 In need of additional
monitoring / clinical
interventions, input or
advice
 Requiring Critical Care
Outreach support
 Stepping Down Care

GOING FROM LEVEL 3

TO LEVEL 2 CARE
 Level 2 Care – A Reminder

 Patients needing single organ system monitoring and

support
 Patients needing pre-operative support
 Patients needing extended post-operative care
 Patients needing a greater degree of monitoring
and/or observation
 Patients moving from a previously higher level of
care
 Patients with major uncorrected physiological
abnormalities
 Level Two Care

 An intermediate level of care between intensive care

and general ward care

 A higher patient to staff nurse ratio

 Effective care should result in better patient

outcomes as well as increased efficiency for the
bedside nurse
 Level 2 Care – what that means

Single Organ Support:

Respiratory
 Airvo/NIV/ CPAP via Tracheostomy/ FiO2 > 0.5L
 At Least 2 hour suctioning to clear secretions
 < 24 hrs post extubation IF intubated >24hrs

NB: the presence of a Tracheostomy for long term

airway access does not qualify as basic or advanced
respiratory support
 Level 2 Care – What that means

Cardiovascular:

 CVP monitoring
 Use of an arterial line for monitoring pressures
and/or sampling of arterial blood
 Single vasopressor used to support CO or organ
perfusion
 Intravenous rhythm controlling drugs to support or
control cardiac arrhythmias
 Level 2 Care - What it Means

Neurological

 Continuous IV medication to control seizures

 CNS depression that does not compromise airway

 Level 2 Care – What it means

Renal Dermatological

 Patients with skin

 Requiring acute renal rashes, exfoliation or
replacement therapy burns
 Use of Complex
Dressings . eg: multiple
limb, open abdomen
(Large body surface area
affected > 30%)
 Level 2 Care – Things to Remember

Assess your patient for their need of care

 If one organ requires 1-2hrly observations do the

others? Maybe they can be reduced?

 Do they need a full patient assessment? Maybe just

assess the organs affected?

 Assess nursing care requirements at the start of a

shift and adapt as required.
 Level 2 Care

Personal Care

 Eye Care – assess  Falls – on admission

frequency
 Mouth Care – assess then weekly
frequency  MUST – on admission
 Dressings – Assess
frequency then dependant on
 Pressure area care – assess result
need and frequency
 Braden – once per shift
 Bowel Care - Amount /
colour / type /
management
 Level 2 Care

Remember:
 Patients conditions change! For the better or the worse
 Reassess your patients needs and provide the most
appropriate care required
 When patients conditions change let your co-ordinator
and doctors know so adjustments can be made if
required
 Just because one organ needs hourly/ two hourly
monitoring it doesn't mean they all do.
 Are you treating your patient or you? Don’t do things just
to make the paperwork look nice.
 Extra work affects you, the unit and the patient!
Level 1 / 0 Care

WHAT IS
REQUIRED
 Ready for Transitional Care?

 Basic Organ Support

 Nil continuous monitoring required
 Pain Controlled
 Established nutritional Support
 No Requirement for advanced lines
 Appropriate renal /gastro function
 Appropriate medications
 Effective Transitional Care

 Remove any unnecessary lines

 Discontinue continuous monitoring

 Review the need for patient assessment

 Reduce frequency of observations – should be 4-6

hourly

 Reduce amount / frequency of blood tests

Level 1 / 0 Remove if you don’t need them!
Care

Invasive Lines you will most likely have:

Lines  PVC
 CVC
 Catheter and Bag
 Drains
 Feeding Tube
 Level 0 / 1 Care

Respiratory Observations required

 Spo2
 Chest Drains  O2 +/- mode of delivery
 Respiratory Rate
 Tracheostomy
 Additional observations
 Physiotherapy as required
(drains/trache/
secretions)
 Continuous O2 Therapy
 Level 0 / 1 Care

