Emergency Department disposition decisions and associated mortality and costs in ICU patients with suspected infection

Abstract

BackgroundFollowing emergency department (ED) assessment, patients with infection may be directly admitted to the intensive care unit (ICU) or alternatively admitted to hospital wards or sent home. Those admitted to the hospital wards or sent home may experience future deterioration necessitating ICU admission.MethodsWe used a prospectively collected registry from two hospitals within a single tertiary care hospital network between 2011 and 2014. Patient information, outcomes, and costs were stored in the hospital data warehouse. Patients were categorized into three groups: (1) admitted directly from the ED to the ICU; (2) initially admitted to the hospital wards, with ICU admission within 72 hours of initial presentation; or (3) sent home from the ED, with ICU admission within 72 hours of initial presentation. Using multivariable logistic regression, we sought to compare outcomes and total costs between groups. Total costs were evaluated using a generalized linear model.ResultsA total of 657 patients were included; of these, 338 (51.4%) were admitted directly from the ED to the ICU, 246 (37.4%) were initially admitted to the wards and then to the ICU, and 73 (11.1%) were initially sent home and then admitted to the ICU. In-hospital mortality was lowest among patients admitted directly to the ICU (29.5%), as compared with patients admitted to the ICU from wards (42.7%) or home (61.6%) (P < 0.001). As compared with direct ICU admission, disposition to the ward was associated with an adjusted OR of 1.75 (95% CI, 1.22–2.50; P < 0.01) for mortality, and disposition home was associated with an adjusted OR of 4.02 (95% CI, 2.32–6.98). Mean total costs were lowest among patients directly admitted to the ICU ($26,748), as compared with those admitted from the wards ($107,315) and those initially sent home ($71,492) (P < 0.001). Cost per survivor was lower among patients directly admitted to the ICU ($37,986) than either those initially admitted to the wards ($187,230) or those sent home ($186,390) (P < 0.001).ConclusionsIn comparison with direct admission to the ICU, patients with suspected infection admitted to the ICU who have previously been discharged home or admitted to the ward are associated with higher in-hospital mortality and costs.Electronic supplementary materialThe online version of this article (10.1186/s13054-018-2096-8) contains supplementary material, which is available to authorized users.

Biomarkers and clinical scores to aid the identification of disease severity and intensive care requirement following activation of an in-hospital sepsis code

“…An early recognition of such patients is crucial, since it has previously been shown that inappropriate ED discharge can result in higher mortality rates in patients initially classified as suitable for outpatient treatment, but later directly admitted onto the ICU. Similar findings were also reported after initial triage onto a medical ward [31]. The relatively high performance of MR-proADM in identifying these patients after presentation to the ED, with a modest performance during treatment on a medical ward, may provide clinicians with an additional tool in assessing suitability for ICU admission.…”

New-onset atrial fibrillation and associated outcomes and resource use among critically ill adults—a multicenter retrospective cohort study

“…We determined patient costs using the case-costing system of the Ottawa Hospital Data Warehouse, as done previously [17,23,27]. Total hospital costs include both direct and indirect sources.…”

“…The Ottawa Hospital uses a standardized case-costing methodology, developed by the Ontario Case Costing Initiative, and based upon the Canadian Institute for Health Information Management guidelines [28]. Costs were indexed to 2018 Canadian Dollars using consumer price indices [23,27].…”

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“…The early recognition and treatment of children with severe malaria can improve survival but, like sepsis, the initial presentation may be subtle and non-specific [ 2 , 10 – 13 ]. Malaria diagnosis across many hospital and community-based settings relies on RDTs that detect circulating parasite antigens.…”

“…Clinical evaluation of infection-related disease severity remains imprecise in paediatric and adult populations in both low and high resource settings, indicating a need for more accurate tools [ 13 , 14 ]. The outcome of any infection depends on a complex interplay between the pathogen and host.…”