Adverse outcomes associated with delayed intensive care unit transfers in an integrated healthcare system

Abstract

BACKGROUND: Patients with intensive care unit (ICU) transfers from hospital wards have higher mortality than those directly admitted from the emergency department. OBJECTIVE: To describe the association between the timing of unplanned ICU transfers and hospital outcomes. DESIGN, SETTING, PATIENTS: Evaluation of 6369 early (within 24 hours of hospital admission) unplanned ICU transfer cases and matched directly admitted ICU controls from an integrated healthcare system. Cohorts were matched by predicted mortality, age, gender, diagnosis, and admission characteristics. Hospital mortality of cases and controls were compared based on elapsed time and diagnosis. RESULTS: More than 5% of patients admitted through the emergency department experienced an unplanned ICU transfer; the incidence and rates of transfers were highest within the first 24 hours of hospitalization. Multivariable matching produced 5839 (92%) case‐control pairs. Median length of stay was higher among cases (5.0 days) than controls (4.1 days, P < 0.01); mortality was also higher among cases (11.6%) than controls (8.5%, P < 0.01). Patients with early unplanned transfers were at an increased risk of death (odds ratio, 1.44; 95% confidence interval, 1.26‐1.64; P < 0.01); an increased risk of death was observed even among patients transferred within 8 hours of hospitalization. Hospital mortality differed based on admitting diagnosis categories. While it was higher among cases admitted for respiratory infections and gastrointestinal bleeding, it was not different for those with acute myocardial infarction, sepsis, and stroke. CONCLUSIONS: Early unplanned ICU transfers—even within 8 hours of hospitalization—are associated with increased mortality; outcomes vary by elapsed time to transfer and admitting diagnosis. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

“Deterioration to Door Time”: An Exploratory Analysis of Delays in Escalation of Care for Hospitalized Patients

“…17 We postulate that there are likely systemrelated and patient-related factors that influence this relationship and contribute to what has come to be known as Bfailure to rescue.^1 8,19 System-related factors may include general inpatient floor staffing models and provider-patient ratios, 20 temporal issues including the time of day and day of the week at which deterioration occurs, 21 adherence to vital sign monitoring protocols, 22 and ICU bed availability. 7,23,24 There are also cultural barriers preventing staff from calling for assistance, [25][26][27][28] and nurse/physician providers often do not accurately self-assess the quality of their care for clinically deteriorating patients. 28 Patient factors, such as severity of illness, age, 29 medical comorbidities, and the number and type of specific criteria heralding deterioration 12,13,30 may all play a role as well.…”

“…1 The early period of deterioration may represent a time at which admission to the intensive care unit (ICU) is associated with improved survival, 2 particularly among patients who experience deterioration after admission to the hospital. 3 The existing studies examining the relationship between the delay from onset of clinical deterioration to ICU transfer and mortality were conducted over a decade ago, 4,5 did not examine the role of delays in care escalation, 6 or were restricted to the first 48 h of hospitalization, 7 collectively precluding a contemporary understanding of the impact of such delays throughout a hospital stay.…”

Incidence and Prognostic Value of the Systemic Inflammatory Response Syndrome and Organ Dysfunctions in Ward Patients

“…However, further investigation into the incidence and prognosis associated with these criteria in ward patients is essential for several reasons. First, many patients who develop sepsis are initially treated on the wards (14), and it has been shown that patients admitted to the ICU from the wards have a higher mortality rate than those admitted to the ICU from the emergency department (15,16). Second, many hospitals are now expanding their sepsis screening programs to the wards (17)(18)(19), and so information regarding the incidence and prognostic value of these criteria would inform these efforts.…”

Colitis after polytrauma

“…These comorbidities may not be identified in the acute care setting, which leads to worse clinical outcomes, increased length of stay, and increased cost [1][2][3][4][5]. Interdisciplinary rehabilitation improves outcomes and reduces length of stay when appropriately implemented [6].…”