After hours discharge, increased mortality

Hot off the online press is this article, the authors of which include our own Dash Gantner and David Pilcher:

Gantner D et al. Mortality related to after-hours discharge from intensive care in Australia and New Zealand, 2005–2012. Intensive Care Medicine, [Accessed 18 August 2015 at URL: http://icmjournal.esicm.org/journals/abstract.html?v=0&j=134&i=0&a=3438_10.1007_s00134-014-3438-x&doi=]

This study shows that the proportion of patients discharged after-hours from ICUs around ANZ hasn’t changed in 8 years, and nor has the associated risk of mortality. These findings are disappointing because concerns about the risks of after-hours discharge have been held for years, yet we seem to have had little success in addressing them.

Here is the study at a glance:

  • It is the largest-ever study of ICU discharge timing – over 700,000 admissions in Australasia from 2005-2012, with data extracted from ANZICS Adult Patient Database (APD)
  • 15.4% of patients were discharged after-hours (1800–0600 hours) overall, ranging between 14.8 to 15.9% depending on the year.
  • The overall odds ratio for mortality was 1.34 (range 1.32 – 1.37) when compared with in-hours discharges, after adjustment for illness severity and treatment limitations.

Unfortunately, this problem has not gone away – there is more work to be done!

To learn more read the Monash University media release: ICU fatalities linked to after-hours discharge.

Abstract

Introduction

After-hours discharge from the intensive care unit (ICU) is associated with adverse patient outcomes including increased ICU readmissions and mortality. Since Australian and New Zealand data were last published, overall ICU patient mortality has decreased; however it is unknown whether changes in discharge practices have contributed to these improved outcomes. Our aim was to examine trends over time in discharge timing and the contemporary associations with mortality and ICU readmission.

Methods

Retrospective cohort study using data from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD) for patients admitted to Australian and New Zealand ICUs between January 2005 and December 2012. Data collected included patient characteristics, time of ICU discharge, hospital mortality and ICU readmissions.

Results

Between 1 January 2005 and 31 December 2012, there were 710,535 patients available for analysis, of whom 109,384 (15.4 %) were discharged after-hours (1800–0600 hours). There were no changes in timing of ICU discharge over the 8 years of the study. Patients discharged after-hours had a higher hospital mortality (6.4 versus 3.6 %; P < 0.001) and more ICU readmissions (5.1 versus 4.5 %; P < 0.001) than patients discharged in-hours. Although post-ICU mortality for all patients declined during the study period, the risk associated with after-hours discharge remained elevated throughout (odds ratio 1.34, 95 % confidence intervals 1.30–1.38).

Conclusions

After-hours discharge remains an important independent predictor of hospital mortality and readmission to ICU. Despite widespread dissemination this evidence has not translated into fewer after-hours discharges or reduction in risk in Australian and New Zealand hospitals.

,

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.