Health & Medical intensive care

Optimal Timing of Transfer Out of the Intensive Care Unit

Optimal Timing of Transfer Out of the Intensive Care Unit

Results


Of 2624 eligible patients, 30-day and 60-day mortality information was unavailable for 223 and 285 patients, respectively. Our primary analysis included the 2401 unique ICU survivors with known 30-day mortality (Table 1). Their mean delay in being transferred out of ICU was 9.6 (SD, 11.7) hours (range, 0–93 hours). The fractions having ICU discharge delay of 0 to 12, 12.01 to 24, 24.01 to 48, 48.01 to 72, and 72.01 to 96 hours were 78.9%, 11.2%, 7.7%, 1.8%, and 0.5%, respectively; 23.7 hours represents the unconditional 90th percentile of this variable. Most patients (85%) were transferred from ICU to general care areas; 12% left the hospital directly from the ICU. Six percent died before hospital discharge; mortality at 30 days after ICU admission was 10.1%. Table 1 also shows the characteristics of the entire cohort of 2624 unique ICU survivors.

Noting that 90% of transfer delays were less than 24 hours, we used all 2624 ICU survivors to construct a quantile regression model for long delays, taken as the 90th conditional percentile of ICU discharge delay. The only variables significant in this model were the number of same-sex patients contemporaneously awaiting transfer from the ICU and the ICU discharge location (Table 2). The first of these, a measure of competition for transferring out of the ICU, ranged from 2.7 extra hours of delay with 1 other ICU patient in competition, to 47.3 extra hours if a patient was vying for beds outside the ICU with 4 or more other patients. This variable had, by far, the strongest association with ICU discharge delay; the pseudo-R of the model decreased from 0.36 including all variables to just 0.08 after this variable was removed from the model. No measures of illness type or severity were significant in this model, including age, APS, or in-hospital death.

The model of 30-day mortality had a c statistic of 0.885 and a Hosmer-Lemeshow P value of .72. Significant covariates were age, sex, comorbid conditions, source of ICU admission, acute diagnosis, APS, mechanical ventilation status, orders limiting use of life-supporting therapies, and ICU discharge delay (Table 3). The relationship between the odds of 30-day mortality and ICU discharge delay was significant (P = .002), nonlinear (P = .001, Wald test of nonlinear spline terms), and U-shaped (see Figure). Using an ICU transfer delay of 0 hours as reference (odds ratio, 1.0), the odds ratio decreases to a nadir of 0.35 with 20 hours of delay, then progressively increases to values of 0.56, 0.91, and 1.39 for transfer delays of 48, 72, and 93 hours, respectively. The corresponding models of hospital and 60-day mortality evidenced similar relationships, with nadirs at 19 and 21 hours, respectively.



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Figure.



Effect of delay in discharge from intensive care unit (ICU) on the odds ratio for death at 30 days after ICU admission among 2401 ICU survivors. Estimate and 95% confidence intervals are shown. ICU discharge delay is the interval from the transfer request until actual transfer out of the ICU.





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