Waiting for the break of dawn?

Beck, Dieter; McQuillan, P. J.; Smith, Gary B.

doi:10.1007/s00134-002-1412-5

Cited by 130 publications

(39 citation statements)

References 20 publications

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“…Nine studies were excluded because they included data also reported in a larger study (i.e. large national database studies) [6, 13, 19, 29–34]. Four studies were deemed ineligible on further review.…”

Section: Resultsmentioning

confidence: 99%

“…Differences in disease severity at admission to ICU have convincingly been shown not to explain the excess mortality and readmission rates found with out-of-hours discharge [1, 2, 8, 13, 15, 35]. The presence of treatment limitations at ICU admission also did not account for the effect [1].…”

Section: Discussionmentioning

confidence: 99%

“…Premature discharge was the main determinant of increased mortality associated with night-time discharge in their model. There is also evidence that patients with a high treatment need are disproportionately discharged at night [13]. Patients discharged out-of-hours also have higher severity of illness on their last ICU day [10, 11] and a greater incidence of treatments normally delivered in ICUs [19].…”

Section: Discussionmentioning

confidence: 99%

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Out-of-hours discharge from intensive care, in-hospital mortality and intensive care readmission rates: a systematic review and meta-analysis

et al. 2018

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PurposeDischarge from an intensive care unit (ICU) out of hours is common. We undertook a systematic review and meta-analysis to explore the association between time of discharge and mortality/ICU readmission.MethodsWe searched Medline, Embase, Web of Knowledge, CINAHL, the Cochrane Library and OpenGrey to June 2017. We included studies reporting in-hospital mortality and/or ICU readmission rates by ICU discharge “out-of-hours” and “in-hours”. Inclusion was limited to patients aged ≥ 16 years discharged alive from a non-specialist ICU to a lower level of hospital care. Studies restricted to specific diseases were excluded. We assessed study quality using the Newcastle Ottowa Scale. We extracted published data, summarising using a random-effects meta-analysis.ResultsOur searches identified 1961 studies. We included unadjusted data from 1,191,178 patients from 18 cohort studies (presenting data from 1994 to 2014). “Out of hours” had multiple definitions, beginning between 16:00 and 22:00 and ending between 05:59 and 09:00. Patients discharged out of hours had higher in-hospital mortality [relative risk (95% CI) 1.39 (1.24, 1.57) p < 0.0001] and readmission rates [1·30 (1.19, 1.42), p < 0.001] than patients discharged in hours. Heterogeneity was high (I2 90.1% for mortality and 90.2% for readmission), resulting from differences in effect size rather than the presence of an effect.ConclusionsOut-of-hours discharge from an ICU is strongly associated with both in-hospital death and ICU readmission. These effects persisted across all definitions of “out of hours” and across healthcare systems in different geographical locations. Whether these increases in mortality and readmission result from patient differences, differences in care, or a combination remains unclear.Electronic supplementary materialThe online version of this article (10.1007/s00134-018-5245-2) contains supplementary material, which is available to authorized users.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Out-of-hours discharge from intensive care, in-hospital mortality and intensive care readmission rates: a systematic review and meta-analysis

et al. 2018

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“…While most studies define it as an unplanned admission to the ICU within 48 hours of discharge (3, 5, 6), definitons range from 3 to 30 days (4, 6, 26, 29). This may partly explain the discrepency in reported readmission rates, from 0.89% to 19% (1–5, 7, 9, 13–16, 18, 22, 29). However, lower percentages do not necessarily infer better quality of care.…”

Section: Discussionmentioning

confidence: 98%

Intensive care unit bounce back in trauma patients

Fakhry

Leon

Derderian

et al. 2013

Journal of Trauma and Acute Care Surgery

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Background Discharging patients from the intensive care unit (ICU) often requires complex decision making to balance patient needs with available resources. Unplanned return to the ICU (“bounce back”, BB) has been associated with increased resource utilization and worse outcomes but few data on trauma patients are available. The goal of this study was to review ICU BB and define ICU discharge variables that may be predictive of BB. Methods Adults admitted to ICU and discharged alive to a ward from 11/18/04 to 9/01/09 (interval with no changes in coverage) were selected from our trauma registry. Patients with unplanned return to ICU (BB cases) were matched 1:2 with controls on age, ISS and duration of post-ICU stay. Data were collected by chart review then analyzed with univariate and conditional multivariate techniques. Results 1971 of 8835 hospital admissions (22.3%) were discharged alive from ICU to a ward. 88 patients (4.5%) met our criteria for BB (male 75%, mean age 52.9 + 21.9, mean ISS 23.1 + 10.2). Most (71.6%) occurred within 72 hours. Mortality for BB cases was high (19.3%). Regression analysis showed that male gender (Odds Ratio 2.9, p=0.01), GCS<9 (Odds Ratio 22.3, p<0.01), discharge during day shift (Odds Ratio 6.9, p<0.0001) and presence of one (Odds Ratio 3.5, p=0.03), two (Odds Ratio 3.8, p=0.03) or three or more co-morbidities (Odds Ratio 8.4, p<0.001) were predictive of BB. Conclusion In this study, BB rate was 4.8% and associated mortality was 19.3%. At the time of ICU discharge, male gender, a GCS <9, higher FiO2, discharge on day shift and presence of one or more co-morbidities were the strongest predictors of BB. A multi-institutional study is needed to validate and extend these results.

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“…The authors suggested that this was in part because more ICU beds had been made available as lower-risk intensive monitoring patients were admitted to the IMCU so that high-risk patients who would otherwise have been managed on the general ward because of bed shortages were being more appropriately managed on the ICU. Beck and colleagues [12] reported that patients with high severity scores who were discharged to hospital wards had a higher risk of in-hospital death compared with patients discharged to a high-dependency unit, suggesting that the IMCU helped prevent ‘premature’ discharges to the ward. However, Campbell and colleagues [13] reported that discharge to a high-dependency unit was an independent risk factor for early ICU re-admission, suggesting that these patients had been discharged prematurely; importantly, as mentioned earlier, ICU readmission is associated with increased mortality rates [10].…”

Section: Intermediate Care Units: the Evidence For And Againstmentioning

confidence: 99%

Does intermediate care improve patient outcomes or reduce costs?

Vincent

Rubenfeld

2015

Crit Care

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ICUs are an essential but expensive part of all modern hospitals. With increasingly limited healthcare funding, methods to reduce expenditure without negatively influencing patient outcomes are, therefore, of interest. One possible solution has been the development of ‘intermediate care units’, which provide more intensive monitoring and patient management with higher nurse:patient ratios than the general ward but less than is offered in the ICU. However, although such units have been introduced in many hospitals, there is relatively little published, especially prospective, evidence to support the benefits of this approach on costs or patient outcomes. We review the available data and suggest that, where possible, a larger unit with combined intermediate care and intensive care beds in one location may be preferable in terms of greater flexibility and efficiency.

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Waiting for the break of dawn?

Cited by 130 publications

References 20 publications

Out-of-hours discharge from intensive care, in-hospital mortality and intensive care readmission rates: a systematic review and meta-analysis

Out-of-hours discharge from intensive care, in-hospital mortality and intensive care readmission rates: a systematic review and meta-analysis

Intensive care unit bounce back in trauma patients

Does intermediate care improve patient outcomes or reduce costs?

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