Out-of-hours Discharge from Intensive Care, In-hospital Mortality and Intensive Care Readmission Rates: a Systematic Review and Meta-analysis

Vollam S, Dutton S, Lamb S et al.

Intensive Care Medicine 2018; 44 (7): 1115-1129

Clinical Question

In patients discharged from a general ICU, is discharge out of hours compared to discharge in hours associated with subsequent in-hospital mortality or ICU readmission?

Study Design

Systematic review and meta-analysis with no geographical, language or date restrictions.

Inclusion Criteria

  • Had to report in hospital mortality and/or ICU readmission rates for all patients aged ≥16 years discharged alive from a general surgical, medical or mixed ICU to a lower level of in-hospital care.
  • Had to report outcomes separately for patients discharged from ICU out of hours and in hours.
  • Had to follow up patients to hospital discharge.

Exclusion Criteria

Excluded specialist ICU (eg: neuro, cardiac).

Primary Outcome

In patients discharged from a general ICU, is discharge out of hours compared to discharge in hours associated with subsequent in-hospital mortality?

Secondary Outcome

In patients discharged from a general ICU, is discharge out of hours compared to discharge in hours associated with ICU readmission?

Results

A significant association between out of hours discharge and in hospital mortality was found. Patients discharged out of hours were found to have a higher in hospital mortality (pooled relative risk 1.39 (95% CI, 1.24, 1.57, p<0.0001)).

In addition, a significant association between out of hours discharge and ICU readmission was found.  Patients discharged out of hours had a higher rate of readmission (pooled relative risk 1.30 (95% CI 1.19, 1.42, p<0.0001)). The effect remained when geographical areas were split up. However, the effect was borderline for UK studies (RR 1.42 (95% CI 1.00-2.02)).

Conclusions

Out of hours discharge from ICU is associated with a substantial increase in subsequent hospital mortality and ICU readmission. The association with increased mortality and readmission is substantial, however the magnitude of the association remains uncertain. Whether this association results from patient differences, differences in care or a combination is unclear.

Weaknesses

The study looked at a large time period (1994-2014) and there was a large range in study duration. In addition, they were unable to perform sub-group analyses of discharge destination due to only 5 of the studies specifying whether the patient was discharged to HDU or a ward. There was also a variable definition of what constituted out of hours.

The absence of data and the fact that different measures of illness severity were used prevented post-hoc analysis. They were also unable to perform sub-group analyses of palliation status due to inconsistent reporting of the data.

Funnel plots suggested that there might be some publication bias, with studies showing a strong association between mortality and out of hours discharge (particularly the smaller studies) not being published.

Summary by Dr D De Caux. Journal Club Meeting  14 March 2019.

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