Transcript ICU Out of Hours Discharges - The Scottish Intensive Care

ICU Discharges
SICSAG
September 2009
Dr Richard A Burnett
Intensive Care Medicine
INTRODUCTION
 Pressure for Critical Care beds has increased
 Review of services




More ICU beds
More HDU beds
Outreach teams
MET teams
 Altered threshold for admissions
Overview
 Associated with increased mortality
 ‘Critical to Success – The place of efficient and
effective critical care services within the acute hospital’
(Audit Commission 1999)
 Recommendations
 Regular outcome audit of patients prematurely
discharged or transferred to another ICU
 Transfer arrangements be put in place with neighboring
hospitals
Overview
 ‘Comprehensive Critical Care – A review of adult critical
care services’ (DoH 2000)
 Re-emphasised the monitoring of case-mix adjusted
mortality
 Bed manager should ensure discharge from critical
care takes place at an appropriate time of day
 Long distance transfers/transfers outwith the agreed
group of hospitals be recorded as an adverse incident
Overview
 Quality Critical Care – Beyond ‘Comprehensive Critical
Care’
 Reinforced and updated the recommendations of
Comprehensive Critical Care
 NICE
 Acutely Ill Patients in Hospital – Recognition of and
response to acute illness in adults in hospital
 Transfer of patients from critical care to the ward out of
hours (2200-0700) to be avoided
 AND reported as an adverse incident
Outcome Measures
 Policy documents highlight 6 potential outcome-based
quality indicators
 3 on external transfers (to another unit)
 All
 Non-clinical
 Outside the ‘transfer group’
 3 on internal timeliness of internal discharge
 Premature
 Delayed
 Out of hours
Consequences of OOH
Discharges – ICNARC 2000
 Out of hours = variable descriptions
 22:00 – 06:59
 20:00 – 07:59
 2.7% in late 80’s vs 6% in mid-90’s
Objectives
 To access the Ward Watcher data for the period 20002008 with reference to :
 Highlighting the number of live discharges from ICU
 Highlighting the reason for discharge
 Out of hours and delayed discharges
 (Re-)Establishing variables associated with increased
mortality
Methods
 Clinicians and epidemiologist
 National Project Manager and National Clinical
Coordinator
 Systems analysts/statisticians
 SICSAG executive for approval
Methods
 Looked at data between 2000-2008
 All live discharges from ICU’s in Scotland
 60,000 patients
 Data extracted for :





time of discharge
reason discharged
delayed discharges
length of delay
discharge destination
Methods
 Logistic regression model designed to assess
associated risk of mortality for :
 Out of hours vs In hours
 Delayed discharge
 Age
 Gender
 APACHE II
 Operative vs Non-operative
 Destination
 More than one CHP
Out of hours discharges 2000 - 2008
16
14
12
10
% 8
6
4
2
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
Hospital Mortality 2000 - 2008
25
20
15
%
Mortality
Night
Day
10
5
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
Reasons for Discharge
90
80
70
60
Ready
50
Early - beds
%
Pall Care
40
Early - staff
30
20
10
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
Delayed Discharge by Year
20
18
16
14
12
%
10
Delayed
8
6
4
2
0
2000
2001
2002
2003
2004
2005
2006
2007
Length of Delay by Year
1.6
1.4
1.2
1.0
Length
of delay,
0.8
fractional
days
0.6
0.4
0.2
0.0
2000
2001
2002
2003
2004
2005
2006
2007
2008
Odds ratios and corresponding 95%
confidence intervals
95% CI for odds ratio
Sig
Odds ratio
Lower
Upper
Delayed discharge
***
.834
.767
.907
Age
***
1.040
1.038
1.042
Sex
*
.937
.886
.991
APACHE II score
***
1.068
1.063
1.073
Admitted from theatre / recovery/ ***
surgical Dx
.545
.512
.579
Discharged to ICU
***
7.294
5.919
8.988
Discharged to HDU
***
1.328
1.251
1.409
>= 1 chronic health point
***
1.607
1.506
1.715
Out of Hours
* p < .05; ** p < .01; *** p < .001
***
1.258
1.135
1.395
Discussion
 Data set is robust when compared to the literature
 Out of hours discharges have increased since 2000
 OOH discharges are consistently associated with poor
outcome
 Delayed discharges have more than doubled since
2000
 Delayed discharges stay on ICU an average of 0.75
days (currently)
 The number of early discharges has fallen and the
number discharged fully ready for non-icu care has