Question 4

College comments

Syllabus topic/section: 2.3.1 Intensive Care Administration: Safety and quality

Discussion: 

Candidates generally did well in part (a) by thinking broadly about the consequences for hospital, staff and patients, as the question asked. Credit was given for ICU-associated complications (eg delirium, delays in allied health intervention), however candidates are encouraged to separate markers of poor-quality care in the ICU (MRO acquisition, poor clinician engagement) from patient flow issues related to exit block; and to use objective language appropriate to an academic exam. Candidates are reminded that if the question lists eight potential causes only the first eight will be included for marking.

Those who scored highly in part (b) demonstrated an ability to interpret the graph by referencing in-hours vs out-of-hours discharges, rather than simply describing the discharge times displayed. Candidates who scored lower tended to approach the question from the viewpoint of a junior trainee, being mostly concerned with ICU workflow patterns and the impact on handover to ward teams. Above-standard answers demonstrated a broader, more conceptual understanding of out-of-hours discharge, considering causes other than ICU workflow (eg discharge of patients with more complex or specialised needs vs the requirement to create capacity for unplanned admissions), and included the specific consequences of out-of-hours discharge such as increased mortality and readmission rates. The understanding of how unit workflow interacts with broader concerns within the hospital and the effect on patient care was a marker of the superior answer.
 

Interpretation

The statement "candidates are encouraged to ... use objective language appropriate to an academic exam" suggests all kinds of hilarious possibilities. The imagination is inflamed by scandal, when one considers what kind of coarse vulgarity would have debased the responses of those frustrated candidates. Without giving in to the strong urge to mould these thoughts as words, the following answer sticks to some basic propriety, so as not to bring our institutions into disrepute.

Anyway: here are eight consequences of ICU exit block:

• Access block for the ED and wards
• Cancellation of elective surgery
• Inefficient use of ICU resources
• ICU staff burnout
• Numerous ward-ready patients = reduced ICU training opportunities
• Delayed rehabilitation
• Ineffective handover during rushed discharge
• Prolonged exposure to the ICU environment (noise, sleep deprivation, nosocomial resistant infectious agents)
• Discharges delayed until after hours 

Now; about that graph. Clearly just listing the findings would not be enough here, as the examines had pointed out. One would probably need to put a spin on this that demonstrates "understanding of how unit workflow interacts with broader concerns", etc. 

Thus:

• Of the ICU discharges, the majority occur during the in-hours period
• A large minority of patients are discharged after hours
• The after hours discharges are associated with:
  • Increased mortality
  • Increased rates of ICU readmission
  • Increased length of hospital stay
• The cause of this is unknown, but the following factors are considered to be important:
  • Potentially some are premature discharges 
  • Higher proportion of patients with treatment limitations
  • Inadequate or absent handover 
  • Reduced vigilance by understaffed night services
  • Delayed specialist attention
  • A representation of increased strain in the system