Night discharge

A seminal early publication from the Case Mix Programme highlighted the pressure on critical care services in England, contributing to substantial increased investment. Subsequent monitoring as a quality indicator has shown improvements over time.

Consequences of discharges from intensive care at night

Following anecdotal reports from critical care clinicians that patients were being discharged from intensive care units (ICUs) during the night because the bed was needed for another patient, ICNARC investigated this practice by comparing the proportion of discharges that were happening at night during the early years of the Case Mix Programme (1995-98) with data from the APACHE II Study in Britain and Ireland (1988-90). We found that in 1995-98, 6% of ICU discharges were between 10pm and 7am compared with less than 3% in 1988-90, and more than 40% of these discharges were classified by the clinicians as being ‘premature’. Patients that were discharged from ICU at night were significantly more likely to die in hospital than those discharged during the day.

A report on this work entitled Consequences of discharges from intensive care at night was published in the leading medical journal The Lancet in April 2000, with some press coverage.

Comprehensive Critical Care and the modernisation programme

ICNARC’s publication on night discharge was cited as an indicator of severe pressure on critical care services in the Department of Health review, Comprehensive Critical Care: a review of adult critical care services. This led to the establishment of a modernisation programme for adult critical care, including additional investment of over £300 million pounds over the winters of 2000-01 and 2001-02, which was predominantly invested in increased capacity of Level 2 (high dependency) beds.

ICNARC, in collaboration with researchers from the London School of Hygiene and Tropical Medicine, was subsequently commissioned by the NIHR Service Delivery and Organisation programme to evaluate the impact of the modernisation of adult critical care and the increased investment in critical care services.

This evaluation found that, although night discharges continued to increase following the increased investment in critical care beds, the numbers of night discharges that were classified as ‘early discharge due to a shortage of unit beds’ fell and the increase overall was driven by increases in discharges that were classified as ‘delayed discharge due to a shortage of ward beds’.

Monitoring night discharges through the Case Mix Programme

When Case Mix Programme reports were redeveloped in 2004, ‘out-of-hours discharge’ was introduced as a quality indicator. The quality indicator was refined over time, first to focus specifically on discharges to the ward and subsequently to remove those patients whose discharge was delayed. Results are fed back to critical care units quarterly to indicate their rate relative to other units and trends over time. With this ongoing audit, overall rates of out-of-hours discharge to the ward (not delayed) halved between 2009 and 2018 but have stayed relatively constant since, with peaks corresponding to seasonal increases in demand and the peaks of the COVID-19 pandemic.