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TRANSCRIPT
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Summer Training Project onStreamlining the process of transfer from ICU to wards to
prevent re-admissions to ICUA quality improvement study
InFortis Memorial Research Institute (Gurgaon)
Submitted To Jamia Hamdard UniversityMBA (Health & Hospital Management)
July 2013
Submitted by:
Sushma Sinhmar(2012-2014)
Under the supervision of
Dr.Shibu John
Faculty of Management Studies & IT, Jamia Hamdard University
Hamdard Nagar, New Delhi-11006
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DECLARATION
I, Sushma Sinhmar, student of Jamia Hamdard University, New Delhi, hereby declare that I
have completed my project, titled Streamlining the process of transfer from ICU to wardsand assurance for prevention of return to ICU within 48 hours A quality improvementstudy. The information submitted herein is true and original to the best of my knowledge.The outcome and original research work was undertaken and carried out by me, under the
guidance ofDr. Anita Arora (Head Quality & Microbiology) and Ms.Divya Gautam
(Deputy Manager, Quality). It has not been submitted to any other University or Institute or
published earlier.
Place:New Delhi
Date:
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ACKNOWLEDGEMENT
I owe a great many thanks to a great many people who helped me and supported me for
completion of this project work.
My deepest thanks to Dr.Anita Arora (Head Quality & Microbiology) and Ms.DivyaGautam (Deputy Manager, Quality) for guiding me throughout the study and provide me the
necessary information to carry out this study.
I express my thanks to the ICU teams, Floor Co-ordinators, Duty doctors, ICUs& Wards
Team Leaders, Supervisors ,Nursing staff for their cooperation & contribution which was
vital for the success of this project.
Thanks and appreciation to the helpful people at Fortis Memorial Research Institute, Gurgaon
for their support.
I would also like to express my gratitude towards Dr Shibu John for his kind co-operation
and encouragement at each step, which helped me in completion of this project.
Sushma Sinhmar
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CONTENTS
Page No.
Acknowledgement
Declaration
Chapter 1.0 Executive summary 1-2
Chapter 2.0 Introduction &Literature review 3-10
Chapter 3.0 Objectives 11
Chapter 4.0 Research methodology 12-15
Chapter 5.0 Data Analysis 16-34
Chapter 6.0 Study findings 35-38
Chapter 7.0 Conclusion 39-40
Chapter 8.0 Limitations 41-42
References
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CHAPTER 1
EXECUTIVE SUMMARY
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Executive Summary:-
Fortis Memorial Research InstituteGurgaon is a 1000 bedded Multi- Super Specialty,
Quaternary care hospital (in initial phase operating at 450 beds) with an enviable
international faculty, reputed clinicians, including super-sub-specialists and specialty nurses,
supported by cutting-edge technology. It is a premium referral hospital which endeavours to
be the 'Mecca of Healthcare'for Asia Pacific and beyond. This Next Generation Hospital
is built on the foundation of 'Trust' and rests on the four strong pillars Talent, Technology,
Infrastructure and Service.
The FMRI- Vision is to be the ultimate healthcare destination - "Mecca of Medicine",
Mission -to provide quaternary care to the community in a compassionate, dignified and
distinctive manner & Mottois Best is the Least We Can Do".
A Study was carried out carried out at 450 bedded (operational in its 1st phase) Fortis
Memorial Research Institute-Hospital, with an objective of Prevention of return to ICU
within 48 hours.
The study was carried out in 3- Phases:
The study was carried out as a result of: the number of unplanned Returns to ICU within 48
hours was high for the month of May 2013 and it remained the same in the month of June
2013.
Phase-1
The first phase of study involved 10 days of Shadowing of Patients throughout the process of
transfers from ICUs (medical, surgical, CTVS) to Wards. Identification and documentation
of the various concerns (loop holes) observed throughout the whole process.
Phase-2The second phase of the study consisted of framing out the various strategies and
implementing. The focus was confined to the various concerns and the aids which could help
in eliminating the loop holes in order to reduce the number of unplanned returns to ICU
within 48 hours.
Phase-3
The third phase of the study done to actually see the effects of the interventions carried out in
phase -2 of the study.
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CHAPTER 2.0
INTRODUCTION AND REVIEW OF LITERATURE
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Hospitals have experienced unprecedented growth in demand for services across a range of
areas including critical care. Factors identified as driving the growing demand for intensive
care include:
a rise in chronic and complex illness
an aging population
more new treatment options through advances in medical technology.1
Wherein, the transfer of patients from the ICU is an everyday procedure. It is an accepted part
of the ICUs routine work.4 Considering the whole transfer process from Intensive Care Unit
(ICU) to wards is complex, involving information exchange among ICU and ward staff in
addition to transferring responsibility and accountability for care. Despite professional guidelines
for managing ICU discharge processes, there are wide variations in practice. Discharges can be
problematic, with issues such as bed-availability delays, inadequate skill mix on the receiving
wards and resource limitations creating delays.3Whereas the earliest appropriate time of
transfer reduces excessive and unnecessary use of this expensive health care facility and
improves the availability of beds for other critically ill patients requiring ICU admission.2
However, early discharge of ICU patients to general wards may expose them to inadequate
levels of care. Moreover, early discharge may result in ICU readmission during the same
hospitalisation with the possibility of a worsening of the patient's original disease process,
increased morbidity and mortality rates, a longer length of stay and increased total costs. ICU
readmission rates reported in the literature vary from 0.9% to 19% with mortality rates for
readmitted patients ranging from 26% to 58%.2
Therefore, ICU transitional care is used and defined as care provided before, during and
after the transfer of an ICU patient to another care unit that aims to ensure minimal disruption
and optimal care for the patient. This care may be provided by ICU nurses, acute care nurses,
physicians and other healthcare professionals. Discharge planning is a part of ICU
transitional care. It is a part of the process that aims to provide continuity of care for the
patients. The effects of a poorly coordinated discharge can lead to readmission to the ICU and
also avoidable deaths. If the transfer for the individual patient is accompanied by scarce,
inadequate or untimely knowledge or preparation, it may be perceived as a threat to security.4
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JUSTIFICATION OF THE STUDY
Unplanned Return to ICU within 48 hours is a Critical Parameter of Medical Operating
System for the Clinical Excellence Scorecard. The main focus is to minimise the unplanned
returns to ICU within 48 hours, which is a matter of concern as a discontinuity in the
continuity of care. Continuous care has to be provided after the Patient has been transferred
from ICU to Wards, as many patients experience high anxiety, stress etc. during relocation
from the intensive care unit to the wards. Thus, they require higher level of care for at least
48 hours , as compared to the patients who are already in the wards in order to prevent the
returns to ICU. The present study was designed to minimise the unplanned returns to ICU
within 48 hours by streamlining the transfer process.
