Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
Department of Hospital Patient Monitoring, Clinical Services, Philips Medizin Systeme Böblingen GmbH, Böblingen, Germany.
BMC Health Serv Res. 2022 Jun 13;22(1):773. doi: 10.1186/s12913-022-08160-6.
BACKGROUND/PURPOSE: Discharge decisions in Intensive Care Unit (ICU) patients are frequently taken under pressure to free up ICU beds. In the absence of established guidelines, the evaluation of discharge readiness commonly underlies subjective judgements. The challenge is to come to the right decision at the right time for the right patient. A premature care transition puts patients at risk of readmission to the ICU. Delayed discharge is a waste of resources and may result in over-treatment and suboptimal patient flow. More objective decision support is required to assess the individual patient's discharge readiness but also the current care capabilities of the receiving unit.
In a modified online Delphi process, an international panel of 27 intensive care experts reached consensus on a set of 28 intensive care discharge criteria. An initial evidence-based proposal was developed further through the panelists' edits, adding, comments and voting over a course of 5 rounds. Consensus was defined as achieved when ≥ 90% of the experts voted for a given option on the Likert scale or in a multiple-choice survey. Round 1 to 3 focused on inclusion and exclusion of the criteria based on the consensus threshold, where round 3 was a reiteration to establish stability. Round 4 and 5 focused on the exact phrasing, values, decision makers and evaluation time frames per criterion.
Consensus was reached on a standard set of 28 ICU discharge criteria for adult ICU patients, that reflect the patient's organ systems ((respiratory (7), cardiovascular (9), central nervous (1), and urogenital system (2)), pain (1), fluid loss and drainages (1), medication and nutrition (1), patient diagnosis, prognosis and preferences (2) and institution-specific criteria (4). All criteria have been specified in a binary decision metric (fit for ICU discharge vs. needs further intensive therapy/monitoring), with consented value calculation methods where applicable and a criterion importance rank with "mandatory to be met" flags and applicable exceptions.
For a timely identification of stable intensive care patients and safe and efficient care transitions, a standardized discharge readiness evaluation should be based on patient factors as well as organizational boundary conditions and involve multiple stakeholders.
背景/目的：在 ICU 患者中，为了腾出 ICU 床位，通常在压力下做出出院决定。在没有既定指南的情况下，出院准备情况的评估通常基于主观判断。挑战在于为合适的患者在合适的时间做出正确的决策。过早的护理过渡会使患者有重新入住 ICU 的风险。延迟出院是对资源的浪费，并且可能导致过度治疗和患者流程不佳。需要更客观的决策支持来评估患者的出院准备情况，还需要评估接收单位的当前护理能力。
在一项改良的在线 Delphi 过程中，一个由 27 名重症监护专家组成的国际小组就 28 项重症监护出院标准达成共识。通过专家组的编辑、添加、评论和投票，在 5 轮过程中进一步制定了一个基于证据的初始提案。当专家们在李克特量表或多项选择调查中对给定选项的投票率达到≥90%时，即达成共识。第 1 轮至第 3 轮侧重于根据共识阈值对标准进行包含和排除，第 3 轮是为了建立稳定性而重复进行的一轮。第 4 轮和第 5 轮侧重于每个标准的确切措辞、值、决策者和评估时间范围。
达成了一套标准的 28 项成人 ICU 患者 ICU 出院标准，这些标准反映了患者的器官系统（呼吸（7）、心血管（9）、中枢神经系统（1）和泌尿生殖系统（2））、疼痛（1）、液体流失和引流（1）、药物和营养（1）、患者诊断、预后和偏好（2）以及机构特定标准（4）。所有标准均已在二进制决策指标中进行了具体说明（适合 ICU 出院与需要进一步强化治疗/监测），并在适用的情况下商定了值计算方法，以及一个重要性等级，其中包含“必须满足”的标志和适用的例外情况。
为了及时识别稳定的重症监护患者并实现安全高效的护理过渡，标准化的出院准备评估应基于患者因素以及组织边界条件，并涉及多个利益相关者。
