- Email: [email protected]
Expedited admission of patients decreases duration of mechanical ventilation and shortens ICU stay
American Journal of Emergency Medicine (2009) 27, 843–846
www.elsevier.com/locate/ajem
Brief Report
Expedited admission of patients decreases duration of mechanical ventilation and shortens ICU stay☆,☆☆ Scott D. Cline MD a , Robyn A.K. Schertz MD a , Eric C. Feucht MD b,⁎ a
Michigan State University/Kalamazoo Center for Medical Studies, Kalamazoo, MI 49007, USA Bronson Methodist Hospital, Adult Critical Care Medicine, Kalamazoo, MI 49007, USA
b
Received 12 February 2008; revised 14 April 2008; accepted 14 April 2008
Abstract Background: To determine if expedited admission (b2 hours) of critically ill patients requiring intubation and mechanical ventilation from the emergency department (ED) to the intensive care unit (ICU) decreases ICU and hospital length of stay. Methods: Patients with respiratory failure that required intubation and mechanical ventilation who were admitted to the hospital between June 2004 and May 2006 were retrospectively identified from the Project IMPACT database. Patients were divided into 2 groups based on ED length of stay: expedited (b2 hours) or nonexpedited (N2 hours). Results: The expedited (n = 12) and nonexpedited (n = 66) groups were comparable in demographics, medical conditions, and disease severity. Mean duration of mechanical ventilation was significantly shorter in the expedited group (28.4 hours vs 67.9 hours; P = .0431), as was mean ICU length of stay (2.4 days vs 4.9 days; P = .0209). Length of hospital stay tended to be shorter for the patients in the expedited group (6.8 days vs 8.9 days; P = .0609). Conclusions: Expedited admission (b2 hours) of critically ill patients requiring intubation and mechanical ventilation from the ED to the ICU was associated with shorter durations of mechanical ventilation and ICU length of stay, suggesting that prompt ICU admission results in improved use of resources. © 2009 Elsevier Inc. All rights reserved.
1. Introduction Critically ill patients wait in the emergency department (ED) for widely variable periods before admission to the intensive care unit (ICU). Published studies have demon☆ This study was performed at Bronson Methodist Hospital, Kalamazoo, Mich. ☆☆ Drs. Cline and Schertz contributed equally to the design, data collection, and analysis of this study. ⁎ Corresponding author. Tel.: +1 269 341 7762; fax: +1 269 341 8098. E-mail address: [email protected] (E.C. Feucht).
0735-6757/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2008.04.018
strated ED boarding times of critically ill patients, before ICU admission, ranging from 145.3 to 367 minutes [1-5]. A recent study by Chalfin et al [6] demonstrated that delayed transfer (N6 hours) of critically ill patients from the ED to the ICU resulted in prolonged ICU length of stay, prolonged hospital length of stay, and increased inhospital mortality. The purpose of this retrospective study was to determine whether expedited (b2 hours) transfer from the ED to ICU reduced the duration of mechanical ventilation, the ICU and hospital lengths of stay, the incidences of organ system failure, and ICU mortality in critically ill
844 patients with respiratory failure who required intubation and mechanical ventilation.