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REVIEW OF LITERATURE
Intensive care units manage the sickest patients in a hospital. They provide time-critical care
and treat patients often utilizing complex medical technology. Clinical staff are highly
trained, with the ratio of nurses to patients much higher than on the wards.1
According toJames and Kendall(2005), ICU transitional care is care provided before,
during and after the transfer of an ICU patient to another care unit that aims to ensure
minimal disruption and optimal continuity of care for the patient.3
Discharge from the intensive care unit (ICU) at the earliest appropriate time reduces
excessive and unnecessary use of this expensive health care facility and improves the
availability of beds for other critically ill patients requiring ICU admission. However, early
discharge of ICU patients to general wards may expose them to inadequate levels of care.
Moreover, early discharge may result in ICU readmission during the same hospitalization
with the possibility of a worsening of the patient's original disease process, increased
morbidity and mortality rates, a longer length of stay and increased total costs.2
An exploratory, qualitative pilot study was done by Polit and Hungler in 1995 involving
one male and four female registered nurses from ward areas taking the most patient transfers
from a general adult intensive care unit over an 18-month period (March 1997 to August
1998) to identify the difficulties faced by ward staff caring for patients transferred from
intensive care.5
In 2009, Appelles Ohanga performed a qualitative study involving registered nurses from
the five surgical ward (K3, K4, K5, K6, K7) ofJorvi hospital involving people who had a
perspective on a particular research topic. The tool used was questionnaire, developed by the
researcher specifically to collect data from the registered nurses working in the surgical
wards. The development of the questionnaire was through literature searches and also
discussing with the critical care unit nurses. An average of fifteen questionnaires was issuedto each ward. The research period was two weeks for all the wards in June 2009.
The study emerged with five themes.
Communication was the most significant aspect in all the themes.
1. Information sharing
2. Timing of patient transfer
3. Documentation as a continuation of patient care
4. Intensive care patient family members5. Post ICU visit3
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Axel Kaben in 2008, investigated the incidence of, outcome from and possible risk factors
for readmission to the surgical intensive care unit (ICU) at Friedrich Schiller University
Hospital, Jena, Germany. The study involved all patients admitted to the post-operative ICU
between September 2004 and July 2006. The results showed, of 3169 patients admitted to the
ICU during the study period, 2852 were discharged to the hospital floor and these patients
made up the study group (1828 male (64.1%), mean patient age 62 years). The readmission
rate was 13.4% (n =381): 314 (82.4%) were readmitted once, 39 (10.2%) were readmitted
twice and 28 (7.3%) were readmitted more than twice. The first readmission to the ICU
occurred within a median of seven days (range 5 to 14 days). Patients who were readmitted to
the ICU had a higher simplified acute physiology II score and sequential organ failure score
on initial admission to the ICU than those who were not readmitted. In hospital mortality was
significantly higher in patients readmitted to the ICU than in other patients. 2
In August 2006, Malcolm Elliott, used the following databases to locate published
data: Medline (1966-present), CINAHL (1982-present), Synergy, Science Direct, Proquest
and Taylor & Francis. The search terms used were 'intensive or critical care', 'recidivism'
'patient follow- up', 'readmission' and 'bounce back'. Discipline-specific journals (e.g.
American Journal of Critical Care, Heart & Lung, Intensive and Critical Care Nursing) were
hand searched to find studies not catalogued in electronic databases. The worldwide web was
also searched using three search engines (yahoo.com, scholar. google. com and
askjeeves.com). Exclusion criteria included was non-research based articles, those not
published in the English language and articles relating to the readmission of patients to
hospital from the community.
These search strategies identified a total of 20 studies specifically relating to the
readmission of patients to ICU reviewed the published studies on readmissions to ICU with
an aim to examine:
1. Determine the frequency of readmissions.
2. Identify the risk factors for readmission.
3. Determine the reasons for readmission or the common 'type' of patient readmitted.
4. Highlight areas for further research.
The Research indicated that patients readmitted to ICU have mortality rates up to six
times higher than those not readmitted and are eleven times more likely to die in hospital. 6
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Wu CJ et ol, 2007 reviewed the case studies of transferring ICU patients to general wards in
order to identify the shortcomings of this process.The study revealed theEvidences thatindicate that the poorly managed transfer of a patient from the intensive care unit (ICU) to the
ward can lead to physical and psychological complications for the patient, and often require
ICU readmission and re-hospitalization. Reviewing this patient transfer process to improve
the quality of care would be a positive step towards enhancing patients' recovery and
providing skills to staff.8
In 2011, St-Louis L et ol, studied to describe an innovative quality initiative to implement the
clinical nurses specialist in medicine to facilitate the transition process between the intensive
care unit and the medical wards, with a rationale of the study Safely transferring patients with
complex health conditions from an area of high technology and increased monitoring, like the
intensive care unit, to an area with lower nurse-to-patient ratio is an intricate process. The
care of these patients, once transferred, also requires varying levels of expertise. As indicated
in the nursing literature, this type of transition is often associated with high stress levels for
the patient and family, as well as for the healthcare providers. To maximize patient safety and
ensure optimal care for this patient population, well-defined mechanisms must be put in
place. The outcomes of the study shows:on average, 150 patients are assessed each year by
the CNS. Among these patients, 15% are considered at high risk for complications upon
transfer to the unit and a systematic evaluation of patients by the CNS, before their transfer
from the ICU to a medical unit, has been proven beneficial in ensuring a comprehensive
patient care plan and patients and families have verbalized that this intervention is helpful.
