Table 5 Pre-identified care issues
Problems in care | Deceased patients with some avoidability n = 65 | Deceased patients without avoidability n = 185 | All discharges from ICU, excluding EOLC n = 250 | Survivors n = 20 |
|---|---|---|---|---|
Discharged n (%) | ||||
 16:00–08:59 | 50 (76.9) | 118 (63.8) | 168 (67.2) | 14 (70) |
 18:00–08:59 | 36 (55.4) | 76 (41.1) | 112 (44.8) | 8 (40) |
 22:00–08:59 | 8 (12.3) | 38 (20.5) | 46 (18.4) | 2 (10) |
Mobility | ||||
 Unable to stand and step from bed to chair on ICU discharge n (%) | 39 (60.0) | 116 (62.7) | 155 (62.0) | 6 (30) |
 Not mobilised to a chair n (%) | 46 (73.0) (n = 63b) | 121 (68.0) (n = 178b) | 167 (69.3) (n = 241) | 7 (35) (n = 20) |
 Not mobilised away from bed n (%) | 42 (84) (n = 50b) | 106 (73.6) (n = 144b) | 148 (76.3) (n = 194b) | 11 (61) (n = 18b) |
Atrial fibrillation | ||||
 New diagnosis n (%) | 9 (13.8) | 31 (16.8) | 40 (16.0) | 1 (5) |
 Initial management assessed as not appropriate n (%) | 5 (55.6) | 7 (22.5) | 12 (30) | 0 (0) |
 No investigation of underlying cause n (%) | 6 (66.6) | 11 (35.5) | 17 (42.5) | 1 (100) |
Sepsis | ||||
 Diagnosis/suspicion n (%) | 43 (66.2) | 107 (57.8) | 150 (60) | 4 (20) |
 Sepsis 6 not completed n (%) | 19 (44.2) | 31 (29) | 50 (33.3) | 3 (75) |
Nutritiona | ||||
 Plan required and not documented on discharge from ICU n (%) | 24/53 (45.3) | 52/132 (39.4) | 76 (41.1) | 8/14 (57) |
Follow-up/outreach | ||||
 Seen by follow-up/outreach n (%) | 53 (81.5) | 154 (83.7) | 207 (82.8) | 15 (75) |
 Discharged n (%) | 30 (56.6) | 72 (46.8) | 102 (49.3) | 14 (93) |
 Day discharged med (IQR) | 1 (1–2) | 1 (1–2) | 1 (1–2) | 2 (1–2) |
 Not re-assessed n (%) | 21 (70) | 53 (73.6) | 74 (72.5) | 13 (93) |