The Impact of ED Boarding Time, Severity of Illness, and Discharge Destination on Outcomes of Critically Ill ED Patients

Abstract

This aim of this study was to determine the association between emergency department (ED) boarding time, severity of illness, and outcomes for critically ill patients. This was a prospective cohort study of ED patients who met criteria for admission to the intensive care unit (ICU). Patients were divided into 2 groups: those who spent less than 6 hr in the ED prior to transfer, and those who spent 6 hr or more. The groups were compared on the basis of severity of illness, Glasgow Coma Scale score, presence of fever, admission time, and hospital survival. Factors associated with increased mortality included patients who spent 6 hr or longer in the ED, had a fever, were admitted in the evening or night, or were indirect ICU admissions. Length of time spent in the ED prior to transfer to inpatient care is one of several factors associated with increased mortality in critical care patients who were intubated in the ED.

The Association Between Hospital Capacity Strain and Inpatient Outcomes in Highly Developed Countries: A Systematic Review

“…[11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][32][33][34][35][36][37][38][39][40][41][42][43]48,49,53 All observational studies were cohort studies; all but four were retrospective. 32,42,43,46 Eight studies described interventions to improve care during times of capacity strain, [55][56][57][58][59][60][61][62] none using randomization to assign treatment category. Outcomes for children were separately analyzed in only six of the observational studies 23,26,32,45,46,51 and none of the experimental studies.…”

“…Studies included in this review used very different terms to describe capacity strain, from general descriptions (e.g., Bstrained,^1 4 Bbusy,^1 5 or high Bworkload^3 1,32,41 ) to descriptions based on the number of admitted patients (e.g., Bcrowding^or Bovercrowding,^2 6,53 high Bcensus^or Boccupancy,^1 7,18,24,35,41,44,47,50 ) to descriptions based on the number of new patients (e.g., Badmission volume^1 9 ). A subset of studies used terms often found in trauma or public health emergency literature (e.g., Bsurge,^1 1 Bmass casualty incident,^2 7 or Bmultiple casualty incident^4 9 ); others used sequelae of high inpatient census to define strain (e.g., BED boarding^1 6,20,21,23,30,38,43 or Btime from receiving the order for a bed and leaving the ED,^2 5 Black of beds^4 2 or Brefused admission due to full unit,^3 6 Bdelayed admission,^4 0 Bboarding^2 2 or Boutlying^4 2 or Bbedspacing^5 2 in non- primary units). This lack of standard terminology contributed to differences in how strain was conceptualized by study authors, i.e., whether it was based on changing patient occupancy, acuity, or turnover or whether it was measured indirectly (Online Appendix).…”

“…In addition, more fundamental differences in care delivery systems may affect the relationship between strain and outcomes. For example, the finding by Intas et al of an almost six-fold increase in hospital mortality among patients with >6 h of ED boarding prior to ICU admission may be due in part to the inability of Greek EDs to initiate ICU treatments at the time of the study, 43 and may not be generalizable to settings where ICU-level care is routinely provided in the ED. Lastly, some hospitals may be more resilient than others to the potentially negative effects of strain, which may have contributed to heterogeneity in findings among studies included in this review.…”

“…[34][35][36]42,53 There was a statistically significant increase in mortality during times of capacity strain in 18 of 30 studies and in 9 of 12 studies in ICU settings (Table 1). While two studies reported over five-fold mortality associated with capacity strain, 13,43 several studies found more modest 50-150% increases in mortality. 32,36,39,41,48 Only two studies included children: a multi-institution UK study that found a doubling in mortality odds for patients admitted at maximum compared to 50% occupancy 32 and a single-institution US study that found no significant association between ED boarding time and subsequent hospital mortality.…”

A quality improvement project to decrease emergency department and medical intensive care unit transfer times

“…Delayed transfer of critically ill patients from the emergency department (ED) to the medical intensive care unit (MICU) may be associated with longer hospital length of stay (LOS) and increased mortality (1)(2)(3)(4)(5). Major factors leading to prolonged ED to MICU transfers are lack of available beds in the ICU and a shortage of ward beds for stable ICU patients (3).…”