Background
Methods
Patient data and outcomes
ICU discharge practices
Discharge practice | Description |
---|---|
Discharge criteria | the usage of set criteria when making the decision to discharge a patient from the ICU |
Bed manager | nurse or physician managing bed availability in ICU and step-down facilities |
Early discharge planninga
| starting with planning a discharge at least 24 h before the transfer of the patient to the ward |
Step-down facilities | beds with less monitoring and a lower nurse-patient ratio than ICU beds, but more monitoring and a higher nurse-patient ratio then ward beds. |
Medication reconciliationa
| creating an actual medication overview of current medications, (temporarily stopped) home medication, and information about allergies. Home medication and allergy information is checked with the patient or relatives. |
Verbal and written handoverb
| oral and written information transfer by nurses, and oral and written information transfer by physicians |
Monitoring of post-ICU patients | patients discharged from the ICU are visited on the ward and evaluated by ICU personnel |
Consulting ICU nurses | an ICU nurse is 24/7 available for questions and assistance on the ward |
Statistical analyses
Results
(n = 42,040) | |
---|---|
Median age in years (IQR) | 65 (54 to 75) |
Male (%) | 23,832 (56.7) |
Mechanical ventilation in the first 24 h of admission (%) | 14,810 (35.2) |
Vasoactive medication (%) | 11,183 (26.6) |
Planned admission (%) | 12,918 (30.7) |
Readmissions (%) | 3463 (8.2) |
Readmissions within 48 h of ICU discharge (%) | 1216 (2.9) |
Length of stay | |
Median intensive care length of stay in days (IQR) | 1.0 (0.80 to 2.9) |
Median hospital length of stay in days (IQR) | 11.0 (6.0 to 20.0) |
Mortality | |
Post-ICU in-hospital mortality rate (%) | 2811 (6.7) |
APACHE IV standardized mortality rate | |
Median APACHE III score (IQR) | 49 (49 to 68) |
Mean APACHE IV probability (SD) | 0.15 (0.19) |
APACHE IV standardized mortality rate (95% CI) | 0.78 (0.77 to 0.80) |
Admission type: | |
Medical/non-surgical (%) | 18,324 (43.6) |
Emergency surgery (%) | 7139 (17.0) |
Planned surgery (%) | 16,577 (39.4) |
Admission source: | |
Operating theatre (%) | 21,694 (51.6) |
Emergency room (%) | 8262 (19.7) |
Ward (%) | 9477 (22.5) |
High or medium care (%) | 159 (0.4) |
Other hospital (%) | 630 (1.5) |
Other (%) | 1818 (4.3) |
Comorbidity on admission: | |
Confirmed infection (%) | 6300 (15.0) |
Cardiopulmonary resuscitation (%) | 1177 (2.8) |
Dysrhythmia (%) | 3136 (7.5) |
Acute renal failure (%) | 2658 (6.3) |
Cardiovascular accident (%) | 1513 (3.6) |
Gastrointestinal bleeding (%) | 977 (2.3) |
Number of chronic comorbidities: | |
None (%) | 25,238 (60.0) |
One (%) | 11,538 (27.4) |
Two (%) | 4042 (9.6) |
Three (%) | 1029 (2.4) |
More than three (%) | 193 (0.6) |
Patients discharged to: | |
Ward (%) | 39,493 (93.9) |
Recovery or medium care (%) | 1239 (3.1) |
Coronary care unit or other intensive care unit (%) | 1308 (3.0) |
Rates of ICU readmissions and post-ICU in-hospital mortality
ICU discharge practices, ICU readmission and post-ICU in-hospital mortality
Individual practice rates in isolation | |||||
---|---|---|---|---|---|
Practices |
n (%) | Case-mix adjusteda readmission rate OR (95% CI) |
p-valueb
| Case-mix adjusteda post-ICU mortality rate OR (95% CI) |
p-valueb
|
Discharge criteria | 53 (70.7) | 0.95 (0.75–1.21) | 0.6775 | 1.02 (0.83–1.24) | 0.8541 |
Bed manager | 71 (94.7) | 1.08 (0.80–1.46) | 0.6164 | 0.93 (0.52–1.68) | 0.8128 |
Early discharge planning | 40 (53.3) | 1.04 (0.84–1.28) | 0.7011 | 1.03 (0.89–1.20) | 0.6667 |
Medication reconciliation | 39 (52.0) | 0.95 (0.78–1.17) | 0.6587 | 1.00 (0.86–1.16) | 0.9722 |
Communication at handover | 49 (65.3) | 0.90 (0.73–1.11) | 0.9912 | 1.08 (0.92–1.28) | 0.9442 |
Step-down facilities | 21 (28.0) | 1.21 (0.98–1.50) | 0.0823 | 1.16 (1.01–1.34) | 0.0423 |
Monitoring of post-ICU patients | 49 (65.3) | 1.02 (0.81–1.27) | 0.8822 | 0.91 (0.78–1.07) | 0.2654 |
Consulting ICU nurse | 70 (93.3) | 0.87 (0.64–1.19) | 0.3948 | 0.90 (0.67–1.23) | 0.5120 |
Combined practices score (median (IQR)) | 6 (5–7) | 1.00 (0.93–1.10) | 0.994 | 1.02 (0.95–1.08) | 0.59548 |
Number of practices incorporated | |||||
1 | 1 (1.3) | ||||
2 | 3 (4.0) | ||||
3 | 7 (9.3) | ||||
4 | 10 (13.3) | ||||
5 | 22 (29.3) | ||||
6 | 18 (24.0) | ||||
7 | 11 (14.7) | ||||
8 | 3 (4.0) |