1. Background Readmissions to the Intensive Care Unit (ICU) have been associated with increased mortality and longer hospital admission lengths 1 The Intensive Care Audit and Research Centre (ICNARC) reported that the national average proportion of ICU survivors discharged to a ward who were then readmitted within 48 hrs was 1.2 % (2015) 2. Previous RSCH audits have reported equivalent figures of 1.2% (July-Sept 2014) 3 and 0.6% (Jan-Mar 2015) 4. As part of an on-going review, we set out to compare readmissions over the period Feb 2015 – Feb 2016 against these local and national standards, and identify factors that contribute to readmission. Conclusions ICU readmissions <48hrs (1.1%) were in line both the national average and below the RSCH audit from the previous year (2014). The majority of cases readmitted <48hrs had been discharged out of recognised ward based team working hours (09:00 - 17:00); although formal comparison has not been made against discharge times of non-readmitted patients, out of hours discharges may represent pressure to discharge and may result in a relatively high-intensity patients arriving in relatively understaffed area. Most cases readmitted <48hrs were initially discharged to ADU. A higher proportion of readmissions from ADU may relate to a lower threshold for discharge from ICU to ADU, or earlier recognition of the deteriorating patient post step-down due to higher staffing levels on ADU. This unit has since been closed (May 2016) and we anticipate that this will have an impact on subsequent readmission figures. Documentation of observations prior to discharge was incomplete for one patient; the EWS themselves were not documented. Recommendations: Record EWS prior to discharge from ICU; implement new documentation on ICIP to calculate EWS and encourage routine review of observations immediately prior to step-down by both medical and nursing staff. Avoid out of hours discharge and hand over to “on-call” ward teams. Re-audit following implementation of recommendation, and assess impact of ADU closure on readmissions. References 1 Rosenbery AL, Watts C; Chest 118 (2) 492-502 (2000) 2 ICNARC Case Mix Program Statistics (2015) 3 Prendecki KR, Ratnasingham M; ICU readmissions audit July-Sept 2014 4 Rehnberg V & Carraretto M; ICU readmissions audit Jan-Mar 2015 5 Adult critical care service specification D16 for NHS England. S Winder-Rhodes*, J Corbett*, S Green, M Carraretto Intensive Care Unit, Royal Surrey County Hospital, Guildford, UK (*contributed equally to work) Results Readmissions Demographic and clinical information for readmissions <48hrs Notes were reviewed for the 13 cases (8 male) with mean age 74 (SD 10.3) yrs who had been readmitted to ICU within 48hrs of discharge (table 1). First admission: Mean length of stay for first admission was 3.6 (range 1-15) days compared to a mean of 4.1 days for all ICU patients across the same period. 62% (8/13) of cases were discharged from their first admission out of hours (i.e. outside of 09:00-17:00); however, of these, only 2 patients were discharged outside of the window recommended by NHS England (i.e. outside of 07:00-21:59) 5. 62% (8/13) of cases were discharged to ADU, compared to 36% of all live ICU dsicharges over the same period. EWS on discharge: Complete observations were not documented for 1 case (#6) before discharge. One case (#4) had an EWS of 3 and another (#12) of 4, both with SpO2 </= 90% despite supplemental O 2. None of the cases were requiring organ support on discharge. Ward review: All 13 cases were reviewed by a consultant or registrar on step down to the ward, an average of 18.2 (range 11-36) hrs from discharge (2 patients >24hrs). All 13 cases were reviewed by the outreach team, an average of 17.2 (range 11-31) hrs from discharge (2 patients >24hrs). Audit of re-admissions to the Intensive Care Unit Methods A retrospective case note audit was carried out. Details of discharges and readmissions to the RSCH ICU between 1 st February 2015 and 29 th February 2016 were obtained from the electronic intensive admissions database Wardwatcher 4D client. Paper case notes, electronic records (Philips – Intellispace Critical Care and Anaesthesia [ICIP], VitalPAC) and discharge summaries (OASIS) of patients were reviewed. Early Warning Scores (EWS) on discharge were calculated retrospectively from observations. #Reason for 1 st admissionReason for readmission 1 Post failed Hartmann’s procedure, SVT post induction of anaesthesia Post completed Hartmann’s procedure 2 D&V, AKI on CKD requiring filtration, hypotension Filtration, awaiting transfer to external renal unit 3Post PPPD & right hepatectomyT1RF, encephalopathy 4Post cystoprostatectomy and ileal conduitIleus and T1RF, CTPA showed PE 5Post free flap, tracheostomy for SCC tongueFast AF 6Post right hepatectomy AKI, anaemia, hypotension, pleural effusions 7Post giant hernia repairPleural effusions 8Sepsis, PE Catastrophic variceal bleed post anticoagulation 9Post oesophagogastrectomyPost re-do thoracotomy after chyle leak 10 Post laparoscopic distal pancreatectomy & splenectomy T2RF, pain 11Neutropenic sepsisSevere electrolyte disturbance, confusion 12Post hemi-colectomyT1RF, HAP, ileus 13CAPHAP and increased oxygen requirements Table 1: Summary of readmissions (n=13) <48hrs Readmission: Mean time between discharge and readmission was 30 (SD 9, range 22-41) hrs. 62% (8/13) patients were readmitted with “new pathology requiring escalation“; amongst these the most common new pathology (5/8) featured respiratory deterioration. 23% (3/13) were readmitted with “progression of their original pathology“ including one patient (#2) who required ICU facilities for renal dialysis (delayed transfer off-site). 15% (2/13) were readmitted following a repeat surgical procedure; this included one patient (#1) who was admitted to ICU following an abandoned first procedure (developed SVT in theatre) and later readmitted post-op. Between 1 st February 2015 and 29 th February 2016, there were 1229 live discharges from ICU. Of these total discharges, 33 (2.7%) were later readmitted including 13 (1.1%) who were readmitted within 48 hrs.