ICU Annual Report 2017 Key Findings

Adult ICU Key Findings
There was considerable variability between Units in the number of admissions, source of admissions, case mix, severity of illness, complexity of care required, and resources utilised in each Unit.
Irish Units are very busy; mean bed occupancy (calculated from the exact number of hours the bed was physically occupied) was 91% (ranging from 82% to 99%). Standard recommendations are for occupancy rates of 70% to 80%.
Illness severity on admission to the Unit was greater in Irish Units than in UK Units; the mean Acute Physiology and Chronic Health Evaluation (APACHE) II score for Ireland was 15.9 compared with 14.8 for the UK. The levels of cardiovascular, respiratory and renal support required were also greater for Irish patients.
Despite higher markers of illness severity, mean length of stay was the same in Ireland and the UK (five days).
The rate of unplanned out-of-hours discharges to the ward was greater in Irish Units (6% versus 2% in the UK).
These data indicate that compared with UK patients, Irish patients need to be sicker to be admitted to ICU. For a given illness severity, they spend less time in ICU before discharge back to the ward, which is more likely to happen at night.
Mortality is high in patients requiring admission to critical care (ICU or HDU); 13% of admitted patients died in ICU/HDU nationally, and a further 6% died after discharge from the Unit, before discharge from hospital.
Outcome measures in Irish Units were comparable to UK Units, including risk-adjusted hospital mortality rates (standardised mortality ratio (SMR) of 1.07 for Ireland versus the expected value of 1.0) and rates of unanticipated readmission to the Unit (1.1% versus 1.1%). This is reassuring and suggests that, despite the strains placed on them, Irish Units provide a high quality of care for patients and are a relatively safe environment for critically ill patients.
It should be noted that the Audit has no way of identifying patients who should be in ICU or HDU based on clinical criteria but are not because of limited Unit bed capacity. The scale of this ‘unmet need’ and the effects on patient outcomes are not known.
One Unit, Beaumont Hospital General ICU had outlier data for risk-adjusted hospital mortality. The SMR for the Unit for 2017 was 1.27 which was more than two standard deviations (SDs) above the expected value of 1.0.
Data from the Beaumont Hospital General ICU provide compelling evidence of the effect on mortality of admitting increased numbers of patients; Unit admissions in the final quarter (Q4) of 2017 were 21% higher than the rate of admission for 2016 (and 67% higher than the rate of admissions in 2001). The number of open staffed beds in the Unit was unchanged during this time. Illness severity in this Unit on admission was increased and levels of cardiovascular, respiratory and renal support required were increased, but length of stay was decreased. The risk-adjusted mortality (SMR) was increased for 2017 overall after a sharp increase in SMR in Q4 2017 (SMR from Q1 to Q3 had been within acceptable limits). The rates of unplanned readmissions to the Unit after discharge also increased in Q4 2017. These data convincingly demonstrate the outcome when demand increases beyond the available ICU bed capacity.
It should be noted that mortality in the Beaumont Hospital General ICU was only marginally outside the acceptable limits in 2017. The Unit has had a mortality rate within the acceptable limits for Quarterly Quality Reports to date in 2018.
The Mater Misericordiae University Hospital HDU and the University Hospital Galway ICU were outliers for unplanned discharges from the Unit to the ward at night (which is recognised to increase patient risk)
Both of these hospitals noted that other indicators of patient outcomes had not been adversely affected. Both identified improved documentation of decisions to clear patients for discharge as a way to improve performance for this QI. In addition, Mater Misericordiae University Hospital noted a requirement for increased critical care capacity.
Some Units have a problem with delayed discharges, presumably because of ward bed shortages. Facilitation of discharges from ICU would reduce ICU bed occupancy, reduce discharges out-of-hours, reduce delays in admission to ICU for critically ill patients, and could make beds available for patients from other Units which are over capacity.
Length of hospital stay after ICU discharge was considerably longer in Ireland than in the UK (the mean was 24 days in Ireland versus 15 days in the UK). This could be related to a lack of step-down or rehabilitation facilities in Ireland, or it could be because the patients in Ireland were sicker on ICU admission than patients in the UK.
The Audit covered only 58% of ICU activity, but a fuller picture will be available in the 2018 report, which will have 78% coverage.
Preparation of this report identified anomalies due to issues with data quality and interpretation of ICNARC definitions. These have been addressed in audit coordinator workshops, which will lead to greater uniformity in data entry in future.
Paediatric ICU Key Findings
The number of bed days delivered in the ROI was approximately 10,000 annually from 2015–2017. Children under the age of one made up 57% of admissions to Our Lady’s Children’s Hospital, Crumlin (OLCHC) and 38% of admissions to Temple Street Children’s University Hospital (TSCUH).
Bed occupancy in both Irish paediatric ICUs (PICUs) was high in 2017 (97% in OLCHC and 86% in TSCUH). These are above the recommended levels for safe patient care and are likely to make staff retention more difficult.
Quality metrics such as risk-adjusted mortality and emergency readmissions in both PICUs were within the expected range. These findings show that PICUs were safe places in the ROI in 2017.
Clinical audit is a tool for improvement in patient care. In this report, both PICUs have shared their experiences of learning from previous PICANet Annual Reports to improve their prevention of unplanned extubation.
There was an improvement in journey commencement times in 2017 for the Irish Paediatric Acute Transport Service (IPATS). Transfer commencement times of less than one hour increased from about 40% in 2015 and 2016 to around 70% in 2017. However, IPATS only operates on weekdays during the daytime, leaving a major gap in service provision outside of normal working hours.
There was considerable variability in nursing staffing levels between participating Units in the PICANet Annual Report 2018. There were also considerable numbers of nursing vacancies in both OLCHC and TSCUH.