Rationing intensive care. Intensive care provision varies widely in Britain

Discharge delay, room for improvement?

AIM

Patients treated in the intensive care unit (ICU) and identified as suitable for discharge to the ward should have their discharge planned and expedited to improve patient outcomes and manage resources efficiently. We examined the hypothesis that the introduction of a critical care outreach role would decrease the frequency of discharge delay from ICU.

METHODS

Discharge delay was compared for two 6-month periods: (1) after introduction of the outreach role in 2008 and (2) in 2000/2001 (from an earlier study). Patients were included if discharged to a ward in the study hospital. Discharge times and reason for delay were collected by Critical Care Outreach Nurses and Critical Care Nurse Specialists.

RESULTS

Of the 516 discharges in 2008 (488 patients compared to 607 in 2000/2001), 31% of the discharges were delayed from ICU more than 8h, an increase of 6% from 2000/2001 (p<0.001). Patients in 2008 spent more in hospital from the time of their ICU admission when their discharge was delayed (p<0.001). The most common reasons for delay in 2008 were due to no bed or delay in bed availability (53%) and medical concern (24%). This is in contrast to 2000/2001 when 80% of delays were due to no bed or delay in bed availability and 9% due to medical concern. Many factors impact on patient flow and reducing ICU discharge delays requires a collaborative, multi-factorial approach which adapts to changing organisational policy on patient flow through ICU and the hospital, not just the discharge process in ICU.

Impact of intensive care unit discharge time on patient outcome

OBJECTIVE

To determine the impact of nighttime intensive care unit (ICU) discharge on patient outcome.

DESIGN

Multiple-center, retrospective observational cohort study.

SETTING

Canadian hospitals.

PATIENTS

We used a prospectively collected dataset containing information on 79,090 consecutive admissions from 31 Canadian community and teaching hospitals.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were categorized according to the time of ICU discharge into daytime (07:00-20:59) and nighttime (21:00-06:59). Admissions were excluded if the patients were a) </=16 yrs of age (392); b) admitted following cardiac surgery (6,641); c) admitted following the initial admission for patients readmitted to the ICU within the same hospital stay (3,632); d) admitted due to a lack of available ward or specialty care beds (457); or c) transferred to another acute care facility (7,724). We found that 62,056 patients were discharged to the ward following the initial ICU admission. Of the 47,062 discharges eligible for analyses, 10.1% were discharged at night. The unadjusted odds of death for patients discharged from ICU at night was 1.35 (95% confidence interval, 1.23, 1.49), compared with patients discharged during the daytime. After adjustment for illness severity, source, case-mix, age, gender, and hospital size, the mortality risk was increased by 1.22-fold (95% confidence interval, 1.10, 1.36) for nighttime discharges. Multivariate regression analysis revealed that patients discharged from the ICU at night have a significantly shorter ICU length of stay than those discharged during the day (p < .001). Whereas hospital length of stay was similar for daytime and nighttime discharges who survived hospital stay, patients discharged at night who did not survive hospital stay had a significantly shorter hospital length of stay (p = .002).

CONCLUSIONS

Patients discharged from the ICU at night have an increased risk of mortality compared with those discharged during the day.

The impact of an ICU liaison nurse on discharge delay in patients after prolonged ICU stay

The mismatch between intensive care unit (ICU) bed availability and demand may be improved with timely patient discharges, however little is known about the nature and contributing factors of discharge delays. This study investigated the impact of a specific intervention--the ICU liaison nurse role--in reducing ICU discharge delay using a prospective block intervention study. One hundred and eighty-six ICUpatients (101 control and 85 liaison nurse intervention) with an ICU length of stay of three days or longer and who survived to ICU discharge were examined. The liaison nurse was involved in assessment of patients for transfer to the ward, with a major focus on coordinating patient transfer including liaison with ward staff prior to and following ICU discharge. Logistic regression was used to quantify the risk of discharge delay associated with the liaison nurse intervention with adjustment for potential confounding variables. While no demographic or clinical variables were significant predictors of ICU discharge delay, those in the liaison nurse group were almost three times less likely to experience a discharge delay of at least two hours and about 2.5 times less likely to experience a delay of four or more hours. The positive effect of the liaison nurse role in reducing the discharge delay remained after adjustingforpotential confounders. We conclude that the liaison nurse role is effective in reducing the discharge delay in ICU transfer

External validation of the SAPS II, APACHE II and APACHE III prognostic models in South England: a multicentre study

OBJECTIVE

External validation of three prognostic models in adult intensive care patients in South England. DESIGN. Prospective cohort study.

SETTING

Seventeen intensive care units (ICU) in the South West Thames Region in South England.

PATIENTS AND PARTICIPANTS

Data of 16646 patients were analysed.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We compared directly the predictive accuracy of three prognostic models (SAPS II, APACHE II and III), using formal tests of calibration and discrimination. The external validation showed a similar pattern for all three models tested: good discrimination, but imperfect calibration. The areas under the receiver operating characteristics (ROC) curves, used to test discrimination, were 0.835 and 0.867 for APACHE II and III, and 0.852 for the SAPS II model. Model calibration was assessed by Lemeshow-Hosmer C-statistics and was Chi(2 )=232.1 for APACHE II, Chi(2 )=443.3 for APACHE III and Chi(2 )=287.5 for SAPS II.

CONCLUSIONS

Disparity in case mix, a higher prevalence of outcome events and important unmeasured patient mix factors are possible sources for the decay of the models' predictive accuracy in our population. The lack of generalisability of standard prognostic models requires their validation and re-calibration before they can be applied with confidence to new populations. Customisation of existing models may become an important strategy to obtain authentic information on disease severity, which is a prerequisite for reliably measuring and comparing the quality and cost of intensive care.

