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09/03/2011 - prediction of ICU re-admission

posted Sep 28, 2011, 5:38 PM by Chief Resident   [ updated Sep 28, 2011, 5:39 PM by Purnema Madahar ]
When talking to Sarah Weiss, one of our new MARs, about triaging MICU discharges, we struggled to identify clear guidelines on how to determine a safe discharge from the ICU. Browsing the literature, it seems that the success of an ICU discharge is oftentimes measured by the need for readmission to the ICU. There is good evidence that patients who require readmission have significantly higher mortality rates and longer lengths of stay.

Studies looking at risk factors for ICU admissions are fraught with confounders, as one can imagine. The attached paper from Chest from 2001 describes a systemic review of 8 primary studies of ICU readmission and 8 ICU outcome studies that reported readmission rates. A few of their key findings:

1. mean readmission rates were 7% (range 4-10%)
2. initial ICU admission diagnoses most frequently associated with readmission: hypoxic respiratory failure, inadequate ventilatory or pulmonary toilet, upper-GI bleeding, neurologic impairments, and sepsis.
3. most common reason for ICU readmission: pulmonary problems, including hypoxia and inadequate pulmonary toilet
4. variables at discharge most frequently associated with ICU readmission: fever, hypoxia, respiratory rate >24 breaths/min, heart rate >104 beats/min, an admission diagnosis of upper-GI bleeding, age >65 yr.

Findings of the included studies were very heterogeneous. It seems that there is no good prediction rule for a successful ICU discharge.

Interestingly, a few papers (one attached) showed increased risk of readmission and death due to after-hour discharges from the ICU, a factor the MAR might be able to influence.