Impact of triage-to-admission time on patient outcome in European intensive care units: A prospective, multi-national study

Mortality and Length of Stay Implications of Deterioration-Associated Transfer to the Intensive Care Unit over Different Time Frames

Background

Quality improvement initiatives in the acute care setting often target reduction of mortality and length of stay (LOS). Unplanned care escalations are associated with increased mortality risk and prolonged LOS, but may be precipitated by different factors, including appropriate triage, bed availability, and post-admission deterioration.

Objectives

This work evaluates different transfer timeframes to quantify the impact of deterioration-associated unplanned transfers to intensive care (ICU) on mortality and LOS, informing evidence-based interventions to improve patient care.

Design

This retrospective analysis examined 519 181 adult inpatients discharged from 15 hospitals in the United States. A propensity matched cohort analysis compared mortality and overall hospital LOS for patients admitted to routine and intermediate care units who did and did not have an unplanned ICU transfer within 12, 12-48, or ⩾48 hours from admission.

Methods

Population cohorts were matched on age, sex, admitting unit type, admission type, and admission acuity. Multivariable regression analysis was used to estimate the impact of unplanned transfer on mortality and LOS. Sensitivity sub-analyses compared direct ICU admissions to unplanned ICU transfers using the same transfer timeframes and endpoints.

Results

Patients with unplanned transfers in each of three timeframes had statistically higher mortality rates and longer LOS than matched cohorts without unplanned transfer. Differences between cohorts was greatest in patients transferring ⩾48 hours post-admission for both mortality (25.1% vs 1.9%, P < .0001) and LOS (x¯ = 14.7 vs 5.3, P < .0001). Multivariate analysis showed unplanned ICU transfer significantly increased odds of mortality and prolonged LOS, with later transfers having the most profound influence (19-fold increase in mortality and 2-fold increase in LOS). Sensitivity analyses found a statistically significant increase in mortality and LOS associated with unplanned ICU transfer across all three timeframes.

Conclusion

The association of later transfers with elevated mortality and LOS underscores the importance of timely intervention on patient deterioration.

Acceptance of electronic referrals across the Kingdom of Saudi Arabia: results from a national e-health database

Introduction

An effective referral system is necessary to ensure quality and an optimum continuum of care. In the Kingdom of Saudi Arabia, an e-referral system known as the Saudi Medical Appointments and Referrals Centre (SMARC), has been fully functioning since 2019. This study aims to explore the rate of medical e-referral request acceptance in the KSA, and to study the factors associated with acceptance.

Methods

This period cross-sectional study utilised secondary collected data from the SMARC e-referral system. The data spans both 2020 and 2021 and covers the entirety of the KSA. Bivariate analyses and binary logistic regression analyses were performed to compute adjusted Odds Ratios (aORs) and 95% confidence intervals.

Results

Of the total 632,763 referral requests across the 2 years, 469,073 requests (74.13%) were accepted. Absence of available machinery was a significant predictor for referral acceptance compared to other reasons. Acceptance was highest for children under 14 with 28,956 (75.48%) and 63,979 (75.48%) accepted referrals, respectively. Patients requiring critical care from all age groups also had the highest acceptance including 6,237 referrals for paediatric intensive care unit (83.54%) and 34,126 referrals for intensive care unit (79.65%). All lifesaving referrals, 42,087 referrals, were accepted (100.00%). Psychiatric patients were observed to have the highest proportion for accepted referrals with 8,170 requests (82.50%) followed by organ transplantations with 1,005 requests (80.92%). Sex was seen to be a significant predictor for referrals, where the odds of acceptances for females increased by 2% compared to their male counterparts (95% CI = 1.01-1.04). Also, proportion of acceptance was highest for the Eastern business unit compared to all other units. External referrals were 32% less likely to be accepted than internal referrals (95% CI = 0.67-0.69).

Conclusion

The current findings indicate that the e-referral system is mostly able to cater to the health services of the most vulnerable of patients. However, there remains areas for health policy improvement, especially in terms of resource allocation.

