Problems in care and avoidability of death after discharge from intensive care: a multi-centre retrospective case record review study

Abstract

Background Over 138,000 patients are discharged to hospital wards from intensive care units (ICUs) in England, Wales and Northern Ireland annually. More than 8000 die before leaving hospital. In hospital-wide populations, 6.7–18% of deaths have some degree of avoidability. For patients discharged from ICU, neither the proportion of avoidable deaths nor the reasons underlying avoidability have been determined. We undertook a retrospective case record review within the REFLECT study, examining how post-ICU ward care might be improved. Methods A multi-centre retrospective case record review of 300 consecutive post-ICU in-hospital deaths, between January 2015 and March 2018, in 3 English hospitals. Trained multi-professional researchers assessed the degree to which each death was avoidable and determined care problems using the established Structured Judgement Review method. Results Agreement between reviewers was good (weighted Kappa 0.77, 95% CI 0.64–0.88). Discharge from an ICU for end-of-life care occurred in 50/300 patients. Of the remaining 250 patients, death was probably avoidable in 20 (8%, 95% CI 5.0–12.1) and had some degree of avoidability in 65 (26%, 95% CI 20.7–31.9). Common problems included out-of-hours discharge from ICU (168/250, 67.2%), suboptimal rehabilitation (167/241, 69.3%), absent nutritional planning (76/185, 41.1%) and incomplete sepsis management (50/150, 33.3%). Conclusions The proportion of deaths in hospital with some degree of avoidability is higher in patients discharged from an ICU than reported in hospital-wide populations. Extrapolating our findings suggests around 550 probably avoidable deaths occur annually in hospital following ICU discharge in England, Wales and Northern Ireland. This avoidability occurs in an elderly frail population with complex needs that current strategies struggle to meet. Problems in post-ICU care are rectifiable but multi-disciplinary. Trial Registration: ISRCTN14658054.

Protocol for a mixed methods exploratory study of success factors to escalation of care: the SUFFICE study

“…A further 50 notes (giving a total of up to 400 care records) will be reviewed from participants who became unwell on the ward were admitted to ICU and died. Records will be reviewed using the Structured Judgement Review (SJR) method (30,31) and will consider all aspects of the patients care by examining records from nursing, allied health professionals, doctors, drugs charts and diagnostic test results (1). Care records reviews are a prime method to assess quality of care (32).…”

“…• 24 hours post-trigger • >24 hours post-trigger (subsequent care period until 3 subsequent triggers of <3 is documented indicating stability) A further 50 notes (giving a total of up to 400 care records) will be reviewed from participants who became unwell on the ward were admitted to ICU and died. Records will be reviewed using the Structured Judgement Review (SJR) method (30,31) and will consider all aspects of the patients care by examining records from nursing, allied health All rights reserved. No reuse allowed without permission.…”

“…Each in-depth Level 2 review may take up to four hours to complete. Based on other studies using this method (31,40) between 200-400 notes were a large enough number that the data will be sufficiently rich, and saturation is likely to be achievable.…”

Leveraging Robust Mixed Methodologies to Advance Implementation Research and Practice*

“…The critical care community has dedicated significant effort to fostering high-performing teams within the ICU (9). The work by Vollam et al (1), particularly the qualitative staff interviews, reminds us that failure to extend effective teamwork to the ICU to ward discharge process poses a steep risk for patients (4). Error proofing this process requires high-functioning teams to be effective not only within their immediate context (e.g., ICU, ward) but also to seamlessly interact with teams outside of their context.…”

“…ICU to ward discharges are a well-recognized, but persistent, patient safety risk point (2). Literature suggests that this risk is particularly high for ICU patients discharged to wards at night, yet meaningful strategies addressing this risk remain elusive (3, 4). To address this problem, a comprehensive ICU to ward discharge strategy is needed to both reduce discharges occurring after hours and increase the safety of ICU discharges.…”