2. Materials and methods 2.1. Patients Patients admitted to Bronson Methodist Hospital, a community teaching hospital with 343 inpatient beds, between June 2004 and May 2006 were retrospectively identified through a review of the Project IMPACT database. Critically ill adult patients who had respiratory failure that required intubation and mechanical ventilation, for any reason, and who were admitted to the ICU from the ED, were included in the study. Patients who were directly admitted to the ICU from outside hospitals, pregnant patients, and patients in whom care was withdrawn in the first 24 hours were excluded. The institutional review board at Bronson Methodist Hospital approved the study protocol. Clinical and demographic data, including age, sex, ethnicity, and chronic medical conditions, were obtained from the patient charts. The ED to ICU admission time, the ICU and hospital lengths of stay, the indications that precipitated mechanical ventilation, and the duration of mechanical ventilation were retrospectively abstracted from the Project IMPACT database. Chronic respiratory disease was defined as chronic restrictive, obstructive, or pulmonary vascular disease that resulted in severe exercise restriction; documented chronic hypoxemia, hypercapnia, secondary polycythemia, or severe pulmonary hypertension; or the need for home oxygen therapy or noninvasive positive pressure ventilation. Chronic cardiovascular disease was defined as angina at rest or upon minimal exertion, New York Heart Association class IV symptoms, and one of the following conditions: severe coronary artery disease, severe valvular disease, or severe cardiomyopathy. Chronic renal disease was defined as a baseline serum creatinine level of greater than 2.0 mg/dL or the need for dialysis. Acute organ system dysfunction was defined as follows: acute cardiovascular dysfunction was defined as a systolic blood pressure of less than 90 mm Hg, a decrease of 40 mm Hg from baseline in systolic blood pressure, a mean arterial pressure of less than 70 mm Hg for greater than 1 hour despite adequate fluid resuscitation, or the need for vasopressor support to maintain systolic blood pressure of greater than 90 mm Hg or mean arterial pressure of greater than 70 mm Hg. Acute renal dysfunction was defined as an increase of greater than 1.0 mg/dL in the serum creatinine level despite adequate fluid resuscitation or a serum creatinine level of greater than 2.0 mg/dL in the absence of a known baseline value. Patients were allocated to 1 of 2 groups: (1) the expedited group, which included patients whose duration of ED stay was less than 120 minutes or (2) the nonexpedited group,
S.D. Cline et al. which included patients whose time of transfer from the ED to the ICU was greater than 120 minutes.
2.2. Statistical analysis Continuous data were summarized as the mean ± SD, and categorical data were summarized as counts and percentages. An unpaired Student t test or Mann-Whitney U test was used to compare the expedited and nonexpedited groups, when appropriate. P values of b 0.05 were used to indicate statistical significance.
3. Results 3.1. Patients A total of 78 patients (39 men and 39 women) of mean age 55.3 ± 13.1 years (range, 26-75 years) were included in the study. The mean elapsed time in the ED before transfer to the ICU was 250.0 ± 147.4 minutes (range, 64-723 minutes). The distribution of elapsed time in the ED before ICU admission is shown in Fig. 1. The elapsed time in the ED before transfer to the ICU was less than 120 minutes for 12 (15%) of the patients (expedited group) and greater than 120 minutes for 66 (85%) of the patients (nonexpedited group). No significant differences were observed between the expedited and nonexpedited groups in age, sex, or ethnicity; in the prevalence of chronic respiratory, cardiovascular, or renal disease; in the prevalence of the acute conditions that precipitated mechanical ventilation; or in the Acute Physiology and Chronic Health Evaluation II (APACHE II) or Simplified Acute Physiology Score II (SAPS II) scores (Table 1). The acute conditions that precipitated the need for intubation and mechanical ventilation, primarily exacerbation of chronic obstructive lung disease, decompensated
Fig. 1 Duration of stay in ED before admission to the ICU. The average ED length of stay was 250 ± 147.7 minutes (range, 64-723 minutes).
Rapid admit decreases ICU LOS
845
Table 1 Demographic characteristics, chronic medical conditions, indications for mechanical ventilation, APACHE II, and SAPS II scores Baseline patient characteristics a Characteristic
Expedited (n = 12)
Nonexpedited (n = 66)
Age (y) 50.0 (±15.8) 56.3 (±12.4) Male sex 7 (58%) 32 (48%) White ethnic group 8 (67%) 55 (83%) 4 (33%) 26 (39%) Chronic conditions b Respiratory 1 (8%) 10 (15%) Cardiovascular 0 (0%) 3 (5%) Renal 2 (17%) 8 (12%) Hemodialysis 1 (8%) 5 (8%) Condition precipitating mechanical ventilation COPD/asthma 1 (8%) 8 (12%) CHF/MI 3 (25%) 11 (17%) Cardiac arrest 3 (25%) 6 (9%) Intoxication 3 (25%) 14 (21%) Neurological 1 (8%) 13 (20%) Pneumonia 1 (8%) 9 (14%) Other 0 (0%) 5 (8%) APACHE II score 21.4 (±9.5) 20.4 (±8.5) SAPS II score 47.3 (±12.8) 45.0 (±14.8)
P (n = 78) .1677 .5302 .1778 .6914 .5325 .4513 .6648 .9278 .7056 .489 .1126 .77 .3454 .6132 .3243 .8998 .3632
COPD indicates chronic obstructive pulmonary disease; CHF, congestive heart failure; MI, myocardial infarction. a Data presented are mean ± SD or no. (%) unless otherwise indicated. b Chronic respiratory disease was defined as chronic restrictive, obstructive, or vascular disease resulting in severe exercise restriction; documented chronic hypoxia, hypercapnia, secondary polycythemia, or severe pulmonary hypertension; or the need for home oxygen therapy or noninvasive positive pressure ventilation. Chronic cardiovascular disease was defined as angina at rest or upon minimal exertion, New York Heart Association class IV symptoms, and one of the following conditions: severe coronary artery disease, severe valvular disease, or severe cardiomyopathy. Chronic renal disease was defined as a baseline serum creatinine of greater than 2.0 mg/dL or the need for dialysis.