Accuracy of nurses’ performance in triage using the emergency severity index and its relationship with clinical outcome measures

Emergency department (ED) triage in hospitals is part of their emergency structure carried out by nurses in emergency units. There have not been many studies available on nurses' performance in triage based on the emergency severity index (ESI). This present study aimed to investigate the nurses’ performance in triage with regard to the emergency severity index and its relation to clinical outcome measures in the emergency department. This was a cross-sectional study. The hospitalization record of 600 patients who arrived at the emergency department of Sanandaj Social Security Hospital was randomly assessed based on the accuracy of triage performed by nurses. The data analysis procedure was done by employing STATA software version 12, as well as Fisher's exact test, independent t-test, and one-way ANOVA. Findings of the study revealed that nurses’ overall performance in triage showed that 82.67% of nurses had perfect triage accuracy, 12.17% had low-level triage accuracy and 5.17% had high-level triage accuracy. There was an association between nurses' performance in triage with the disposition of patients (p=0.029) and length of stay (p=0.009). Results of the study highlighted the importance of theoretical and practical triage training courses for nurses and provided a foundation for identifying effective factors for decreasing the length of stay and disposition of patients in emergency care units.

Comparison of the Outcomes of Patients Starting Mechanical Ventilation in the General Ward Versus the Intensive Care Unit

OBJECTIVE

Mechanical ventilation is sometimes initiated in the general ward (GW) due to the shortage of intensive care unit (ICU) beds. We investigated whether invasive mechanical ventilation (MV) started in the GW affects the patient's prognosis compared with its initiation in the ICU.

METHODS

From January 2016 to December 2018, medical records of patients who started MV in the GW or ICU were collected. The 28-day mortality, ICU mortality, ventilator-free days, and complications related to the ventilator and the ventilator-free days were analyzed as outcomes.

RESULTS

A total of 673 patients were enrolled. Among these, 268 patients (39.8%) started MV in the GW and 405 patients (60.2%) started MV within 24 hours after admittance to the ICU. There was no difference in 28-day mortality between the 2 groups (27.2% versus 27.2%, P = 0.997). In addition, there was no difference between ventilator-related complication rates, ventilator-free days, or the length of hospital stay. A high Acute Physiology and Chronic Health Evaluation II score, the presence of solid tumor, the absence of chronic kidney diseases, and low platelet count were associated with higher 28-day mortality. However, the initiation of MV in the GW was not associated with an increase in 28-day mortality compared with the initiation in the ICU.

CONCLUSIONS

Starting MV in the GW was not a risk factor for 28-day mortality. Therefore, prompt application of a ventilator if medically indicated, regardless of the patient's location, is desirable if a skilled airway team and appropriate monitoring are available.

Delayed Admission to the Intensive Care Unit and Mortality of Critically Ill Adults: Systematic Review and Meta-analysis

Delayed admission of patients to the intensive care unit (ICU) is increasing worldwide and can be followed by adverse outcomes when critical care treatment is not provided timely. This systematic review and meta-analysis appraised and synthesized the published literature about the association between delayed ICU admission and mortality of adult patients. Articles published from inception up to August 2021 in English-language, peer-reviewed journals indexed in CINAHL, PubMed, Scopus, Cochrane Library, and Web of Science were searched by using key terms. Delayed ICU admission constituted the intervention, while mortality for any predefined time period was the outcome. Risk for bias was evaluated with the Newcastle-Ottawa Scale and additional criteria. Study findings were synthesized qualitatively, while the odds ratios (ORs) for mortality with 95% confidence intervals (CIs) were combined quantitatively. Thirty-four observational studies met inclusion criteria. Risk for bias was low in most studies. Unadjusted mortality was reported in 33 studies and was significantly higher in the delayed ICU admission group in 23 studies. Adjusted mortality was reported in 18 studies, and delayed ICU admission was independently associated with significantly higher mortality in 13 studies. Overall, pooled OR for mortality in case of delayed ICU admission was 1.61 (95% CI 1.44-1.81). Interstudy heterogeneity was high (I² = 66.96%). According to subgroup analysis, OR for mortality was remarkably higher in postoperative patients (OR, 2.44, 95% CI 1.49-4.01). These findings indicate that delayed ICU admission is significantly associated with mortality of critically ill adults and highlight the importance of providing timely critical care in non-ICU settings.

Association of delayed time in the emergency department with the clinical outcomes for critically ill patients

BACKGROUND

Previous studies have shown the association of waiting time in the emergency department with the prognosis of critically ill patients, but these studies linking the waiting time to clinical outcomes have been inconsistent and limited by small sample size.

AIM

To determine the relationship between the waiting time in the emergency department and the clinical outcomes for critically ill patients in a large sample population.

DESIGN

A retrospective cohort study of 13 634 patients.

