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Effect of Emergency Department and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients.
Crit Care Med. 2018 05; 46(5):720-727.CC

Abstract

OBJECTIVES

ICU admission delays can negatively affect patient outcomes, but emergency department volume and boarding times may also affect these decisions and associated patient outcomes. We sought to investigate the effect of emergency department and ICU capacity strain on ICU admission decisions and to examine the effect of emergency department boarding time of critically ill patients on in-hospital mortality.

DESIGN

A retrospective cohort study.

SETTING

Single academic tertiary care hospital.

PATIENTS

Adult critically ill emergency department patients for whom a consult for medical ICU admission was requested, over a 21-month period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patient data, including severity of illness (Mortality Probability Model III on Admission), outcomes of mortality and persistent organ dysfunction, and hourly census reports for the emergency department, for all ICUs and all adult wards were compiled. A total of 854 emergency department requests for ICU admission were logged, with 455 (53.3%) as "accept" and 399 (46.7%) as "deny" cases, with median emergency department boarding times 4.2 hours (interquartile range, 2.8-6.3 hr) and 11.7 hours (3.2-20.3 hr) and similar rates of persistent organ dysfunction and/or death 41.5% and 44.6%, respectively. Those accepted were younger (mean ± SD, 61 ± 17 vs 65 ± 18 yr) and more severely ill (median Mortality Probability Model III on Admission score, 15.3% [7.0-29.5%] vs 13.4% [6.3-25.2%]) than those denied admission. In the multivariable model, a full medical ICU was the only hospital-level factor significantly associated with a lower probability of ICU acceptance (odds ratio, 0.55 [95% CI, 0.37-0.81]). Using propensity score analysis to account for imbalances in baseline characteristics between those accepted or denied for ICU admission, longer emergency department boarding time after consult was associated with higher odds of mortality and persistent organ dysfunction (odds ratio, 1.77 [1.07-2.95]/log10 hour increase).

CONCLUSIONS

ICU admission decisions for critically ill emergency department patients are affected by medical ICU bed availability, though higher emergency department volume and other ICU occupancy did not play a role. Prolonged emergency department boarding times were associated with worse patient outcomes, suggesting a need for improved throughput and targeted care for patients awaiting ICU admission.

Authors+Show Affiliations

Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY. Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

29384780

Citation

Mathews, Kusum S., et al. "Effect of Emergency Department and ICU Occupancy On Admission Decisions and Outcomes for Critically Ill Patients." Critical Care Medicine, vol. 46, no. 5, 2018, pp. 720-727.
Mathews KS, Durst MS, Vargas-Torres C, et al. Effect of Emergency Department and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients. Crit Care Med. 2018;46(5):720-727.
Mathews, K. S., Durst, M. S., Vargas-Torres, C., Olson, A. D., Mazumdar, M., & Richardson, L. D. (2018). Effect of Emergency Department and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients. Critical Care Medicine, 46(5), 720-727. https://doi.org/10.1097/CCM.0000000000002993
Mathews KS, et al. Effect of Emergency Department and ICU Occupancy On Admission Decisions and Outcomes for Critically Ill Patients. Crit Care Med. 2018;46(5):720-727. PubMed PMID: 29384780.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Effect of Emergency Department and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients. AU - Mathews,Kusum S, AU - Durst,Matthew S, AU - Vargas-Torres,Carmen, AU - Olson,Ashley D, AU - Mazumdar,Madhu, AU - Richardson,Lynne D, PY - 2018/2/1/pubmed PY - 2019/9/20/medline PY - 2018/2/1/entrez SP - 720 EP - 727 JF - Critical care medicine JO - Crit Care Med VL - 46 IS - 5 N2 - OBJECTIVES: ICU admission delays can negatively affect patient outcomes, but emergency department volume and boarding times may also affect these decisions and associated patient outcomes. We sought to investigate the effect of emergency department and ICU capacity strain on ICU admission decisions and to examine the effect of emergency department boarding time of critically ill patients on in-hospital mortality. DESIGN: A retrospective cohort study. SETTING: Single academic tertiary care hospital. PATIENTS: Adult critically ill emergency department patients for whom a consult for medical ICU admission was requested, over a 21-month period. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient data, including severity of illness (Mortality Probability Model III on Admission), outcomes of mortality and persistent organ dysfunction, and hourly census reports for the emergency department, for all ICUs and all adult wards were compiled. A total of 854 emergency department requests for ICU admission were logged, with 455 (53.3%) as "accept" and 399 (46.7%) as "deny" cases, with median emergency department boarding times 4.2 hours (interquartile range, 2.8-6.3 hr) and 11.7 hours (3.2-20.3 hr) and similar rates of persistent organ dysfunction and/or death 41.5% and 44.6%, respectively. Those accepted were younger (mean ± SD, 61 ± 17 vs 65 ± 18 yr) and more severely ill (median Mortality Probability Model III on Admission score, 15.3% [7.0-29.5%] vs 13.4% [6.3-25.2%]) than those denied admission. In the multivariable model, a full medical ICU was the only hospital-level factor significantly associated with a lower probability of ICU acceptance (odds ratio, 0.55 [95% CI, 0.37-0.81]). Using propensity score analysis to account for imbalances in baseline characteristics between those accepted or denied for ICU admission, longer emergency department boarding time after consult was associated with higher odds of mortality and persistent organ dysfunction (odds ratio, 1.77 [1.07-2.95]/log10 hour increase). CONCLUSIONS: ICU admission decisions for critically ill emergency department patients are affected by medical ICU bed availability, though higher emergency department volume and other ICU occupancy did not play a role. Prolonged emergency department boarding times were associated with worse patient outcomes, suggesting a need for improved throughput and targeted care for patients awaiting ICU admission. SN - 1530-0293 UR - https://www.unboundmedicine.com/medline/citation/29384780/Effect_of_Emergency_Department_and_ICU_Occupancy_on_Admission_Decisions_and_Outcomes_for_Critically_Ill_Patients_ L2 - https://dx.doi.org/10.1097/CCM.0000000000002993 DB - PRIME DP - Unbound Medicine ER -