A Quality improvement Project held at Lancashire teaching hospital
Abstract
Background
It is well known that early readmission to intensive care during the same hospital admission is associated with increased mortality, morbidity, and increased length of stay in intensive care and overall hospital stay. A review of the readmission rate at Royal Preston Hospital Intensive Care found it to be always been below the national average apart from August 2020 to August 2021, which may be due to the effect of Covid. Reducing the early readmissions to Preston critical care is part of the Trust Big Plan strategy for Consistently Delivering Excellent care.
Method
I collected the number of patients who were readmitted within 48 hours to intensive care between August 2020 and August 2021 from the ICNARC database. After that, we looked at the clinical information on the QuadraMed computer system. For each patient I deeply investigated the documentation behind the decision-making process and reason for the first admission, clinical interventions, and communications with the other specialties during the intensive care admission and after discharge in addition to the cause of readmission.
Results
There were 35 patients found to be readmitted within 48 hours. Most patients (46%) who were readmitted to intensive care during that period were aged 50 year or less, compared to 17% aged 70 years old or above and the rest 37% aged between 50 and 70 years old. Patients admitted in an emergency setting were found to have high risk of readmission compared to the elective admitted patient, 94 % vs 6 % respectively. The percentage of patients who had a high NEWs score (6 or above), one hour before discharge was approximately 70% compared to 40% when the patient was seen earlier by a consultant during the ward round. Another important correlation was the high WBCs and CRP in patients likely to be discharged within 24 hours – approximately 30% had high levels of CRP and WBCs 24 hours before being discharged to the ward. There was poor communication and handover to the ward, as 86% of the discharged patients were not handed over to the ward doctor, but they had a written discharge summary. The main cause of readmission was respiratory failure including Covid-related patients, but the Covid was not the leading cause of readmission despite it was being the main cause of the primary intensive care admission in this group. Many of those patients were discharged successfully from intensive care (86%) compared to 14% who died in ICU. After those findings significant changes were made in the clinical pathway and communication tools aiming to decrease the readmission rates to intensive care.
Conclusion
Early unplanned intensive care readmission is associated with high mortality rate, long hospital and intensive care stay and increased financial burden on the trust. Some important simple and achievable interventions like: NEWs score 1 hour before discharge, 24 hours and inflammatory markers checks before discharge and proper hand over using the SmartPage can decrease the rate of intensive care readmission but cannot totally prevent it.
Introduction and problem
Readmission to intensive care is a marker of poor outcome. The aim of the Quality improvement Project was to answer the following question: Why are the intensive care readmission rates in Royal Preston Hospital higher than the national rates? The simplistic answer would be to simply state that the readmission rates have always been increasing at Preston Hospital Intensive Care Unit due to increased workload and high patient flow! However, my primary objective was to look for a deeper understanding; the factors associated with this alarming rate of readmission and to prevent the preventable.
Royal Preston Hospital Intensive care is the largest Critical Care in Lancashire and South Cumbria, with a total capacity of 34 beds, with a plan to expand to 50 beds. Royal Preston Hospital intensive care provides tertiary care for different specialties as neurocritical care, major trauma, vascular and oncology services for a population of 1.5 million people in addition to providing the intensive car