This article appears as part of the Inside the NHS newsletter.

Intensive care and high dependency units care for the sickest of all patients, so monitoring how well they are coping with demand is a important bellwether for the NHS as a whole.

The latest annual audit for critical care shows that it is increasingly feeling the pressure from a shortage of staff and beds elsewhere in hospital.

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Bed problem

The total number of people being admitted to critical care in Scotland - including intensive care, standalone high-dependency units, and combined ICU/HDUs - has fallen from around 44,000 in 2014 to less than 38,000 in 2023.

On average, the occupancy rate for ICU/combined units was 64% in 2023, and 80% for HDUs.

That is within safe limits, but a growing problem for critical care doctors is that they cannot get patients onto wards when they are ready for discharge.

In 2023, 62% of ICU patients and 63% of HDU patients were "delayed" for more than four hours, at least.

At Forth Valley Royal and Glasgow Royal Infirmary, the audit found that more than 80% of patients in ICU/combined units had their discharge delayed in 2023.

Professor Nazir Lone, a critical care doctor, academic and chair of the Scottish Intensive Care Society Audit Group (SICSAG), which produces the report, noted that an "increasing proportion of patients [are] being discharged directly home from critical care units".

It is the first time that the audit has highlighted this problem, which it notes has worsened in recent years due to the "unavailability of beds and/or staffing shortages in ward areas".

One in 10 patients are now discharged straight to their 'normal residence' (Image: PHS) Roughly one in 10 patients are now going straight home from critical care, up from around one in 20 pre-pandemic. 

Prof Lone added: "Previously, direct discharge home was infrequent and limited to particular subgroups of patients who required minimal follow-up from hospital services.

"In contrast, patients with more complex follow-up needs are now being discharged directly from critical care units, bypassing the period of time spent in downstream wards, in which most of the discharge planning services are located."

Spending too long in ICU/HDU is bad for patients (Image: PA)

The cost of waiting

Remaining in critical care longer than necessary is associated with an increased risk for patients of developing depression, delirium, delayed rehabilitation, and an overall increased length of hospital stay.

The report also notes that the "usual practice of stepping patients down to a ward allows for the facilitation of rehabilitation, discharge planning and follow up prior to discharge" - something that is lost if patients are sent straight home from critical care instead.

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The trend in critical care mirrors something that has been happening more at more in A&E departments, where unprecedented numbers of patients are now spending so long waiting for a bed on a ward - two or three days in some cases - that they end up being sent home instead. 

While existing studies have not found that direct discharge home from critical care increases the risk of re-admission or mortality, the report notes that it is associated with lower patient satisfaction.

There is also the issue of cost. 

Providing an intensive care bed cost the NHS an average of £2,957 a day in 2023, compared to median and minimum daily costs for a ward bed of £1,178 and £606 respectively.

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The report concludes: "Delaying discharge may not only have a negative impact on patient safety, but also considerable cost implications for NHS Scotland.

"Excess costs resulting from delayed discharges in ICUs and combined units in Scotland in 2023 are estimated to be almost £15 million [but] could be as much as nearly £19 million.

"Timely discharge from critical care is therefore essential for patient safety and reducing avoidable costs."