Research paperDischarge delay, room for improvement?
Introduction
There are 167 hospitals with intensive care units (ICU) in Australia which, in 2003, admitted 143,000 patients.1 Overall, survival is good with 84% of patients surviving hospitalisation.2 The demand for intensive care services is increasing and is being driven by increasingly sophisticated technology in clinical care, increasing numbers of older patients with concomitant comorbidity and increased consumer expectations. The demand is growing at a rate that is higher than the average for all health services.3 Resources are often scarce and the increasing demand and predicted shortage in the critical care workforce4, 5 are likely to exacerbate the problem. Furthermore, intensive care beds are a significant cost driver in a tertiary hospital. In the USA in 2000, critical care costs represented 13% of hospital costs, 4% of national health expenditures, and 0.6% of the gross domestic product.6 The number of ICU admissions and the cost per day of ICU care are substantially lower in Australia, but it is reasonable to assume costs of 0.1% of GDP, that is, about AUD$ 900 million per annum. The cost of an ICU bed-day is considerably higher than that of ward beds, approximately $5,000 (personal communication 2008) and unnecessarily prolonging patient stays in ICU are costly. It is imperative that intensive care resources are used effectively and efficiently to improve patient outcomes.
For patients who require treatment in the ICU, the goal is to expedite timely and safe admission to ICU. Once patients are identified as suitable for discharge to the ward, their discharge should also be expedient. Retaining patients in the ICU who no longer require critical care can delay recovery and expose patients to unnecessary risks, e.g. from exposure to multi-resistant microorganisms or delay rehabilitation. It may lead to ICU bed-block, delaying timely access to ICU for patients who would benefit from ICU treatment, e.g. from the Emergency Department (ED) or urgent ward admissions, with negative consequences.7, 8, 9 For example, it has been reported patients in the ED delayed 6 or more hours before transfer to the ICU had longer hospital length of stay and higher ICU and hospital mortality.10 Furthermore, elective surgery may have to be cancelled,11, 12 referrals refused,11, 13 and there may be a need for interhospital transfers. Interhospital transfers have been shown to increase patients’ length of stay in ICU and hospital.11, 14, 15 Models of ICU patient flow demonstrate that reducing discharge delays can result in substantial improvements in the deferral of surgery and interhospital transfer rates.16
Reports describe the rate of discharge delay among the critically ill to range from 21% to 27%.17, 18, 19, 20 Reasons for discharge delay from ICU included a shortage of beds, lack of skilled staff on the wards and unavailability of appropriate accommodation, e.g. single rooms and high dependency beds, but there is a paucity of studies that examine interventions to reduce delays. Among 1440 discharges in an United States neonatal ICU 1994/1995, there were 83 delayed discharges at an estimated cost of US$ 226,298 ($749/day – 1994 costs).20 In the following year there was a substantial decrease in discharge delays (n = 33) and concomitant reduction in costs (US$ 41,553 i.e. $233/day) that was attributed to the introduction of a focused team-approach and monitoring for potential discharge delays. In an Australian tertiary hospital, the change in the bed management model from a decentralised divisional model to a centralised model in which ICU discharges were given priority for ward beds, was likely to have contributed to the 6% reduction in delays (p = 0.03).19 Similarly, a reduction in delay time among ICU survivors who stayed in ICU for three days or longer was reported after the introduction of the ICU critical care outreach role.18 The investigators found those in the liaison nurse group were almost three times less likely to experience a discharge delay of at least 2 h and about 2.5 times less likely to experience a delay of four or more hours.18
Understanding the frequency and outcomes of discharge delay is needed to facilitate patient flow and to inform the development of effective interventions. While discharge delays are common the information on interventions to reduce delay is limited. The critical care outreach role provides communication channels between ICU and the ward to facilitate discharge from ICU,21, 22 and after patient transfer, continues to enable communication and support for ward staff.21, 23, 24 As part of a larger multicentre study that evaluated the impact of introducing a critical care nursing outreach service in 2008 (paper submitted for publication 2009), this single centre study aimed to examine the hypothesis that introduction of the service would decrease the frequency of discharge delay from ICU and to compare the results with the study conducted in our hospital in 2000/200117 when there was no critical care outreach service.
Section snippets
Ethical considerations
Approval for the study was granted by the institutional ethics committee (IEC). This descriptive survey had no intervention arm and no perceived potential for harm in regard to participation. The data collection was undertaken by experienced nurses. Personal identifiers were removed from the database after completion of data collection and before the data was analysed. Data was stored in a secure, password protected computer at the hospital.
Design
This study compared the proportion of patients whose
Results
There were 516 discharges (488 patients) compared to 607 in 2000/2001. Thirty-one percent of the discharges were delayed from ICU more than 8 h in 2008, an increase of 6% from 2000/2001 (p < 0.001). Patients spent substantially less time in ICU when their discharge was delayed in 2008, as shown in Table 1. The median time of delay in 2008 from the time deemed eligible for discharge was 26 (IQR 10–36) hours, with the longest delay time of 191 h. Excluding patients with medical complications
Discussion
The results of this study did not support the hypothesis that introducing the critical care outreach role would decrease delays in discharge from ICU. The study found the delays in discharge from ICU increased to 31% in 2008 compared to 27% in 2000/2001. The critical care outreach role (ICU liaison role) is reported to facilitate discharge by promotion of effective communication with ward staff and assessment of bed status to prepare the patient for transfer to the ward. Chaboyer et al.18 found
Conclusion
Delays in discharge from ICU occur frequently. Whilst lack of ward bed availability continues to be the most important reason for delay, the contribution of medical complications as a cause of delay have increased in importance over time. As found in another Australian study, the liaison nurse role can influence the duration of delay, but we did not see a reduction in the number of delayed patients. Many factors impact on patient flow. Reducing discharge delays from ICU will continue to require
Acknowledgements
This study was funded by a grant from the Western Australian Department of Health Innovation Fund. We would like to thank the staff for their support of this project.
References (36)
- et al.
Mortality among appropriately referred patients refused admission to intensive-care units
Lancet
(1997) - et al.
Supporting ward staff in acute care areas: expanding the service
Intensive Crit Care Nurs
(2001) Reducing readmissions to the intensive care unit
Heart Lung
(1999)- et al.
The Intensive Care Unit liaison nurse: towards a clear role description
Intensive Crit Care Nurs
(2004) - et al.
The impact of a liaison nurse on ICU nurses’ perceptions of discharge planning
Aust Crit Care
(2004) - et al.
Nurse-led discharge to the ward from high dependency: a service improvement project
Intensive Crit Care Nurs
(2005) - et al.
Consequences of discharges from intensive care at night
Lancet
(2000) - et al.
Review of Intensive Care Resources & Activity 2002/2003
(2005) - et al.
Mortality and length-of-stay outcomes, 1993–2003, in the binational Australian and New Zealand intensive care adult patient database
Crit Care Med
(2008) - Acute Health Division DoHS. Review of intensive care in Victoria [Phase 1 report]. Melbourne: Department of Human...