(1289) MEWS News: Risk Factors in Near-Miss ICU Downgrades

Introduction: Transfer out of the medical intensive care unit (MICU) is a high-risk period of a hospitalization with readmission at 48 hours commonly used as a quality metric. Our quality improvement strategy was to analyze patients clinically considered ready for transfer out (‘downgraded’) who ultimately required further intensive care before definitive transfer out of the MICU. These patients represent a near-miss safety event. Many studies have investigated risk factors for readmission; none have evaluated a near-miss population. We hypothesized that similar risk factors for MICU readmission would predict re-upgrade.

Methods: We conducted a retrospective cohort study of level of care outcomes in patients hospitalized in a MICU at a large academic hospital over 6 months. Patients who died or transferred to another ICU were excluded. The primary outcome was patient level of care status 48-hours post-downgrade order. The patient was either successfully transferred (routine care), transferred out then readmitted to the ICU (readmission), or re-upgraded to intensive care before a transfer (near-miss). Covariates of age, sex, race, ICU length of stay, modified early warning score (MEWS) prior to downgrade, Glasgow Coma Score, as well as time of day and day of the week at time of downgrade were analyzed.

Results: 1056 patient encounters were analyzed. The mean age was 58.3 years old, with a mean ICU length of stay of 3.8 days. Females made up 46.4% (490/1056), 43.3% (457/1056) were white and 47.8% (505/1056) were black. Successful downgrade and transfer occurred in 90.6% (957/1056) of patients, 1.2% (13/1056) of patients were readmitted within 48-hour, and 8.1% (86/1056) of patients were downgraded then re-upgraded before transfer. There were no significant differences among populations regarding age, sex, race or day-of-week of downgrade. Patients with MEWS score of 0-3 were less likely to be re-upgraded at 7.4% (64/863) as compared to patients with a MEWS score of 4 or greater who were re-upgraded at a rate of 11.7% (21/180).

Conclusions: A MEWS score of 4 or greater at time of downgrade order had an elevated rate of re-upgrade to intensive level of care. Future QI interventions could target patients with MEWS scores greater than 4 to reduce re-upgrades and possibly readmissions.