difference was observed between the 2 groups in ICU mortality; however, there was a trend for the ICU survival rate to be higher in the nonexpedited group (59/66 [89%]) than in the expedited group (9/12 [75%]) (P = .0850).
4. Discussion Critically ill patients get admitted from the ED to an ICU when a bed is available. Unfortunately, the wait time for an “open” bed varies and is dependent upon many factors. Previously published reports have shown that ICU bed availability, as well as delays in processing admission orders, slow the rate of ICU admission [1,7]. Other reasons for delayed admission to the ICU include hospital policies on admission bed management, holding admissions until shift changes, delays incurred while awaiting diagnostic testing in the ED, and ED and ICU acuity levels. However, growing evidence suggest that delayed ICU admission of the critically ill is associated with longer ICU and hospital stays and worse outcomes. Our study was limited by its small sample size and the inherent limitations of a single-center study; however, it adds to the work of Chalfin et al [6]. Although Chalfin's group demonstrated that prolonged boarding times in the ER before ICU admission were associated with increased hospital length of stay and higher ICU and hospital mortality, our study further suggests that a reduction in the ED time is associated with a reduction in ICU and hospital lengths of stay. As opposed to the Chalfin study, we focused on critically
Table 2 of stay
Clinical outcomes based on elapsed time in the ED a Outcome
heart failure, cardiac arrest, neurologic disorders (eg, seizures, stroke, intracranial hemorrhage), intoxications, and pneumonia, were similar between the 2 groups.
3.2. Clinical outcomes The percentage of patients who developed acute cardiovascular or renal dysfunction was not significantly different between the expedited and nonexpedited groups (Table 2). However, the mean duration of mechanical ventilation (28.4 ± 33.4 hours for the expedited group vs 67.9 ± 99.2 hours for the nonexpedited group) and the mean length of stay in the ICU (2.4 ± 2.2 days for the expedited group vs 4.9 ± 5.2 days for the nonexpedited group) were significantly shorter for the patients in the expedited group than for those in the nonexpedited group (P = .0431 and P = .0209, respectively). Additionally, the length of hospital stay tended to be shorter for the patients in the expedited group than for those in the nonexpedited group (6.8 ± 7.4 days vs 8.9 ± 7.8 days; P = .0609). No significant
Clinical outcomes based on duration of ED length
Expedited (n = 12)
Nonexpedited P (n = 66)
Acute organ dysfunction b Cardiovascular 6 (50%) 22 (33%) Renal 1 (8%) 5 (8%) Duration of mechanical 28.4 (±33.4) 67.9 (±99.2) ventilation (h) Length of ICU stay (d) 2.4 (±2.2) 4.9 (±5.2) Length of hospital stay (d) 6.8 (±7.4) 8.9 (±7.8) Survivors of ICU 9 (75%) 59 (89%) admission a
.2682 .9278 .0431 .0209 .0609 .085
Data presented are mean ± SD or no. (%) unless otherwise indicated. Cardiovascular dysfunction—systolic blood pressure less than 90 mm Hg, systolic blood pressure drop of 40 mm Hg from baseline, or mean arterial blood pressure less than 70 mm Hg for at least 1 hour despite adequate fluid resuscitation; or the need to use vasopressors to maintain systolic blood pressure greater than 90 mm Hg or mean arterial blood pressure greater than 70 mm Hg. Renal dysfunction—an increase in serum creatinine by more than 1 mg/dL from baseline after adequate fluid resuscitation or a serum creatinine greater than 2.0 mg/dL in the absence of known baseline and does not apply to patients on chronic dialysis. b
846 ill patients with respiratory failure that required intubation and mechanical ventilation. In this group, we demonstrated that expedited ICU admission resulted in a greater than 50% reduction in the duration of mechanical ventilation. We were surprised to find that the patients in the expedited group had a trend toward higher mortality. When the manner of death between the 2 groups was reviewed, we found that more patients in the nonexpedited group had, after discussion with families, termination of life support compared with those in the expedited group, 7 of 7 vs 1 of 3, respectively. Two deaths of patients in the expedited group were in patients who had unstable cardiac rhythms. Furthermore, it is possible that the small sample size of the study, with only 12 patients in the expedited group, may have magnified the apparent mortality. Although not directly studied, this reduction in the duration of mechanical ventilation and shorter ICU stay likely reduced health care expenditures and increased the virtual capacity of both the ICU and the ED. In conclusion, expedited admission of critically ill patients who require intubation and mechanical ventilation was associated with a reduction in the duration of mechanical ventilation and shorter ICU and hospital lengths of stay.
