Does the implementation of a novel intensive care discharge risk score and nurse-led inpatient review tool improve outcome? A prospective cohort study in two intensive care units in the UK

Abstract

<jats:sec><jats:title>Objective</jats:title><jats:p>To develop a clinical prediction model for poor outcome after intensive care unit (ICU) discharge in a large observational data set and couple this to an acute post-ICU ward-based review tool (PIRT) to identify high-risk patients at the time of ICU discharge and improve their acute ward-based review and outcome.</jats:p></jats:sec><jats:sec><jats:title>Design</jats:title><jats:p>Retrospective patient cohort of index ICU admissions between June 2006 and October 2011 receiving routine inpatient review. Prospective cohort between March 2012 and March 2013 underwent risk scoring (PIRT) which subsequently guided inpatient ward-based review.</jats:p></jats:sec><jats:sec><jats:title>Setting</jats:title><jats:p>Two UK adult ICUs.</jats:p></jats:sec><jats:sec><jats:title>Participants</jats:title><jats:p>4212 eligible discharges from ICU in the retrospective development cohort and 1028 patients included in the prospective intervention cohort.</jats:p></jats:sec><jats:sec><jats:title>Interventions</jats:title><jats:p>Multivariate analysis was performed to determine factors associated with poor outcome in the retrospective cohort and used to generate a discharge risk score. A discharge and daily ward-based review tool incorporating an adjusted risk score was introduced. The prospective cohort underwent risk scoring at ICU discharge and inpatient review using the PIRT.</jats:p></jats:sec><jats:sec><jats:title>Outcomes</jats:title><jats:p>The primary outcome was the composite of death or readmission to ICU within 14 days of ICU discharge following the index ICU admission.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>PIRT review was achieved for 67.3% of all eligible discharges and improved the targeting of acute post-ICU review to high-risk patients. The presence of ward-based PIRT review in the prospective cohort did not correlate with a reduction in poor outcome overall (P=0.876) or overall readmission but did reduce early readmission (within the first 48 hours) from 4.5% to 3.6% (P=0.039), while increasing the rate of late readmission (48 hours to 14 days) from 2.7% to 5.8% (P=0.046).</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>PIRT facilitates the appropriate targeting of nurse-led inpatient review acutely after ICU discharge but does not reduce hospital mortality or overall readmission rates to ICU.</jats:p></jats:sec>