METHODS

We used the Medical Information Mart for Intensive Care III database. Multivariable logistic regression was used to determine the independent relationships of the in-hospital mortality rate with the delayed time and different groups. Interaction and stratified analysis were conducted to test whether the effect of delayed time differed across various subgroups.

RESULTS

After adjustments, the in-hospital mortality in the ≥6 h group increased by 38.1% (OR 1.381, 95% CI 1.221-1.562). Moreover, each delayed hour was associated independently with a 1.0% increase in the risk of in-hospital mortality (OR 1.010, 95% CI 1.008-1.010). In the stratified analysis, intensive care unit (ICU) types, length of hospital stay, length of ICU stay, simplified acute physiology score II and diagnostic category were found to have interactions with ≥6 h group in in-hospital mortality.

CONCLUSIONS

In this large retrospective cohort study, every delayed hour was associated with an increase in mortality. Furthermore, clinicians should be cautious of patients diagnosed with sepsis, liver/renal/metabolic diseases, internal hemorrhage and cardiovascular disease, and if conditions permit, they should give priority to transferring to the corresponding ICUs.

Increased time from physiological derangement to critical care admission associates with mortality

Background

Rapid response systems aim to achieve a timely response to the deteriorating patient; however, the existing literature varies on whether timing of escalation directly affects patient outcomes. Prior studies have been limited to using ‘decision to admit’ to critical care, or arrival in the emergency department as ‘time zero’, rather than the onset of physiological deterioration. The aim of this study is to establish if duration of abnormal physiology prior to critical care admission [‘Score to Door’ (STD) time] impacts on patient outcomes.

Methods

A retrospective cross-sectional analysis of data from pooled electronic medical records from a multi-site academic hospital was performed. All unplanned adult admissions to critical care from the ward with persistent physiological derangement [defined as sustained high National Early Warning Score (NEWS) > / = 7 that did not decrease below 5] were eligible for inclusion. The primary outcome was critical care mortality. Secondary outcomes were length of critical care admission and hospital mortality. The impact of STD time was adjusted for patient factors (demographics, sickness severity, frailty, and co-morbidity) and logistic factors (timing of high NEWS, and out of hours status) utilising logistic and linear regression models.

Results

Six hundred and thirty-two patients were included over the 4-year study period, 16.3% died in critical care. STD time demonstrated a small but significant association with critical care mortality [adjusted odds ratio of 1.02 (95% CI 1.0–1.04, p = 0.01)]. It was also associated with hospital mortality (adjusted OR 1.02, 95% CI 1.0–1.04, p = 0.026), and critical care length of stay. Each hour from onset of physiological derangement increased critical care length of stay by 1.2%. STD time was influenced by the initial NEWS, but not by logistic factors such as out-of-hours status, or pre-existing patient factors such as co-morbidity or frailty.

Conclusion

In a strictly defined population of high NEWS patients, the time from onset of sustained physiological derangement to critical care admission was associated with increased critical care and hospital mortality. If corroborated in further studies, this cohort definition could be utilised alongside the ‘Score to Door’ concept as a clinical indicator within rapid response systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03650-1.

Early mortality in critical illness - A descriptive analysis of patients who died within 24 hours of ICU admission

PURPOSE

To describe patients who die within 24 h of ICU admission in order to better optimize care delivery.

METHODS

This was a retrospective cohort study of patients ≥18 years old admitted to 17 adult ICUs in Alberta, Canada from January 1, 2016 and June 30, 2017. Data were obtained from a provincial clinical information system and data repository. The primary outcome was incidence of ICU death within 24 h of admission. Secondary outcomes were patient and system factors associated with early death. Variables of interest were identified a priori and examined using multivariable logistic regression.

RESULTS

Of 19,556 patients admitted to ICU in an 18-month period, 3.3% died within 24 h, representing 29.8% of ICU deaths. Factors associated with early death were age (adjusted-OR 0.99, 95% CI, 0.9-1.0), acuity (adjusted-OR 1.3, 95% CI, 1.3-1.4), admission from the Emergency Department (ED; adjusted-OR 1.5, 95% CI, 1.1-1.9) and surgical (adjusted-OR 2.27, 95% CI, 1.4-3.6), neurologic (adjusted-OR 4.6, 95% CI, 3.1-6.9) or trauma diagnosis (adjusted-OR 6.1, 95% CI, 2.4-15.6).

CONCLUSION

Patients who die within 24 h constitute one third of ICU deaths. Age, acuity, admission from the ED and surgical, neurologic or trauma-related admission diagnosis correlate with early death.