S.D. Cline et al. Hospitals need to consider strategies to help facilitate the prompt admission of these patients from the ED to the ICU.
References [1] Svenson J, Besinger B, Stapcynski JS. Critical care of medical and surgical patients in the ED: length of stay and initiation of intensive care procedures. Am J Emerg Med 1997;15:654-7. [2] Varon J, Fromm Jr RE, Levine RL. Emergency department procedures and length of stay for critically ill medical patients. Ann Emerg Med 1994;23:546-9. [3] Fromm Jr RE, Gibbs LR, McCallum WG, et al. Critical care in the emergency department: a time-based study. Crit Care Med 2003;21: 970-6. [4] Nguyen HB, Rivers EP, Havstad S, et al. Critical care in the emergency department: a physiologic assessment and outcome evaluation. Acad Emerg Med 2000;9:1354-61. [5] Parkhe M, Myles PS, Leach DS, et al. Outcome of emergency department patients with delayed admission to an intensive care unit. Emerg Med 2002;14:50-7. [6] Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007;35:1477-83. [7] Clark K, Normile LB. Delays in implementing admission orders for critical care patients associated with length of stay in emergency departments in six mid-Atlantic States. J Emerg Nurs 2002;28:489-95.
www.elsevier.com/locate/ajem
Brief Report
Expedited admission of patients decreases duration of mechanical ventilation and shortens ICU stay☆,☆☆ Scott D. Cline MD a , Robyn A.K. Schertz MD a , Eric C. Feucht MD b,⁎ a
Michigan State University/Kalamazoo Center for Medical Studies, Kalamazoo, MI 49007, USA Bronson Methodist Hospital, Adult Critical Care Medicine, Kalamazoo, MI 49007, USA
b
Received 12 February 2008; revised 14 April 2008; accepted 14 April 2008
Abstract Background: To determine if expedited admission (b2 hours) of critically ill patients requiring intubation and mechanical ventilation from the emergency department (ED) to the intensive care unit (ICU) decreases ICU and hospital length of stay. Methods: Patients with respiratory failure that required intubation and mechanical ventilation who were admitted to the hospital between June 2004 and May 2006 were retrospectively identified from the Project IMPACT database. Patients were divided into 2 groups based on ED length of stay: expedited (b2 hours) or nonexpedited (N2 hours). Results: The expedited (n = 12) and nonexpedited (n = 66) groups were comparable in demographics, medical conditions, and disease severity. Mean duration of mechanical ventilation was significantly shorter in the expedited group (28.4 hours vs 67.9 hours; P = .0431), as was mean ICU length of stay (2.4 days vs 4.9 days; P = .0209). Length of hospital stay tended to be shorter for the patients in the expedited group (6.8 days vs 8.9 days; P = .0609). Conclusions: Expedited admission (b2 hours) of critically ill patients requiring intubation and mechanical ventilation from the ED to the ICU was associated with shorter durations of mechanical ventilation and ICU length of stay, suggesting that prompt ICU admission results in improved use of resources. © 2009 Elsevier Inc. All rights reserved.
1. Introduction Critically ill patients wait in the emergency department (ED) for widely variable periods before admission to the intensive care unit (ICU). Published studies have demon☆ This study was performed at Bronson Methodist Hospital, Kalamazoo, Mich. ☆☆ Drs. Cline and Schertz contributed equally to the design, data collection, and analysis of this study. ⁎ Corresponding author. Tel.: +1 269 341 7762; fax: +1 269 341 8098. E-mail address: [email protected] (E.C. Feucht).