Cardiovascular Observations required

 Requiring IVI bolus

through a CVC  NIBP

 Requiring intermittent  HR
IV medications
through a CVC
 Level 0/1 Care

Neurological Issues and

Observations

 GCS or AVPU  Pain Score

 Temperature  PCEA

 Blood Glucose (if  PCA

diabetic or requiring
support)
 Level 0 /1 Care

Fluid Balance issues and

observations

 Urine Output  Oral Intake

 Vomit  IVI Infusions

 Drains  Feeding ( NGT / TPN)

 Level 1 / 0 care

Personal Care
Documentation

 Falls – on admission
 Eye Care – assess - PRN then weekly
 Mouth Care – assess - PRN
 MUST – on admission
 Dressings – once per shift
 Pressure area care – assess
then dependant on
need – may not be four result
hourly!  Braden – once per shift
 Bowel Care - Amount /
colour / type /
management
Blood Test
Values in the  Magnesium > 0.7
NOT acutely ill

 Potassium 3.5 – 4.5

 Phosphate > 0.7

 Hb > 7 (> 10 in cardiac patients)

 These are all normal and

acceptable values in non – acute
patients
Going to the Ward?

DISCHARGE PLANNING
 Discharge Criteria

 RED – Might Be Ready. Identified as possible

Transfer in the next 12 hours. Consultant aware
 AMBER – Getting Ready. Decision made that fit for
the ward by ICU doctor. Documentation to be
completed and invasive lines to come out
 GREEN – Patient can leave the unit without delay.
Lines out, monitor off, nursing and medical
documentation completed. Ward Charts in use.

Only when GREEN the 4 hour clock starts!

 Getting Discharge Ready

 Lines Out
 Send
 Fluid Balance on EPR
 Pain Chart +/- epidural care plan / pain team
referral
 Blood Glucose chart
 Medical and Nursing Discharge summaries
 EPR drug chart
 Safe Discharge Checklist
 Notes!
 Safe Discharge Planning

 Patients identified for discharge

 Start paperwork overnight
 Operational Managers at the bed meeting will need
to know if paperwork and the patient is ready to
leave
 Only then will the four hour clock start
 All of this should be done ASAP/ Early morning
 Effective step down care will make it easier
 Discharges to be completed by 4pm
  The patient

Overview  The relative

Not
providing  The ICU nurse
transitional
care is  The ICU unit
detrimental
to :  The receiving ward

 The receiving nurse

 How does the patient feel about it all?

 No / very little recollection of their ICU stay

 Nightmares/strange dreams
 No day/night routine
 Lack of energy
 Unable to do normal things (feeding/pass urine)
 Change of appearance
 Mood swings
 Stress / depression
 A very worried family
 An ITU discharge

“It is important that we give the patient courage and

trust before the actual discharge, one has to inform
and support the patients and tell them that they
actually are getting better and that they will manage
the new level of care”
 A Ward Admission

“I think that the staff ratio mirrors in the relation… I

mean if they are calling for you at six pm and they want
help, and you don’t have the time then, they are very
disappointed. And its difficult, difficult to make them
understand”

“ You can feel unbelievably “small” when you are getting a

patient from ICU.. Their language is totally different and
if you ask what it means, you can be really questioned.
Sometimes I feel like a fly on a wall”
 A Patient View

'They sent me back to the general ward. Now that is a very

chastening experience because you're coming out of
intensive care where they have looked after you on a one-to-
one basis.
They then throw you into a general ward, where they don't
really know what you've been through. No one actually
seemed to be that interested. And you lie there and you think
to yourself, "What's happening to me?
I came down here, I was feeling really well. I've been in this
ward now for two hours and I feel ill again.”
Questions

?
 References

 Armony et al (2014) Critical care in hospitals: when

to introduce a step down unit
 Haggstrom et al (2009) Struggle with a gap between
intensive care units and general wards
 Haggstrom, Backstrom (2014) Organizing safe
transitions from intensive care
 Intensive care society (2015) Guidelines for the
Provision of Intensive Care Services (GPICS)
 Stelfox etal (2013) Identifying intensive care unit
discharge planning tools: protocol for a scoping
review