Team situational awareness, competing priorities, and organisational hierarchy influence the patient discharge process in intensive care

Background: Patient flow from intensive care to acute care units is often problematic and many discharges from intensive care to acute care are unsuccessful on the first attempt. Objectives: The aim of this study was to explore the factors that influence intensive care patient discharge. Design, setting, and participants: This ethnographic study was undertaken in an Australian metropolitan tertiary hospital that had a 14-bed level 3 intensive care unit. Intensive care and acute care unit medical and nursing staff, and other hospital staff who were involved in the intensive care patient discharge process participated in this study. A total of 28 discharges were observed, and 56 one on one interviews were conducted. Methods: Data collection techniques including direct observations, semi-structured interviews, and collection of existing documents were used. Activity theory was the theoretical framework that underpinned this study. Findings: Three patient activity systems were identified: intensive care patient discharge activity, acute care unit accepting patient activity, and hospital bed management activity. Analysis of the interactions among these activity systems revealed conflicting objects (goals), communication breakdowns, and teamwork issues. Conclusion: Discharge delay was found to be a significant problem, which was associated with limited acute care unit bed availability. Strategies to improve acute care unit bed availability are needed. Routine after-hours ICU discharge could raise patient safety concerns which need to be considered. All team members’ input in discharge decision making should be encouraged. Problems identified in clinical handover call for actions to change the handover practice. Activity theory successfully guided the study by providing a practical and descriptive framework for the study, facilitating the understanding of the interrelationships among the activity systems. What is already known about the topic • After-hours intensive care unit (ICU) discharge has been associated with increased mortality. • ICU resources are limited and demand constantly outstrips supply. • Admissions, discharges and transfers (ADTs) are high workload tasks. Patients exposed to nursing shifts with high ADTs and high nursing workload are associated with increased risk of mortality and morbidity. What this paper adds • The process of safely discharging patients from ICU to acute care units is a complex activity requiring integrated teamwork not just between the disciplines in ICU but also between the ICU and acute care unit staff. • The handover and other communication tools used to facilitate ICU patient discharge can be misused if staff from different care areas, for example, ICU and acute care unit, have different goals. • Sometimes ICU patients’ discharges are delayed and subsequently occur after-hours. These patients may be at increased risk of adverse events if not addressed. • Activity theory is a suitable theoretical framework to understand and improve clinical practice in healthcare organisations.