0735-6757/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2008.04.018
strated ED boarding times of critically ill patients, before ICU admission, ranging from 145.3 to 367 minutes [1-5]. A recent study by Chalfin et al [6] demonstrated that delayed transfer (N6 hours) of critically ill patients from the ED to the ICU resulted in prolonged ICU length of stay, prolonged hospital length of stay, and increased inhospital mortality. The purpose of this retrospective study was to determine whether expedited (b2 hours) transfer from the ED to ICU reduced the duration of mechanical ventilation, the ICU and hospital lengths of stay, the incidences of organ system failure, and ICU mortality in critically ill
844 patients with respiratory failure who required intubation and mechanical ventilation.
2. Materials and methods 2.1. Patients Patients admitted to Bronson Methodist Hospital, a community teaching hospital with 343 inpatient beds, between June 2004 and May 2006 were retrospectively identified through a review of the Project IMPACT database. Critically ill adult patients who had respiratory failure that required intubation and mechanical ventilation, for any reason, and who were admitted to the ICU from the ED, were included in the study. Patients who were directly admitted to the ICU from outside hospitals, pregnant patients, and patients in whom care was withdrawn in the first 24 hours were excluded. The institutional review board at Bronson Methodist Hospital approved the study protocol. Clinical and demographic data, including age, sex, ethnicity, and chronic medical conditions, were obtained from the patient charts. The ED to ICU admission time, the ICU and hospital lengths of stay, the indications that precipitated mechanical ventilation, and the duration of mechanical ventilation were retrospectively abstracted from the Project IMPACT database. Chronic respiratory disease was defined as chronic restrictive, obstructive, or pulmonary vascular disease that resulted in severe exercise restriction; documented chronic hypoxemia, hypercapnia, secondary polycythemia, or severe pulmonary hypertension; or the need for home oxygen therapy or noninvasive positive pressure ventilation. Chronic cardiovascular disease was defined as angina at rest or upon minimal exertion, New York Heart Association class IV symptoms, and one of the following conditions: severe coronary artery disease, severe valvular disease, or severe cardiomyopathy. Chronic renal disease was defined as a baseline serum creatinine level of greater than 2.0 mg/dL or the need for dialysis. Acute organ system dysfunction was defined as follows: acute cardiovascular dysfunction was defined as a systolic blood pressure of less than 90 mm Hg, a decrease of 40 mm Hg from baseline in systolic blood pressure, a mean arterial pressure of less than 70 mm Hg for greater than 1 hour despite adequate fluid resuscitation, or the need for vasopressor support to maintain systolic blood pressure of greater than 90 mm Hg or mean arterial pressure of greater than 70 mm Hg. Acute renal dysfunction was defined as an increase of greater than 1.0 mg/dL in the serum creatinine level despite adequate fluid resuscitation or a serum creatinine level of greater than 2.0 mg/dL in the absence of a known baseline value. Patients were allocated to 1 of 2 groups: (1) the expedited group, which included patients whose duration of ED stay was less than 120 minutes or (2) the nonexpedited group,
S.D. Cline et al. which included patients whose time of transfer from the ED to the ICU was greater than 120 minutes.
2.2. Statistical analysis Continuous data were summarized as the mean ± SD, and categorical data were summarized as counts and percentages. An unpaired Student t test or Mann-Whitney U test was used to compare the expedited and nonexpedited groups, when appropriate. P values of b 0.05 were used to indicate statistical significance.
3. Results 3.1. Patients A total of 78 patients (39 men and 39 women) of mean age 55.3 ± 13.1 years (range, 26-75 years) were included in the study. The mean elapsed time in the ED before transfer to the ICU was 250.0 ± 147.4 minutes (range, 64-723 minutes). The distribution of elapsed time in the ED before ICU admission is shown in Fig. 1. The elapsed time in the ED before transfer to the ICU was less than 120 minutes for 12 (15%) of the patients (expedited group) and greater than 120 minutes for 66 (85%) of the patients (nonexpedited group). No significant differences were observed between the expedited and nonexpedited groups in age, sex, or ethnicity; in the prevalence of chronic respiratory, cardiovascular, or renal disease; in the prevalence of the acute conditions that precipitated mechanical ventilation; or in the Acute Physiology and Chronic Health Evaluation II (APACHE II) or Simplified Acute Physiology Score II (SAPS II) scores (Table 1). The acute conditions that precipitated the need for intubation and mechanical ventilation, primarily exacerbation of chronic obstructive lung disease, decompensated
Fig. 1 Duration of stay in ED before admission to the ICU. The average ED length of stay was 250 ± 147.7 minutes (range, 64-723 minutes).
