How Can We Prevent the ICU Team in Transferring our Dad to the Ward Too Soon?

Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in Intensive Care!

This is another episode of “YOUR QUESTIONS ANSWERED” and in last week’s episode I answered another question from our readers and the question was

Is My Dad At The Right Hospital Ward For His Needs? He Seems To Be Getting Less Care Here. Help!

You can check out last week’s question by clicking on the link here.

In this episode of “YOUR QUESTIONS ANSWERED” I want to answer a question from one of my clients Anna as part of my 1:1 consulting and advocacy service! Anna is disappointed with her dad’s fast turnover from ICU to the general ward and she is asking how they can prevent the ICU team in transferring her dad to the ward too soon.

How Can We Prevent the ICU Team in Transferring our Dad to the Ward Too Soon?

Hi Anna,

You should trust that they assessed his cough appropriately and if the description is accurate from the matron he will be able to manage and protect his airway. It sounds like contingency is in place at least on paper if your Dad was to deteriorate! You just need to keep an eye on it. As long as they don’t make decisions over your and your Dad’s head it’ll be fine! If what they are saying is accurate it was about time to leave ICU. ICU is not a great environment, so look at the positives for now! You probably should still clarify the DNR status and also ask your Dad. It sounds like there is no DNR at present but you need to clarify to get certainty!

Kind Regards

Patrik

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Hi Patrik,

Thanks so much Patrik, as ever. Well, I rang ICU right away this morning to discover that Dad was already being discharged to the neuro rehab ward today!!!! I asked could someone ring me back urgently and the senior matron called me back. She is very nice – I have watched her with other patients and with dad on occasion and think she is excellent. She appraised me of the situation.

The multidisciplinary team met this morning and felt Dad is safe to leave ICU for neuro rehab on these grounds:

13 days off the ventilator successfully with no contraindications

Tracheostomy removed and internal tube removed yesterday with no adverse effects

Breathing stable and oxygen saturation levels above 92

Strong cough reflex

Vital signs consistently stable

No delirium

The physio team reported dad sat on the edge of the bed himself this morning and then stood up unaided. They were amazed. They told me they are thrilled with Dad’s progress over the last 10 days and feel this is the window of opportunity to grasp his next stage of rehab.

She said they feel Dad has the best chance of recovering outside of ICU and that they rate the neuro rehab ward. She said Dad will be under the same physio team. She also said the speech & language therapist had already popped up to see dad and will be assessing his swallow once he’s settled in.

I asked about secretion management; she said Dad will manage it in the same way with the mouth suction tool himself. I told her I’m worried about him aspirating on his secretions but she said he has a very strong, good cough and can clear into his mouth well. She said he can spit it out or suction it, whatever he feels comfortable with.

She explained that once a patient is conscious and able to communicate, stable and able to breathe, they are safe to leave ICU.

I told her we are very concerned about Dad being a high-risk transfer and that we don’t want him to fall at the first hurdle. She told me she wanted to assure me that they wouldn’t discharge Dad if he wasn’t safe and that they have come to know and care for Dad these last 3 months and want to see him do well.

I told her that numerous consultants had told us that Dad wouldn’t be readmitted to ICU if he required it after discharge. I said that was not acceptable and was duty bound to challenge it. She said that has changed now: the ICU consultant on duty feels Dad is of sound mind and spent a long time talking to him 1-1 about all aspects of his time there and his care.

She said the consultant felt Dad had a good understanding of what had happened to him and the subsequent weeks. More importantly, that Dad had told him that he wanted to recover and continue to have all available treatments. So they told me that, if Dad were to deteriorate, he would be scored and if required an ICU doctor would come to assess him, and would readmit him if clinically necessary.

She said the nurse-patient ratio on the neuro rehab ward is 1-6. She said Dad will be in a high visibility bed with the nurse and auxiliary fairly close. She says they would remain in contact with the ward to keep an eye on Dad.

The plan is that he would start in the rehab ward, and then move to the residential rehab unit which is more of a home-from-home, with the goal of transferring Dad home eventually. Dad would be under the care of the consultant neurologist who leads the ward and the residential rehab unit.

