Transition of care at discharge from the Intensive Care Unit: a scoping review

Objective: to map the available evidence on the components of the transition of care, practices, strategies, and tools used in the discharge from the Intensive Care Unit (ICU) to the Inpatient Unit (IU) and its impact on the outcomes of adult patients. Method: a scoping review using search strategies in six relevant health databases. Results: 37 articles were included, in which 30 practices, strategies or tools were identified for organizing and executing the transfer process, with positive or negative impacts, related to factors intrinsic to the Intensive Care Unit and the Inpatient Unit and cross-sectional factors regarding the staff. The analysis of hospital readmission and mortality outcomes was prevalent in the included studies, in which trends and potential protective actions for a successful care transition are found; however, they still lack more robust evidence and consensus in the literature. Conclusion: transition of care components and practices were identified, in addition to factors intrinsic to the patient, associated with worse outcomes after discharge from the Intensive Care Unit. Discharges at night or on weekends were associated with increased rates of readmission and mortality; however, the association of other practices with the patient’s outcome is still inconclusive.

to assess the elements identified, adapted to local needs and contexts before widespread implementation (4) . The association between different discharge practices and patient outcomes was also not assessed.
Thus, this study intends to map the available evidence on the components of the transition of care, the practices, strategies and tools used in the discharge of patients from the ICU to the IU and the impact on the outcomes of adult patients.

Results
The search in the databases identified 2,124 potentially eligible studies and another four articles were selected from the references, 37 remaining in the final sample, as shown in Figure 2.
The characteristics of the articles are summarized in   The transition of care components presented in the studies are extremely varied, ranging from factors related to the patient (11,(19)(20)(21) , going through the practices, strategies and tools used for the organization and execution of the transfer process (22)(23)(24) , to factors related to the unit to which the patient will be transferred (11,24) .
The factors related to the patient, identified in the primary studies, are severity of the disease (11,(19)(20)(21) , presence of comorbidities (11,19) , presence of tracheostomy, older age (19)(20) , altered state of consciousness, need for greater use of supportive therapies in the ICU, longer ICU stay, need for dialysis, and clinical causes of admission (20) . They are evidenced as predisposing factors for worse outcomes of the patients after being discharged from the ICU, such as adverse events or readmissions, in the perception of the professionals involved (11,21) , the association with the increase in readmission and mortality rates also being quantitatively verified (19)(20) .
Some barriers are found for the continuity of care in the follow-up of the ICU, among these, the absence of specific discharge criteria and a feedback culture, the overestimation by the ICU team on the ability of the IU to monitor complex patients (25) , the change of health professionals, the changes in routines, and the substantial decrease in human resources and monitoring materials (13,21,(24)(25) .
On the other hand, several practices are identified as potential tools to improve the quality of transition of care and patient safety. One of the practices suggested is the adoption of a transfer checklist with items to check whether the patient is ready and the necessary adjustments before discharge, such as removal of invasive devices and medication reconciliation (23,26) . The oral or written communication was analyzed by several studies in different aspects. The use of a structured communication process using transfer of patients at bedside and standardized tools with multi-modal communication are strategies suggested (23,27) .
The involvement and preparation of the family is presented as an essential stage in the discharge process, with individual assessment of the information needs, preparing the family to adjust to a different environment with less staff, technology and support (28) . A study that Rev. Latino-Am. Enfermagem 2020;28:e3325.
investigated family members' perceptions about the quality of care during the transfer process showed that the information about the transfer was significant for them, as they wanted to be part of the patient care and felt important when they had some vision and control over the necessary assistance. However, more than 20% felt that the information provided to them was inadequate (29) .
Another positive practice evidenced in the studies is being monitored or advised after discharge by  outcomes.
Practices, strategies and tools with potential positive or negative impact on the transition from the Intensive Care Unit to the Inpatient Unit Impact

Factors related to the Intensive Care Unit
Discharge at night (11, Transfer of care to their respective peers by all members of the multidisciplinary team (43) Positive

Factors related to the Inpatient Unit
Lack of qualification and experience by the staff (11,25,
In studies with qualitative approaches on readmissions (21) or post-discharge adverse events (11) , in the view of the care providers, factors related to the patient are listed, such as severity of the disease, undefined care goals, transfers at shift changes, nights or weekends, inadequate decision for discharge, professionals' lack of experience (11,21) , limited resources, lack of institutional policies (21) , staff sizing and inadequate monitoring in the IU, choosing the wrong destination for the patient and fragmenting care in several teams (11) . . Discharges with delays of more than 24 hours showed a significant association with a higher incidence of delirium (40) . Medication reconciliation or pharmaceutical intervention by reviewing medications prior to patient transfer may contribute to a decrease in the number and severity of medication-related problems; however, the impact on the mortality rate, length of hospital stay or ICU readmission is still inconclusive (49) . Using a medical alert form for the most vulnerable patients with guidance to the IU team, in addition to improvements in oral communication, tended to reduce readmission rates and calls to the RRT (43) .
On the other hand, some studies that tried to IU nurses) did not achieve significant results in reducing bad outcomes such as readmission and mortality (13)(14)(39)(40) .