Staff members have indicated that this safety initiative is useful in planning patient transfers.
The next step would be to formally measure patient, family, and staff satisfaction with this
initiative.7
In December 2012, Grottenthaler et ol, studied early identification of high-risk patients
through the use of an assessment checklist and risk score will predict and reduce ICU
readmissions within 72 hours of discharge for respiratory-related complications using a
qualitative study design. The research was a pilot study involving five adult ICUs with 165
patients . To validate accurate identification of high-risk patients, the ICU-designated
Respiratory Care Practitioner (RCP) completed a Respiratory Bounce back Risk Score
(RBRS) assessment checklist prior to each patient transfer out of the ICU. Statistical analysis
was performed using a Statistical Package for Social Sciences (SPSS). A non-identifiable
http://www.ncbi.nlm.nih.gov/pubmed?term=Wu%20CJ%5BAuthor%5D&cauthor=true&cauthor_uid=17300545http://www.ncbi.nlm.nih.gov/pubmed?term=St-Louis%20L%5BAuthor%5D&cauthor=true&cauthor_uid=22016020http://www.ncbi.nlm.nih.gov/pubmed?term=St-Louis%20L%5BAuthor%5D&cauthor=true&cauthor_uid=22016020http://www.ncbi.nlm.nih.gov/pubmed?term=Wu%20CJ%5BAuthor%5D&cauthor=true&cauthor_uid=17300545 -
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dataset of patients enabled the ability to statistically identify patients who presented as high-
risk due to respiratory-related complications. Patients with a cumulative risk score of 14 or
greater were identified as high-risk patients (p
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unexpected ICU readmission were classified into themes: Communication, Physician, Patient,
Processes, Hospital & Staffing.10
Wendy Chaboyer, in 2008 performed a quality improvement study using a time-series
design and statistical control analysis process in an Australian general ICU : To evaluate the
impact of a redesigned intensive care unit (ICU) nursing discharge process on ICU discharge
delay, hospital mortality and ICU readmission within 72 hours. A total of 1,787 ICU
discharges were included in this study, 1,001 in the 15 months before and 786 in the 12
months after the implementation of the new discharge processes. . The redesign process
included appointing a change agent to facilitate process improvement, developing a patient
handover sheet, requesting ward staff to nominate an estimated transfer time and designing a
daily ICU discharge alert sheet that included an expected date of discharge. The primary
outcome measure was hours of discharge delay per patient discharged alive per month,
measured for 15 months prior to, and for 12 months after the redesigned process was
implemented. There was no difference in in-hospital mortality after discharge from ICU or
ICU readmission within 72 hours during the study period. However, process improvement
was demonstrated by a reduction in the average patient discharge delay time of 3.2 hours
(from 4.6 hour baseline to 1.0 hours post-intervention).3
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OBJECTIVES OF THE STUDY
1. To determine the root causes of unplanned ICU re-admission byemploying Qualitative Method.
2. To Directly observe work flow and transition of care processesacross specific ICUs.
3. To Map observed work flow and Transfer process.
4. To Design the corrective measures and recommendations to minimize
Re-admissions to ICU.
5. To determine the effectiveness of the interventional programme undertaken by
concerned stakeholders after circulation of Corrective measures recommendations.
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CHAPTER 4.0RESEARCH METHODLOGY
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This chapter discusses in detail the research methodology selected in order to streamline the
transfer process from ICU to Wards and assurance of prevention of unplanned returns to ICU
within 48 hours.
4.1 Research design
The Research approach used in this study was Retrospective, Observational, Descriptive &
Interventional. The primary Research included observing & analysing the root cause for
Unplanned return to ICU within 48 hours and data collection for the process of transfers
from ICU to Wards. The secondary research included finding out the concerns in the process
and planning interventions in order to reduce the number of unplanned returns to ICU within
48 hours and designing the recommendations, interventions & implementation. Third phase
includes analysing the effectiveness of the interventions.
4.2 Study tools
M.S excel was the tool used in the study for data collection and analysis. A Medical
Operating System (MOS) checklist for prevention of return to ICU within 48 hours &
Checklist for transfers of patient from ICU to Wards was used to record observations
(observations were recorded in MS excel).
4.3 Methods of data collection
A tri-phasic approach was used in the study. Primary data collection (Pre-intervention &
Post-intervention) & initially secondary data (Retrospective) for last 3-months reviewed for
Returns to ICU within 48 hours.
PRIMARY RESEARCH (Phase 1)
Initially, retrospective study was done to evaluate the Returns to ICU within 48
hours to find the root causes of the re-admissions.
In First phase included observations regarding the process of the transfers from ICUs
to Wards was documented for 10 days, using a checklist prepared by the observer.
The process flow of the transfers from ICU to Wards including the information flow
to various areas and co-ordination among them was observed for ICU-2 (Surgical
ICU), ICU-6 (CTVS-ICU) & ICU-7 (Medical ICU). The data collection was done
using the Checklist for transfer process from ICU to wards.
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The various parameters which were looked into were as follows:
MOS- Checklist for Prevention of Return to ICU within 48 hours:-
Audit to be done after 24 hours of transfer of patient from ICU to Wards
1. Transfer from ICU is signed/authorized by the responsible ICU Consultant.(Check the transfer sheet/progress notes for instructions by critical care
consultant.)
2. Treating Consultant/Team has been consulted and the same has been documented.(If the intensivist is ordering transfer for another consultants patient-verify that
the information given to the treating team is documented in progress notes).
