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Discharge Time, Discharge TISS Scores, and Discharge Facility and Post-ICU Discharge Hospital Mortality
Abstract & Commentary
Synopsis: Both late discharge and high discharge TISS scores are indicators of "premature" ICU discharge and were associated with increased post-ICU hospital mortality.
Source: Beck DH, et al. Waiting for the break of dawn? The effects of discharge time, discharge TISS scores and discharge facility on hospital mortality after intensive care. Intensive Care Med. 2002;28(9):1287-1293.
Intensive care is part of a continuum of progressive patient care, and a significant number of research groups are now focusing their attention on ways to improve the organization of the ICU and its place in the continuum of care. An important aspect of this process is the evaluation of ICU discharge policies and their consequences.
Beck and colleagues carried out a retrospective cohort study to assess the effects of discharge Therapeutic Intervention Scoring System (TISS) scores, discharge time, and type of discharge facility on ultimate hospital mortality after intensive care. The study was conducted in a general ICU located in a district general hospital in the United Kingdom. A total of 1654 ICU patients discharged to hospital wards or high dependency units (HDUs) were analyzed. Two hundred eight died during their hospital stay (12.6%). More than half of all deaths (55%) occurred in the first week, and 71% occurred in the first 2 weeks after ICU discharge.
Beck et al observed that crude hospital mortality after ICU discharge (12.6%) was significantly associated with increasing discharge TISS scores even after adjusting for severity of disease. Moreover, patients with high TISS scores (> 30) who were discharged to hospital wards had a higher risk (1.31; CI: 1,02-1,83) of in-hospital mortality compared with patients discharged to HDUs.
As far as the time of ICU discharge is concerned, crude mortality was significantly higher for late (20.00-7.59 h) than for early (8.00-19.59 h) discharges (18.8% vs 11.2%; P = 0.0004). Adjusted for disease severity, the mortality risk was 1.70-fold (CI: 1.28-2.25) increased for late discharges. Another important finding is that patients discharged late to hospital wards had significantly higher severity-adjusted risks (1.87; CI: 1.36-2.56) than had patients discharged to HDUs (1.35; CI: 0.77-2.36).
Comment by Francisco Baigorri, MD, PhD
There are important regional differences in admission policies, organization of ICUs, type of admissions, severity of illness, and source of admission that contribute to regional differences in outcome. Availability of ICU beds seems to be a crucial factor. The increased pressure for ICU beds may result in premature discharge and a rise in post-ICU hospital mortality. It is known that the precipitate discharge of a patient, for example at night, can have a negative effect on outcome.1 Moreover, previous studies had also found a significant relationship between the TISS score on the last day in ICU and post-ICU outcome. In fact, nursing workload resources required by the patient seem to be just a surrogate marker of the amount of the underlying degree of organ dysfunction or failure.2
It is particularly interesting that the presence of HDUs may help us to minimize the number of preventable deaths after ICU discharge as shown in the study of Beck et al. Another way of looking at this question has been proposed. Some authors suggest that for patients at high risk of in-hospital death after ICU discharge, a system of follow-up by ICU personnel (doctors and nurses) should be instituted.3 Ideally, the objective should be to guarantee the continuum of care without moving patients from one area to another to meet their needs, thus avoiding transfer problems. It requires a multidisciplinary, organized effort. Hopefully, current trends in technology will redefine the physical and organizational boundaries of the ICU, helping us in this aim. Changes in networks, computing platforms, human-machine interfaces, and software infrastructures will mean that the ICU no longer will persist as a self-contained entity interacting as needed with other hospital departments. Tomorrow’s ICUs are likely to regularly draw on resources—both human and technological—located outside the unit’s physical space.4 In the meanwhile, we should not forget that "the sickest group of patients in the hospital is in the ICU; the next sickest group are the ones who have been transferred out of the ICU. Keep an eye on them."5
Dr. Baigorri of Corporacio Sanitaria Parc Tauli Sabadell, Spain.
1. Goldfrad C, Rowan K. Consequences of discharges from intensive care at night. Lancet. 2000;355: 1138-1142.
2. Moreno R, et al. Mortality after discharge from intensive care: the impact of organ system failure and nursing workload use at discharge. Intensive Care Med. 2001;27:999-1004.
3. Moreno R, et al. Discharging the critically ill patient. In: Vincent JL, ed. Yearbook of Intensive Care and Emergency Medicine. Springer, Berlin: 2002;937-941.
4. Craft RL. Trends in technology and the future intensive care unit. Crit Care Med. 2001;29:N151-N158.
5. Franklin C. 100 thoughts for the critical care practitioner in the new millennium. Crit Care Med. 2000;28: 3050-3052.