Elsevier

The Lancet

Volume 355, Issue 9210, 1 April 2000, Pages 1138-1142
The Lancet

Articles
Consequences of discharges from intensive care at night

https://doi.org/10.1016/S0140-6736(00)02062-6Get rights and content

Summary

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 10 806 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% Cl 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.

Introduction

It is generally believed that pressure for beds on intensive care units (ICUs) has increased. Although no rigorous research evidence exists, the increasing number of reports and correspondence related to this subject does suggest that the pressure on bed availability in ICUs may be greater now than before.

Increasing numbers of admissions with a concomitant decrease in length of stay in the ICU have been reported.1, 2, 3 Occupancy rates have been described as very high.4 The shortage of available ICU beds in London, UK, and elsewhere2 has been detailed and a wide variation in provision of facilities has been recorded.4, 5, 6 Cancelled operations due to the lack of available ICU beds4 and high rates of refused admissions have been reported, both regionally7 and nationally.5, 6 The transfer of patients over long distances in search of an ICU bed has also been reported8, 9, 10 and the potential dangers of transferring critically ill patients has been highlighted.11 Premature discharge of patients has been described.3, 12, 13

A national bed register covering England was introduced in 1996 by the Department of Health to ease the problem of finding a suitable bed for a critically ill patient.14 In addition, the Intensive Care Society, the professional organisation of intensive-care doctors, has called for both an increase in ICU facilities in areas of low provision and a formal transport system.15

High dependency units (HDUs) have been proposed for low-risk, short-stay ICU admissions to ease the pressure.1, 3, 12, 16, 17 However, a shortage of such intermediate facilities also seems to exist.

With the results of the Intensive Care Society's UK APACHE II study from July, 1988 to September, 1990, which indicated a high death rate on the ward after discharge from ICU (variation 6–16% across ICUs),18 and the belief that discharging patients from ICUs at night does not constitute good quality care and, where possible, is to be avoided, our study used discharge at night as a proxy measure to investigate pressure on ICUs. The aim was to investigate the change, over time, in the rate of discharge at night from ICUs and to find whether there were any adverse consequences following discharge at night.

By the use of two high-quality clinical databases, the UK APACHE II study database,18, 19 and the Intensive Care National Audit & Research Centre's Case Mix Programme Database (CMPD),20 the rate of discharge at night for 1988–90 was compared with the rate for December, 1995, to April, 1998. We used data solely from the CMPD to compare the consequences of discharge at night with discharge during the day.

Section snippets

Database

Data were extracted for the 10 806 admissions to 26 ICUs in the UK APACHE II study database, covering 1988–90, and for the 22 059 admissions to 62 ICUs in the CMPD, covering 1995–98. All these data had been collected prospectively. Age exclusion criteria (age <16 years) used in the UK APACHE II study were applied to the CMPD resulting in 21 295 adult admissions. Deaths in ICU were excluded from the analyses.

Data

Data were extracted for “time of discharge from ICU”. We consulted with ICU colleagues

Trend in night discharges

There were 2269 (21·0%) admissions who did not survive the ICU during 1988–90 compared with 4487 (21·1%) during 1995–98. Overall, 2·7% of discharges occurred at night in 1988–90 compared with 6·0% in 1995–98 (table 1), a 2·2-fold increase. The proportion of discharges at night varied 16-fold across ICUs in 1988–90 compared with 25-fold in 1995–98. Similar results were seen when the definition for discharge at night was restricted to discharge from ICU between 0000 h and 0459 h. When the ICUs

Discussion

Night discharges from ICU doubled in the UK over the past decade—a worrying trend because patients discharged at night fare significantly worse than those discharged during the day. Before considering possible explanations for these findings, it is important to recognise a potential methodological limitation—the adequacy of the UK APACHE II model for case-mix adjustment. While we can never be certain that all potential risk factors have been taken into account, the model used was developed and

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