Expedited ICU Admission from the ED Decreases Mechanical Ventilation Days and ICU Stay

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: Expedited admission (< 2 hours) of critically ill patients who require intubation and mechanical ventilation from the emergency department to the ICU improves patient outcomes.

Source: Cline SD, et al. Expedited admission of patients decreases duration of mechanical ventilation and shortens ICU stay. Am J Emerg Med 2009;27:843-846.

Prior studies have demonstrated that delayed transfer of critically ill patients from the emergency department (ED) to the ICU (> 6 hours) prolongs ICU and hospital stay. The purpose of this retrospective study was to determine whether this difference persists when ED wait time is reduced to < 2 hours. Subjects were 78 patients age 55.3 ± 13.1 years (range, 26-75 years) with respiratory failure of sufficient severity to require intubation and mechanical ventilation prior to transfer from the ED to the ICU. Patients directly admitted to the ICU from outside hospitals or patients for whom care was withdrawn in < 24 hours were excluded.

Two patient groups were identified. The expedited group (n = 12) remained in the ED < 120 minutes prior to ICU transfer and the non-expedited group (n = 66) waited > 120 minutes. Mean wait time for the entire group was 250 ± 148 minutes. No significant between-group differences were found for age, sex, chronic health conditions, or the condition that precipitated need for mechanical ventilation (that is, primarily exacerbation of COPD, heart failure, neurologic disorders, substance abuse, or pneumonia). APACHE II scores were similar between the expedited and non-expedited patients (21.4 ± 9.5 vs 20.4 ± 8.5; P = 0.8998) as were SAPS II scores (47.3 ± 12.8 vs 45.0 ± 14.8; P = 0.3632). However, mean duration of mechanical ventilation was shorter for the expedited vs the non-expedited group (28.4 ± 33.4 vs 67.9 ± 99.2 hours; P = 0.0431). Length of ICU stay was also shorter (2.4 ± 2.2 vs 4.9 ± 5.2 days; P = 0.0209). The length of hospital stay also tended to be shorter (6.8 ± 7.4 vs 8.9 ± 7.8 days; P = 0.0609). No significant between-group differences were found for ICU survival or survival to discharge.

Commentary

Multiple factors influence the wait time for an open bed, including ICU bed availability, hospital admission policies, ED staffing, and wait times for diagnostic procedures. Findings of this study suggest that such delays can increase time on mechanical ventilation and days in the ICU, factors that substantially increase costs. The time interval examined in this study (< 2 hours) was considerably shorter than that examined in a prior study (< 6 hours) by Chalfin et al,1 which reported essentially the same findings in a larger sample of patients admitted from the ED to the ICU. In contrast to the Chalfin study, which examined outcomes in all patients admitted to the ICU from the ED, the present study only enrolled patients who required intubation and mechanical ventilation prior to ICU transfer. Mean elapsed time in the ED before transfer to the ICU was slightly more than 4 hours, shorter than the interval examined by Chalfin et al.1

What can be done to remedy this situation? The first step is to recognize the value of rapid movement through the system. Because of its busy nature, crowding, and practice characteristics, e.g., the need to simultaneously manage the care of patients with varying acuity, ED clinicians may not be able to provide the close monitoring that critically ill patients receive in the ICU or have the best resources to provide this care. Transfer entails a handoff, which inevitably results in the need to review the current management plan, assess patient response, and determine what changes, if any, might be needed, additional factors that might impact patient outcomes. Patients who may be beginning to stabilize in the ED must be transported to another setting and routines begun again. Findings of this study suggest that systems of care that promote rapid transfer from the ED to the ICU are likely to result in better outcomes and lower costs. The results also suggest that relatively minor differences in time spent in the ED (< 2 hours) can produce significant differences in outcomes.

Reference

  1. Chalfin DB, et al; DELAY-ED study group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007;35:1477-1483.