3. Transfer form is complete (Doctors as well Nurse Section).(Check the in-house transfer form for completion and correct documentation
including legible name and signature).
4. Taking over/patient receiving documentation is complete- Nurse & Doctorsection.
5. Care instructions for next 24 hours are documented.(Check the progress notes/transfer form for care instructions apart from
medications).
6. Suctioning frequency is mentioned (for tracheotomised patients).(Check for written instructions for those who are transferred in with ETT/TT).
7. Instructions for care of drains have been documented (if applicable).(Check for written instructions for those patients who are transferred in with
drains including intercostal drain).
8. Care instructions are carried out in the ward.(Compare progress notes with transfer instructions).
Checklist for transfers of patient from ICU to Wards:-
Shadowing of patient throughout the process of transfer from ICU to Wards
1. Interpreter requirement and availability.2. Written orders from Consultant team & Critical care team.3. Room Availability delays.
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4. Co-ordination among ICU- supervisor & Ward Team Leader.5. In-house transfer summary sheet complete (Doctor Section).6. In-house transfer summary sheet complete (Nurse Section).7. Patient profile explanation by ICU nurse to ward nurse.8. Transfer book complete.9. Co-ordination b/w assigned Nurse and Team Leader.10.Co-ordination b/w Team Leader and Duty Doctor.11.Co-ordination b/w Duty Doctor and Consultant Team.
Phase-2
The second phase of the study included planning of the interventions for the concerns through
the process of transfers from ICU to Wards. Implementation of interventional plans using
various quality improvement interventions, in order to streamline the process of transfers and
prevent the unplanned returns to ICU within 48 hours involving the following: ICU-2,ICU-6,
ICU-7, Nightingale ward (1st floor), 2nd floor and 3rd floor (Insignia) areas.
SECONDARY RESEARCH
Third phase of the research was done to determine the effectiveness of the interventions
carried out in the phase-2. In this phase again patients were shadowed and the transfer
process parameters were evaluated for its compliance.
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CHAPTER 5.0
DATA ANALYSIS
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Data analysis
The outcome indicators for Prevention of unplanned returns to ICU within 48 hours in
Clinical excellence scorecard is the number of patients returning to ICU (within 48 hours of
transfers) divided by the number of patients transferred out from ICU * 100.
Calculation of Returns to ICU (within 48 hours of transfers):-
Returns to ICU Rate:No. Of cases returning to ICU within 48 hours * 100
No. Of patients shifted out from ICU in a month
The number of patients transferred out from ICU & number of patients returning to ICU
includes the total number of transfers from all ICUs in a month & returns in the month from
all ICUs.
The data collected was represented in percentage.
Exclusion Criteria:- ICU-1, & ICU-9 is not included in the study as ICU-1 (recovery area)
has post-operative patient & patients only stay for few hours and ICU-9 is the paediatric
surgery ICU and the number of patients transferred from OT are very few (1-2 patients).
ICU-5 is not functional yet so, not included in the study.
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FINDINGS FOR FIRST PHASE OF THE STUDY:
STANDARD PROTOCOL FOR MOS PARAMETER PREVENTION OF RETURN TO
ICU WITHIN 48 HOURS.
PROTOCOL
PRE-TRANSFER PROCESS:
1. Status of patients admitted in ICU is monitored continuously to identify patientswho no longer needs ICU care. Transfers is considered when:
a. Patients physiological status has stabilised and the need for ICU monitoringand care is no longer necessary. Parameters to be considered for this decision
are listed below for guidance purpose (Box at end of text).
b. Patients physiological status has deteriorated and active interventions are nolonger planned, and transfer to a lower level of care is appropriate.
2. A patient who does not require intensive care but needs more care than thatprovided in a general ward is shifted to HDU. Such patients require more frequent
monitoring of vital signs &/ or nursing interventions.
3. Patients with ICU status of more than 7 days and who are hemodynamically stableare shifted to HDU before considering shifting to general wards with monitoring
facilities and higher patient-nurse ratios.
4. Patients with ICU stay of less than 7 days and who are hemodynamically stablemay be shifted to general wards directly.
5. As far as possible, transfer from ICU should be completed before 7 pm. In case oftransfers being considered after 7 pm or if delay has occurred despite transfer
instructions issued earlier in the day, a re-approval from the ICU consultant as
well as parent clinical unit/team is obtained.
TRANSFER PROCESS
1. Transfer must be approved by responsible ICU consultant and signed by theconsultant himself/herself or a member of his/ her team.
2. Parent clinical unit/team is consulted prior to patient transfer and patientsclinical condition (including current and potential problems) is discussed.
3. Medical and nursing transfer summary must be completed by the critical careteam and this must accompany the patient to the receiving ward.
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4. Transfer form/document (see box below) must include clear medicalmanagement plan for next 24 hours. Special care of At risk patients (eg.
Patients with tracheostomy, GCS lower than 9 etc.).
5. If patient is on Insulin, parent units are informed of the insulin protocol.6. Other care teams involved (like Physiotherapy, Dieticians etc.) should be
informed of transfer.
7. Treatment limitation/non-escalation directives must be discussed with thepatients attendants and with parent clinical unit. The same must be documented.
POST ICU TRANSFER
1. Patient condition at the time of receiving the patient (in the ward) should bedocumented along with any special instructions.
2. Care in the ward includes patient management as per the instructions mentionedin the transfer form.
3. Critical care team should be involved in early management of At risk patientsin order to minimise chances of unplanned return to ICU.
OBJECTIVE PARAMETERS BEFORE TRANSFER FROM ICU:
VITAL SIGNS:
Pulse > 40 or < 120 beats/minute Systolic arterial pressure > 80 mmHg Mean arterial pressure > 70 mmHg Diastolic arterial pressure < 100 mmHg Respiratory rate < 30 breaths/minute
LABORATORY VALUES (NEWLY DISCOVERED)
Serum sodium > 130 mEq/L or < 150 mEq/L Serum potassium > 3.5 mEq/L or < 5.5 mEq/L PaO2 > 60 mmHg pH > 7.2 or < 7.5 Serum glucose < 200 mg/dl Serum calcium < 10 mg/dl Toxic level of drug or other chemical substances have cleared.