Rapid admit decreases ICU LOS
845
Table 1 Demographic characteristics, chronic medical conditions, indications for mechanical ventilation, APACHE II, and SAPS II scores Baseline patient characteristics a Characteristic
Expedited (n = 12)
Nonexpedited (n = 66)
Age (y) 50.0 (±15.8) 56.3 (±12.4) Male sex 7 (58%) 32 (48%) White ethnic group 8 (67%) 55 (83%) 4 (33%) 26 (39%) Chronic conditions b Respiratory 1 (8%) 10 (15%) Cardiovascular 0 (0%) 3 (5%) Renal 2 (17%) 8 (12%) Hemodialysis 1 (8%) 5 (8%) Condition precipitating mechanical ventilation COPD/asthma 1 (8%) 8 (12%) CHF/MI 3 (25%) 11 (17%) Cardiac arrest 3 (25%) 6 (9%) Intoxication 3 (25%) 14 (21%) Neurological 1 (8%) 13 (20%) Pneumonia 1 (8%) 9 (14%) Other 0 (0%) 5 (8%) APACHE II score 21.4 (±9.5) 20.4 (±8.5) SAPS II score 47.3 (±12.8) 45.0 (±14.8)
P (n = 78) .1677 .5302 .1778 .6914 .5325 .4513 .6648 .9278 .7056 .489 .1126 .77 .3454 .6132 .3243 .8998 .3632
COPD indicates chronic obstructive pulmonary disease; CHF, congestive heart failure; MI, myocardial infarction. a Data presented are mean ± SD or no. (%) unless otherwise indicated. b Chronic respiratory disease was defined as chronic restrictive, obstructive, or vascular disease resulting in severe exercise restriction; documented chronic hypoxia, hypercapnia, secondary polycythemia, or severe pulmonary hypertension; or the need for home oxygen therapy or noninvasive positive pressure ventilation. Chronic cardiovascular disease was defined as angina at rest or upon minimal exertion, New York Heart Association class IV symptoms, and one of the following conditions: severe coronary artery disease, severe valvular disease, or severe cardiomyopathy. Chronic renal disease was defined as a baseline serum creatinine of greater than 2.0 mg/dL or the need for dialysis.
difference was observed between the 2 groups in ICU mortality; however, there was a trend for the ICU survival rate to be higher in the nonexpedited group (59/66 [89%]) than in the expedited group (9/12 [75%]) (P = .0850).
4. Discussion Critically ill patients get admitted from the ED to an ICU when a bed is available. Unfortunately, the wait time for an “open” bed varies and is dependent upon many factors. Previously published reports have shown that ICU bed availability, as well as delays in processing admission orders, slow the rate of ICU admission [1,7]. Other reasons for delayed admission to the ICU include hospital policies on admission bed management, holding admissions until shift changes, delays incurred while awaiting diagnostic testing in the ED, and ED and ICU acuity levels. However, growing evidence suggest that delayed ICU admission of the critically ill is associated with longer ICU and hospital stays and worse outcomes. Our study was limited by its small sample size and the inherent limitations of a single-center study; however, it adds to the work of Chalfin et al [6]. Although Chalfin's group demonstrated that prolonged boarding times in the ER before ICU admission were associated with increased hospital length of stay and higher ICU and hospital mortality, our study further suggests that a reduction in the ED time is associated with a reduction in ICU and hospital lengths of stay. As opposed to the Chalfin study, we focused on critically
Table 2 of stay
Clinical outcomes based on elapsed time in the ED a Outcome
heart failure, cardiac arrest, neurologic disorders (eg, seizures, stroke, intracranial hemorrhage), intoxications, and pneumonia, were similar between the 2 groups.
