Risk factors for unplanned transfer to

Intensive care within 24 hours of admission from

the emergency department

Dr Suganthi SingaraveluSpR5 Anaesthetics

Journal Club presentation -Arrowe park Hospital

Introduction

5% of ED admissions undergo unplanned transfer to ICU1

Unplanned admission has a higher mortality than direct admission from ED to ICU

Better recognition and interventions in ED are needed.

Aim of the study

To describe the risk factors associated with unplanned transfer to ICU within 24hours of admission to the ward from ED

Methods- Patients identification

All adult patients admitted in ED between 2007 and 2009

Data obtained from Kaiser Permanente North California -13 hospitals with similar patient populations.

Exclusion: Direct transfer to theatre or ICU, pregnant patients

Methods- Patient characteristics

Patient: Age, gender, admitting diagnosis, chronic illness burden, acute physiological derangement in the ED and hospital length of stay

Chronic illness: Comorbidity Point Score (COPS)

Acute: Laboratory Acute Physiological Score (LAPS)

LAPS

COPS

Statistics

Univariate analysis:

ANOVA and

chi square test

Multivariate logistic regression

Results

Total: 178,315 non ICU admission from ED

4,252 (2.4%) – admitted to ICU within 24 hours of leaving ED

Multivariate analysis

Multivariate analysis

Multivariate analysis

Significant Risk factors

Higher co-morbidity

More deranged physiology

Arrived overnight in the ward

More frequent in lower volume hospitals

Results

Respiratory conditions (COPD/ pneumonia/acute RTI) comprised nearly half (47%) of all conditions.

1 in 30 pneumonia and 1 in 33 COPD were transferred to ICU from ward

Overall 1 in 42 with respiratory condition – worse mortality

Respiratory problems

Tendency for rapid deterioration

ICU may accept in early stage

Applying prediction rules to identify the patients who may need ventilation

Intermediate (HDU) care for these patients

Discussion- Hospital size

Unplanned transfers X 2 higher in low volume centers- Reasons???

- Less resources

- lower ICU capacity

- less on –call intensivists

- less experience with certain critical care conditions

Dark hours 11pm to 7 am?

Unclear why arriving overnight has higher risk

Possibilities are

ED overcrowding in the evening

Decreased staffing

longer delays in critical diagnostic

tests and interventions

Lesser risk of ICU admission

TCU (HDU)

Age >85 – advanced directives or patient preferences

Limitation of the study

Not designed to distinguish the underlying cause i.e. under recognition of illness or delays in interventions

vital signs and mental status that were not included could improve the risk adjustment.

Study conclusions

Unplanned admission to ICU is more likely in patients with respiratory conditions, sepsis and MI, higher co morbidity burden and grossly abnormal lab results.

Better inpatient triage, earlier interventions or closer monitoring may prevent unplanned ICU admissions.

How to apply in our hospital

Prediction rules can be considered for better triage

Organisational changes for night shift, more HDU beds or A&E resources

Compare data with high volume centers and regular monitoring