Inpatient transfers to the intensive care unit

Delays are associated with increased mortality and morbidity

Abstract

OBJECTIVE: To examine if delayed transfer to the intensive care unit (ICU) after physiologic deterioration is associated with increased morbidity and mortality.

DESIGN: Inception cohort.

SETTING: Community hospital in Ogden, Utah.

PATIENTS: Ninety-one consecutive inpatients with noncardiac diagnoses at the time of emergent transfer to the ICU. We determined the time when each patient first met any of 11 pre-specified physiologic criteria. We classified patients as “slow transfer” when patients met a physiologic criterion 4 or more hours before transfer to the ICU. Patients were followed until discharge.

INTERVENTIONS: None.

MEASUREMENTS: In-hospital mortality, functional status at hospital discharge, hospital resources.

MAIN RESULTS: At the time when the first physiologic criterion was met on the ward, slow- and rapid-transfer patients were similar in terms of age, gender, diagnosis, number of days in hospital prior to ICU transfer, prehospital functional status, and APACHE II scores. By the time slow-transfer patients were admitted to the ICU, they had significantly higher APACHE II scores (21.7 vs 16.2; P=.002) and were more likely to die inhospital (41% vs 11%; relative risk [RR], 3.5; 95% confidence interval [95% CI], 1.4 to 9.5). Slow-transfer patients were less likely to have had their physician notified of deterioration within 2 hours of meeting physiologic criteria (59% vs 31%; P=.001) and less likely to have had a bedside physician evaluation within the first 3 hours after meeting criteria (23% vs 83%; P=.001).

CONCLUSIONS: Slow transfer to the ICU of physiologically defined high-risk hospitalized patients was associated with increased risk of death. Slow response to physiologic deterioration may explain these findings.

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References

  1. 1.

    Zimmerman JE, Wagner DP, Draper EA, Wright L, Alzola C, Knaus WA. Evaluation of acute physiology and chronic health evaluation III predictions of hospital mortality in an independent database. Crit Care Med. 1998;26:1317–26.

    PubMed  Article  CAS  Google Scholar 

  2. 2.

    Lundberg JS, Perl TM, Wiblin T, Costigan MD, Dawson J, Nettelman MD, Wenzel RP. Septic shock: an analysis of outcomes for patients with onset on hospital wards versus intensive care units. Crit Care Med. 1988;26:1020–4.

    Article  Google Scholar 

  3. 3.

    Rapoport J, Teres D, Lemeshow S, Harris D. Timing of intensive care unit admission in relation to ICU outcome. Crit Care Med. 1990;18:1231–6.

    PubMed  Article  CAS  Google Scholar 

  4. 4.

    Berensen RA. Intensive Care Units (ICU’s) Clinical Outcomes, Costs and Decision Making. Office of Technology Assessment Case Study 28. Washington DC: U.S. Government Printing Office; 1984.

    Google Scholar 

  5. 5.

    Oye RK, Bellamy PF. Patterns of resource consumption in medical intensive care. Chest. 1991;99:685–8.

    PubMed  CAS  Google Scholar 

  6. 6.

    Schroeder SA, Showstack JA, Schwartz J. Survival of adult highcost patients. Report of a follow-up study from nine acute-care hospitals. JAMA. 1981;245:1446–9.

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    Simmons J, Willens HJ, Kessler KM. Acute myocardial infarction. Chest. 1996;107:1732–43.

    Google Scholar 

  8. 8.

    Cales RH, Trunkey DD. Preventable trauma deaths: a review of trauma care systems development. JAMA. 1995;254:1059–63.

    Article  Google Scholar 

  9. 9.

    Phillips P. New pharmaceutical approaches to stroke prevention, treatment. JAMA. 1999;281:2075–6.

    PubMed  Article  CAS  Google Scholar 

  10. 10.

    Hersey CH, Fisher L. Why outcome of cardiopulmonary resuscitation in general medical wards is poor. Lancet. 1982;1:32–4.

    Google Scholar 

  11. 11.

