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Intensive care outflow limitation--frequency, etiology, and impact
Phillip D Levin1, Theresa M Worner, Sigal Sviri
1Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel.
Objective:
To assess the frequency, causes, and effect of unsuccessful discharge decisions from the ICU.
Setting:
An 11-bed general intensive care unit of a 750-bed urban university hospital, tertiary referral center and level one trauma center.
Design:
A prospective, observational study.
Patients:
All ICU patients judged appropriate for discharge by the ICU attending physician.
Measurements And Results:
A total of 856 attempted discharges in 706 patients were analyzed over 16 months. Of these, 703 (82%) were successful within 24 hours. Of the remaining 153 unsuccessful discharges, 51 (33%) were deferred because of medical deterioration, 32 (21%) at the request of the ward physicians or nurses and 70 (46%) because of administrative difficulties (lack of ward bed space or disagreement over admitting service). When compared to patients successfully discharged on the first attempt, those whose discharge was deferred had a significantly longer ICU admission prior to the first discharge attempt (median 4d v 3d, P =.009), and a higher proportion required intermediate care (48% v 26%, P <.001). Both these factors were independently associated with unsuccessful discharge in a logistic regression analysis (OR 1.04, 95%CI 1.02, 1.06, P =.0001, OR 2.05 95%CI 1.30, 3.26, P =.002, respectively). Deferred discharges accounted for 153 days of ICU care (2.6% of the total) and were associated with ICU overflow on 118 days (2% of all ICU days).
Conclusion:
ICU outflow limitation occurs in up to 1 in 6 discharges. It can be due to medical deterioration, level of care issues or administrative problems, and may lead to inefficient use of ICU resources.