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Delayed Transfer to the ICU Increases Length of Stay and Mortality
Abstract & Commentary
By Leslie A. Hoffman, PhD, RN, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.
Dr. Hoffman reports no financial relationship to this field of study.
Synopsis: Critically ill emergency department patients with a ≥ 6 hour delay in ICU transfer had an increased hospital length of stay and higher ICU and hospital mortality.
Source: Chalfin DB, et al. Crit Care Med. 2007;35:1477-1483.
This study examined outcomes in 50,322 patients admitted to the emergency department and later transferred to the ICU during the period from 2000-2003. Study data were obtained from Project IMPACT, a voluntary database that includes a nationwide sample of 120 adult ICUs in 90 hospitals. Patients admitted from the emergency department to the ICU were divided into two groups: those remaining in the emergency department ≥ 6 hours (delayed) and those remaining < 6 hours (non-delayed).
Patients whose admission to the ICU was delayed (n = 1,036) or non-delayed (n = 49,286) were similar in age, gender, and do-not-resuscitate status as well as APACHE II score (p = NS). Among hospital survivors, the median hospital length of stay was 7.0 days (delayed) vs 6.0 days (non-delayed) (p < .001). ICU mortality was 10.7% (delayed) vs 8.4% (non delayed) (p <.01). In-hospital mortality was 17.4% (delayed) vs 12.9% (non-delayed) (p <.001). A diagnosis of sepsis was more common in the delayed group (p <.001), whereas multiple trauma (p <.01), coronary artery disease (p <.001) and respiratory diagnostic categories (p <.01) were more common in the non-delayed group. When examined using logistic regression, delayed admission, advancing age, higher APACHE II score, male gender, and a diagnosis of either trauma, intracerebral hemorrhage, or neurologic disease were associated with lower hospital survival (odds ratio for delayed admission, 0.79; 95% confidence interval, 0.561-0.895).
Today our emergency care system faces an epidemic of crowded emergency departments, patients experiencing long waits to be seen and admitted, and ambulance diversions. Hospitals are faced with the difficulty of simultaneously meeting the needs of patients who require urgent and lifesaving care and providing non urgent care for the uninsured who use the emergency department as a safety net. The Institute of Medicine reports that 40% of hospitals experience crowding on a daily basis in their emergency department.1 More than one-third report using diversion (closure to ambulance traffic) within the past year as a consequence of a lack of critical care beds.
In this study, critically ill patients whose admission to the ICU was delayed had a longer hospital stay and an increase in ICU and hospital mortality. As might be expected, there was considerable overlap in the APACHE II diagnostic categories between delayed and non-delayed patients. Among delayed patients, those with sepsis were significantly more likely to be delayed. In patients with septic shock, mortality can be significantly reduced if goal-directed therapy is instituted as soon as the diagnosis is made. Categories of patients diagnosed with other "time-sensitive" conditions, such as coronary artery disease or trauma, did not experience delays, suggesting that the time-sensitive nature of sepsis management may not be fully appreciated.
A second concern relates to the availability of critical care beds as a cause of the delay. Boarding of critically ill patients in the emergency department while waiting for an available bed is a common occurrence. Noting this, the Institute of Medicine recently identified emergency department boarding as a major public health concern,1 a conclusion supported by study findings.
There were several limitations to this study. It used retrospective data and therefore could not identify the cause of the observed delays. The database did not include information about institutional characteristics, physician or nurse staffing or other variables, such as board certification or eligibility, or the availability of specialists, which might have influenced outcomes. Further studies are necessary to identify the specific factors that led to a prolonged emergency department stay and ways to modify them.