3.2. Clinical outcomes The percentage of patients who developed acute cardiovascular or renal dysfunction was not significantly different between the expedited and nonexpedited groups (Table 2). However, the mean duration of mechanical ventilation (28.4 ± 33.4 hours for the expedited group vs 67.9 ± 99.2 hours for the nonexpedited group) and the mean length of stay in the ICU (2.4 ± 2.2 days for the expedited group vs 4.9 ± 5.2 days for the nonexpedited group) were significantly shorter for the patients in the expedited group than for those in the nonexpedited group (P = .0431 and P = .0209, respectively). Additionally, the length of hospital stay tended to be shorter for the patients in the expedited group than for those in the nonexpedited group (6.8 ± 7.4 days vs 8.9 ± 7.8 days; P = .0609). No significant
Clinical outcomes based on duration of ED length
Expedited (n = 12)
Nonexpedited P (n = 66)
Acute organ dysfunction b Cardiovascular 6 (50%) 22 (33%) Renal 1 (8%) 5 (8%) Duration of mechanical 28.4 (±33.4) 67.9 (±99.2) ventilation (h) Length of ICU stay (d) 2.4 (±2.2) 4.9 (±5.2) Length of hospital stay (d) 6.8 (±7.4) 8.9 (±7.8) Survivors of ICU 9 (75%) 59 (89%) admission a
.2682 .9278 .0431 .0209 .0609 .085
Data presented are mean ± SD or no. (%) unless otherwise indicated. Cardiovascular dysfunction—systolic blood pressure less than 90 mm Hg, systolic blood pressure drop of 40 mm Hg from baseline, or mean arterial blood pressure less than 70 mm Hg for at least 1 hour despite adequate fluid resuscitation; or the need to use vasopressors to maintain systolic blood pressure greater than 90 mm Hg or mean arterial blood pressure greater than 70 mm Hg. Renal dysfunction—an increase in serum creatinine by more than 1 mg/dL from baseline after adequate fluid resuscitation or a serum creatinine greater than 2.0 mg/dL in the absence of known baseline and does not apply to patients on chronic dialysis. b
846 ill patients with respiratory failure that required intubation and mechanical ventilation. In this group, we demonstrated that expedited ICU admission resulted in a greater than 50% reduction in the duration of mechanical ventilation. We were surprised to find that the patients in the expedited group had a trend toward higher mortality. When the manner of death between the 2 groups was reviewed, we found that more patients in the nonexpedited group had, after discussion with families, termination of life support compared with those in the expedited group, 7 of 7 vs 1 of 3, respectively. Two deaths of patients in the expedited group were in patients who had unstable cardiac rhythms. Furthermore, it is possible that the small sample size of the study, with only 12 patients in the expedited group, may have magnified the apparent mortality. Although not directly studied, this reduction in the duration of mechanical ventilation and shorter ICU stay likely reduced health care expenditures and increased the virtual capacity of both the ICU and the ED. In conclusion, expedited admission of critically ill patients who require intubation and mechanical ventilation was associated with a reduction in the duration of mechanical ventilation and shorter ICU and hospital lengths of stay.
S.D. Cline et al. Hospitals need to consider strategies to help facilitate the prompt admission of these patients from the ED to the ICU.
References [1] Svenson J, Besinger B, Stapcynski JS. Critical care of medical and surgical patients in the ED: length of stay and initiation of intensive care procedures. Am J Emerg Med 1997;15:654-7. [2] Varon J, Fromm Jr RE, Levine RL. Emergency department procedures and length of stay for critically ill medical patients. Ann Emerg Med 1994;23:546-9. [3] Fromm Jr RE, Gibbs LR, McCallum WG, et al. Critical care in the emergency department: a time-based study. Crit Care Med 2003;21: 970-6. [4] Nguyen HB, Rivers EP, Havstad S, et al. Critical care in the emergency department: a physiologic assessment and outcome evaluation. Acad Emerg Med 2000;9:1354-61. [5] Parkhe M, Myles PS, Leach DS, et al. Outcome of emergency department patients with delayed admission to an intensive care unit. Emerg Med 2002;14:50-7. [6] Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007;35:1477-83. [7] Clark K, Normile LB. Delays in implementing admission orders for critical care patients associated with length of stay in emergency departments in six mid-Atlantic States. J Emerg Nurs 2002;28:489-95.