Background
Methods
Setting
Sampling strategy
Non-survivors
Survivors
Variables
Data extraction
Bias
Statistical analyses
Results
Participants
Descriptive data
Characteristics | Study data Non-survivors: EOLC n = 50 | Study data Non-survivors: excluding EOLC n = 250 | Study data Analyzed survivors n = 20 | Study data All survivors n = 7082 | Study data ICU discharges excluding EOLC† n = 7332 | National CMP†† data ICU discharges excluding EOLC n = 437,586 |
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Age median (IQR) | 73 (65–82.75) | 74 (63.25–80) | 66 (55–69.5) | 62 (46–73) | 62 (47–73) | 63 (48–74) |
Female n (%) | 18 (34.6) | 90 (36) | 7 (35) | 3075 (43.4) | 3165 (43.2) | 198,319 (45.3) |
APACHE II median (IQR) | 21 (18–24) | 21 (17–26) | 16 (14–22) | 15 (12–20) | 16 (12–20) | 13 (10–18) |
Admission diagnosis n (%) | ||||||
Surgical | 14 (28) | 112 (44.8) | 13 (65) | 3529 (49.8)a | 3641 (49.7)a | 209,098 (47.8)d |
Medical | 36 (72) | 138 (55.2) | 7 (35) | 3194 (45.1) | 3332 (45.4) | 228,439 (52.2) |
Type of admission n (%) | ||||||
Emergency | 50 (100) | 233 (93.2) | 17 (85) | 4352 (61.5)b | 4585 (62.5) b | 313,790 (71.7)d |
Elective | 0 (0) | 17 (6.8) | 3 (15) | 1702 (24.0) | 1719 (23.4) | 123,747 (28.3) |
Clinical frailty scale n (%) | ||||||
1–4 | 23 (46) | 128 (51.2) | 15 (75) | 5471 (77.3)c | 5599 (76.4)c | 339,919 (77.7)e |
5 | 12 (24) | 57 (22.8) | 3 (15) | 1218 (17.2) | 1275 (17.4) | 73,822 (16.9) |
6 | 5 (10) | 44 (17.6) | 2 (10) | 185 (2.6) | 229 (3.1) | 17,631 (4.0) |
7–9 | 10 (20) | 21 (8.4) | 0 | 105 (1.5) | 126 (1.7) | 4459 (1.0) |
ICU LOS (hours) median (IQR) | 72 (48–144) | 96 (48–168) | 312 (138–534) | 72 (48–120) | 72 (48–120) | 57 (26–120) |
Post-ICU LOS (days) median (IQR) | 1.5 (0–4) | 9 (5–21) | 15.5 (6.5–24.5) | 8 (4–17) | 8 (4–17) | 8 (4–16) |
Avoidability of death and quality of care
Scale used to judge avoidability of death n (%) | Discharges from ICU, excluding EOLC n = 250 (% [95% CI]) |
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1. Definitely avoidable | 0 (0 [0–1.5]) |
2. Strong evidence of avoidability | 0 (0 [0–1.5]) |
3. Probably avoidable (more than 50:50) | 20 (8) [5.0–12.1]) |
4. Possibly avoidable but not very likely (less than 50:50) | 24 (9.6 [6.2–14.0]) |
5. Slight evidence of avoidability | 21 (8.4 [5.3–12.6]) |
6. Definitely not avoidable | 185 (74 [68.1–79.3]) |
An elderly patient was discharged on a weekend evening with a high early warning score after a 1-day elective ICU admission following major intra-abdominal surgery. Their surgery was deemed high risk because of a past history of significant chronic obstructive pulmonary disease (COPD). As the patient was at risk of developing a hospital-acquired respiratory infection, a plan for immediate treatment with antibiotics in the event of respiratory deterioration was decided on by the ICU team. However, this plan was not included in the patient’s ICU discharge document. The patient’s low oxygen saturations worsened from the first post-discharge day but were attributed to fluid overload. Physical examination of the chest was not documented, and mobilisation did not occur. A chest X-ray was taken on the evening of the second day following ICU discharge but was not reported until a specialist respiratory team reviewed the patient on the afternoon of the third post-discharge day. The respiratory team diagnosed hospital-acquired pneumonia, commenced appropriate antibiotics and arranged chest physiotherapy (which had not occurred following ICU discharge). The patient deteriorated further. A decision was made not to escalate treatment, and the patient died from hospital-acquired pneumonia. Overall judgement Discharge from an ICU late in the day with continuing physiological abnormalities leading to a high early warning score with inadequate information exchange at ICU discharge contributed to missed subsequent opportunities to prevent or manage hospital acquired pneumonia in a patient at risk for this complication. |
