Effect of Emergency Department and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients

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. Presented, in part, at the annual meeting of the Society for Academic Emergency Medicine, New Orleans, LA, May 12, 2016, during a Poster Discussion Session. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute, the National Institutes of Health, or the American Thoracic Society Foundation. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/29S62lw). Dr. Mathews has received study support from the National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute (Awards: 1K12HL109005-PI [to Dr. Richardson] and 1K23HL130648-PI [to Dr. Mathews]) and the 2016 Unrestricted Grant in Critical Care from the American Thoracic Society Foundation, and he received support for article research from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: kusum.mathews@mssm.edu Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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