DOI: 10.1097/CCM.0b013e3181ce4858

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PMID: 20335711

Issn Print: 0090-3493

Publication Date: 2010/04/01


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Mandatory checklists at discharge may have the potential to prevent readmissions

Marcus J. Schultz; Ognjen Gajic

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Recently in Critical Care Medicine, Chrusch et al (1) showed that intensive care unit (ICU) readmission or unexpected death after ICU discharge were not only dependent on age, particular diagnoses, Acute Physiology and Chronic Health Evaluation II score, and ICU length of stay but also dependent on ICU discharge at a time of no vacancy (relative risk of 1.56; 95% confidence interval, 1.05–2.31). From this finding the authors conclude that overloading the capacity of an ICU could affect physician decision-making, resulting in premature ICU discharge. In that same issue of Critical Care Medicine, Byrnes et al (2) showed that a daily mandatory checklist covering a diverse group of ICU protocols improved physician consideration and practice patterns. Of interest, after initiation of this daily mandatory checklist, a more than two-fold increase was noticed in transferring patients out of the ICU on telemetry (from 16% to 35%) and physical therapy (from 28% to 42%).
Although most patients surviving critical illness no longer require life support interventions after ICU discharge, 4% to 10% of patients are reported to be readmitted to the ICU (3). Patients with unplanned ICU readmission have higher mortality rates and longer length of stay than patients who survive critical illness and stay out of the ICU after transfer (3, 4). One complicating factor is that ICU discharge criteria are often subjective and may not be reproducible. Even within the same ICU these criteria could fluctuate daily, particularly when there is overload of the ICU capacity. Another complicating factor is that the sometimes higher-than-recognized standards of care provided in the ICU may mask high demands of patients at risk for ICU readmission. Finally, hand-over processes at ICU discharge are usually not standardized, leading to frequent information corruption and omission of important details of care delivery once the patient is discharged to the floor service.
Recognition of patients at risk, preferably before transfer, may allow for additional measures to prevent clinical deterioration and eventually ICU readmission, including appropriate hand-over, transfer to a higher acuity step-down or progressive care unit than “the floor,” if available; increased supervision on the floor with overlapping rounds by outreach teams, or simply keeping the patient in the ICU until further improvement is observed, even when there is overload of the ICU capacity. A mandatory checklist at ICU discharge may not only prevent premature ICU discharge and readmission but also have the potential to improve and standardize hospital care delivery beyond ICU.
The authors have not disclosed any potential conflicts of interest.
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