Note: If any parameter is out of range, a special note should be made by the ICU team.
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ANALYSIS POINTERS INCLINICAL EXCELLENCE SCORECARD FOR RETURN TO ICU
WITHIN 48 HOURS:
S.NO. ANALYSIS POINTERS ANALYSIS CUE/ TRIGGER CUE
1. Inappropriate step down due to
deviation from the transfer protocol
of ICU.
Refer to transfer criteria of critical care units for Inappropriate
monitoring of patients condition priorto shifting to ward.
2. Inappropriate care planning in the
ward by healthcare providers.
One or more of the following in the patient file will indicate
the appropriateness of care plan:
1. Gross variation in vitals not addressed in time.2.
Care plan not documented based on assessment.
3. Critical investigation reports not addressed in time.4. Inadequate monitoring on prescribed intervals.
3. Early step down Due to high
occupancy
Self explanatory
Staff/ specialist interviews may also be reflective
4. Early step down due to patient
financial constraints
Self explanatory
5. Communication gap One or more of the following in the patient file will indicatethe inadequacy in communication:
1. Inappropriate/incomplete inter-departmental transfernotes. Eg. Incomplete physician focus section.
2. Inappropriate intra-departmental handover3. Incomplete/missed documentation by healthcare
service provider.
6. Aggravation of pre-existing patient
risk factors despite a proper treatment
This explanation is to be supported by appropriate
documentation of risk factors & the factors that have led to this
aggravation of pre-existing ailment in the patient file.
7. Escalation of risk factors associated
with procedure despite a proper
treatment
This explanation is to be supported by appropriate
documentation of risk factors & the factors that have led to this
aggravation of pre-existing ailment in the patient file.
8. Any other (Please specify) Explanations to be included
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Transfer process from ICU to wards:-
Written orders from consultant team + critical care team
Discussion with Patient/ relatives inRoom decision.
Information flow from ICU to IPD for availability of room(E-mail)
Delay Conveyed to ICU-supervisor
Conveyed to ICU-supervisor and ward Team Leader(E-mail)
Information flow from ICU-supervisor to Ward Team Leader Regarding
Transfer ( E-mail)
In-house transfer summary sheet completion + Pharmacy clearance
Transfer of patient with assigned ICU-nurse & GDA
Patient received by assigned nurse in ward
Patient progress explanation by ICU-nurse to ward nurse + received sign.
by ward nurse on In-house transfer summary sheet & Transfer book.
TL informed about patient receival by assigned ward nurse
TL informs duty doctor
Duty doctor informs consultant team
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TABLE-1
NO. OF UNPLANNED RETURNS TO ICU WITHIN 48 HOURS IN MONTH OF MAY , JUNE & JULY
TIME PERIODMAY JUNE JULY(27th)
AREAS ICU-2 ICU-6 ICU-7 ICU-2 ICU-6 ICU-7 ICU-2 ICU-6 ICU-7
Total Number Of Patients
Transferred From ICU
52 49 48 61 53 47 51 46 53
Total number of returns to
ICU within 48 hours
0 1 2 2 0 1 0 1 0
Calculation of Returns to ICU (within 48 hours of transfers):-
Returns to ICU Rate:No. Of cases returning to ICU within 48 hours * 100
No. Of patients shifted out from ICU in a month
NUMBER OF UNPLANNED RETURNS TO ICU IN MONTH OF MAY 2013:
98%
2%
Unplanned Returns to ICU Within 48
hours (May)
Total no. of patients transferred from ICU's to wardsUnplanned returns to ICU within 48 hours
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No. Of Unplanned Returns To ICU In Month Of June No. Of Unplanned Returns to ICU in Month of July
COMPARISION : RETURN TO ICU IN THE MONTH OF MAY, JUNE & JULY:
98.14
%
1.86%
Total no. of patients transferred from
ICU's to wardsUnplanned returns to ICU within 48
hours
99.33
%
0.67%
Total no. of patients transferred
from ICU's to wards
Unplanned returns to ICU within 48
hours
98 98.14 99.33
2 1.86 0.670
20
40
60
80
100
120
MAY JUNE JULY
Total no. of patients transferred from ICU's to wards
Unplanned returns to ICU within 48 hours
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Table-2
Pre-intervention -Transfer process from ICU to wards (% compliance):
Parameters % Present % Absent
Interpreter required and available (sample size-2) 50 50
Written orders from consultant & critical care
team
93 7
Room availability (Delays) 86 14
Co-ordination b/w ICU-supervisor & ward TL 86 14
Co-ordination b/w Assigned ward nurse & TL 64 36
Co-ordination b/w TL and Duty doctor 64 36
In house transfer summary sheet complete
(doctors part)
57 43
In house transfer summary sheet complete
(nurses part)
21 79
Patient progress explained by ICU-nurse to ward
nurse verbally
100 0
ICU-transfer book complete 93 7
Patient first seen by duty doctor/consultant team
(delays)
64 36
Note: The number of patients shadowed during the whole process of transfer from ICU to wards
were 14 patients, each consuming approximately 3 hours and the time period of shadowing was
from 10th June to 20th June 2013.
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% Compliance of Transfer process from ICU to Wards
Sample size - 14 (Complete shadowing of patients:10th
-20th
June)
The graphical presentation of the percentage compliance of the transfer process from ICU to wards
is depicted above with the various parameters against which the compliance rate was checked and
the documented to take the corrective actions to enhance the compliance rate.