Discussion
The 37 studies were published uniformly over According to the results identified, the transition of care in the discharge from intensive care is influenced by numerous components, whether intrinsic to the patient or related to the policies, practices or structure of the scenarios and professionals involved. Likewise, a previous study (4) identified countless themes and factors related to professionals and the institution, which can act as facilitators or barriers to high quality care, confirming that being discharged from the ICU is a multifaceted and complex process.
With regard to factors related to the patient, conditions were identified that may predispose to worse outcomes after discharge from the ICU, especially conditions prior to discharge, such as the comorbidities and severity at the moment of hospitalization (11,(19)(20)(21) , older age (19)(20) , altered state of consciousness, and greater need for supportive therapies (20) . These findings are similar to other studies which identified that sicker patients, with greater severity at the moment of hospitalization (53) and older patients (9) had a greater chance of adverse events, readmission, and death after being discharged from intensive care. The altered state of consciousness was also found as a risk factor, along with polyneuropathy, myopathy and being discharged from the ICU using tube feeding, which often affect critically ill patients (53)(54) .
Such factors are intrinsic to the patients, that is, they cannot be changed; therefore, they suggest the need to adopt specific strategies according to the profile and the individual demands of each patient, providing optimization and careful evaluation of the right moment for discharge, anticipated planning, more supervision for patients with greater severity, choice of the best destination unit or resizing of personnel and care for the most complex and dependent patients in the IU, in addition to stimulating greater family support, among other actions (11,23) .
Based on the 37 studies included, 30 practices, strategies and tools with a potential positive or negative impact were verified in the transition from the ICU to the IU, of which 21 were related to the ICU, seven were related to IU and two related to both.
It is observed that most applies to the execution of the transfer, monitoring and care provided after the transfer, with a smaller portion representing actions taken in advance, such as planning individual needs, assessing readiness for discharge and preparing the people involved (team-patient-family).
A previous study (4)  Attention is drawn to studies that highlight the phase of discharge execution more than the other phases.
In addition, actions focused on patient-centered care were commonly verified in studies with pediatric and neonatal patients, suggesting that there is a long way to go in the care of adult patients (4) . The medication review by a pharmacist before transferring the patient to the IU proved to be effective in reducing the number and severity of medicationsrelated problems (49) , although the impact on outcomes such as mortality and readmission is inconclusive (14,49) .
A recent study (61) found that medication reconciliation by a pharmacist reduced errors in medication transfer, potential adverse events, and related costs.
The choice of the destination can be a decisive factor in the patient's outcomes, as in the example of the availability of intermediate care units; however, its impact is still controversial, both in the analyzed articles (14,50) , and also as noted by other authors (52,62) . In a study conducted in Brazil, referral to an intermediate care unit did not affect in-hospital mortality or the incidence of readmissions in the ICU (52) , while other study showed a significantly lower risk of readmission for patients transferred to an intermediate care unit (62) .
The follow-up or guidance after discharge by members of the intensive care team is one of the strategies with a potential positive impact on the patients' outcomes, as evidenced by some studies, showing a decrease in the length of hospital stay (31) and in the ICU readmission rate (31,47) ; however, there was no consensus (13)(14) . Corroborating these findings, a meta-analysis carried out in 2014 identified that transition of care programs focused on the followup after discharge from the intensive care were associated with reduced risk of readmission to the ICU (6) . The programs were developed by medical emergency teams or liaison nurses who did follow-up or offered consultations to patients after discharge from the ICU, but the team members did not always have prior contact with the patient before discharge.
Thus, there is a need for more research to prove the real impact of the programs and services of follow-up after discharge from the ICU.
Few studies were devoted to assessing other adverse outcomes; however, it is important to note that not all patients undergoing an inadequate transition process evolve to death or readmission but, even so, they may be subjected to unwanted repercussions with serious consequences, such as the need to change or increase the length of treatment, increased length of hospital stay, disabilities, increased hospital costs, and dissatisfaction (9) .
A recent study found that 21% of the discharged at discharge from the ICU, presented a higher risk regardless of deterioration. In addition to these factors intrinsic to the patient, it was found that the patient being ready for discharge less than 48 hours before was an independent risk factor, which may indicate insufficient time for planning the transition of care (63) .
A broader analysis of the adverse outcomes due to failures in the ICU discharge process is essential, considering its potential impact on outcomes that