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

Division of Emergency Medicine and the Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California. .
Journal of Hospital Medicine (Impact Factor: 2.3). 01/2013; 8(1). DOI: 10.1002/jhm.1979
Source: PubMed


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 4252 (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 2012; © 2012 Society of Hospital Medicine.

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    • "The recovery process that follows a life-threatening condition has been studied from different perspectives. For example , organisational perspectives have been used to describe and evaluate patients' discharge processes and the transfer from intensive care units (ICU) to other hospital wards or to community care (H€ aggstr€ om et al. 2012, Delgado et al. 2013, Lin et al. 2013). To study physical/bodily recovery, the rehabilitation process and exercise prescription across the continuum of care, a rehabilitation perspective has been used (Berney et al. 2012). "
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    ABSTRACT: Aims and objectiveThe aim of this study was to describe and interpret the essential meaning of the lived experiences of being in a critical illness-recovery process after a life-threatening condition.Background The critical illness-recovery process after a life-threatening condition takes several years and does not only include patients' experiences during intensive care. Previous research has mainly focused on what critically ill patients recall. However, from a phenomenological point of view, experiences are more than memories alone. To plan and perform relevant health care and social support for patients who have survived a life-threatening condition, a more profound understanding about their lived experiences is needed.Design and methodIn this qualitative study, a phenomenological hermeneutical approach was used. Interviews were conducted with seven patients, two to four years after they had received care in an intensive care unit in Sweden.ResultsThe comprehensive understanding of the results shows that the critical illness-recovery process after a life-threatening condition means an existential struggle to reconcile with an unfamiliar body and with ordinary life. This can be understood as an ‘unhomelikeness’ implying a struggle to create meaning and coherence from scary and fragmented memories. The previous life projects, such as work and social life become unfamiliar when the patient's fragile and weak body is disobedient and brings on altered sensations.Conclusions Patients who survive a life-threatening condition have an immense need for care and support during the entire critical illness-recovery process, and also after the initial acute phase. They need a coherent understanding of what happened, and support to be able to perform their changed life projects.Relevance to clinical practiceSupporting and caring for patients' recovery from a life- threatening condition involves recognising the patients' struggle and responding to their existential concerns.
    Journal of Clinical Nursing 10/2015; DOI:10.1111/jocn.13002 · 1.26 Impact Factor
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    • "Many unplanned ICU transfers are due to sepsis. Delgado et al. found that respiratory tract infections, urinary tract infections, sepsis, and other acute infections are responsible for 26.9% of unplanned ICU transfers after ED admissions [4]. "
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    ABSTRACT: Background: The objectives of this study were to compare the risk factors for unplanned intensive care unit (ICU) transfer after emergency department (ED) admission in patients with infections and those without infections and to explore the feasibility of using risk stratification tools for sepsis to derive a prediction system for such unplanned transfer. Methods: The ICU transfer group included 313 patients, while the control group included 736 patients randomly selected from those who were not transferred to the ICU. Candidate variables were analyzed for association with unplanned ICU transfer in the 1049 study patients. Results: Twenty-four variables were associated with unplanned ICU transfer. Sixteen (66.7%) of these variables displayed association in patients with infections and those without infections. These common risk factors included specific comorbidities, physiological responses, organ dysfunctions, and other serious symptoms and signs. Several common risk factors were statistically independent. Conclusions: The risk factors for unplanned ICU transfer in patients with infections were comparable to those in patients without infections. The risk factors for unplanned ICU transfer included variables from multiple dimensions that could be organized according to the PIRO (predisposition, insult/infection, physiological response, and organ dysfunction) model, providing the basis for the development of a predictive system.
    The Scientific World Journal 01/2014; 2014:102929. DOI:10.1155/2014/102929 · 1.73 Impact Factor

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