Skip to main content

Advertisement

SpringerLink
Log in

Critical care transition programs and the risk of readmission or death after discharge from ICU

  • Original
  • Published:
Intensive Care Medicine Aims and scope Submit manuscript

Abstract

Purpose

Critical care transition programs have been widely implemented to improve the safety of patient discharge from ICU, but have undergone limited evaluation. We sought to evaluate implementation of a critical care transition program on patient readmission to ICU (72 h) and mortality (14 days).

Methods

Interrupted time series analysis of 32,234 consecutive adult patients discharged alive from medical-surgical ICUs in eight hospitals in two cities between January 1, 2002 and January 1, 2012. A multidisciplinary ICU provider team (physician, nurse, respiratory therapist) that serially evaluated each patient after ICU discharge was implemented in three hospitals in one city (study group), but not the five hospitals in the other city (control group). Temporal changes were examined using multivariable, segmented linear regression models.

Results

After implementation of the program, there was an immediate non-significant decrease in the absolute proportion of patients readmitted to ICU in the study group (−0.4 %, 95 % CI −1.7 to +1.0 %) and a non-significant increase in the absolute proportion of patients readmitted to ICU in the control group (+1.0 %, 95 % CI −0.3 to +2.2 %). Subsequently, there were non-significant changes in the absolute proportion of patients readmitted to ICU in both the study (+0.1 % per quarter; 95 % CI, −0.1 to +0.2 %) and control (−0.1 per quarter; 95 % CI, −0.2 to +0.1 %) groups over time. No significant changes were observed in mortality. The results were stable across patient subgroups.

Conclusions

Implementation of a critical care transition program was not associated with patient readmission to ICU or mortality.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Bell CM, Brener SS, Gunraj N, Huo C, Bierman AS, Scales DC, Bajcar J, Zwarenstein M, Urbach DR (2011) Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA 306:840–847

    CAS  PubMed  Google Scholar 

  2. Eijsbroek H, Howell DC, Smith F, Shulman R (2013) Medication issues experienced by patients and carers after discharge from the intensive care unit. J Crit Care 28:46–50

    Article  Google Scholar 

  3. McLaughlin N, Leslie GD, Williams TA, Dobb GJ (2007) Examining the occurrence of adverse events within 72 hours of discharge from the intensive care unit. Anaesth Intensive Care 35:486–493

    Article  CAS  Google Scholar 

  4. Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH (2008) Consequences of inadequate sign-out for patient care. Arch Intern Med 168:1755–1760

    Article  Google Scholar 

  5. Li P, Stelfox HT, Ghali WA (2011) A prospective observational study of physician handoff for intensive-care-unit-to-ward patient transfers. Am J Med 124:860–867

    Article  Google Scholar 

  6. Coleman EA, Berenson RA (2004) Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med 141:533–536

    Article  Google Scholar 

  7. Kahn JM, Angus DC (2011) Going home on the right medications: prescription errors and transitions of care. JAMA 306:878–879

    Article  CAS  Google Scholar 

  8. Stelfox HT, Lane D, Boyd JM, Taylor S, Perrier L, Straus S, Zygun D, Zuege DJ (2015) A scoping review of patient discharge from intensive care: opportunities and tools to improve care. Chest 147:317–327

    Article  Google Scholar 

  9. Chaboyer W, James H, Kendall M (2005) Transitional care after the intensive care unit: current trends and future directions. Critical Care Nurse 25:16–18 (20–12, 24–16 passim; quiz 29)

    PubMed  Google Scholar 

  10. Niven DJ, Bastos JF, Stelfox HT (2014) Critical care transition programs and the risk of readmission or death after discharge from an ICU: a systematic review and meta-analysis. Crit Care Med 42:179–187

    Article  Google Scholar 

  11. Shadish WR, Cook TD, Campbell DT (2002) Experimental and quasi-experimental de- signs for generalized causal inference. Houghton-Mifflin, Boston

    Google Scholar 

  12. Dunning T (2012) Natural Experiments in the Social Sciences: A Design-Based Approach. Cambridge University Press, Cambridge

    Book  Google Scholar 

  13. Jandoc R, Burden AM, Mamdani M, Levesque LE, Cadarette SM (2015) Interrupted time series analysis in drug utilization research is increasing: systematic review and recommendations. J Clin Epidemiol 68(8):950–956

    Article  Google Scholar 

  14. Hosein FS, Bobrovitz N, Berthelot S, Zygun D, Ghali WA, Stelfox HT (2013) A systematic review of tools for predicting severe adverse events following patient discharge from intensive care units. Crit Care 17:R102

    Article  Google Scholar 

  15. Hosein F, Roberts DJ, Turin T, Zygun D, Ghali WA, Stelfox HT (2014) A meta-analysis to derive literature-based benchmarks for readmission and hospital mortality after patient discharge from intensive care. Crit Care 18:2558

    Article  Google Scholar 

  16. Chiasson TC, Manns BJ, Stelfox HT (2009) An economic evaluation of venous thromboembolism prophylaxis strategies in critically ill trauma patients at risk of bleeding. PLoS Med 6:e1000098

    Article  Google Scholar 

  17. Stelfox HT, Hemmelgarn BR, Bagshaw SM, Gao S, Doig CJ, Nijssen-Jordan C, Manns B (2012) Intensive care unit bed availability and outcomes for hospitalized patients with sudden clinical deterioration. Arch Intern Med 172:467–474

    Article  Google Scholar 

  18. Wagner AK, Soumerai SB, Zhang F, Ross-Degnan D (2002) Segmented regression analysis of interrupted time series studies in medication use research. J Clin Pharm Ther 27:299–309

    Article  CAS  Google Scholar 

  19. Carroll N (2008) Application of segmented regression analysis to the Kaiser Permanente Colorado Critical drug interaction program. Proceedings of the Fifthteenth Annual Western Users of SAS Software Conference. Universal City, California, USA, 5–7 November, 2008

  20. Zhang F, Wagner AK, Soumerai SB, Ross-Degnan D (2009) Methods for estimating confidence intervals in interrupted time series analyses of health interventions. J Clin Epidemiol 62:143–148

    Article  Google Scholar 

  21. Zeger SL, Liang KY (1986) Longitudinal data analysis for discrete and continuous outcomes. Biometrics 42:121–130

    Article  CAS  Google Scholar 

  22. Carlin JB, Wolfe R, Brown CH, Gelman A (2001) A case study on the choice, interpretation and checking of multilevel models for longitudinal binary outcomes. Biostatistics 2:397–416

    Article  CAS  Google Scholar 

  23. Hu FB, Goldberg J, Hedeker D, Flay BR, Pentz MA (1998) Comparison of population-averaged and subject-specific approaches for analyzing repeated binary outcomes. Am J Epidemiol 147:694–703

    Article  CAS  Google Scholar 

  24. Carroll N (2006) Application of segment regression analysis to the Kaiser Permanente Colorado Critical Drug Interaction Program. Proceedings of the Fifthteenth Annual Western Users of SAS Software Conference. Universal City, California, USA, 5–7 November, 2008

  25. McDonnell A, Esmonde L, Morgan R, Brown R, Bray K, Parry G, Adam S, Sinclair R, Harvey S, Mays N, Rowan K (2007) The provision of critical care outreach services in England: findings from a national survey. J Crit Care 22:212–218

    Article  Google Scholar 

  26. Plowright C, Fraser J, Smith S, Buras-Rees S, Dennington L, King D, MacLellan C, Seymour P, Scott G, Brindle A (2006) Perceptions of critical care outreach within a network. Nurs Time 102:36–40

    Google Scholar 

  27. Athifa M, Finn J, Brearley L, Williams TA, Hay B, Laurie K, Leen T, O’Brien K, Stuart M, Watt M, Leslie G (2011) A qualitative exploration of nurse’s perception of Critical Outreach Service: a before and after study. Aust Crit Care 24:39–47

    Article  Google Scholar 

  28. Gao H, Harrison DA, Parry GJ, Daly K, Subbe CP, Rowan K (2007) The impact of the introduction of critical care outreach services in England: a multicentre interrupted time-series analysis. Crit Care 11:R113

    Article  Google Scholar 

  29. Medical Research Council (2000) Developing and evaluating complex interventions: new guidance. MRC, London

  30. Leape LL (2014) The checklist conundrum. New Engl J Med 370:1063–1064

    Article  Google Scholar 

  31. Bonafide CP, Localio AR, Song L, Roberts KE, Nadkarni VM, Priestley M, Paine CW, Zander M, Lutts M, Brady PW, Keren R (2014) Cost-benefit analysis of a medical emergency team in a children’s hospital. Pediatrics 134:235–241

    Article  Google Scholar 

  32. Heyland DK, Barwich D, Pichora D, Dodek P, Lamontagne F, You JJ, Tayler C, Porterfield P, Sinuff T, Simon J (2013) Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Intern Med 173:778–787

    Article  Google Scholar 

  33. Starmer AJ, Spector ND, Srivastava R, West DC, Rosenbluth G, Allen AD, Noble EL, Tse LL, Dalal AK, Keohane CA, Lipsitz SR, Rothschild JM, Wien MF, Yoon CS, Zigmont KR, Wilson KM, O’Toole JK, Solan LG, Aylor M, Bismilla Z, Coffey M, Mahant S, Blankenburg RL, Destino LA, Everhart JL, Patel SJ, Bale JF Jr, Spackman JB, Stevenson AT, Calaman S, Cole FS, Balmer DF, Hepps JH, Lopreiato JO, Yu CE, Sectish TC, Landrigan CP, Group IPS (2014) Changes in medical errors after implementation of a handoff program. New Engl J Med 371:1803–1812

    Article  CAS  Google Scholar 

  34. Romano MJ, Segal JB, Pollack CE (2015) The association between continuity of care and the overuse of medical procedures. JAMA Intern Med 175:1148–1154

    Article  Google Scholar 

  35. Rao JK, Anderson LA, Inui TS, Frankel RM (2007) Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care 45:340–349

    Article  Google Scholar 

  36. Walsh TS, Salisbury LG, Merriweather JL, Boyd JA, Griffith DM, Huby G, Kean S, Mackenzie SJ, Krishan A, Lewis SC, Murray GD, Forbes JF, Smith J, Rattray JE, Hull AM, Ramsay P, Investigators R (2015) Increased hospital-based physical rehabilitation and information provision after intensive care unit discharge: the RECOVER randomized clinical trial. JAMA Intern Med 175:901–910

    Article  Google Scholar 

  37. Gawande A (2010) The checklist manifesto: how to get things right. Profile, London

    Google Scholar 

Download references

Acknowledgments

The study was funded by an establishment grant from Alberta Innovates—Health Solutions (20,100,368). HTS is supported by a Population Health Investigator Award from Alberta Innovates—Health Solutions. DJN is supported by a Clinician Fellowship Award from Alberta Innovates—Health Solutions, and a Knowledge Translation Canada Student Fellowship and Training Program grant. SMB is supported by a Canada Research Chair in Critical Care Nephrology and Clinical Investigator Award from Alberta Innovates—Health Solutions. Funding sources had no role in the design, conduct, or reporting of this study and we are unaware of any conflicts of interest. Dr Stelfox and Mr Gao had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Author information

Authors and Affiliations

  1. Departments of Critical Care Medicine, and Community Health Sciences, University of Calgary and Alberta Health Services, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada

    Henry T. Stelfox, Jaime Bastos & Daniel J. Niven

  2. Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada

    Sean M. Bagshaw

  3. Department of Family Medicine, University of Calgary and Alberta Health Services, Calgary, Canada

    T. C. Turin

  4. Alberta Health Services, Calgary, Canada

    Song Gao

Authors
  1. Henry T. Stelfox
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jaime Bastos
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Daniel J. Niven
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sean M. Bagshaw
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. T. C. Turin
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Song Gao
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Henry T. Stelfox.

Ethics declarations

Conflicts of interest

Funding sources had no role in the design, conduct, or reporting of this study and we are unaware of any conflicts of interest.

Additional information

Take-home message: Implementing a multidisciplinary critical care transition program to serially evaluate patients after discharge from ICU was not associated with patient readmission to ICU or mortality. Alternative strategies are needed to improve the quality of care for patients discharged from ICU.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 97 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Stelfox, H.T., Bastos, J., Niven, D.J. et al. Critical care transition programs and the risk of readmission or death after discharge from ICU. Intensive Care Med 42, 401–410 (2016). https://doi.org/10.1007/s00134-015-4173-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00134-015-4173-7

Keywords

Search

Navigation