Unexpected Deaths of Critically Ill Surgical Patients Following Surgical ICU Discharge: A Six-Year Retrospective Analysis

Abstract

SESSION TITLE: Quality Improvement to Improve Patient Safety and Reduce Healthcare Costs SESSION TYPE: Original Investigation Slide PRESENTED ON: Wednesday, October 28, 2015 at 07:30 AM - 08:30 AM PURPOSE: To investigate the cause of death in surgical patients who died unexpectedly following discharge from the surgical intensive care unit (SICU) at a tertiary care medical center over a six year period. METHODS: All patients discharged alive to the floor from the SICU between January 1, 2008 and September 30, 2013 were screened for enrollment. Unexpected death was defined as patients who expired on the floor within 28 days from SICU discharge who were not in hospice program, on Palliative Care service or with a DNR/DNI order. A retrospective chart review was conducted and a matched control group selected based on intensive care unit (ICU) diagnosis, age and sex. The APACHE II score on SICU admission, SWIFT (Stability and Workload Index for Transfer) score on SICU discharge, time of ICU discharge, and ICU and hospital length of stay were calculated and analyzed. RESULTS: In this period, 3,213 patients were discharged alive from the SICU and 2,986 patients (93%) survived until hospital discharge, 227 (7%) expired. Of the 227 floor deaths, 130 (4%) died within 28 days of SICU discharge and 96 (3%) expired after 28 days post SICU discharge. Of these, 116 (3.6%) were classified as expected deaths and 14 (0.4%) as unexpected deaths. The most common cause of unexpected death was sepsis (5, 36%) and PE (4, 29%). There was autopsy confirmation of diagnosis in two cases of abdominal sepsis, two cases of PE and one aortic dissection. In the first week following ICU discharge, abdominal sepsis was the most common cause of death, cardiovascular events were the most common from week 2-4 after discharge. In the unexpected death group when compared to matched control, there was no difference in time of discharge or APACHE II score on SICU admission or SWIFT score on SICU discharge. CONCLUSIONS: Of all critically ill surgical patients who were discharged alive, unexpected death within 28 days after SICU discharge was very low 14/3,213 (0.4%). Sepsis was the most common cause in the first week from discharge, while cardiovascular events were most common from day 8 to 28 post discharge. SWIFT score and APACHE II score on admission were poor predictors of post ICU mortality. CLINICAL IMPLICATIONS: While unexpected deaths following SICU discharge is low (0.4%), patients with sepsis remain at high risk of death in the first week of SICU discharge. Predictive indices (APACHE II, SWIFT) have failed to reliably predict unexpected death in surgical patients. It is unclear if post ICU monitoring would have changed outcomes in this population. DISCLOSURE: The following authors have nothing to disclose: Adel Bassily Marcus, Jun Makino, Raja Singh, Ehizode Udevbulu, John Oropello, Anthony Manasia, Roopa Kohli-Seth No Product/Research Disclosure Information