As ever I’d really welcome your thoughts Patrik. I’m disappointed that things moved so quickly beyond my control and that I was unable to stall Dad’s transfer out of ICU. I know in many ways it’s a positive step that it’s felt he is well enough to leave! We just worry as a family what would happen if he has a setback.

Many thanks & best wishes

Anna

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Hi Anna,

Ok thank you Anna for shedding more light on the situation. I can see why you are so concerned!

Now there is a bigger picture forming with more information! Please see comments below!

Please let me know what else you need or want to know!

Kind Regards,

Patrik

Hi Patrik,

This is all so helpful as always!

To answer your question, they’ve never talked about specific timescales, but they certainly never implied it would be a quick process moving from weaning to tracheostomy removal to transfer. Indeed, they have always talked negatively about how slow the pace has had to be to match Dad’s extremely slow recovery (which has never been an issue to us of course, but clearly has been to them!!!)

Patrik: Yes, absolutely. Again, the worst case scenario for an ICU is to look after a critically ill Patient indefinitely with an uncertain outcome! Your Dad fits that criteria! ICU is trying to manage their worst case scenario, whereas you are trying to manage your worst case scenario which is losing your Dad!

At a meeting with one of the consultants and senior matrons a few weeks ago, they cautioned us about the reality of transferring him out to the rehab ward. He won’t get the monitoring, he won’t get the nurse-patient ratio, he won’t get the same level of physio. They told us he is fragile and could deteriorate very quickly there, and that by the time it was noticed the outlook may be too serious to recover from.

Patrik: This is probably accurate what they are describing. You certainly had to watch and manage ICU staff, the next challenges are ahead and you will need to watch and manage the ward staff! He could deteriorate very quickly but they have been negative all the way along and that hasn’t stopped you or your Dad and he does keep improving. Have they looked at long-term Rehab in a proper Rehab facility? Who is going to be his primary doctor once he will have left ICU?

I don’t think they actually thought about the significance of what they were telling us, but for my sister and me especially, it was important information. It made us determined to protect his care so that he leaves ICU with the lowest risk factors possible. I can see that Dad is still very weak and if he is as fragile as they say, my instincts are that another week (or two) of monitoring could be what he needs. It would help inform the picture going forward for us as a family.

Patrik: Ok, this is excellent information! You should then definitely ask for another week or two for the very reasons that they shared with you that going to the ward too early could potentially kill your Dad.

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Also he still needs a lot of help suctioning. The night before last he barely slept as he had a lot of secretions he needed help with. How successfully would this be dealt with on the neuro rehab ward? What are the risks of aspiration Patrik if he’s moved out of ICU too soon?

Patrik: The questions here is if your Dad can cough and protect his own airway? If he can cough and get rid of his sputum without any suctioning in his throat he should be able to protect himself from aspiration from secretions. In order to do that successfully he will need to have strong cough though! Is your Dad eating and drinking? Has he had speech and swallow therapy? If he can eat and drink he should also be able to protect his airway and not aspirate.

I’m suspicious because throughout we’ve had mixed messages. Just a week ago Patrik, another consultant told my Stepmom Martha that she didn’t think Dad would successfully wean and have the tracheostomy removed, that he would never be safe to leave ICU, that he was unlikely to recover further from the delirium in her view and fast forward a week Dad has weaned and fad the tracheostomy removed; his neurology is improving every day -and suddenly the message is different. Now it suits them, he is apparently ok to leave ICU!

Patrik: Yes, now they may take the “sink or swim” approach and yet your Dad has to recover in his own time! Keep asking them to keep him in ICU. The level of care will significantly decrease on the ward!

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A lot of it will really depend what skill level is available on the ward from the nurses, Physiotherapy and also if there is an ICU outreach or ICU liaison team that will keep an eye. Until you found out about ICU liaison and ICU outreach, keep him in the ICU until you know that he can safely manage his secretions without the risk of aspiration! An aspiration Pneumonia could set him back big time!

Many thanks again

Best wishes

Anna

The 1:1 consulting session will continue in next week’s episode.

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