Predictors of Delayed Recognition of Critical Illness in Emergency Department Patients and Its Effect on Morbidity and Mortality

Overview

Journal J Intensive Care Med

Publisher Sage Publications

Specialty Critical Care

Date 2020 Oct 29

PMID 33118840

Citations 3

Authors

Neha N Goel

Matthew S Durst

Carmen Vargas-Torres

Lynne D Richardson

Kusum S Mathews

Affiliations

Soon will be listed here.

Abstract

Purpose: Timely recognition of critical illness is associated with improved outcomes, but is dependent on accurate triage, which is affected by system factors such as workload and staffing. We sought to first study the effect of delayed recognition on patient outcomes after controlling for system factors and then to identify potential predictors of delayed recognition.

Methods: We conducted a retrospective cohort study of Emergency Department (ED) patients admitted to the Intensive Care Unit (ICU) directly from the ED or within 48 hours of ED departure. Cohort characteristics were obtained through electronic and standardized chart abstraction. Operational metrics to estimate ED workload and volume using census data were matched to patients' ED stays. Delayed recognition of critical illness was defined as an absence of an ICU consult in the ED or declination of ICU admission by the ICU team. We employed entropy-balanced multivariate models to examine the association between delayed recognition and development of persistent organ dysfunction and/or death by hospitalization day 28 (POD+D), and multivariable regression modeling to identify factors associated with delayed recognition.

Results: Increased POD+D was seen for those with delayed recognition (OR 1.82, 95% CI 1.13-2.92). When the delayed recognition was by the ICU team, the patient was 2.61 times more likely to experience POD+D compared to those for whom an ICU consult was requested and were accepted for admission. Lower initial severity of illness score (OR 0.26, 95% CI 0.12-0.53) was predictive of delayed recognition. The odds for delayed recognition decreased when ED workload is higher (OR 0.45, 95% CI 0.23-0.89) compared to times with lower ED workload.

Conclusions: Increased POD+D is associated with delayed recognition. Patient and system factors such as severity of illness and ED workload influence the odds of delayed recognition of critical illness and need further exploration.

Citing Articles

Emergency critical care: closing the gap between onset of critical illness and intensive care unit admission.

Dunser M, Noitz M, Tschoellitsch T, Bruckner M, Brunner M, Eichler B Wien Klin Wochenschr. 2024; 136(23-24):651-661.

PMID: 38755419 PMC: 11632058. DOI: 10.1007/s00508-024-02374-w.

Predictors of Respiratory Support Use in Emergency Department Patients With COVID-19-Related Respiratory Failure.

Goel N, Eschbach E, McConnell D, Beattie B, Hickey S, Rozehnal J Respir Care. 2022; 67(9):1091-1099.

PMID: 35764346 PMC: 9994335. DOI: 10.4187/respcare.09772.

Factors contributing to delay intensive care unit admission of critically ill patients from the adult emergency Department in Tikur Anbessa Specialized Hospital.

Teklie H, Engida H, Melaku B, Workina A BMC Emerg Med. 2021; 21(1):123.

PMID: 34702169 PMC: 8547562. DOI: 10.1186/s12873-021-00518-z.

References

Dimick J, Pronovost P, Heitmiller R, Lipsett P . Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection. Crit Care Med. 2001; 29(4):753-8. DOI: 10.1097/00003246-200104000-00012. View

Robert R, Coudroy R, Ragot S, Lesieur O, Runge I, Souday V . Influence of ICU-bed availability on ICU admission decisions. Ann Intensive Care. 2015; 5(1):55. PMC: 4695477. DOI: 10.1186/s13613-015-0099-z. View

Stelfox H, Hemmelgarn B, Bagshaw S, Gao S, Doig C, Nijssen-Jordan C . Intensive care unit bed availability and outcomes for hospitalized patients with sudden clinical deterioration. Arch Intern Med. 2012; 172(6):467-74. DOI: 10.1001/archinternmed.2011.2315. View

Mery E, Kahn J . Does space make waste? The influence of ICU bed capacity on admission decisions. Crit Care. 2013; 17(3):315. PMC: 3745081. DOI: 10.1186/cc12688. View

