I See You: How research is improving intensive care
With every transfer of a patient in a hospital, there's a chance for a communication breakdown, especially around the intensive care unit (ICU). It might happen between ICU specialists and the medical team on a different ward who are taking over a patient's care. It could also happen between doctors and patients during the process of discharging the patient out of hospital and back home.
"If someone has been in the ICU, then they have been very, very sick," explains Dr. Tom Stelfox, a professor of critical care medicine and Scientific Director of the O'Brien Institute for Public Health at the University of Calgary. "Regardless of whether they were in the ICU because of trauma, infection, stroke or anything else, the next phase of their care – and their recovery needs – could be complex. So, it's imperative for everyone involved to have access to information that will support the patient in the best possible way."
In theory, such a transition and support system for patients being discharged from the ICU sounds straightforward. In practice, however, it's not so easy.
"We have found that discharge practices and handovers in care are not always as smooth as we would hope – patients sometimes fall through the cracks as they move from one care team and location to another," says Dr. Stelfox. "But we are working on evidence-based tools to address that."
Working with the current system
Initially, Dr. Stelfox was drawn to the question of ICU discharge practices in response to two related challenges: the increasingly specialized nature of care (or "silos of care" for different specialties) and the decreasing level of control patients have in their own care.
"A hundred years ago, we probably would have been cared for by the same family doctor for the majority of our lives," he explains. "Today, the health system is more specialized, which is great in terms of having access to deep expertise for different needs – but it also means that the system is more fragmented, so patients don't often get that same long-term, single-point-of-contact type of relationship with a doctor."
Dr. Stelfox points out that many patients now have to navigate the health care system on their own, which can be daunting. There is also an added concern that patients may not get the complete care they need if they don't have one trusted doctor or nurse guiding them through the whole health care journey. Addressing these issues involves building better supports across the health care system to create easier transitions from one care setting to another. And when it comes to both the care provided in the ICU and the transition to the next step, Dr. Stelfox is a strong advocate for including the patient and their family in the process.
The ICU, however, can be bewildering. Most ICU patients will end up on a breathing machine and will have to take medications to help them tolerate the experience, which makes it difficult for them to express their needs or even ask questions. Family members often take on the role of patient advocate in this situation, but this can present its own challenges, especially during such a stressful ordeal.
"Our team has conducted several observational studies focused on ICU care, particularly for older adults, and it became very clear that communication can be a big problem," says Dr. Stelfox. "But the same is true for discharge – or transfer – from the ICU. That step represents a big change in the patient's care environment and day-to-day experience, and that can lead to confusion and disorientation for patients and their families."
Building better health care supports therefore starts with better communication, and Dr. Stelfox's team made a point of including patients in their efforts. "We've developed a lay-friendly tool for patients that summarizes, in plain language, what's happened to them, what care they've received, and what they need going forward," he says, adding that the tool also includes what they call a 'teach-back' mechanism that allows patients to provide feedback to their ICU care team.
The tool is being piloted in Calgary and will become available for ICU care teams across Canada later this year through the Calgary Critical Care Research Network.
Planning for long-term recovery
Historically, the ICU has focused on the short-term survival of patients. As a further step in his research, Dr. Stelfox wants to get everyone thinking about the long-term trajectory of recovery, even for brief stays in the ICU.
"Imagine a patient arrives in the ICU because of an overdose," he says. "When they wake up, their level of consciousness is low. There may be important social factors influencing the overdose, such as their living and working circumstances. If we don't have a way to connect them to the right experts, we're going to see them back at the ICU again – or worse, we won't see them because they'll die the next time."
This scenario, along with countless other ICU situations and stories, has led Dr. Stelfox and his team to begin developing a "care pathway" for patients discharged from the ICU. A care pathway is a management tool that outlines the different tasks or interventions required from the people who may be involved in a patient's care, such as physicians, nurses, pharmacists, physical therapists, social workers, and other specialists. With the pathway model, specific needs are defined and then the care tasks are organized into a sequence that will help address the patient's needs in an efficient way. When it is implemented well, the pathway becomes a beautiful mix of standardized processes and personalized care.
Creating a care pathway as a tool involves a lot of research, analysis, and consultation. Dr. Stelfox's team has been making good progress on these fronts, but they also stumbled across a surprising trend: about 14% of adult ICU patients in Alberta are discharged directly home rather than to a different hospital ward.
"When I started 20 years ago, that would never happen," Dr. Stelfox says, noting that discharge from the ICU has traditionally been a two-step process (transition to another hospital ward for a period of care, followed by a return home). "When I shared this data, some of my senior colleagues were shocked."
And yet, he points out, these patients don't seem to be doing any worse at home than those who stay in the hospital. Getting sent home may even be beneficial for them and more efficient for the health care system. Without further study, the impact of the practice is not clear.
"This is why this type of research matters," he continues. "We need tools in place to ensure a smooth transition from the ICU to the home environment, and we need to study them to make sure they work. And if the practice is safe, even advantageous for some patients, then we have to figure out how to best incorporate that option into a care pathway tool for discharging patients from the ICU."
Looking to the future of care
With all of these research projects and practices, Dr. Stelfox's ultimate goal is to empower patients and families to become stewards of their own care. "We don't want to burden individuals who are stressed and ill," he says. "But I think we'll end up with better care practices and better health outcomes for patients if we get them as engaged and empowered as they can be in their own care."
Doing so will involve developing new tools to further improve communication between medical staff and ICU patients and their families, along with components in the care pathway that involve them in decisions about everything from rehabilitation to end-of-life practices. Dr. Stelfox recognizes that some people may not wish to be so heavily immersed in their care, which is why the tools also need to allow patients and families to be as involved or uninvolved as they'd like.
This kind of flexibility may become even more crucial in the decades ahead. "The nature of care will likely be different 10 or 20 years from now," Dr. Stelfox says. "We need a mechanism for it to evolve."
One approach, he says, might be ensuring family doctors are equipped to discuss care needs with their patients before a health crisis. Another approach could involve designing a whole new evidence-based program that assigns advocates to guide a person's stay in the hospital.
A key part of planning for the future also involves training early career scientists. Just as patients need to be more engaged in their care, Dr. Stelfox believes the health system could benefit from involving younger clinicians in leadership roles at an earlier stage.
"I used to think I was helping train a future generation of scientists," he says, "but I'm increasingly convinced the younger generation is training me. They show me new perspectives I hadn't considered before, and the benefit of that for me – and, by extension, my patients – is invaluable."
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