Optimizing use Of ICU resources by proactively managing the ICU patient:Discharge process to the next lower level of care

This thesis focusses on the dilemma of present ICU capacity waste in face of strained ICU resources and an increase in an aging, more multimorbid patient population needing timely access to this level of care. The overall research aim was to provide a conceptual framework to optimize the use of ICU resources by proactively managing the patient discharge process to the next lower level of care. Insights from previous research and performed consulting projects of some team members, as well as the results of the performed survey study on the current state of ICU discharge practice, all manifested that the major contributor to ICU capacity waste was discharge delays. Here, poorly aligned admission and transfer processes, lack or overestimation of general care capacities, and mostly no structured and standardized discharge readiness assessment were the root causes of patients’ discharge delay or suboptimal discharges. Systematic literature research was performed on the rather limited scientific evidence for a structured ICU patient discharge readiness assessment, management of the care transition process and adequate tools. In this context, we identified an evidence gap in scientific literature, as there were no comprehensive and formalized discharge readiness assessment criteria to be found that reflect on the patients’ individual discharge readiness but also the receiving units’ capabilities. Per given evidence and the insights from our previous work, we prepared a proposal for a type of ICU discharge criteria checklist that went through a five-stage Delphi process with a panel of 27 international intensive care experts. It resulted in 28 criteria that reflected on the patient’s discharge readiness as well as on downstream organizational capabilities with outlined value calculation metrics and a criteria importance ranking. We implemented the results of the consensus study in an observatory trial, testing the criteria set on clinical utility. Based on the findings from the implementation in different clinical workflows, measured KPIs and collected user feedback, we finally could propose eleven criteria of the initial Delphi set as a core set to assess ICU patients’ discharge readiness. We indicated that per patient group and pathway further criteria could be added to the set. Proposals for future research areas focused on further validation in larger trials and clinical utility improvement of the discharge criteria set. In our aim to provide a conceptual framework to optimize ICU capacity utilization and care transitions, we also provided some guidance on process optimization and constant change management. Here, the willingness to change, stakeholders taking a holistic hospital wide patient flow perspective, defining common goals, working together across departmental boundaries and professions, and constantly measuring change and improvement with suitable KPIs across the care continuum are paramount for the success of any effort in this context. Ultimately, the summarized lessons-learned from our survey study during the COVID pandemic underpin that the described type of change towards better patient flow management and intersectoral collaboration was possible even under extreme pressure. Ideally, provided examples of proven concepts could motivate sustainable implementation in daily clinical routine for an equal, timely and high quality care provision within the given boundary conditions.