Jottings from JICS: CQUINS, delayed discharges & perverse incentives
by Jeremy Groves, Consultant Anaesthetist in Intensive Care
Looking at JICS this month the article by Stephen Gilligan, “Critical care delayed discharges: Good or bad?”, caught my eye.(1) He argues that the evidence from ICNARC suggests that delayed discharges, especially in sicker patients, may be no bad thing. He goes on to articulate that NHS England’s proposed CQUIN on delayed discharges (currently in limbo) would act as a perverse incentive that may have a detrimental effect on some of our patients’ outcomes.
I have to say that I agree with him.
Now I don’t really understand CQUINs but according to NHS England they aim to – “deliver clinical quality improvements and drive transformational change”. (2) I think they do this by taking money out of a contract, then giving it back if you achieve the desired objectives. A typical health service zero sum game. The proposed critical care CQUIN would incentivise Providers to ensure patients are discharged from the unit within 4 hours of a decision to discharge. (3) Now that is all well and good, providing there’s space to put the patients in elsewhere in the hospital and that they’re fit for discharge.
According to ICNARC over 60% of critical care discharges are delayed by more than 4 hours.
According to ICNARC over 60% of critical care discharges are delayed by more than 4 hours. That’s a remarkable figure and reinforces the fact that either our hospitals are bursting at the seams or that we’re slow at getting the paperwork ready; it may also indicate that 4 hours is not the best definition of a delay. If you see and discharge patients on the round between 08:00 and 09:00, do they have to be gone by 13:00? Are we expecting the general wards to discharge all their patients in the morning? Do we believe the NHS would be able to deliver the hospital bed occupancy that would facilitate this?
Managing patient flow in in a UK hospital is at times an absolute nightmare.
Managing patient flow in in a UK hospital is at times an absolute nightmare. It certainly can be in mine. While recognising that a critical care bed may not be the best place to keep an individual ready for discharge to a ward or even home home, I can see it may be better to keep them there in the overall scheme of things, rather than have them sitting on a ward and another, sicker, patient lying on a trolley in the emergency department waiting for that bed.
The evidence Dr Gilligan presents from ICNARC indicates that the adjusted acute hospital mortality of patients whose discharge was delayed by more than 24 hours was lower than those who were discharged within 4 hours or between 4 and 24 hours; the longer you stay in ICU, the better – at least for some. This too makes sense. If the resources are available to monitor a patient more closely on the unit, especially one of who is in the early stages of recovery after a period of critical illness, why discharge them unless there is a clinical imperative so to do?
If I were recuperating after a critical illness, I know where I’d rather be.
- Critical care delayed discharges: Good or bad? Stephen Gilligan. JICS Volume: 18 issue: 2, page(s): 146-148
Read the journal here: http://journals.sagepub.com/loi/inca