Mathews K, Durst M, Vargas-Torres C, Olson A, Mazumdar M, Richardson L . Effect of Emergency Department and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients. Crit Care Med. 2018; 46(5):720-727. PMC: 5899025. DOI: 10.1097/CCM.0000000000002993. View

Edbrooke D, Minelli C, Mills G, Iapichino G, Pezzi A, Corbella D . Implications of ICU triage decisions on patient mortality: a cost-effectiveness analysis. Crit Care. 2011; 15(1):R56. PMC: 3221989. DOI: 10.1186/cc10029. View

Rathi N, Haque S, Morales F, Kaul B, Ramirez R, Ovu S . Variability in triage practices for critically ill cancer patients: A randomized controlled trial. J Crit Care. 2019; 53:18-24. DOI: 10.1016/j.jcrc.2019.05.012. View

Lapichino G, Gattinoni L, Radrizzani D, Simini B, Bertolini G, Ferla L . Volume of activity and occupancy rate in intensive care units. Association with mortality. Intensive Care Med. 2003; 30(2):290-297. DOI: 10.1007/s00134-003-2113-4. View

Young M, Gooder V, McBride K, James B, Fisher E . Inpatient transfers to the intensive care unit: delays are associated with increased mortality and morbidity. J Gen Intern Med. 2003; 18(2):77-83. PMC: 1494814. DOI: 10.1046/j.1525-1497.2003.20441.x. View

10.

Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K . Nurse-staffing levels and the quality of care in hospitals. N Engl J Med. 2002; 346(22):1715-22. DOI: 10.1056/NEJMsa012247. View

11.

. Boarding of Admitted and Intensive Care Patients in the Emergency Department. Ann Emerg Med. 2017; 70(6):940-941. DOI: 10.1016/j.annemergmed.2017.08.027. View

12.

Chalfin D, Trzeciak S, Likourezos A, Baumann B, Dellinger R . Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007; 35(6):1477-83. DOI: 10.1097/01.CCM.0000266585.74905.5A. View

13.

Valley T, Admon A, Zahuranec D, Garland A, Fagerlin A, Iwashyna T . Estimating ICU Benefit: A Randomized Study of Physicians. Crit Care Med. 2018; 47(1):62-68. PMC: 6298833. DOI: 10.1097/CCM.0000000000003473. View

14.

Churpek M, Wendlandt B, Zadravecz F, Adhikari R, Winslow C, Edelson D . Association between intensive care unit transfer delay and hospital mortality: A multicenter investigation. J Hosp Med. 2016; 11(11):757-762. PMC: 5119525. DOI: 10.1002/jhm.2630. View

15.

Tarnow-Mordi W, Hau C, Warden A, Shearer A . Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet. 2000; 356(9225):185-9. DOI: 10.1016/s0140-6736(00)02478-8. View

16.

Kennedy M, Joyce N, Howell M, Mottley J, Shapiro N . Identifying infected emergency department patients admitted to the hospital ward at risk of clinical deterioration and intensive care unit transfer. Acad Emerg Med. 2010; 17(10):1080-5. PMC: 3058807. DOI: 10.1111/j.1553-2712.2010.00872.x. View

17.

Heyland D, Muscedere J, Drover J, Jiang X, Day A . Persistent organ dysfunction plus death: a novel, composite outcome measure for critical care trials. Crit Care. 2011; 15(2):R98. PMC: 3219367. DOI: 10.1186/cc10110. View

18.

Perimal-Lewis L, Hakendorf P, Thompson C . Characteristics favouring a delayed disposition decision in the emergency department. Intern Med J. 2014; 45(2):155-9. DOI: 10.1111/imj.12618. View

19.

McQuillan P, Pilkington S, Allan A, Taylor B, Short A, MORGAN G . Confidential inquiry into quality of care before admission to intensive care. BMJ. 1998; 316(7148):1853-8. PMC: 28582. DOI: 10.1136/bmj.316.7148.1853. View

20.

Owyang C, Kim J, Loo G, Ranginwala S, Mathews K . The effect of emergency department crowding on lung-protective ventilation utilization for critically ill patients. J Crit Care. 2019; 52:40-47. PMC: 6579686. DOI: 10.1016/j.jcrc.2019.03.008. View