Closure of an Intermediate Care Unit: Results

Closure of an Intermediate Care Unit: ResultsTable 1 summarizes demographic and admission data for patients admitted during both 9-month data collection periods. The number of CCU admissions increased from 217 to 407 with closure of the ICA and expansion of the CCU from 7 to 9 beds. The increased throughput in CCU was from 31 patients per CCU bed per 9 months to 45.2 patients per CCU bed per 9 months. There was no significant change in the proportion of CCU patients who were emergency hospital admissions (129/194 vs 220/376); however, the proportion of nonemergency admissions increased significantly (p<0.03). After ICA closure, the number of emergency postoperative admissions remained similar (59 vs 47); however, an increased number of nonemergency postoperative surgical admissions were noted compared with the 9-month period before ICA closure (Table 1). A reduction in the mean length of hospital stay (Table 2) was found after ICA closure; however, no difference in CCU length of stay was noted between the two time periods. The range of CCU length of stay varied from a minimum of 1 day to a maximum of 156 days before ICA closure and from 1 to 105 days after ICA closure. These data are highly skewed to the left (Fig 1). The median CCU length of stay was 3 days pre-ICA closure and 2 days after ICA closure.
A significant decrease in the APACHE II score on admission to the CCU was noted from 21.9 ±7.4 pre-ICA closure to 18.6 ± 7.4 after ICA closure (p<0.0001). The number of APACHE II points for chronic health disability decreased from 4.52 ±1.10 to 3.82 ±1.47 (p<0.0001). The proportion of CCU admissions with APACHE II scores greater than or equal to 15 did not increase (187/217 vs 271/407) significantly after closure of the ICA (Fig 2). However, a larger number of CCU admissions with APACHE II scores less than 15 were admitted to the CCU after closure of the ICA (136/ 407) than prior to closure (30/217). The total number of CCU days attributed to patients with APACHE II scores less than 15 increased from 5.4 percent (100/ 1850) to 12.7 percent (329/2702). No death occurred in the 29 patients admitted prior to ICA closure with APACHE II scores less than 15. After ICA closure, there were only two deaths among patients admitted to CCU with APACHE II scores less than 15 (one in CCU and one after CCU discharge). Both patients died suddenly; one unexpectedly 26 days after CCU discharge of pulmonary embolus and the other of irreversible central nervous system damage within 2 days of admission to the CCU.
The average TISS on admission to the CCU decreased (p<0.0001) after ICA closure (Table 2). In addition, the TISS (modified) at the time of discharge decreased from 23.5 ± 16.9 to 13.5 ± 13.4 (p<0.0001) after ICA closure.
After ICA closure, the number of short-stay patients (1- and 2-day CCU length of stay) increased significantly from 92 to 243. The hospital mortality rate of short-stay patients was 20.5 percent and 15.9 percent, respectively, in each time period and the percentage of total CCU days attributed to short-stay patients increased from 6.64 percent to 11.59 percent after ICA closure. Short-stay (1 to 2 days) patients had admission TISS, after ICA closure, that was significantly lower (22.8 ±14.0) than for patients staying longer than 2 days (34.7 ±3.3) (p<0.0006). The modified TISS at the time of discharge was decreased significantly in the short-stay group from 21.3 ± 17.2 to 13.0± 13.9 (p<0.0006) between the two time periods.

Table 1—Demographic and Admission Data for AS CCU Patients During Each 9-Month Time Period

Pre-ICAClosure Post-ICAClosure Significance
No. of patients 194 376
Age, yr 58.2 ±18.6 59.9 ±16.7 NS
Sex, M/F 108/86 228/148 NS
Hospital admission status
Nonemergency 65 156 p<0.03
Emergency 129 220 NS
Postoperative admissions 105 178
Nonemergency 46 131 p<0.05
Emergency 59 47

Table 2—Utilization Data for AR Patients During Each 9-Month Time Period

Pre-ICAClosure Post ICA Closure Significance
CCU length of stay, days 8.5 ±15.8 6.7 ±22.5 NS
Hospital length of stay, days 37.3 ±42.1 26.5 ±31.3 p<0.001
Outcome CCU (admissions)
Survival 177 342 \ NS
Death 40 65 J
Outcome hospital (patients)
Survival 133 282 1 NS
Death 61 94 J
TISS score
Admission 37.1 ±15.9 27.9±14.9 p<0.0001
Discharge (modified TISS) 23.8 ±16.9 13.5 ±13.4 p<0.0001
APACHE II score (admission) 21.9±7.4 18.6±7.4 p<0.0001

Figure-1

Figure 1. The number of admissions to the critical care unit (CCU) during two 9-month data collection periods and the length of CCU stay; the first (October 1, 1989 to June 30, 1990) was before closure of a six-bed intermediate care unit (pre-ICA closure) and the second (April 1, 1991 to January 5, 1992) was after ICA closure and expansion of the CCU from 7 to 9 beds (post-ICA closure). ICA = intermediate care

Figure-2

Figure 2. The number of admissions to the critical care unit (CCU) with varying severity’ of illness (APACHE II score10) during two 9-month data collection periods before (pre-ICA closure) and after (post-ICA closure) closure of an intermediate care area (ICA).

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