title: Night-shift discharge from intensive care unit increases the mortality-risk of ICU survivors.
abstract: Intensive Care (ICU) survivors discharged from ICU to the general ward at night have a higher mortality. We sought to clarify which factors, including night-shift discharge, influence outcome following ICU discharge in a metropolitan hospital, using a cohort study of critically-ill patients between 1/1/1999-30/4/2003. Patients were excluded from analysis if they (a) died in ICU, (b) were transferred to another hospital, (c) had an ICU length of stay <8 hours, or (d) age <16 years. Logistic regression was used to derive a predictive model based on the following variables: patient demographics, severity of illness following ICU admission (APACHE II mortality-risk, p(m)), final diagnosis, discharge timing including premature or delayed (>4 hours) ICU discharge, and "limitation of medical treatment" orders. The outcome measures were patient status at hospital discharge and ICU readmission rate. Of the 1870 ICU survivors, 92 (4.9%) died after discharge from ICU. Patients discharged to the ward during the night-shift (2200-0730 hours) had a higher APACHE II score and crude mortality. The difference in APACHE II p(m) did not reach statistical significance. No significant calendar or seasonal pattern was identified. Logistic regression identified night-shift discharge (RR=1.7; 95% CI 1.03-2.9; P=0.03), limited medical treatment order (RR=5.1; 95% CI 2.2-12) and admission APACHE II p(m) (RR=3.3; 95% CI 1.3-7.6) as independent predictors of patient outcome following ICU transfer to the ward.
  
  
  CONCLUSIONS
  At the time of ICU discharge to the ward three factors are predictive of hospital outcome: timing of ICU discharge, limited medical treatment orders and initial illness severity.
authors.affiliation: Intensive Care Department, The Northern Hospital, Epping, Victoria.
authors.forename: G J
authors.initials: GJ
authors.lastname: Duke
authors.forename: J V
authors.initials: JV
authors.lastname: Green
authors.forename: J H
authors.initials: JH
authors.lastname: Briedis
mesh_terms: D018806:APACHE; D002423:Cause of Death; D015331:Cohort Studies; D016001:Confidence Intervals; D003422:Critical Care / Q000379:methods; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007362:Intensive Care Units; D016015:Logistic Models; D008297:Male; D009551:Night Care / Q000592:standards* / Q000639:trends; D010351:Patient Discharge; D010360:Patient Transfer / Q000592:standards* / Q000639:trends; D011237:Predictive Value of Tests; D011336:Probability; D011446:Prospective Studies; D018570:Risk Assessment