100
93 93
86 86
64 64 64
57
50
21
0
7 7
14 14
36 36 36
43
50
79
0
20
40
60
80
100
120
% Present % Absent
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CONCERNS ASSOCIATED WITH THE TRANSFER PROCESS FROM ICU TO
WARDS
1. Unavailability of Interpreter (international patients), affecting the delivery ofcare needed by the patient during the whole process, which takes around an
hour. The nurse is not able to understand the needs of the patient due to
language barrier.
2. Incomplete In-house transfer summary sheet :Nurses part: Eg. Patient wound details (Type of dressing, Frequency of change
etc.), Drain details (Type, color etc.), Handover details etc.
Doctor-s part: Analgesia details etc.
3. In-efficient management by team leader (Ward Nurse) asassociated withthe assigning of patient to the nurse before the patient reaches the room, which
contributes to the delays in transfer process.
4. Delays in the rounds by the duty doctor/consultant team due to thecommunication gap between the Assigned nurse and team leader regarding thetime of patient transferred to the room and hence contributing to the inco-
ordination between team leader and duty doctor .
5. Delays in the transfer process excluding the delays due to inefficientmanagement by team leader includes: In-efficiency & in-appropriate
prioritization of work by the assigned nurse for the patient and hence
contributing to the delays in the transfer process. The delays , as the assignednurse is busy with the other patient for which he/she has been assigned earlier.
6. Critical care daily progress notes incomplete. Eg. Patient plan for the day,current problems, vital system status etc.
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FISH BONE ANAYSIS
Fish Bone Analysis was done for the various concerns associated with the transfer process as a quality
defect prevention, to identify potential factors causing returns to ICU. Each cause or reason for
imperfection is a source of variation.
Unplanned returns
to ICU
Communication
Transfer Delays
In-house transfer summary sheet incomplete
Nurse Unaware for details to be filled in
certain columns .
Lack of training
Casual approach of Doctors
Casual approach of Nurses
Interpreter unavailability
Phone switched off
Nurse unaware of
protocol for
Instant call for
Interpreter
Lack of training
Inefficient Management
Inefficient utilization of GDAs
Incomplete Instructions to GDAs
Casual approach of
Management
Casual approach of GDAs
Physician DelaysDuty Doctor busy in care of other
patients
Communication Gap between Duty
doctor and Team Leader (Nurse)
Communication gap
between assigned
nurse(ward) and Team
LeaderCasual approach of
assigned nurse
Consultant team busy in
OT/OPD/other patients
Unavailability of Room
Delay in discharge process
Delay in room preparation
Inefficient management
of house-keeping staff
Nurse not assigned prior to patient arrival
Inefficient management by Team Leader
Assigned nurse busy with other patient
Inefficient time-management
Inappropriate prioritization
Team Leader
unaware of
planned transfers
information sent a
day before the
transfer.
Lack of
Training
Formulation of roaster
not done for planned
transfers
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S . No. Observations Recommendations Responsibilities
1 Interpreter unavailabilityTraining on whom to esclate the call, in case
interpreter is not available Nursing supervisor.
2
Inefficient use of GDA's(GDA waits till the nurse completes the
handover).
After transporting the patient to ward , GDA shall go
back to ICU
ICU-Nursing supervisor
Casual attitude of GDA to be looked in.
3 Delay in Room availability Delay in discharge process Billing
Delay in preparation of room for next patient (Ward) Supervisor - House
Keeping
4Team Leaders (3rd &4th floor) Unaware about planned
transfers information a day before
TL to infromed and trained about the planned step
down intimation mail.
Nursing supervisors.
5Unavailability of information of planned transfers from ICU to
nightingale ward, prior evening
Circulation of information to Nightingale ward by ICU-
supervisor.
ICU - Nursing Supervisor
6 At time of patient being received in wards- no nurse available totake hand over
Nursing roaster to could be be prepared as per the list
of planned step down from ICU - to assign poper
number of nurses.
Floor TL
Team Leaders to be more proactive in assigning duties
for patient received from ICU
Floor TL
7 Casual approach of nursing staff (ICU &Wards) in completingthe details of transfer form
ICU-nursing staff to be trained- how to fill the in
transfer summary sheet.
Nursing Educator
8Doctor's not completing the transfer form
Training and orientation for doctors - completing form
details
9 Delays in rounds by Duty doctor/Consultant team Flow of information from assigned nurse to ward-teamleader needs to be focussed.
Staff Nurse
Team leaders should be accountable for informing
duty doctor about arrival of patient to ward (team
leader busy).
Team Leaders &
nursing supervisors
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DESIGNING OF INTERVENTIONS
1. The interventions which were required to be taken for the implementation of the corrective actionswere designed according to the concerns associated with the transfer process.
UNAVAILABILITY OF INTERPRETER
Step-1: Discussion with the floor managers of 1st (Nightingale ward), 3rd floor (Insignia ward) & 4th floor
regarding the protocol for the instant call for Interpreter. The discussion concluded the existence of
protocol for the instant call for interpreter. Whereas, the nursing staff of all the floors were unaware of the
protocol.
Step-2 : Nursing supervisors & team leaders of 1st, 3rd & 4th floor informed regarding the unawareness
among nursing staff.
Step-3: Acknowledgement of nursing staff about theprotocol for instant call for interpreter by the
nursing supervisors of the respective floors.
IN-EFFICIENT MANAGEMENT BY THE TEAM LEADER (NURSE)
Planned transfers
Step-1 Discussion with the ICU-supervisors of ICU-2, ICU-6 & ICU-7 about the circulation of list of
planned transfers to the ward a day before (evening). The discussion concluded with the information that
circulation of the list of planned transfers is sent to nursing stations of 1 st, 3rd & 4th floors. Whereas,the
team leader found unaware of this information flow.
Step-2 Nursing supervisors of all floors informed regarding the unawareness among team leaders.
Step-3 Education of team leaders by the nursing supervisors of respective floors about the information
flow that happens a day before the patient is to be transferred. Team leaders taught about the formulation
of the roasters for assigning the nursing staff for the patients to be transferred the next day. This would
streamline the process of transfers and minimise the delays.
