Background: With the advancement of technology and medical care, more critically ill patients are surviving the medical intensive care unit (ICU) and are transferred to the general wards, where they spend the majority of their hospitalization. While there are guidelines that address common complications in the ICU (delirium and functional decline), once patients are transferred out of the ICU, hospitalists operate without guidance. This study aimed to characterize the unmet needs of ICU survivors on the general wards.
Methods: A multi-site, retrospective chart review (1/1/2017 – 12/31/2017) of randomly selected patients who were admitted to the medical ICU from the emergency department and subsequently transferred to the medical ward. Exclusion criteria included patients who were admitted for acute stroke s/p TPA and those with DKA. The EHR was reviewed to collect patient demographic information and the frequency of unaddressed conditions that occurred after transfer to the medical ward. Conditions were based on evidenced based ICU guidelines (PADIS and ABCDEF bundle), and included dysphagia, immobility, delirium, malnutrition, use of high-risk medications, new indwelling urinary catheters, and advanced directives.
Results: Of the 400 charts that were reviewed, 151 patients met inclusion criteria. Amongst this cohort, the median age was 64 (SD ± 19.13), 73% were female and 67% were White. The most frequent admission diagnoses to the ICU were sepsis (54%), respiratory failure (51%) and gastrointestinal bleeding (12%). Just under one-quarter of patients (23%) demonstrated surrogate markers for delirium (restraint use 4.6%, new antipsychotic use 12.0%, and constant observation 13.3%). One quarter (25.0%) of patients still had an indwelling urinary catheter (new from admission) on the medical ward. Over one quarter (25.8%) of patients had bedrest orders on the wards and 34.3% had evidence of functional decline during the post-ICU period. With regard to pain control, 23.8% patients had opiates ordered on the floor and of those, only 58.5% had a concomitant order for acetaminophen. Fifteen percent of patients received new benzodiazepine on the ward. Nearly half of the patients (45.6%) had an NPO order on the floor, with 31% requiring speech and swallow and 20% modified barium evaluations. The majority (77.0%) of ICU survivors did not have documentation of advanced directives; only 10% had documented advanced directives prior to transfer and an additional 13% were addressed on the ward.
Conclusions: For ICU survivors, complications that are frequent in the ICU setting persist and are often unaddressed on the medical wards. Future studies are urgently needed to further characterize the early ICU aftercare period and address potential unmet needs.