    Franklin C, Mathew J. Developing strategies to prevent in-hospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med. 1987;22:244–47.

    Article  Google Scholar 

  12. 12.

    Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest. 1990;98:1388–92.

    PubMed  CAS  Google Scholar 

  13. 13.

    Sax L, Charlson M. Medical patients at high risk for catastrophic deterioration. Crit Care Med. 1987;15:510–5.

    PubMed  CAS  Article  Google Scholar 

  14. 14.

    Dubois RW, Brook RH. Preventable deaths: who, how often, and why? Ann Intern Med. 1988;109:582–9.

    PubMed  CAS  Google Scholar 

  15. 15.

    Buist MD, Jarmolowski E, Burton PR, Bernartd SA, Waxman BP, Anderson J. Recognising clinical instability in hospital patients before cardiac arrest or unplanned admission to intensive care. A pilot study in a tertiary-care hospital. Med J Aust. 1999;171:22–5.

    PubMed  CAS  Google Scholar 

  16. 16.

    Bone RC, McElwee NE, Eubanks DH, Gluck EH. Analysis of indications for intensive care unit admission. Chest. 1993;104:1806–11.

    PubMed  CAS  Google Scholar 

  17. 17.

    Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;10:818–29.

    Article  Google Scholar 

  18. 18.

    LeGall JR, Loirat P, Alperovitch A. Simplified acute physiology score for intensive care patients. Lancet. 1983;2:741–6.

    Article  CAS  Google Scholar 

  19. 19.

    Nyein K, McMichael L, Turner-Stokes L. Can a Barthel score be derived from the FIM? Clin Rehabil. 1999;13:56–63.

    PubMed  Article  CAS  Google Scholar 

  20. 20.

    Knaus WA, Draper EA, Wagner DP, Zimmerman JE. An evaluation of outcomes from intensive care in major medical centers. Ann Intern Med. 1986;104:410–8.

    PubMed  CAS  Google Scholar 

  21. 21.

    Talbot B. Intermountain Health Care Procedural Costing Summary. Salt Lake City, Utah: Intermountain Health Care; 1995.

    Google Scholar 

  22. 22.

    Concato J, Feinstein AR, Holford T. The risk of determining risk with multivariate models. Ann Intern Med. 1993;118:201–10.

    PubMed  CAS  Google Scholar 

  23. 23.

    Zhang J, Yu KF. What is the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA. 1998;280:1690–1.

    PubMed  Article  CAS  Google Scholar 

  24. 24.

    Connors AF, Speroff T, Dawson N, et al. The effectiveness of right heart catherization in the initial care of critically ill patients. JAMA. 1996;276:889–97.

    PubMed  Article  Google Scholar 

  25. 25.

    Argenziano M, Oz MC, Rose EA. The continuing evolution of mechanical ventricular assistance. Curr Probl Surg. 1997;34:317–86.

    PubMed  Article  CAS  Google Scholar 

  26. 26.

    Shoemaker WC, Wo CC. Circulatory effects of whole blood, packed red cells, albumin, starch and crystalloids in resuscitation of shock and acute critical illness. Crit Care Med. 1997;74(suppl 2):69–74.

    Google Scholar 

  27. 27.

    Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. New Engl J Med. 2001;345:1368–77.

    PubMed  Article  CAS  Google Scholar 

  28. 28.

    Knaus WA, Harrell FE, Lynn J, et al. The SUPPORT prognostic model. Objective estimates of survival for seriously ill hospitalized adults. Ann Intern Med. 1995;122:191–203.

    PubMed  CAS  Google Scholar 

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Correspondence to Dr. Michael P. Young MD, MS.

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Funding for this project was provided in part by the McKay-Dee Foundation of Ogden, Utah

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Young, M.P., Gooder, V.J., McBride, K. et al. Inpatient transfers to the intensive care unit. J GEN INTERN MED 18, 77–83 (2003). https://doi.org/10.1046/j.1525-1497.2003.20441.x

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Key words

  • intensive care unit
  • physiologic monitoring
  • mortality
  • length of stay
  • APACHE II score