Consequences of discharges from intensive care at night

BACKGROUND

It is generally believed that pressure for beds on intensive-care units (ICUs) has increased in the UK. This study used discharge at night as a proxy measure to investigate pressure.

METHODS

Night was defined in two ways: "out of office hours' from 2200 to 0659 h and "the early hours of the morning" from 0000 to 0459 h. The rate of discharge at night was compared for 21 295 adult admissions to 62 ICUs covering the period 1995-98 with 10806 admissions to 26 ICUs covering the period 1988-90. With data solely from 1995-98, the consequences of discharge at night and premature discharge were investigated.

FINDINGS

Overall, 2269 (21.0%) admissions did not survive the ICU in 1988-90 compared with 4487 (21.1%) in 1995-98. Of ICU survivors, 2.7% were discharged at night (2200-0659 h) in 1988-90 compared with 6.0% in 1995-98. In 1995-98, night discharges (2200-0659 h) had a higher crude (odds ratio 1.46, 95% CI 1.18-1.80) and case-mix adjusted (1.33, 1.06-1.65) ultimate hospital mortality. Higher odds ratios were observed when the definition of night was 0000-0459 h. Premature discharge was commoner at night, 42.6% vs 5.0% and its importance was apparent when incorporated into the logistic-regression model (premature discharge 1.35, 1.10-1.65; night discharge 1.17, 0.92-1.49).

INTERPRETATION

Night discharges from ICU are increasing in the UK. This practice is of concern because patients discharged at night fare significantly worse than those discharged during the day. Night discharges are more likely to be "premature" in the view of the clinicians involved. The implication of these results is that many hospitals have insufficient intensive-care beds. In deciding whether or not to invest more resources in intensive care we must, however, consider the cost-utility of this particular service compared with other ways that additional resources could be used.

Comparison of outcome from intensive care admission after adjustment for case mix by the APACHE III prognostic system

STUDY OBJECTIVES

To evaluate the acute physiology, age, chronic health evaluation III (APACHE III) scoring system in the context of general adult ICUs in the United Kingdom.

DESIGN

Prospective, noninterventional, cohort study.

SETTING

Seventeen general adult ICUs in a discrete area of southwest England.

PATIENTS

12,793 patients admitted between April 1, 1993 and December 31, 1995.

MEASUREMENTS

Sociodemographic and severity-of-illness data were collected for all patients admitted to the study units. Formal goodness-of-fit tests were applied and observed mortality was compared with that predicted by using the APACHE III system.

RESULTS

For the group of ICUs as a whole, the risk-adjusted standardized mortality ratio (SMR) was 1.23 (95% confidence intervals, 1.12-1.25). For 11 out of 17 ICUs, the SMR was significantly greater than unity (p < 0.05). Calibration, as tested by Hosmer-Lemeshow statistics, was poor (H2 = 312.54; C2 = 332.85; df = 8; p < 0.01); however, model discrimination was good with a total correct classification rate of 82.9% and an area under the receiver operating characteristic curve of 0.89.

CONCLUSIONS

The excess mortality observed after case-mix adjustment using the APACHE III system in this study may be the result of either poor intensive care performance as compared with the United States or a failure of the APACHE III equation to fit the UK data.

Analysis of intensive care populations to select possible candidates for high dependency care

OBJECTIVES

To identify the proportion, and range across intensive care units, of intensive care patients who might potentially be managed on a high dependency unit (HDU) using three different classification systems.

METHODS

8095 adult patients admitted to 15 intensive care units in the south of England between 1 April 1993 and 31 December 1994 were studied. Patients were identified as potential HDU admissions if their APACHE III derived risk of hospital mortality was < or =10%, if they were categorised as a low risk monitor (LRM) patient using the Wagner risk stratification method, or if they did not require advanced respiratory support (ARS).

RESULTS

4146 patients (51.2%) had an APACHE III derived risk of hospital death of < or =10%, 1687 (20.8%) were classified as LRM, and 3860 (47.7%) did not receive ARS. The values for each intensive care unit ranged from 32.8-63.3% (APACHE III group), 7.2-29.9% (LRM group), and 14.4-68.2% (ARS group). No matter which of the three methods was used, there were significant differences between the 15 units (p<0.0001) with regard to the number of potential HDU patients identified within the scored population.

CONCLUSIONS

The percentage of intensive care patients who might be more appropriately managed in a HDU varies considerably between hospitals, and depends upon both local circumstances and the method used to define a high dependency patient. However, whichever method is used, it appears that significant numbers of patients of low dependency status currently fill intensive care beds in the units studied. If these analyses are correct, the perceived national shortage in intensive care beds might be improved by the development of HDUs.

Intermediate care, possibilities, requirements and solutions

The inadequate supply of intensive care facilities has focused interest on intermediate care as a means of bridging the gulf between the level of support available in the intensive care unit and the general ward. However, few hospitals have developed intermediate care, in the form of high-dependency care units, and little information exists concerning the use or potential of such areas. Therefore, this review proposes to cover the definition of intermediate care and to discuss some of the possible reasons why intermediate care is now believed necessary. The capabilities of intermediate care for selected groups of patients and the treatment modalities offered are described. The present provision of high-dependency care in the United Kingdom is discussed and the methods for estimating the required size of a high-dependency unit are outlined. The impact of a high-dependency unit on the workload of the intensive care unit and the potential cost saving of managing such patients in an intermediate care area are illustrated.