Abstract
Objectives:
To examine whether and how step-down unit admission after ICU discharge affects patient outcomes.
Design:
Retrospective study using an instrumental variable approach to remove potential biases from unobserved differences in illness severity for patients admitted to the step-down unit after ICU discharge.
Setting:
Ten hospitals in an integrated healthcare delivery system in Northern California.
Patients:
Eleven-thousand fifty-eight episodes involving patients who were admitted via emergency departments to a medical service from July 2010 to June 2011, were admitted to the ICU at least once during their hospitalization, and were discharged from the ICU to the step-down unit or the ward.
Interventions:
None.
Measurements and Main Results:
Using congestion in the step-down unit as an instrumental variable, we quantified the impact of step-down unit care in terms of clinical and operational outcomes. On average, for ICU patients with lower illness severity, we found that availability of step-down unit care was associated with an absolute decrease in the likelihood of hospital readmission within 30 days of 3.9% (95% CI, 3.6–4.1%). We did not find statistically significant effects on other outcomes. For ICU patients with higher illness severity, we found that availability of step-down unit care was associated with an absolute decrease in in-hospital mortality of 2.5% (95% CI, 2.3–2.6%), a decrease in remaining hospital length-of-stay of 1.1 days (95% CI, 1.0–1.2 d), and a decrease in the likelihood of ICU readmission within 5 days of 3.6% (95% CI, 3.3–3.8%).
Conclusions:
This study shows that there exists a subset of patients discharged from the ICU who may benefit from care in an step-down unit relative to that in the ward. We found that step-down unit care was associated with statistically significant improvements in patient outcomes especially for high-risk patients. Our results suggest that step-down units can provide effective transitional care for ICU patients.