Emergency department length of stay and outcomes of emergency department–based intensive care unit patients

Abstract

Objective Emergency department (ED) boarding of patients who are critically ill is associated with poor outcomes. ED‐based intensive care units (ED‐ICUs) may mitigate the risks of ED boarding. We sought to analyze the impact of ED length of stay (LOS) before transfer to an ED‐ICU on patient outcomes. Methods We retrospectively analyzed adult ED patients managed in the ED‐ICU at a US medical center. Bivariate and multivariable linear regressions tested ED LOS as a predictor of inpatient ICU and hospital LOS, and separate bivariate and multivariable logistic regressions tested ED LOS as a predictor of inpatient ICU admission, 48‐hour mortality, and hospital mortality. Multivariable analyses’ covariates were age, sex, Charlson Comorbidity Index (CCI), Emergency Severity Index, and eSimplified Acute Physiology Score (eSAPS3). Results We included 5859 ED visits with subsequent care in the ED‐ICU. Median age, CCI, eSAPS3, ED LOS, and ED‐ICU LOS were 62 years (interquartile range [IQR], 48–73 years), 5 (IQR, 2–8), 46 (IQR, 36–56), 3.6 hours (IQR, 2.5–5.3 hours), and 8.5 hours (IQR, 5.3–13.4 hours), respectively, and 46.3% were women. Bivariate analyses showed negative associations of ED LOS with hospital LOS (β = −3.4; 95% confidence interval [CI], −5.9 to −1.0), inpatient ICU admission (odds ratio [OR], 0.86, 95% CI, 0.84–0.88), 48‐hour mortality (OR, 0.89; 95% CI, 0.82–0.98), and hospital mortality (OR, 0.89; 95% CI, 0.85–0.92), but no association with inpatient ICU LOS. Multivariable analyses showed a negative association of ED LOS with inpatient ICU admission (OR, 0.91; 95% CI, 0.88–0.93), but no associations with other outcomes. Conclusions We observed no significant associations between ED LOS before ED‐ICU transfer and worsened outcomes, suggesting an ED‐ICU may mitigate the risks of ED boarding of patients who are critically ill.

Impact of emergency department‐based intensive care unit on outcomes of decompensating boarding emergency department patients

“…Prior evaluation of ED‐ICU implementation found this model was associated with reductions in 30‐day mortality and ICU admission for ED patients 6 . A prior study analyzed the impact of ED LOS before transfer to ED‐ICU and found that that the presence of an ED‐ICU may mitigate risks of ED boarding of critically ill patients 10 . In a variety of specific disease states including upper gastrointestinal bleeding, diabetic ketoacidosis, and leukostasis, the ED‐ICU has been associated with improved patient and resource utilization outcomes 11–13 .…”

“… 6 A prior study analyzed the impact of ED LOS before transfer to ED‐ICU and found that that the presence of an ED‐ICU may mitigate risks of ED boarding of critically ill patients. 10 In a variety of specific disease states including upper gastrointestinal bleeding, diabetic ketoacidosis, and leukostasis, the ED‐ICU has been associated with improved patient and resource utilization outcomes. 11 , 12 , 13 These prior studies focused on patient populations initially recognized as requiring ICU level of care, whereas the present study focuses on patients initially admitted to non‐ICU levels of care.…”

Patient and hospital characteristics predict prolonged emergency department length of stay and in-hospital mortality: a nationwide analysis in Korea

“…This view emphasises the importance of introducing mitigation strategies regardless of hospital volume. Recent studies on mitigation strategies have shown that suitable interventions, such as ED-based electronic ICU monitoring systems, streamlined admissions, and ED-based ICUs, can reduce EDLOS or improve clinical outcomes in critically ill patients [ 53 , 66 – 70 ].…”

What Should Students and Trainees Be Taught About Turfing and Where Patients Belong?

“…Overcrowding significantly increases length of stay in the ED, and ED boarding before transfer to an intensive care unit has resulted in significantly worse patient outcomes for both admitted and new patients. 17,18 Hospitals should have a policy in place to determine disposition in circumstances in which services do not agree on optimal management, which leads to delays in care. The hospital and health care team need to be in alignment, with processes and policies that facilitate moving patients out of the ED and into inpatient beds as quickly as possible to maintain patient flow and improve care.…”