Medical intensive care unit consults occurring within 48 hours of admission: A prospective study

doi:10.1016/j.jcrc.2014.11.001

Journal of Critical Care

Volume 30, Issue 2, April 2015, Pages 363-368

https://doi.org/10.1016/j.jcrc.2014.11.001 Get rights and content

Abstract

Rationale

Critical care consults requested shortly after admission could represent a triage error. This consult process has not been adequately assessed, and data are retrospective relying on discharge diagnoses.

Objectives

The aims of this study were to identify reasons for medical Intensive care unit (MICU) consultations within 48 hours of admission and to detect differences between those accepted and those denied MICU admission.

Methods

Data were prospectively collected including demographics, reason for consultation, Acute Physiology and Chronic Health Evaluation II score, Elixhauser comorbidity measure, functional status, need for assisted ventilation or vasopressor, presence of do-not-resuscitate (DNR) order, and whether a DNR order was obtained after MICU consultation.

Results

Ninety-four percent of patients consulted were not initially evaluated in the emergency department, half of whom were accepted. Respiratory failure, sepsis, and alcohol withdrawal were the most frequent reasons for MICU transfers. Factors predicting MICU admission included respiratory illness, better baseline functional status, and less comorbidity, whereas DNR predicted rejection. We did not find differences in hospital mortality; but hospital length of stay was longer.

Conclusions

Prospective examination of the consult process suggests that disease progression rather than triage error accounted for most unplanned transfers. Functional status and comorbidity predicted MICU admission rather than illness severity. Goals of care were not being discussed adequately. We did not detect differences in mortality although hospital length of stay was increased.

Introduction

The transfer of patients to an intensive care unit (ICU) soon after hospital admission, also known as unanticipated or unplanned ICU transfer, may represent an initial triage error. On the other hand, such ICU admission may be due to unexpected clinical deterioration or due to development of a new problem. Studies assessing patients transferred to the ICU shortly after ward admission concluded that these transfers are associated with higher mortality and longer hospital stays compared with patients admitted directly from the emergency department (ED) and attributed these transfers to triage errors [1], [2], [3], [4]. However, these studies were retrospective potentially limiting their conclusions. More importantly, previous studies did not investigate the ICU consult process; rather, they described patients already transferred to the ICU [1], [2], [3], [4]. There are few data on why critical care consults are triggered shortly after hospital admission and why some patients are transferred to the ICU and others are not.

To better identify whether an error in triage had occurred, it is important to assess the process from the time the ICU consult is requested rather than subsequent to patients' arrival to the ICU. We therefore undertook a 6-month prospective study to assess all patients admitted from the ED to the general medical ward (GMW) for whom a medical ICU (MICU) consult was requested within 48 hours of admission. Our primary aims were to identify the reasons for MICU consultations within 48 hours of admission and to detect any differences between those accepted and those denied MICU admission.

Section snippets

Setting

The study was conducted in a 600-bed adult academic hospital averaging 33 600 annual admissions. The ED, with more than 68 000 annual visits, is the main route of patients' entry into the hospital. The MICU is an 18-bed closed model averaging 1300 annual admissions and is continuously staffed by physicians certified in critical care medicine. The daytime MICU team consists of an attending, a pulmonary/critical care fellow, and 3 residents. During evenings and nights, there is an attending, 1

Statistical analyses

To improve discriminatory power, some continuous variables (APACHE II, MRS, and Elixhauser scores) were evaluated as categorical variables. The MRS scores were categorized as reflecting a level of disability that was low, medium, or high. For the APACHE II and Elixhauser scores, we created dichotomous variables indicating whether the patient's score was in the upper or lower half of the distribution of scores for all patients in the study. The median score for each variable (APACHE, 15;

Results

One hundred thirty-four MICU consults were requested within 48 hours of admission to the GMW, and 49% of these patients were accepted to the MICU (Fig. 1). The mean age of the admitted group was 62 ± 21 years, and 54% were male. Most of the patients (82%) came from home, and 18% were from long-term care facilities. Most (59%) of all MICU consults not requested by the ED (that is requested after admission) occurred within 48 hours, and approximately half of these patients were accepted. Fig. 1

Discussion

In this single-center study, we did not detect a difference in hospital mortality between patients admitted to the MICU directly from the ED compared with those admitted within 48 hours. Further, we did not find a difference in hospital mortality when we specifically compared those with respiratory failure, the most common MICU admitting diagnosis between these 2 groups. In addition, we did not find a mortality difference between those accepted or denied MICU admission when the MICU consult was

Conclusions

In our single-center prospective study, we reexamined early MICU transfer process. Our data suggest that there was little triage error, and most MICU transfers were due to disease progression. Indeed, 94% of these patients were not initially evaluated by the MICU team in the ED. When consulted, critical care physicians accepted half of these patients, taking into account functional status and comorbidity rather than severity of illness. We found that COPD with pco₂ retention, alcohol

Authors' contribution

RIC: project planning and implementation, data gathering and analysis, manuscript preparation, review, and submission.

AE: data preparation, statistical analyses, manuscript review and revision.

CM: project implementation, data gathering and analysis, abstract presentation at ATS conference, and manuscript revision.

VL: data analysis.

NG: data gathering and analysis, presentation of abstract at ATS conference, and manuscript revision.

GL: data analysis.

HS: data analysis, manuscript preparation, and

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For patients with chronic, life-limiting illnesses, admission to the intensive care unit (ICU) near the end of life might not improve patient outcomes or be consistent with patient and family values, goals, and preferences. In this context, advance care planning and palliative care interventions designed to clarify patients' values, goals, and preferences have the potential to reduce provision of high-intensity interventions that are unwanted or non-beneficial. In this Series paper, we have assessed interventions that are effective at helping patients with chronic, life-limiting illnesses to avoid an unwanted ICU admission. The evidence found was largely from observational studies, with considerable heterogeneity in populations, methods, and types of interventions. Results from randomised trials of interventions to improve communication about goals of care are scarce, of variable quality, and mixed. Although observational studies show that advance care planning and palliative care interventions are associated with a reduced number of ICU admissions at the end of life, causality has not been well established. Using the available evidence we suggest recommendations to help to avoid ICU admission when it does not align with patient and family values, goals, and preferences and conclude with future directions for research.
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Using a structured quality improvement process targeting triage education and increased resident/supervisor communication, we demonstrated reduced mortality among patients transferred from the IMCU to the MICU.
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^☆: Support: None.

^☆☆: Conflict of Interest: The authors declare that they have no conflict of interest with the work described herein.

^★: This work was presented in part and in poster format at the 2012 ATS International Conference in San Francisco.

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GuidelinesMedical intensive care unit consults occurring within 48 hours of admission: A prospective study☆,☆☆,★

Abstract

Rationale

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Setting

Statistical analyses

Results

Discussion

Conclusions

Authors' contribution

Resuscitation

J Crit Care

J Crit Care

Crit Care Resusc

Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care

J Hosp Med

Unplanned transfers to the intensive care unit: the role of the shock index

J Hosp Med

Adverse outcomes associated with delayed intensive care unit transfers in an integrated healthcare system

J Hosp Med

Critical care nurses' perception of time spent at rapid responses

Ann Am Thorac Soc

Guidelines
Medical intensive care unit consults occurring within 48 hours of admission: A prospective study☆,☆☆,★