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Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit*

Chalfin, Donald B. MD, MS, FCCM; Trzeciak, Stephen MD, MPH; Likourezos, Antonios MA, MPH; Baumann, Brigitte M. MD, MSCE; Dellinger, R Phillip MD, FCCM

doi: 10.1097/01.CCM.0000266585.74905.5A
Feature Articles

Objective: Numerous factors can cause delays in transfer to an intensive care unit for critically ill emergency department patients. The impact of delays is unknown. We aimed to determine the association between emergency department “boarding” (holding admitted patients in the emergency department pending intensive care unit transfer) and outcomes for critically ill patients.

Design: This was a cross-sectional analytical study using the Project IMPACT database (a multicenter U.S. database of intensive care unit patients). Patients admitted from the emergency department to the intensive care unit (2000–2003) were included and divided into two groups: emergency department boarding ≥6 hrs (delayed) vs. emergency department boarding <6 hrs (nondelayed). Demographics, intensive care unit procedures, length of stay, and mortality were analyzed. Groups were compared using chi-square, Mann-Whitney, and unpaired Student’s t-tests.

Setting: Emergency department and intensive care unit.

Patients: Patients admitted from the emergency department to the intensive care unit (2000–2003).

Interventions: None.

Measurements and Main Results: Main outcomes were intensive care unit and hospital survival and intensive care unit and hospital length of stay. During the study period, 50,322 patients were admitted. Both groups (delayed, n = 1,036; nondelayed, n = 49,286) were similar in age, gender, and do-not-resuscitate status, along with Acute Physiology and Chronic Health Evaluation II score in the subgroup for which it was recorded. Among hospital survivors, the median hospital length of stay was 7.0 (delayed) vs. 6.0 days (nondelayed) (p < .001). Intensive care unit mortality was 10.7% (delayed) vs. 8.4% (nondelayed) (p < .01). In-hospital mortality was 17.4% (delayed) vs. 12.9% (nondelayed) (p < .001). In the stepwise logistic model, delayed admission, advancing age, higher Acute Physiology and Chronic Health Evaluation II score, male gender, and diagnostic categories of trauma, intracerebral hemorrhage, and neurologic disease were associated with lower hospital survival (odds ratio for delayed admission, 0.709; 95% confidence interval, 0.561–0.895).

Conclusions: Critically ill emergency department patients with a ≥6-hr delay in intensive care unit transfer had increased hospital length of stay and higher intensive care unit and hospital mortality. This suggests the need to identify factors associated with delayed transfer as well as specific determinants of adverse outcomes.

From the Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (DBC); Analytica International, New York, NY (DBC); Division of Cardiovascular Disease and Critical Care Medicine (ST, RPD) and Department of Emergency Medicine (ST, BMB), UMDNJ-Robert Wood Johnson Medical School at Camden, Cooper University Hospital, Camden, NJ; and Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, NY (AL).

Dr. Chalfin has consulted for Project IMPACT. The remaining authors have not disclosed any potential conflicts of interest.

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© 2007 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins