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High Intensive Care readmission rates, risk factors and possible solutions, Quality improvement Project, Lancashire teaching hospital
EP38989
Poster Title: High Intensive Care readmission rates, risk factors and possible solutions, Quality improvement Project, Lancashire teaching hospital
Submitted on 15 Jul 2022
Author(s): Mohammed Hatab, Peter Fark, Jasbir Chhabra, Marco Parolin and Alecia Wegstape
Affiliations: Lancashire teaching hospital
Poster Views: 165
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Poster Information
Abstract: Abstract

Background
It is well known that early readmission to intensive care during the same hospital admission is associated with increased mortality, morbidity, and increased length of stay in Intensive care and over all hospital stay(4). Due to its drastic consequences on patient outcomes and financial burden, the early intensive care readmission rates are used as surrogate markers of quality of care in the intensive care unit(1). The admission and discharge journey of a patient to intensive care is a very complex process that involves multiple factors like proper communication, proper management, escalation plans and efficient discharging plan. Identifying patients who are at risk of readmission should start early once the decision was taken to admit the patient to intensive care in the first place. The risk of readmission is multifactorial and should be investigated in a systematic organised way to find simple, practical, and applicable solutions and interventions that can be applied to change the practice and improve the patients’ outcome.

Method
The aim of this quality improvement project was to answer the following question: Why are the Intensive care readmission rates in Royal Preston Hospital higher than the national rates? The simplistic answer would be to simply state that the readmission rates have always been increasing at Preston Hospital Intensive Care Unit due to increased workload and high patient flow! However, my primary objective was to look for a deeper understanding; the factors associated with this alarming rate of readmission and to prevent the preventable (2). To address this problem, I collected the number of patients who were readmitted within 48 hours to Intensive care between August 2020 and August 2021 from the ICNARC database. After that, we looked at the clinical information on the QuadraMed computer system. Early readmission was defined as readmission within 48 hours after being discharged from intensive care. For each patient I deeply investigated the documentation behind the decision-making process and reason for the first admission, clinical interventions, and communications with the other specialties during the Intensive Care admission and after discharge in addition to the cause of readmission. We looked at multiple factors like age, comorbidities and the most important was the few hours before discharging the patient from intensive care.

Results
This was a retrospective data collection and there were 35 Intensive care patients found to be readmitted within 48 hours. The majority of patients (46%) who were readmitted to intensive care during that period of time were aged 50 year or less, compared to 17% aged 70 years old or above. Patients admitted in an emergency setting were found to have high risk of readmission compared to the elective admitted patient, 94 % vs 6 % respectively. Inappropriate use and documentation of the NEWs score especially after the patient was identified for discharge to the ward by the consultant ward round till the actual time of discharge was an important single factor that was found. The percentage of patients who had a high NEWs score (6 or above), one hour before discharge was approximately 70% compared to 40% when the patient was seen earlier by a consultant during the ward round. Only 31% was discharged to the ward within 4 hours after the decision was taken to discharge them. Another important correlation was the high WBCs and CRP in patients likely to be discharged within 24hours - approximately 30% had high levels of CRP and WBCs 24 hours before being discharged to the ward. There was poor communication and hand over to the ward as 86% of the discharged patients were not handed over to the ward doctor, but they had a written discharge summary. In addition to that there was no proper escalation plan regarding readmission if the patient had deteriorated. Interestingly, length of stay was less than 7 days in 71% during the first admission and 66% after the readmission. The main cause of readmission was respiratory failure including COVID related patients, but the COVID was not the leading cause of readmission despite it being the main cause of the primary intensive care admission in this group. The majority of those patients were discharged successfully from Intensive care (86%) compared to 14% who died in ICU. The findings and recommendations of this quality improvement project were discussed in multiple clinical governance meetings and departmental meetings and significant changes were made in the clinical pathway and communication tools aiming to decrease the readmission rates to intensive care.

Conclusion
Early unplanned Intensive care readmission is associated with high mortality rate, long hospital and intensive care stay and increased financial burden on the trust. In our intensive care, the majority of the readmitted patients were successfully discharged within the first week of readmission which indicates that the cause of readmission may be preventable, and the discharge may be premature. Some important simple and achievable interventions like: NEWs score 1 hour before discharge(3), 24 hours and inflammatory markers checks before discharge and proper hand over using the SmartPage can decrease the rate of intensive care readmission but cannot totally prevent it.
Summary: Readmission to intensive care is not only having high risk to the patient but also increase the stress on the families as well. Since 2010, when the Patient Protection Affordable Care Act have created the Hospital Readmission Reduction Programme to penalise the hospital with high readmission rates in united states of America, an enormous efforts, trials and studies were done to decrease it especially in the intensive care unit. References: 1- Guidelines for the Provision of Intensive Care Services (GPICS, Faculty of Intensive Care medicine &Intensive care society, 2019.
2- Al-Jaghbeer MJ, Tekwani SS, Gunn SR, et al. Incidence and etiology of potentially preventable intensive care unit readmissions. Society of Critical Care Medicine journal, September 2016 , Volume 44, Number 9.
3- Heidi Mcneill , Saif Khairat. mpact of Intensive Care Unit Readmissions on Patient Outcomes and the Evaluation of the National Early Warning Score to Prevent Readmissions: Literature Review, (JMIR Perioper Med 2020;3(1):e13782) doi: 10.2196/13782.
4- Carolina R. Ponzoni, Thiago D. Correa, Roberto R. Filho, Ary Serpa Neto, Murillo S. C. Assunção, Andreia Pardini, and ˆ Guilherme P. P. Schettino. Readmission to the Intensive Care Unit: Incidence, Risk Factors, Resource Use, and Outcomes, A Retrospective Cohort Study. Ann Am Thorac Soc Vol 14, No 8, pp 1312–1319, Aug 2017
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