John D. Santamaria, Graeme J. Duke, David V. Pilcher, D. James Cooper, John Moran, and Rinaldo Bellomo Am. J. Resp. Crit. Care Med. May 1, 2015, vol. 191, no. 9: 1033-1039
Rationale: Previous studies suggested an association between after-hours intensive care unit (ICU) discharge and increased hospital mortality. Their retrospective design and lack of correction for patient factors present at the time of discharge make this association problematic.
Objectives: To determine factors independently associated with mortality after ICU discharge.
Methods: This was a prospective, multicenter, binational observational study involving 40 ICUs in Australia and New Zealand. Participants were consecutive adult patients discharged alive from the ICU between September 2009 and February 2010.
Measurements and Main Results: We studied 10,211 patients discharged alive from the ICU. Median age was 63 years (interquartile range, 49–74), 6,224 (61%) were male, 5,707 (56%) required mechanical ventilation, and their median Acute Physiology and Chronic Health Evaluation III risk of death was 9% (interquartile range, 3–25%). A total of 8,539 (83.6%) patients were discharged in-hours (06:00–18:00) and 1,672 (16.4%) after-hours (18:00–06:00). Of these, 408 (4.8%) and 124 (7.4%), respectively, subsequently died in hospital (P < 0.001). After risk adjustment for markers of illness severity at time of ICU discharge including limitations of medical therapy (LOMT) orders, the time of discharge was no longer a significant predictor of mortality. The presence of a LOMT order was the strongest predictor of death (odds ratio, 35.4; 95% confidence interval, 27.5–45.6).
Conclusions: In this large, prospective, multicenter, binational observational study, we found that patient status at ICU discharge, particularly the presence of LOMT orders, was the chief predictor of hospital survival. In contrast to previous studies, the timing of discharge did not have an independent association with mortality.