OBJECTIVES: 

Out-of-hours discharge from ICU to the ward is associated with increased in-hospital mortality and ICU readmission. Little is known about why this occurs. We map the discharge process and describe the consequences of out-of-hours discharge to inform practice changes to reduce the impact of discharge at night.

DESIGN: 

This study was part of the REcovery FoLlowing intensive CarE Treatment mixed methods study. We defined out-of-hours discharge as 16:00 to 07:59 hours. We undertook 20 in-depth case record reviews where in-hospital death after ICU discharge had been judged “probably avoidable” in previous retrospective structured judgment reviews, and 20 where patients survived. We conducted semistructured interviews with 55 patients, family members, and staff with experience of ICU discharge processes. These, along with a stakeholder focus group, informed ICU discharge process mapping using the human factors–based functional analysis resonance method.

SETTING: 

Three U.K. National Health Service hospitals, chosen to represent different hospital settings.

SUBJECTS: 

Patients discharged from ICU, their families, and staff involved in their care.

INTERVENTIONS: 

None.

MEASUREMENTS AND MAIN RESULTS: 

Out-of-hours discharge was common. Patients and staff described out-of-hours discharge as unsafe due to a reduction in staffing and skill mix at night. Patients discharged out-of-hours were commonly discharged prematurely, had inadequate handover, were physiologically unstable, and did not have deterioration recognized or escalated appropriately. We identified five interdependent function keys to facilitating timely ICU discharge: multidisciplinary team decision for discharge, patient prepared for discharge, bed meeting, bed manager allocation of beds, and ward bed made available.

CONCLUSIONS: 

We identified significant limitations in out-of-hours care provision following overnight discharge from ICU. Transfer to the ward before 16:00 should be facilitated where possible. Our work highlights changes to help make day time discharge more likely. Where discharge after 16:00 is unavoidable, support systems should be implemented to ensure the safety of patients discharged from ICU at night.

中文翻译：

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重症监护室非工作时间出院的患者伤害和机构可避免性：使用混合方法的分析*

 目标：

非工作时间从 ICU 转至病房与院内死亡率和 ICU 再次入院增加相关。人们对为什么会发生这种情况知之甚少。我们绘制出院流程图，并描述非工作时间出院的后果，以告知实践变化，以减少夜间出院的影响。

 设计：

这项研究是强化护理治疗后恢复混合方法研究的一部分。我们将非工作时间出院定义为 16:00 至 07:59 小时。我们进行了 20 个深入的病例记录审查，其中 ICU 出院后的院内死亡在之前的回顾性结构化判断审查中被判定为“可能避免”，其中 20 个患者幸存。我们对 55 名具有 ICU 出院流程经验的患者、家属和工作人员进行了半结构化访谈。这些人员与利益相关者焦点小组一起，使用基于人为因素的功能分析共振方法为 ICU 出院流程绘制提供信息。

 环境：

三家英国国家医疗服务医院被选择代表不同的医院环境。

 科目：

从 ICU 出院的患者、他们的家人以及参与护理的工作人员。

 干预措施：

 没有任何。

测量和主要结果：

非工作时间出院很常见。患者和工作人员表示，由于夜间人员配备和技能组合的减少，非工作时间出院是不安全的。非工作时间出院的患者通常过早出院、交接不充分、生理不稳定、病情恶化没有得到适当的识别或升级。我们确定了促进 ICU 及时出院的五个相互依赖的功能键：多学科团队出院决策、患者出院准备、床位会议、床位经理分配床位以及提供病床。

 结论：

我们发现从 ICU 过夜出院后，非工作时间护理提供存在重大限制。应尽可能在 16:00 之前转入病房。我们的工作强调了有助于提高日间出院可能性的变化。若无法避免16:00后出院，应建立支持系统，确保夜间出院患者的安全。