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

Delayed Transfer of Critically Ill Patients from Emergency Department to Intensive Care Unit

Background and aim

Delay in the transfer of critically ill patients from the emergency department (ED) to intensive care units (ICUs) may worsen clinical outcomes. This prospective, observational study was done to find the incidence of delayed transfer.

Materials and methods

After approval from the institute ethics committee and written informed consent, all patients admitted to ICU from ED over 6 months were divided into groups I and II as patients getting transferred to ICU within 30 minutes of the decision or not, respectively. The factors affecting the immediate transfer and clinical outcome of all patients were noted. Monthly feedback was given to the ED team.

Results

Out of 52 ICU admissions from ED, 35 (67.3%) patients were not transferred within 30 minutes, and the most frequent factor preventing immediate transfer was ED-related (54%). A statistically significant difference was found in acute physiology and chronic health evaluation (APACHE II) score, clinical deterioration during transfer, longer duration of mechanical ventilation and length of stay, and higher mortality with patients transferred immediately to ICU. A reduction of 42.6% was noted in transfer time from the first month to the last month of study.

Conclusion

The incidence of delayed transfer of patients from ED to ICU was 67.3% with ED-related factors being the most frequent cause of delay (54.2%).

How to cite this article

Bosco S, Sahni N, Jain A, Arora P, Raj V, Yaddanapudi L. Delayed Transfer of Critically Ill Patients from Emergency Department to Intensive Care Unit. Indian J Crit Care Med 2023;27(8):580-582.

Emergency Department Length of Stay and Mortality in Critically Injured Patients

OBJECTIVE

Multicenter data from 2 decades ago demonstrated that critically ill and injured patients spending more than 6 hours in the emergency department (ED) before transfer to the intensive care unit (ICU) had higher mortality rates. A contemporary analysis of ED length of stay in critically injured patients at American College of Surgeons' Trauma Quality Improvement Program (ACS-TQIP) centers was performed to test whether prolonged ED length of stay is still associated with mortality.

METHODS

This was an observational cohort study of critically injured patients admitted directly to ICU from the ED in ACS-TQIP centers from 2010-2015. Spending more than 6 hours in the ED was defined as prolonged ED length of stay. Patients with prolonged ED length of stay were matched to those with non-prolonged ED length of stay and mortality was compared.

MAIN RESULTS

A total of 113,097 patients were directly admitted from the ED to the ICU following injury. The median ED length of stay was 167 minutes. Prolonged ED length of stay occurred in 15,279 (13.5%) of patients. Women accounted for 29.4% of patients with prolonged ED length of stay but only 25.8% of patients with non-prolonged ED length of stay, P < 0.0001. Mortality rates were similar after matching-4.5% among patients with prolonged ED length of stay versus 4.2% among matched controls. Multivariable logistic regression of the matched cohorts demonstrated prolonged ED length of stay was not associated with mortality. However, women had higher adjusted mortality compared to men Odds Ratio = 1.41, 95% Confidence Interval 1.28 -1.61, P < 0.0001.

CONCLUSION

Prolonged ED length of stay is no longer associated with mortality among critically injured patients. Women are more likely to have prolonged ED length of stay and mortality.

Moving patients from emergency department to medical intensive care unit: Tracing barriers and root contributors

BACKGROUND

Patient transfers involve the physical movement of patients, along with the transfer of their care-related information, responsibility, and control between sending and receiving clinicians. Patient transfers between critical care units are complex and vulnerable to bottlenecks.

OBJECTIVE

To examine the patient transfer process from emergency department (ED) to medical intensive care unit (MICU).

MATERIALS AND METHOD

A qualitative study on transfers from ED to MICU was conducted at two academic hospitals. Using a process-based methodological approach supported by shadowing of patient transfers and clinician interviews, we examined the process-based similarities and differences in barriers and strategies used across hospitals.

RESULTS

Phases underlying ED-MICU transfer process included: pre-transfer phase involving ED care coordination and MICU transfer decision-making; transfer phase involving ED-MICU resident handoff, and post-transfer phase involving MICU care planning and management.

DISCUSSION AND CONCLUSION

Transfer of information, responsibility and control between sending and receiving clinicians is key to effective management of interdependencies between the pre-transfer, transfer and post-transfer phases underlying the patient transfer process. Evidence-based strategies to address challenges related to transfer of information, responsibility and control include the use of videophones and communication checklists, the allocation of a crash bed, engagement of sending, receiving and consulting teams in the physical movement of patients, and in-hospital transfer protocols.

Effectiveness of the Lean process compared to other quality improvement initiatives on length of stay and wait times in healthcare organizations: a systematic review protocol

REVIEW QUESTION

What is the effectiveness of the Lean process compared to other quality improvement initiatives on length of stay and wait times in healthcare organizations?