ICU Triage/Quality of LifeUnplanned discharges from a surgical intensive care unit: Readmissions and mortality
Introduction
Intensive care units (ICUs) all over the world face the problem of having too few beds in relationship to the number of patients needing intensive care. Resources cannot be liberally expanded given the tremendous cost of delivering intensive care. Although around 5% of the beds in a teaching hospital are usually allocated to intensive care units (actually 7.5% at our institution including intermediate care), they account for about 20% of the patient care expenses [1]. Staff Salaries account for most of these expenses [2]; just being on an ICU creates expenses before any expensive treatments have been carried out.
Triage decisions must frequently be made as to whom to admit to or discharge from the ICU so as to create the capacity for admitting a new patient [3]. The turnover on a surgical ICU is considerable because one of its main purposes is to provide intensive postoperative care for patients having undergone major surgery. The average utilization ratio of our surgical ICU (SICU) is 92%, with those few available beds occurring mainly on weekends. Thus, nearly every time an emergency patient is scheduled for SICU admission, someone must be discharged to a regular ward whose discharge had been scheduled for later. Every ICU faces this problem [4].
There is evidence in the literature that unplanned discharges from an ICU and discharges at night may correlate with a worse outcome [5], [6], [7], [8], [9]. The aim of this study was to evaluate whether unplanned discharges from our SICU would also correlate with a worse outcome and to identify the main determinants thereof.
Section snippets
Materials and methods
In a retrospective observational study, we analyzed 2558 patients who were discharged over a one-year period from our SICU. The SICU is run by surgeons with subspecialty training in intensive care medicine. Most of the patients are admitted following elective or emergency surgery. Complications within the surgical wards warranting intensive care are managed on this ICU even if nonsurgical. Our ICU has 8 intensive care beds (intubated patients) and 12 intermediate care beds.
We screened the
Results
Of 2114 patients transferred to a surgical general ward, 1675 (79%) were transferred electively in the daytime, and 439 patients (21%) were transferred late or at night (after 4 pm). Patient characteristics of these 2 groups are described in Table 1. There was no difference between groups except for a slightly higher rate of unplanned discharges in elective orthopedic patients. Thirty-three of 1675 daytime patients died (2%), and 13 (3%) of 439 nighttime patients died on the general ward (P =
Discussion
On our SICU, various demands for beds conflict with each other: each day, 5 to 10 patients must be discharged to free up beds for elective surgery. Discharge plans are made every morning depending on the day’s operation schedule. If too many patients needing postoperative intensive care are scheduled, operations must be cancelled. Various numbers of emergency patients are admitted to the ICU every day, so elective surgery plans cannot be guaranteed 100% to take place on schedule [10].
Of our
Study limitations
The retrospective character of this study does not allow conclusions about causality. The differentiation between elective and unplanned discharge based only on the hour of discharge may seem rather unreliable at first sight. But considering the enormous demand for SICU beds, which exceeds daily the number we have available, we are certain that no patient ready for discharge remained on the SICU. Elective discharges usually occur by noon, so any patient being discharged after 4 pm is surely not
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