Our results demonstrate that the Sabadell score is an independent predictor of five-year survival after critical care discharge. Sabadell scores of two and three predicted poor patient survival for patients discharged from critical care both in-hospital and for patients who survive their hospital episode. This instrument could potentially be used to guide informed discussions with patients (and/or their relatives) about dying to ascertain their future wishes. Further multicentre studies are required to validate our findings for critical care patients and potentially, patients admitted under other specialties.
There is increasing recognition of the need “to empower doctors, patients and carers to make shared decisions about care and treatment that balance duration and quality of life” (7). In the UK nearly half of all deaths occur in hospital (21). Poor communication in the final stages of life is a frequently cited source of complaint. Subsequently, the UK Royal College of Physicians have proposed a number of recommendations for medical professionals to initiate timely and honest conversations with patients about their future (7). Episodes of illness that require critical care admission increasingly result from acute exacerbations of chronic disease rather than a single curable event. Patients who survive a critical illness episode frequently suffer significant and persistent morbidity (1, 2, 22).
The point of discharge from critical to ward-based care represents an opportunity to intervene for high-risk patients and/or guide discussion between professionals and their relatives about death to ascertain their wishes. Our study demonstrates that the Sabadell score, a subjective prediction of longer-term patient outcome, has strong potential to guide initiation of these discussions. We observed this effect for both patients who died in hospital after their critical care discharge and for those who survived their index admission. The observed effect for patients allocated a Sabadell score of three was lower for hospital survivors (aHR 7.13 vs. 23.60). As Sabadell score three patients are expected to die in hospital, this is an expected finding. Importantly, patients who survived hospital admission despite allocation of this score still had a persistently higher risk of death compared to patients allocated Sabadell scores zero, one and two (Table S4).
Our study confirms previous findings that the Sabadell score is strongly predictive of in-hospital mortality (13, 14). This suggests that the tool may be of use in identifying patients at risk of physiological deterioration once discharged to the ward, as described previously (14). For example, patients with a Sabadell score of two could be managed with an enhanced level of support with an aim to prevent deterioration and death in hospital and improve survival in the community. In contrast to the study by Soliman et al, we found that the Sabadell score was strongly predictive of outcomes at one year post critical care discharge (9). We noted that critical care doctors from our unit were pessimistic with allocation of Sabadell scores with patient survival frequently living beyond their allocated score. However, on a population level, the Sabadell score could be a very useful tool to signpost “at-risk” patients to guide rehabilitation interventions post critical care discharge and/or determine if they are willing to engage with end-of-life discussion and begin the process of advanced care planning.
Despite data from a single centre only, we have accumulated a large cohort with comprehensive follow up for at least 18 months after critical care discharge. We have produced long term data on survival, but could not collect data to assess of quality of life, an important outcome measure for critical care survivors (23). Previous concerns regarding the Sabadell scoring system relate to the concept of a self-fulfilling prophecy, in other words, allocating a score to any particular patient may affect decision making in relation to their future management and that relying on subjective opinions alone may not be acceptable for this reason. (24) In the present study, the ward team were blinded to the patients Sabadell score, therefore, care received should be independent of the score. In the situation whereby a patient was deemed not suitable for further admission to intensive care, this decision was made before allocating the score.
We found that in-hospital mortality was 5.6% after critical care discharge, in keeping with previously published data (14, 25, 26). Mortality one year following critical care discharge was 17.2%, also in keeping with previous studies (3, 4, 9, 22, 26). There appears to be more limited data on mortality at five years, however, the finding of an overall mortality of 64.5% appears to be higher than recent data published by Lone (32%) (22). Contrary to finding from other studies (27, 28), we did not find a relationship between socioeconomic deprivation and longer term outcome. This is potentially explained by the distribution of socioeconomic deprivation in our cohort: 40.8% of patients were from the lowest income decile (Table S7).