Clinical PotpourriA “Code ICU” expedited review of critically ill patients is associated with reduced emergency department length of stay and duration of mechanical ventilation
Introduction
Previous studies have suggested a complex relationship between Emergency Department (ED) length of stay (LOS) and Intensive Care Unit (ICU) patient outcome. In 2007 a large US database study found that an ED LOS of greater than 6 h was associated with increased in-hospital mortality and hospital LOS, an effect that persisted in a multivariate model (survival OR 0.70 [95% CI 0.56–0.89]) [1]. Subsequently, two large similar studies from Australia [2] and Canada [3] found no such association using ED LOS cut-offs of 8 or 6 h respectively. Smaller observational studies have also reported associations between such delays and longer ventilation time [4] or higher mortality [5], [6], [7], [8], although not in all cohorts including medical patients [9], trauma [10], [11] and spontaneous intracerebral haemorrhage [12]. Illness severity may affect speed of ICU admission [2], [10] and high volume centres may be more susceptible to delays, while also treating a sicker cohort [4], [8], [13]. There is also considerable heterogeneity in patient demographics, ED LOS targets studied (ranging from 2 to over 8 h) and the outcomes assessed in these observational studies.
Three interventional studies have attempted to reduce ED LOS for ICU patients [14], [15], [16]. In two of these, additional staff were employed: a 24-hour medical officer (‘hospitalist’) to coordinate medical ICU admissions for the service [14], or an outreach team to assume responsibility for patient care in ED once the need for medical ICU admission had been identified [15]. These reported 99 min (P < 0.001) and 1.5 h (P = 0.02) reductions in ED LOS respectively. The third study enacted a protocol to ensure 24-hour-a-day availability of a trauma ICU bed to receive admissions from ED, reporting a 1.1 h reduction in ED LOS between time periods two years apart (P < 0.01) [16]. No study was able to demonstrate reductions in ICU or hospital LOS or hospital mortality, and no studies have specifically examined intubated patients.
In 2012 a National Emergency Access Target (NEAT) system was introduced to Australian public hospitals in an effort to improve patient flow through EDs [17]. This target aims to have 90% of patients admitted to hospital or discharged within 4 h of presentation to ED. Subsequent Australian data suggests a complex relationship between ED LOS under the NEAT system and patient outcome. Increasing NEAT compliance may be associated with reductions in Standardised Mortality Ratio (SMR), although the relationship is non-linear, with increased SMR seen at hospitals with very high compliance rates [18]. The impact of the NEAT system on critically ill patients is of great importance given that patients requiring ICU represent arguably the highest risk group of ED patients, and that over 25% of patients admitted to Australian ICUs come directly from EDs [19]. Despite this, the impact of this system on Australian ICU patients remains poorly understood.
As part of efforts to improve NEAT compliance for critically ill patients a ‘Code ICU’ system was introduced to the Royal Melbourne Hospital in February 2014 (two years after the NEAT began). This system aimed to identify ED patients who had a high likelihood of requiring an Intensive Care Unit (ICU) admission and facilitate their rapid assessment and admission to the ICU for ongoing care. This study explores whether this simple intervention, using existing resources, was associated with a reduction in ED to ICU admission delay (defined by the NEAT target ED LOS of < 240 min) and improvements in ICU patient outcomes, particularly for patients already intubated in ED.
Section snippets
Material and methods
We performed a single centre, retrospective cohort study utilising data prospectively recorded for all patients admitted from ED to ICU at the Royal Melbourne Hospital before and after the introduction of a ‘Code ICU’ protocol of expedited patient review in ED (Fig. 1). A ‘Code ICU’ involved ED staff notifying the ICU referral registrar, ICU access nurse and hospital bed management via an electronic page of any ED patient likely to require ICU admission. The inclusion criterion for activating
Results
There were 622 and 629 admissions from ED to ICU during the 2013 and 2015 study periods respectively (Table 1). There were no differences in patient characteristics, except a smaller proportion of male patients in 2013 when compared to 2015 (59.2% vs. 64.7%, P = 0.044), and fewer patients with acute renal failure in 2013, although the number in both groups was small [16 vs. 39, P = 0.002].
Patients already intubated in the ED (Table 2) made up a similar proportion of each year's cohort [283 (45.5%)
Discussion
In this study, a simple intervention using existing personnel and resources to facilitate expedited assessment of critically ill patients in the ED was associated with an increase in the proportion of ICU patients admitted from ED within 4 h plus a reduction in ICU and hospital length of stay. During the intervention, Code ICU patients had a shorter ED LOS and ICU LOS despite these patients having higher illness severity scores, an effect which persisted after adjusting for known confounding
Conclusions
The use of a Code ICU system of expedited admission from ED to ICU at a tertiary referral hospital was associated with an increase in proportion of patients admitted within the NEAT timeframe of 240 min, as well as reduced ICU and hospital length of stay. Intubated patients who were admitted to ICU under the system had a shorter ED, ICU and hospital LOS and duration of ventilation compared with those in the same time period who were not.
Conflict of interest statement
The authors have no conflicts of interest to report. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Acknowledgments
We acknowledge the efforts of ICU, ED and administrative staff at the Royal Melbourne Hospital who developed the ‘Code ICU’ system including A/Prof Christopher MacIsaac, A/Prof Nerina Harley, Dr Steven Pincus and Ms Philippa Hall.
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