Unplanned transfers
Step-1 Discussion with team leaders of 1st, 3rd & 4th floor regarding the pattern followed for the assigning
of nurse for the unplanned transfers. The discussion concluded that nurse is not assigned prior to the
patient arrival from the ICU & it was done when the patient has arrived.
Step-2 Nursing supervisor informed about approach of the team leaders.
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Step-3 Education of the team leaders by the nursing supervisors of the respective floors regarding the
prior planning the nurse to be assigned, as co-ordination among ICU-supervisor and Ward team leader
exist before the patient is transferred to the ward. This prior assignment of the nurse for the patient
transferring from ICU, minimize the transfer delays and reduce the panic among the nursing staff Hence,
smooth workflow can be seen.
IN HOUSE TRANSFER SUMMARY SHEET INCOMPLETE:
NURSES PART:
Step-1 Evidence based information provided to the Nursing supervisors of ICU-2, ICU-6 & ICU-7 for
the areas in In-house transfer summary sheet to be focused for deficiencies and lack of knowledge
among nursing staff about the details to be filled in certain columns.
Step-2 ICU- nursing staff educated about the deficiencies by the ICU-supervisors of the respective
ICUs.
Step-3 Individually pointing out the errors in the ICUs by the observer and correcting the nursing staff
for the deficiencies or errors made.
DOCTORS PART:
Step-1 Informing the Doctors (Critical care team) regarding the deficient areas in the In-house transfer
summary sheet in doctors part. Such as Analgesia details etc.
DELAYS IN ROUNDS BY THE DUTY DOCTOR/CONSULTANT TEAM
Step-1 Delays in rounds by the duty doctor/ consultant team were captured using the patient file
(progress notes of the patient).
Step-2 Information regarding the delays conveyed to team leader & nursing supervisor of the floor by the
observer. The factors contributing to delays included the casual attitude of the team leader and
communication gap between assigned nurse and team leader about the arrival of the patient.
Step-3 Nursing supervisors educated the team leader for the continuity of information flow to the duty
doctor and team leaders educated nursing staff of the respective floor for maintaining the flow of
information .
DELAYS IN TRANSFER PROCESS
Step-1 Detection of the delays in the transfer process by the observer and contributing factors.
Step-2 Nursing supervisor informed about the delays and the factors contributing as nursing staff in-
efficiency & in-appropriate prioritization of the work by the assigned nurse for the patient.
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Step-3 Education of the nursing staff regarding the prioritization of the work & increasing their efficiency
by eliminating wasteful processes.
2. Circulation of the results of the pre-intervention transfer process with details of the deficiencies andareas of concerns and focus points in the various departments as follows:
ICU-2 incharge ICU-6 incharge ICU-7 incharge Nursing supervisors of 1st, 3rd & 4th floor.
3. Presentation of the results of the pre-intervention in the monthly meeting of the quality departmentfocusing the deficient areas and the focus areas.
4. Doctors (ICU-incharges) feedback for any changes in the In-house transfer summary sheet andadditions were recommended for the next prints of the In-house transfer summary sheet.
The Recommendations were:
1. Drug details2. Advisory orders by doctors (Critical care team & Consultant team)3. Dietary advisory column for doctors.
INTERVENTIONAL LAYOUT OF THE CONCERNS
E
Training of nursing staff
(wards) by nursing
supervisor to escalate the
call, in case interpreter is
not available.
Unavailabilityof interpreter
In-efficientmanagement
causing delay'sin transferprocess).
Incomplete "Inhouse transfer
summary sheet
Delays in roundsby duty doctorsand consultants
Training of nurses in order
to improve flow of
information from assigned
nurse to team leader (ward).
Orientation of Team leaders
by nursing supervisor to be
accountable for informing
duty doctor about arrival of
patient to ward.
Orientation of TL by Nursing supervisors about the planned
step down intimation mails sent a day prior.
ICU-supervisors informed about circulation of information
(mail) to Nightingale ward (1st floor) about the planned step-
downs a day prior to transfer.
Teamleaders oriented about
nursing roasters to be made a
day prior for planned step
downs and team leaders to be
more pro-active in assigning
duties.
ICU-nursing staff trained-
how to fill the in transfer
summary sheet by
Nursing- educator.
Training and orientation
for doctors - completing
form details.
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Suggestion:
1. Suggestion for Improvement in In-house transfer summary sheet was given by the observer , inorder to capture the transfer time taken from the ICU to the handover given to the ward nurse.
So, inclusion of the TIME at which patient is received by the ward nurse. Presently , the summary
sheet captures only the time of transferring ICU-nurse.
Table-3
Post-intervention -Transfer process from ICU to wards (% compliance):
Parameters % Present % Absent
Written orders from consultant & critical careteam
100 0
Room availability (Delays) 93 7
Co-ordination b/w ICU-supervisor & ward TL 93 7
Co-ordination b/w Assigned ward nurse & TL 60 40
Co-ordination b/w TL and Duty doctor 80 20
In house transfer summary sheet complete(doctors part)
80 20
In house transfer summary sheet complete
(nurses part)
67 33
Patient progress explained by ICU-nurse to ward
nurse verbally
100 0
ICU-transfer book complete 100 0Patient first seen by duty doctor/consultant team
(delays)
87 13
Note: The post intervention phase was from 17th July to 25th July. Wherein, again the patients were
shadowed during the transfer process and documented for the compliance rate. The post-intervention
shadowing was done to check the effectiveness of the interventions.
