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Risk factors for unplanned transfer to intensive care within 24 hours of admission from the emergency department in an integrated healthcare system†

  1. M. Kit Delgado MD, MS1,‡,*,
  2. Vincent Liu MD, MS2,
  3. Jesse M. Pines MD, MBA, MSCE3,
  4. Patricia Kipnis PhD2,4,
  5. Marla N. Gardner BA2,
  6. Gabriel J. Escobar MD2,5,†

Article first published online: 28 SEP 2012

DOI: 10.1002/jhm.1979

Issue

Journal of Hospital Medicine

Journal of Hospital Medicine

Volume 8, Issue 1, pages 13–19, January 2013

Additional Information

How to Cite

Delgado, M. K., Liu, V., Pines, J. M., Kipnis, P., Gardner, M. N. and Escobar, G. J. (2013), Risk factors for unplanned transfer to intensive care within 24 hours of admission from the emergency department in an integrated healthcare system. J. Hosp. Med., 8: 13–19. doi: 10.1002/jhm.1979

Author Information

  1. 1

    Division of Emergency Medicine and the Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California

  2. 2

    Systems Research Initiative, Division of Research, Kaiser Permanente Medical Care Program, Oakland, California

  3. 3

    Center for Health Care Quality, School of Public Health and Health Services, George Washington University, Washington, DC

  4. 4

    Management, Information, and Analysis, Kaiser Foundation Health Plan, Oakland, California

  5. 5

    Hospital Operations Research, Division of Research, Kaiser Permanente Medical Care Program, Oakland, California

  1. †

    Disclosures: M. Kit Delgado was supported by the Agency for Healthcare Research and Quality (AHRQ) training grant to Stanford University (T32HS00028). Vincent Liu was supported by AHRQ grant F32HS019181-01. Drs Escobar and Kipnis were supported by The Permanente Medical Group, Inc; the Sidney Garfield Memorial Fund (grant 115-9518, “Early detection of impending physiologic deterioration in hospitalized patients”); and the Agency for Healthcare Research and Quality (grant 1R01HS018480-01, “Rapid clinical snapshots from the EMR among pneumonia patients”). The authors have no conflicts of interest to disclose.

  2. ‡

    Telephone: 650-725-9445; Fax: 650-723-0121

*Division of Emergency Medicine, 300 Pasteur Drive, Alway Building, Room M121, Stanford, CA 94305

  1. †

    Disclosures: M. Kit Delgado was supported by the Agency for Healthcare Research and Quality (AHRQ) training grant to Stanford University (T32HS00028). Vincent Liu was supported by AHRQ grant F32HS019181-01. Drs Escobar and Kipnis were supported by The Permanente Medical Group, Inc; the Sidney Garfield Memorial Fund (grant 115-9518, “Early detection of impending physiologic deterioration in hospitalized patients”); and the Agency for Healthcare Research and Quality (grant 1R01HS018480-01, “Rapid clinical snapshots from the EMR among pneumonia patients”). The authors have no conflicts of interest to disclose.

  2. ‡

    Telephone: 650-725-9445; Fax: 650-723-0121

Publication History

  1. Issue published online: 3 JAN 2013
  2. Article first published online: 28 SEP 2012
  3. Manuscript Accepted: 10 AUG 2012
  4. Manuscript Revised: 11 JUL 2012
  5. Manuscript Received: 12 APR 2012

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Abstract

BACKGROUND:

Emergency department (ED) ward admissions subsequently transferred to the intensive care unit (ICU) within 24 hours have higher mortality than direct ICU admissions.

DESIGN, SETTING, PATIENTS:

Describe risk factors for unplanned ICU transfer within 24 hours of ward arrival from the ED.

METHODS:

Evaluation of 178,315 ED non-ICU admissions to 13 US community hospitals. We tabulated the outcome of unplanned ICU transfer by patient characteristics and hospital volume. We present factors associated with unplanned ICU transfer after adjusting for patient and hospital differences in a hierarchical logistic regression.

RESULTS:

There were 4,252 (2.4%) non-ICU admissions transferred to the ICU within 24 hours. Admitting diagnoses most associated with unplanned transfer, listed by descending prevalence were: pneumonia (odds ratio [OR] 1.5; 95% confidence interval [CI] 1.2–1.9), myocardial infarction (MI) (OR 1.5; 95% CI 1.2–2.0), chronic obstructive pulmonary disease (COPD) (OR 1.4; 95% CI 1.1–1.9), sepsis (OR 2.5; 95% CI 1.9–3.3), and catastrophic conditions (OR 2.3; 95% CI 1.7–3.0). Other significant predictors included: male sex, Comorbidity Points Score >145, Laboratory Acute Physiology Score ≥7, arriving on the ward between 11 PM and 7 AM. Decreased risk was found with admission to monitored transitional care units (OR 0.83; 95% CI 0.77–0.90) and to higher volume hospitals (OR 0.94 per 1,000 additional annual ED inpatient admissions; 95% CI 0.91–0.98).

CONCLUSIONS:

ED patients admitted with respiratory conditions, MI, or sepsis are at modestly increased risk for unplanned ICU transfer and may benefit from better triage from the ED, earlier intervention, or closer monitoring to prevent acute decompensation. More research is needed to determine how intermediate care units, hospital volume, time of day, and sex affect unplanned ICU transfer. Journal of Hospital Medicine 2013. © 2012 Society of Hospital Medicine

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