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
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.
Available from: Roland Faigle
- "Unnecessary ICU admissions may lead to Emergency Department (ED) overcrowding and prolonged ED boarding times; in addition, patients unnecessarily subjected to a critical care environment may be at increased risk of health-care associated infections and delirium associated with poor outcomes678. Conversely, delay of ICU transfer for patients in genuine need of critical care may result in poor outcome and increased mortal- ity91011. No established parameters exist that would allow for risk stratification of post-IVT patients by critical care needs, and there is currently no known scoring system that reliably identifies post-IVT patients in need of critical care or allows for identification of patients for which ICU care may be unnecessary and potentially harmful. "
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Patients receiving intravenous thrombolysis (IVT) for acute ischemic stroke are at risk of developing complications, commonly necessitating admission to an intensive care unit (ICU). At present, most IVT is administered in the Emergency Department or in dedicated stroke units, but no evidence-based criteria exist that allow for early identification of patients at increased risk of developing ICU needs. The present study describes a novel prediction score aiming to identify a subpopulation of post-IVT patients at high risk for critical care interventions.
We retrospectively analyzed data from 301 patients undergoing IVT at our institutions during a 5-year period. Two hundred and ninety patients met inclusion criteria. The sample was randomly divided into a development and a validation cohort. Logistic regression was used to develop a risk score by weighting predictors of critical care needs based on strength of association.
Seventy-two patients (24.8 %) required critical care interventions. Black race (odds ratio [OR] 3.81, p =0.006), male sex (OR 3.79, p =0.008), systolic blood pressure (SBP; OR 1.45 per 10 mm Hg increase in SBP, p <0.001), and NIH stroke scale (NIHSS; OR 1.09 per 1 point increase in NIHSS, p =0.071) were independent predictors of critical care needs. The optimal model for score development, predicting critical care needs, achieved an AUC of 0.782 in the validation group. The score was named the ICAT (Intensive Care After Thrombolysis) score, assigning the following points: black race (1 point), male sex (1 point), SBP (2 points if 160–200 mm Hg; 4 points if >200 mm Hg), and NIHSS (1 point if 7–12; 2 points if >12). Each 1-point increase in the score was associated with 2.22-fold increased odds for critical care needs (95 % CI 1.78–2.76, p <0.001). A score ≥2 was associated with over 13 times higher odds of critical care needs compared to a score <2 (OR 13.60, 95 % CI 3.23–57.19), predicting critical care with 97.2 % sensitivity and 28.0 % specificity.
The ICAT score, combining information about race, sex, SBP, and NIHSS, predicts critical care needs in post-IVT patients and may be helpful when triaging post-IVT patients to the appropriate monitoring environment.
Electronic supplementary material
The online version of this article (doi:10.1186/s13054-016-1195-7) contains supplementary material, which is available to authorized users.
Available from: Carina Palesjö
- "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.
Available from: PubMed Central
- "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 . "
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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.
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.
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.
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.
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