PubMed · 9433254
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J Masanz. 1996-05-20. RN APACHE coordinator.. https://pubmed.ncbi.nlm.nih.gov/9433254/
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BACKGROUND: It is generally believed that pressure for beds on intensive-care units (ICUs) has increased in the UK. This study used discharge at night as a proxy measure to investigate pressure. METHODS: Night was defined in two ways: "out of office hours' from 2200 to 0659 h and "the early hours of the morning" from 0000 to 0459 h. The rate of discharge at night was compared for 21 295 adult admissions to 62 ICUs covering the period 1995-98 with 10806 admissions to 26 ICUs covering the period 1988-90. With data solely from 1995-98, the consequences of discharge at night and premature discharge were investigated. FINDINGS: Overall, 2269 (21.0%) admissions did not survive the ICU in 1988-90 compared with 4487 (21.1%) in 1995-98. Of ICU survivors, 2.7% were discharged at night (2200-0659 h) in 1988-90 compared with 6.0% in 1995-98. In 1995-98, night discharges (2200-0659 h) had a higher crude (odds ratio 1.46, 95% CI 1.18-1.80) and case-mix adjusted (1.33, 1.06-1.65) ultimate hospital mortality. Higher odds ratios were observed when the definition of night was 0000-0459 h. Premature discharge was commoner at night, 42.6% vs 5.0% and its importance was apparent when incorporated into the logistic-regression model (premature discharge 1.35, 1.10-1.65; night discharge 1.17, 0.92-1.49). INTERPRETATION: Night discharges from ICU are increasing in the UK. This practice is of concern because patients discharged at night fare significantly worse than those discharged during the day. Night discharges are more likely to be "premature" in the view of the clinicians involved. The implication of these results is that many hospitals have insufficient intensive-care beds. In deciding whether or not to invest more resources in intensive care we must, however, consider the cost-utility of this particular service compared with other ways that additional resources could be used.
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BACKGROUND: The provision of adult critical-care facilities is not based on a rational or scientific assessment of need. We aimed to define the numbers of adult critical-care beds required for a population of 500000. METHODS: In five hospitals in Wales, UK, we classified patients who might be suitable for critical care in intensive-care or high-dependency units. On every 12th day for 1 calendar year, we counted the numbers of such patients admitted in a defined geographical population. A panel of ten intensivists made consensus decisions about whether individual patients were in the appropriate unit. The data were used to predict the numbers of beds and units required for the population. FINDINGS: 4058 patients were suitable for critical care, of whom 3028 lived in the study area. 56.4% were in general wards, 22.3% in high-dependency units, and 21.3% in intensive-care units. The mean risk of death was 22.0% and the in-hospital death rate 17.3%. According to the masked consensus, 41.3% of patients required high-dependency beds and 21.5% intensive-care beds. Mean risk of death increased from general wards (14.7%) to high-dependency units (19.2%) to intensive care (37.0%). Based on the consensus decisions, the average daily requirement of intensive-care beds was 21 and of high-dependency beds 43; to meet needs 95% of times required 30 and 55 beds, respectively, in a single critical-care unit. INTERPRETATION: We estimated, scientifically, numbers of adult critical-care beds required to meet population needs. Studies are necessary periodically to track changes in admissions requiring critical care.