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Table-4: Comparison Pre & post intervention:
Parameters % Pre-compliance % post compliance
Written orders from consultant & critical care team 93 100
Room availability (Delays) 86 93
Co-ordination b/w ICU-supervisor & ward TL 86 93
Co-ordination b/w Assigned ward nurse & TL 64 60
Co-ordination b/w TL and Duty doctor 64 80
In house transfer summary sheet complete (doctors part) 57 80
In house transfer summary sheet complete (nurses part) 21 67
Patient progress explained by ICU-nurse to ward nurse verbally 100 100
ICU-transfer book complete 93 100
Patient first seen by duty doctor/consultant team (delays) 64 87
% Compliance pre and post intervention:
100
93 93
8686
64
6464
57
21
100
100
100 93
93
60
80
87
80
67
0
20
40
60
80
100
120
% Compliance Pre- intervention % Compliance Post-intervention
Sample size-14
Sample size-15
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CHAPTER 6.0
STUDY FINDINGS
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FINDINGS OF THE FIRST PHASE:
I. The primary research carried out was for the purpose of extracting the concerns associated withthe transfer process from ICU to wards.
II. The concerns associated were documented & discussed with the concerned departments.III. The primary data collected during the shadowing of the patients was checked for the compliance,
considering the various parameters, prepared as checklist in the process of the transfer of patients
from ICU to wards.
% COMPLIANCE OF THE VARIOUS PARAMETERS (PRE-INTERVENTION)
Parameters % Present % Absent
Interpreter required and available (sample size-2) 50 50
Written orders from consultant & critical care
team
93 7
Room availability (Delays) 86 14
Co-ordination b/w ICU-supervisor & ward TL 86 14
Co-ordination b/w Assigned ward nurse & TL 64 36
Co-ordination b/w TL and Duty doctor 64 36
In house transfer summary sheet complete
(doctors part)
57 43
In house transfer summary sheet complete
(nurses part)
21 79
Patient progress explained by ICU-nurse to ward
nurse verbally
100 0
ICU-transfer book complete 93 7
Patient first seen by duty doctor/consultant team
(delays)
64 36
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FINDINGS FOR SECOND PHASE:
I. The second phase of the study involved the discussions with the concerned departments anddesigning of the interventions.
II. The designed interventions were circulated to the various concerned departments.III. Implementation of the interventions for the concerns by the nursing supervisors of ICU-2,ICU-
6,ICU-7,1st floor, 3rd floor & 4th floor and the researcher.
IV. The concerns were addressed as follows:
E
Training of nursing staff(wards) by nursing
supervisor to escalate thecall, in case interpreter isnot available.
Unavailabilityof interpreter
In-efficientmanagement
causing delay'sin transferprocess).
Incomplete "Inhouse transfer
summary sheet
Delays in roundsby duty doctorsand consultants
Training of nurses in order
to improve flow of
information from assigned
nurse to team leader (ward).
Orientation of Team leadersby nursing supervisor to be
accountable for informing
duty doctor about arrival of
patient to ward.
Orientation of TL by Nursing supervisors about the planned
step down intimation mails sent a day prior.
ICU-supervisors informed about circulation of information
(mail) to Nightingale ward (1st floor) about the planned step-downs a day prior to transfer.
Teamleaders oriented about
nursing roasters to be made a
day prior for planned step
downs and team leaders to be
more pro-active in assigning
duties.
ICU-nursing staff trained-
how to fill the in transfer
summary sheet by
Nursing- educator.
Training and orientationfor doctors - completing
form details.
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FINDINGS OF THE THIRD PHASE:
I. The third phase of the study was done to review the effects of the interventions implemented toimprove the compliance rate.
II. The data collection in the third phase involved the shadowing of patients and documentation of thevarious parameters for their compliance.
% COMPLIANCE OF THE VARIOUS PARAMETERS (POST-INTERVENTION)
Parameters % Present % Absent
Written orders from consultant & critical care
team
100 0
Room availability (Delays) 93 7
Co-ordination b/w ICU-supervisor & ward TL 93 7
Co-ordination b/w Assigned ward nurse & TL 60 40
Co-ordination b/w TL and Duty doctor 80 20
In house transfer summary sheet complete
(doctors part)
80 20
In house transfer summary sheet complete
(nurses part)
67 33
Patient progress explained by ICU-nurse to ward
nurse verbally
100 0
ICU-transfer book complete 100 0
Patient first seen by duty doctor/consultant team
(delays)
87 13
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The study showed that there is an established process flow for the transfer of patients from ICU to wards to
smoothen the transfers. Whereas, some concerns were identified in the process by the observer.
The retrospective study of the Unplanned Returns to ICU Within 48 hours showed a trend where
in the 2 months i.e. May & June the returns to ICU remained same with 3 cases. Whereas, in the month of
July the number of unplanned returns to ICU dropped down to 1 case.
The transfer process from ICU to Wards in the Phase-1 of the study included the data collection of
pre-interventional phase in order to check for the compliance in the process. After the compliance rate was
calculated and the concerns associated with the process were documented.
The second phase of the study included the Designing of interventions for the concerns associated
with the transfer process and implementation of the designed interventions by the nursing supervisor. The
concerns were addressed by the observer to nursing supervisor. The compliance results against various
parameters were circulated to the ICU-2 incharge, ICU-6-incharge, ICU-7-incharge, nursing supervisors of
1st, 3rd & 4th floor.
The third phase of the study was done to check the effectiveness of the interventions taken in the
second phase of the study. In this phase the various parameters of the transfer process were checked for its
compliance rate.
The comparison of the results of pre-intervention and post-intervention showed that the
interventional programme played an effective role where it shows a marked improvement in the
compliance rate of every parameter under the study. Therefore, contributing to streamline the transfer
process from ICU to wards.
The effectiveness of the interventions contributed to the reduction in the Unplanned returns to ICU Within
48 hours, which was reduced to 1case in the month of July to 3 cases in the month of MAY & JUNE.
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CHAPTER 8.0
LIMITATIONS
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Sample size was small.
ICU-1 & ICU-9 were not involved in the study. There was a time-constraint. Indirect involvement of observer in the interventional programme.
Suggestion:
The study can be isolated to the specific ICUs as Medical, Surgical and CTVS as than results canbe compared for any difference in the outcomes in the work flow with more accuracy as needs varyamong all the ICUs.
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