Patients admitted via the emergency department to the intensive care unit: An observational cohort study

Intensive care unit admission from the emergency department in the setting of National Emergency Access Targets

Purpose

Since the introduction of National Emergency Access Targets (NEATs) in 2012 there has been little research examining patients admitted to the intensive care unit (ICU).We assessed differences in baseline characteristics and outcomes of patients admitted from the Emergency Department (ED) to the ICU within 4 hours compared with patients who were not.

Methods

This retrospective observational study included all adults (≥18 years old) admitted to the ICU from the ED of Austin Hospital, Melbourne, Australia, between 1 January 2017 and 31st December 2019 inclusive.

Results

1544 patients were admitted from the ED to the ICU and 65% had an ED length of stay (EDLOS) > 4 hour. Such patients were more likely to be older, female, with less urgent triage category scores and lower illness severity. Sepsis and respiratory admission diagnoses, and winter presentations were significantly more prevalent in this group.After adjustment for confounders, patients with an EDLOS > 4 hours had lower hospital mortality; 8% v 21% (p = 0.029; OR, 1.62), shorter ICU length of stay 2.2 v 2.4 days (p = 0.043), but a longer hospital length of stay 6.2 v 6.8 days (p = < 0.001).

Conclusion

Almost two thirds of patients breached the NEAT of 4 hours. These patients were more likely to be older, female, admitted in winter with sepsis and respiratory diagnoses, and have lower illness severity and less urgent triage categories. NEAT breach was associated with reduced hospital mortality but an increased hospital length of stay.

Length-of-Stay in the Emergency Department and In-Hospital Mortality: A Systematic Review and Meta-Analysis

The effect of emergency department (ED) length of stay (EDLOS) on in-hospital mortality (IHM) remains unclear. The aim of this systematic review and meta-analysis was to determine the association between EDLOS and IHM. We searched the PubMed, Medline, Embase, Web of Science, Cochrane Controlled Register of Trials, CINAHL, PsycInfo, and Scopus databases from their inception until 14−15 January 2022. We included studies reporting the association between EDLOS and IHM. A total of 11,337 references were identified, and 52 studies (total of 1,718,518 ED patients) were included in the systematic review and 33 in the meta-analysis. A statistically significant association between EDLOS and IHM was observed for EDLOS over 24 h in patients admitted to an intensive care unit (ICU) (OR = 1.396, 95% confidence interval [CI]: 1.147 to 1.701; p < 0.001, I2 = 0%) and for low EDLOS in non-ICU-admitted patients (OR = 0.583, 95% CI: 0.453 to 0.745; p < 0.001, I2 = 0%). No associations were detected for the other cut-offs. Our findings suggest that there is an association between IHM low EDLOS and EDLOS exceeding 24 h and IHM. Long stays in the ED should not be allowed and special attention should be given to patients admitted after a short stay in the ED.

Profile of referrals to an intensive care unit from a regional hospital emergency centre in KwaZulu-Natal

Introduction

The objective was to describe the clinical characteristics, disease profile and outcome of patients referred from a regional hospital Emergency Centre (EC) to the Intensive Care Unit (ICU).

Methods

A retrospective review was performed using data extracted from the Integrated Critical Care Electronic Database (iCED). Data were extracted from the database with respect to patient characteristics, Society of Critical Care Medicine (SCCM) grading, and outcome of the ICU referral. Modified early warning scores (MEWS) were calculated from EC referral data.

Results

There were a total of 2187 referrals. Of these, 56.3% (1231/2187) were male. The mean age of referrals was 36 years. Of the referred patients, 41.5% (907/2187) were initially accepted for admission. A further 378 patients were accepted for admission after a follow up ICU review. Medical conditions accounted for the majority of patient referrals, followed by general surgery and trauma. Most patients initially accepted to ICU were classified as SCCM I and II and had a mean MEWS of 4. Almost half of the patients experienced a delay in admission, most commonly due to a lack of ICU bed availability. ICU mortality was 13.6% for patients admitted from the EC.

Discussion

The EC population referred to the ICU was young with a high burden of medical and trauma conditions. Decisions to accept patients to ICU are limited by available resources, and there was a need to apply ICU triage criteria. Delays in the transfer of ICU patients from the EC increase the workload and contribute to EC crowding.

Identifying 'at-risk' critically ill patients who present to the emergency department and require intensive care unit admission: A retrospective observational cohort study

BACKGROUND

Emergency department (ED) triage is the process of prioritising patients by medical urgency. Delays in intensive care unit (ICU) admission can adversely affect patients.

OBJECTIVES

This study aimed to identify characteristics associated with ICU admission for patients triaged as Australasian Triage Scale (ATS) 3 but subsequently admitted to the ICU within 24 h of triage.

METHODS

This retrospective, observational cohort study was conducted in a public teaching hospital in Queensland, Australia. Patients older than 18 y triaged with an ATS 3 and admitted to the ICU within 24 h of triage or admitted to the ward between January 1, 2012, and December 31, 2012, were included. The demographic and clinical profiles of ICU admissions vs. all other ward admissions for patients triaged an ATS of 3 were compared. Multivariable regression analysis compared characteristics of patients triaged with an ATS of 3 who did and did not require ICU transfer. Descriptive data are reported as n (%) and median and interquartile range (IQR). Regression analysis is reported as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs).

RESULTS

Of the 27 454 adult ED presentations triaged with an ATS of 3, 22.4% (n = 6138) required hospital admission, comprising 5302 individuals, 2.1% of whom (n = 110) were admitted to the ICU within 24 h of triage. Age- and sex-adjusted predictors of ICU admission for patients triaged with an ATS of 3 included infectious (aOR: 3.7; 95% CI: 2.0-6.9), neurological (aOR: 2.8; 95% CI: 1.6-5.0), and gastrointestinal disorders (aOR: 2.2; 95% CI 1.2-3.5); arriving by ambulance; arriving after hours; or arriving on weekends. Regardless of diagnosis or sex, persons older than 80 y were less likely to be admitted to the ICU (aOR: 0.4; 95% CI: 0.2-0.8).

CONCLUSIONS

Patients triaged as ATS 3 presenting on weekends or after hours, and those with infectious, gastrointestinal, or neurological conditions warrant careful attention as these factors were associated with higher odds of ICU admission. Ongoing staff education regarding triage and signs of deterioration are important to prevent avoidable outcomes.