An elderly frail patient with cardiac and other co-morbidities was discharged from ICU during the day, following emergency abdominal surgery. A clear management plan was in place at the time of ICU discharge. They received no medical team review, physiotherapy assessment or critical care follow-up on the first post-ICU ward day. Hypotension was first recognised the next day, leading to an increased early warning score. The hypotension was not addressed in a consultant review, and they were discharged from the critical care outreach service. Worsening hypotension subsequently led to suspicion of abdominal sepsis and the Sepsis Six care bundle complied with, including administration of antibiotics. On the same day they were treated for a suspected myocardial infarction and subsequently developed atrial fibrillation. They continued to deteriorate until instigation of end-of-life care several days later. Overall judgement Delay in the initial recognition and management of sepsis and myocardial infarction may have contributed to the outcome; however, the presence of co-morbidities and frailty suggests their death was unlikely to have been preventable. |
An elderly, very frail patient was discharged from ICU during the day, following a short ICU stay after elective abdominal surgery. There was a clear written handover from ICU including a management plan and ICU follow-up occurred. Over the next 3 days they deteriorated with increasing tachycardia, reducing haemoglobin concentration and abdominal distension. Sepsis was suspected and the Sepsis Six care bundle complied with. Although the symptoms of deterioration were treated, there was no investigation of the underlying cause of this deterioration or sepsis source until the fourth day after ICU discharge when a small bowel perforation was diagnosed with a CT scan. The patient returned to ICU but did not recover. Overall judgement There was a significant delay in investigating the underlying cause of deterioration. Despite this, the high level of frailty meant the patient was unlikely to have survived. |
Score n (%) | Deceased patients with some degree of avoidability n = 65 | Deceased patients without avoidability n = 185 | Discharges from ICU, excluding EOLC n = 250 | Survivors n = 20 |
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1. Very poor care | 8 (12.3) | 3 (1.6) | 11 (4.4) | 0 |
2. Poor care | 38 (58.5) | 13 (7) | 51 (20.4) | 8 (40) |
3. Adequate care | 15 (23.1) | 55 (29.7) | 70 (28) | 5 (25) |
4. Good care | 4 (6.1) | 109 (58.9) | 113 (45.2) | 7 (35) |
5. Excellent care | 0 (0) | 5 (2.7) | 5 (2) | 0 |
Problems in care
Phase of care n (%) | Deceased patients with some degree of avoidability Total problems in care = 189 | Deceased patients without avoidability Total problems in care = 90 | All discharges from ICU, excluding EOLC Total problems in care = 279 | Survivors n = 20 |
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First 24 h | 43 (22.8) | 39 (43.3) | 82 (29.4) | 13 (33.3) |
Procedure | 1 (0.5) | 2 (2.2) | 3 (0.43) | 0 |
Ongoinga | 132 (69.8) | 38 (42.2) | 170 (60.9) | 26 (66.7) |
Perioperative | 0 | 0 | 0 | 0 |
End of life | 13 (6.9) | 11 (12.2) | 24 (8.6) | 0 |
Problems in care | Deceased patients with some avoidability n = 65 | Deceased patients without avoidability n = 185 | All discharges from ICU, excluding EOLC n = 250 | Survivors n = 20 |
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Discharged n (%) | ||||
16:00–08:59 | 50 (76.9) | 118 (63.8) | 168 (67.2) | 14 (70) |
18:00–08:59 | 36 (55.4) | 76 (41.1) | 112 (44.8) | 8 (40) |
22:00–08:59 | 8 (12.3) | 38 (20.5) | 46 (18.4) | 2 (10) |
Mobility | ||||
Unable to stand and step from bed to chair on ICU discharge n (%) | 39 (60.0) | 116 (62.7) | 155 (62.0) | 6 (30) |
Not mobilised to a chair n (%) | 46 (73.0) (n = 63b) | 121 (68.0) (n = 178b) | 167 (69.3) (n = 241) | 7 (35) (n = 20) |
Not mobilised away from bed n (%) | 42 (84) (n = 50b) | 106 (73.6) (n = 144b) | 148 (76.3) (n = 194b) | 11 (61) (n = 18b) |
Atrial fibrillation | ||||
New diagnosis n (%) | 9 (13.8) | 31 (16.8) | 40 (16.0) | 1 (5) |
Initial management assessed as not appropriate n (%) | 5 (55.6) | 7 (22.5) | 12 (30) | 0 (0) |
No investigation of underlying cause n (%) | 6 (66.6) | 11 (35.5) | 17 (42.5) | 1 (100) |
Sepsis | ||||
Diagnosis/suspicion n (%) | 43 (66.2) | 107 (57.8) | 150 (60) | 4 (20) |
Sepsis 6 not completed n (%) | 19 (44.2) | 31 (29) | 50 (33.3) | 3 (75) |
Nutritiona | ||||
Plan required and not documented on discharge from ICU n (%) | 24/53 (45.3) | 52/132 (39.4) | 76 (41.1) | 8/14 (57) |
Follow-up/outreach | ||||
Seen by follow-up/outreach n (%) | 53 (81.5) | 154 (83.7) | 207 (82.8) | 15 (75) |
Discharged n (%) | 30 (56.6) | 72 (46.8) | 102 (49.3) | 14 (93) |
Day discharged med (IQR) | 1 (1–2) | 1 (1–2) | 1 (1–2) | 2 (1–2) |
Not re-assessed n (%) | 21 (70) | 53 (73.6) | 74 (72.5) | 13 (93) |