Critical care survivors experience multiple care transitions, with no formal follow-up care pathway. What are the potential solutions to improve the communication between treating teams and integration of care following an ICU admission, from the perspective of patients, their caregivers, intensivists, and general practitioners (GPs) from diverse socioeconomic areas? This study included a qualitative design using semi-structured interviews with intensivists, GPs, and patients and caregivers. Framework analysis was used to analyze data and to identify solutions to improve the integration of care following hospital discharge. Patients were previously mechanically ventilated for > 24 h in the ICU and had access to a video-enabled device. Clinicians were recruited from hospital networks and a state-wide GP network. Forty-six interviews with clinicians, patients, and caregivers were completed (15 intensivists, 8 GPs, 15 patients, and 8 caregivers). Three higher level feedback loops were identified that comprised 10 themes. Feedback loop 1 was an ICU and primary care collaboration. It included the following: (1) developing collaborative relationships between the ICU and primary care; (2) providing interprofessional education and resources to support primary care; and (3) improving role clarity for patient follow-up care. Feedback loop 2 was developing mechanisms for improved communication across the care continuum. It included: (4) timely, concise information-sharing with primary care on post-ICU recovery; (5) survivorship-focused information-sharing across the continuum of care; (6) empowering patients and caregivers in self-management; and (7) creation of a care coordinator role for survivors. Feedback loop 3 was learning from post-ICU outcomes to improve future care. It included: (8) developing comprehensive post-ICU care pathways; (9) enhancing support for patients following a hospital stay; and (10) integration of post-ICU outcomes within the ICU to improve clinician morale and understanding. Practical solutions to enhance the quality of survivorship for critical care survivors and their caregivers were identified. These themes are mapped to a novel conceptual model that includes key feedback loops for health system improvements and foci for future interventional trials to improve ICU survivorship outcomes.

中文翻译：

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临床医生和患者确定的解决方案可减少澳大利亚 ICU 术后护理的分散性


重症监护幸存者经历多次护理过渡，没有正式的后续护理途径。从来自不同社会经济领域的患者、其护理人员、重症监护医生和全科医生 (GP) 的角度来看，改善治疗团队之间的沟通以及入 ICU 后的护理整合有哪些潜在的解决方案？这项研究包括使用对重症医生、全科医生、患者和护理人员的半结构化访谈进行的定性设计。使用框架分析来分析数据并确定改善出院后护理一体化的解决方案。患者之前在 ICU 接受机械通气超过 24 小时，并且可以使用支持视频的设备。临床医生是从医院网络和全州全科医生网络中招募的。完成了对临床医生、患者和护理人员的 46 次访谈（15 名重症医生、8 名全科医生、15 名患者和 8 名护理人员）。确定了三个更高级别的反馈循环，其中包含 10 个主题。反馈环 1 是 ICU 和初级保健部门的合作。它包括以下内容：（1）发展 ICU 和初级保健之间的合作关系； (2) 提供跨专业教育和资源以支持初级保健； (3) 提高患者后续护理的角色清晰度。反馈环 2 正在开发改善整个护理连续体沟通的机制。其中包括：(4) 与初级保健机构及时、简明地分享有关 ICU 后康复的信息； (5) 在整个护理过程中以幸存者为中心的信息共享； (6) 赋予患者和护理人员自我管理的能力； (7) 为幸存者设立护理协调员角色。反馈循环 3 是从 ICU 后的结果中学习，以改善未来的护理。 它包括：(8) 制定全面的 ICU 后护理途径； (9) 加强对住院患者的支持； (10) 将 ICU 后的结果整合到 ICU 内，以提高临床医生的士气和理解。确定了提高重症监护幸存者及其护理人员生存质量的实用解决方案。这些主题被映射到一个新颖的概念模型，其中包括卫生系统改进的关键反馈循环和未来干预试验的重点，以改善 ICU 生存结果。