title: Intensive care outflow limitation--frequency, etiology, and impact.
abstract: OBJECTIVE
  To assess the frequency, causes, and effect of unsuccessful discharge decisions from the ICU.
  
  
  METHODS
  An 11-bed general intensive care unit of a 750-bed urban university hospital, tertiary referral center and level one trauma center.
  
  
  METHODS
  A prospective, observational study.
  
  
  METHODS
  All ICU patients judged appropriate for discharge by the ICU attending physician.
  
  
  RESULTS
  A total of 856 attempted discharges in 706 patients were analyzed over 16 months. Of these, 703 (82%) were successful within 24 hours. Of the remaining 153 unsuccessful discharges, 51 (33%) were deferred because of medical deterioration, 32 (21%) at the request of the ward physicians or nurses and 70 (46%) because of administrative difficulties (lack of ward bed space or disagreement over admitting service). When compared to patients successfully discharged on the first attempt, those whose discharge was deferred had a significantly longer ICU admission prior to the first discharge attempt (median 4d v 3d, P =.009), and a higher proportion required intermediate care (48% v 26%, P <.001). Both these factors were independently associated with unsuccessful discharge in a logistic regression analysis (OR 1.04, 95%CI 1.02, 1.06, P =.0001, OR 2.05 95%CI 1.30, 3.26, P =.002, respectively). Deferred discharges accounted for 153 days of ICU care (2.6% of the total) and were associated with ICU overflow on 118 days (2% of all ICU days).
  
  
  CONCLUSIONS
  ICU outflow limitation occurs in up to 1 in 6 discharges. It can be due to medical deterioration, level of care issues or administrative problems, and may lead to inefficient use of ICU resources.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Hospital, Jerusalem, Israel.
authors.forename: Phillip D
authors.initials: PD
authors.lastname: Levin
authors.forename: Theresa M
authors.initials: TM
authors.lastname: Worner
authors.forename: Sigal
authors.initials: S
authors.lastname: Sviri
authors.forename: Sergey V
authors.initials: SV
authors.lastname: Goodman
authors.forename: Yoram G
authors.initials: YG
authors.lastname: Weiss
authors.forename: Sharon
authors.initials: S
authors.lastname: Einav
authors.forename: Charles
authors.initials: C
authors.lastname: Weissman
authors.forename: Charles L
authors.initials: CL
authors.lastname: Sprung
mesh_terms: D001509:Bed Occupancy / Q000191:economics / Q000706:statistics & numerical data; D003657:Decision Making; D005260:Female; D006746:Hospital Bed Capacity, 500 and over; D006785:Hospitals, University; D006786:Hospitals, Urban; D006801:Humans; D007362:Intensive Care Units / Q000191:economics / Q000458:organization & administration / Q000706:statistics & numerical data; D007902:Length of Stay / Q000191:economics / Q000706:statistics & numerical data; D008297:Male; D010360:Patient Transfer / Q000191:economics / Q000458:organization & administration*; D011446:Prospective Studies