Introduction
Materials and methods
Case Mix Programme
Selection of cases and controls
Adjusted odds ratio | 95% confidence interval | Pvalue | |
---|---|---|---|
Sex | |||
Male versus female | 1.00 | 0.87 to 1.16 | 0.95 |
Age | See Figure 1 | < 0.001 | |
Quintiles of IMD | |||
1 (least deprived) | 1 | - | 0.95 |
2 | 0.97 | 0.75 to 1.26 | |
3 | 0.99 | 0.77 to 1.28 | |
4 | 1.06 | 0.83 to 1.35 | |
5 (most deprived) | 0.98 | 0.77 to 1.25 | |
Past medical history of one or more specified serious conditionsa | |||
Yes versus no | 0.96 | 0.79 to 1.17 | 0.70 |
Admission type | |||
Unplanned local admission | 1 | - | < 0.001 |
Planned local medical admission | 0.89 | 0.42 to 1.90 | |
Planned local surgical admission | 0.33 | 0.16 to 0.68 | |
Unplanned transfer in | 1.16 | 0.82 to 1.64 | |
Planned transfer in | 1.84 | 1.31 to 2.59 | |
Repatriation | 0.36 | 0.13 to 0.96 | |
Surgical status | |||
Nonsurgical | 1 | - | < 0.001 |
Emergency/urgent | 0.49 | 0.38 to 0.64 | |
Elective/scheduled | 0.23 | 0.12 to 0.42 | |
Reason for admission by body system | |||
Cardiovascular | 1 | - | < 0.001 |
Respiratory | 1.00 | 0.80 to 1.25 | |
Neurological | 1.51 | 1.17 to 1.94 | |
Gastrointestinal | 0.81 | 0.61 to 1.06 | |
Genitourinary including renal | 0.63 | 0.45 to 0.87 | |
Haematological/immunological | 0.68 | 0.36 to 1.31 | |
Endocrine, metabolic, thermoregulation and poisoning | 0.66 | 0.46 to 0.91 | |
Musculoskeletal | 0.98 | 0.59 to 1.65 | |
Dermatological | 1.12 | 0.57 to 2.22 | |
ICNARC Physiology Score | See Figure 2 | < 0.001 | |
Month of admission to critical care | |||
January | 1 | - | 0.003 |
February | 0.70 | 0.51 to 0.95 | |
March | 0.80 | 0.59 to 1.06 | |
April | 0.71 | 0.53 to 0.97 | |
May | 0.68 | 0.50 to 0.92 | |
June | 0.55 | 0.40 to 0.77 | |
July | 0.50 | 0.35 to 0.72 | |
August | 0.73 | 0.53 to 1.00 | |
September | 0.54 | 0.38 to 0.77 | |
October | 0.61 | 0.44 to 0.86 | |
November | 0.61 | 0.43 to 0.85 | |
December | 0.80 | 0.59 to 1.08 | |
Time of admission to critical care | |||
07:00 to 18:59 | 1 | - | 0.24 |
19:00 to 23:59 | 0.86 | 0.72 to 1.03 | |
00:00 to 06:59 | 0.93 | 0.78 to 1.11 | |
Number of beds in referring critical care unit | 0.96 | 0.94 to 0.98 | < 0.001 |
Analysis
Results
Study population
Matching on propensity
Non-clinical transfer patients (n= 759) | Matched patients not undergoing transfer (n= 1,518) | Pvaluea | |
---|---|---|---|
Age (years) | 55.7 (17.5) | 55.7 (17.7) | 0.99 |
Sex | |||
Female | 328 (43.2%) | 660 (43.5%) | 0.91 |
Male | 431 (56.8%) | 858 (56.5%) | |
Quintiles of IMD | |||
1 (least deprived) | 107 (14.1%) | 231 (15.2%) | 0.82 |
2 | 121 (15.9%) | 241 (15.9%) | |
3 | 140 (18.5%) | 297 (19.6%) | |
4 | 179 (23.6%) | 330 (21.7%) | |
5 (most deprived) | 212 (27.9%) | 419 (27.6%) | |
Past medical history of one or more specified serious conditions | |||
No | 629 (82.9%) | 1,278 (84.2%) | 0.42 |
Yes | 130 (17.1%) | 240 (15.8%) | |
Admission type | |||
Unplanned local admission | 664 (87.5%) | 1,318 (86.8%) | 0.75 |
Planned local medical admission | 7 (0.9%) | 10 (0.7%) | |
Planned local surgical admission | 12 (1.6%) | 19 (1.3%) | |
Unplanned transfer in | 35 (4.6%) | 90 (5.9%) | |
Planned transfer in | 37 (4.9%) | 71 (4.7%) | |
Repatriation | 4 (0.5%) | 10 (0.7%) | |
Surgical status | |||
Nonsurgical | 669 (88.1%) | 1,315 (88.6%) | 0.37 |
Emergency/urgent | 73 (9.6%) | 174 (11.5%) | |
Elective/scheduled | 17 (2.2%) | 29 (1.9%) | |
Reason for admission by body system | |||
Cardiovascular | 119 (15.7%) | 247 (16.3%) | 0.97 |
Respiratory | 248 (32.7%) | 508 (33.5%) | |
Neurological | 152 (20.0%) | 286 (18.8%) | |
Gastrointestinal | 103 (13.6%) | 197 (13.0%) | |
Genitourinary including renal | 50 (6.6%) | 98 (6.5%) | |
Haematological/immunological | 10 (1.3%) | 25 (1.7%) | |
Endocrine, metabolic, thermoregulation and poisoning | 51 (6.7%) | 108 (7.1%) | |
Musculoskeletal | 17 (2.2%) | 26 (1.7%) | |
Dermatological | 9 (1.2%) | 23 (1.5%) | |
ICNARC Physiology Score | 20.1 (8.3) | 20.6 (7.8) | 0.31 |
Mortality
Non-clinical transfer patients (n= 759) | Propensity-matched patients not undergoing transfer (n= 1,518) | |
---|---|---|
Ultimate acute hospital mortality | 223 (29.4%) | 471 (31.0%) |
Ultimate critical care unit mortality | 162 (21.3%) | 345 (22.7%) |
Total critical care unit length of stay (days) | 11.0 (16.9)/6 (2 to 14) | 7.8 (9.7)/4 (2 to 9) |
Acute hospital length of stay (days) | 29.8 (36.4)/19 (9 to 37) | 26.9 (33.8)/16 (7 to 33) |
Length of stay
Discussion
Comparison with other studies
Limitations of the study
Conclusion
Key messages
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No matter how well resourced, individual hospitals cannot expect to meet all peaks in demand for adult general critical care, but transferring patients outside the critical care environment involves risk.
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In our analysis there was no statistically significant difference in ultimate acute hospital mortality in patients transferred for non-clinical reasons, but we cannot rule out a level of harm that may be considered clinically significant.
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Transferred patients also received, on average, three additional days of critical care.
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Non-clinical transfers may also involve an additional burden in terms of distress, inconvenience and cost for patients and their families. We need further evidence - for example, from qualitative interviews with family members - to understand the broader effects of non-clinical transfer.