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Intensive Care Med. 2018 Jul;44(7):1115-1129. doi: 10.1007/s00134-018-5245-2. Epub 2018 Jun 25.

Out-of-hours discharge from intensive care, in-hospital mortality and intensive care readmission rates: a systematic review and meta-analysis.

Author information

1
Nuffield Department of Clinical Neurosciences, Kadoorie Centre for Critical Care and Trauma Research and Education, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK. sarah.vollam@ndcn.ox.ac.uk.
2
Centre for Statistics in Medicine, Botnar Research Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK.
3
Oxford Clinical Trials Research Unit, Botnar Research Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, UK.
4
Bodleian Healthcare Libraries, Level 3, Academic Centre, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK.
5
Nuffield Department of Clinical Neurosciences, Kadoorie Centre for Critical Care and Trauma Research and Education, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK.

Abstract

PURPOSE:

Discharge from an intensive care unit (ICU) out of hours is common. We undertook a systematic review and meta-analysis to explore the association between time of discharge and mortality/ICU readmission.

METHODS:

We searched Medline, Embase, Web of Knowledge, CINAHL, the Cochrane Library and OpenGrey to June 2017. We included studies reporting in-hospital mortality and/or ICU readmission rates by ICU discharge "out-of-hours" and "in-hours". Inclusion was limited to patients aged ≥ 16 years discharged alive from a non-specialist ICU to a lower level of hospital care. Studies restricted to specific diseases were excluded. We assessed study quality using the Newcastle Ottowa Scale. We extracted published data, summarising using a random-effects meta-analysis.

RESULTS:

Our searches identified 1961 studies. We included unadjusted data from 1,191,178 patients from 18 cohort studies (presenting data from 1994 to 2014). "Out of hours" had multiple definitions, beginning between 16:00 and 22:00 and ending between 05:59 and 09:00. Patients discharged out of hours had higher in-hospital mortality [relative risk (95% CI) 1.39 (1.24, 1.57) p < 0.0001] and readmission rates [1·30 (1.19, 1.42), p < 0.001] than patients discharged in hours. Heterogeneity was high (I2 90.1% for mortality and 90.2% for readmission), resulting from differences in effect size rather than the presence of an effect.

CONCLUSIONS:

Out-of-hours discharge from an ICU is strongly associated with both in-hospital death and ICU readmission. These effects persisted across all definitions of "out of hours" and across healthcare systems in different geographical locations. Whether these increases in mortality and readmission result from patient differences, differences in care, or a combination remains unclear.

KEYWORDS:

In-hospital mortality; Intensive care; Intensive care readmission; Out of hours

PMID:
29938369
PMCID:
PMC6061448
DOI:
10.1007/s00134-018-5245-2
[Indexed for MEDLINE]
Free PMC Article

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