Unplanned early hospital readmission among critical care survivors: a mixed methods study of patients and carers

BACKGROUND: Many intensive care (ICU) survivors experience early unplanned hospital readmission, but the reasons and potential prevention strategies are poorly understood. We aimed to understand contributors to readmissions from the patient/carer perspective. METHODS: This is a mixed methods study with qualitative data taking precedence. Fifty-eight ICU survivors and carers who experienced early unplanned rehospitalisation were interviewed. Thematic analysis was used to identify factors contributing to readmissions, and supplemented with questionnaire data measuring patient comorbidity and carer strain, and importance rating scales for factors that contribute to readmissions in other patient groups. Data were integrated iteratively to identify patterns, which were discussed in five focus groups with different patients/carers who also experienced readmissions. Major patterns and contexts in which unplanned early rehospitalisation occurred in ICU survivors were described. RESULTS: Interviews suggested 10 themes comprising patient-level and system-level issues. Integration with questionnaire data, pattern exploration and discussion at focus groups suggested two major readmission contexts. A 'complex health and psychosocial needs' context occurred in patients with multimorbidity and polypharmacy, who frequently also had significant psychological problems, mobility issues, problems with specialist aids/equipment and fragile social support. These patients typically described inadequate preparation for hospital discharge, poor communication between secondary/primary care, and inadequate support with psychological care, medications and goal setting. This complex multidimensional situation contrasted markedly with the alternative 'medically unavoidable' readmission context. In these patients medical issues/complications primarily resulted in hospital readmission, and the other issues were absent or not considered important. CONCLUSIONS: Although some readmissions are medically unavoidable, for many ICU survivors complex health and psychosocial issues contribute concurrently to early rehospitalisation. Care pathways that anticipate and institute anticipatory multifaceted support for these patients merit further development and evaluation.