Time between decision to admit and icu arrival of patients from emergency department

Time between decision to admit and ICU arrival of patients from emergency department

Authors A. Al-Harthy, A.F. Mady, M. A. Rana, W. Al-Etreby, O. A. Ramadan, K. T. Rahman Department of Intensive Care Medicine,

King Saud Medical City, Riyadh, Kingdom of Saudi Arabia

Corresponding Author Waleed Tharwat Hashim Al-Etreby Kingdom of Saudi Arabia, Riyadh, P.O. Box 331140 ZIP code 11373 Al-Shemaisi [email protected]

Lead Consultant Abdul Rahman Mishal Al-Harthy

King Saud Medical City, Critical Care Department

Riyadh, Kingdom of Saudi Arabia The Online Journal of Clinical Audits. 2014; Vol 6(4).

Published November 2014 To subscribe to The Online Journal of Clinical Audits go to: http://www.clinicalaudits.com/index.php/ojca/user/register Article submission and authors instructions: http://www.clinicalaudits.com/index.php/ojca/about/submissions

ISSN 2042-4779 ClinicalAudits.com

Abstract One of the most important quality measures is process, which includes access to care and timeliness as key dimensions. Reduction of the time taken to transfer admitted patients to ICU from ED helps enhance process greatly. In addition, early admission to ICU of critical patients, not only helps to solve the problem of ED overcrowding, it was also shown by studies to improve patients’ outcome. Aims To measure the median time between the decision to admit a patient from ED, and actual arrival to ICU, at King Saud Medical City, Riyadh, KSA. Methods Median time (in minutes) between decision to admit a patient from ED and arrival to ICU, during April 2014 Results The median time between decision to admit and ICU arrival during April 2014 was 100 minutes, which is below our delay deadline of 240 minutes, however, 13 patients were delayed, out of which 7 delays were justified medically, but 6 cases were delayed due to non-medical reasons. Conclusions Despite having a median time between decision to admit and ICU arrival of 100 minutes, we had a delay of admission in about 15% of all of our admissions from ED, about half of those delays were not due to medical reasons, and may have resulted from shortage of staff or poor interdepartmental communication.

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Introduction Process is one of the clinical quality measures identified in the specifications manual for national hospital inpatient quality measures, by the Centres for Medicare and Medicaid services (CMS), and The Joint Commission 1. Two of the important key dimensions of quality performance (that involve process) are availability or access to care and timeliness 2. Reduction of the time patients remain in the emergency department (ED) and arrive to the intensive care unit (ICU), can significantly improve access to care and allow for provision of additional treatment specific to each patient’s condition in a timely fashion3. It also helps in solving the problem of ED overcrowding, that is becoming a phenomenon, involving not only large urban teaching hospitals, but also involves suburban and rural healthcare facilities 3,4. As for the outcome of the patients themselves, studies were able to show an independent association between delayed admission and higher mortality, even if the patient is eventually admitted to the ICU, and that each hour of delay is associated with increased mortality 5. The same conclusion of increased mortality associated with delayed ICU admission was reached by other authors as well 6-8. Aims

• To measure the median time between the decision to admit a patient from ED, and actual arrival to ICU, at King Saud Medical City, Riyadh, KSA.

• To identify delayed admissions, as defined by our policy 9 as: 240 minutes or more.


Audit Standards All patients admitted to ICU directly from ED. Methods

• Inclusion: Any patient admitted to ICU from ED. • Exclusion: ward, or post-operative admissions. • Time frame: 1/4/2014 to 30/4/2014 • Source of data: patient’s medical record: o Computerized admission form from ED. o ICU admission notes. • Scoring: Median time. • The median time of each day’s admissions is calculated to generate a line

graph. Results

In the month of April, 2014. A total of 144 patients were admitted to the ICU at King Saud Medical City, Riyadh, Saudi Arabia. Patients that were admitted directly from ED were 87 (60.4%), divided over the days of the month, only 13 cases (14.9%) were delayed (240 minutes or more), (table 1) (figure 1). Table 1: ICU admissions, April/2014

Admitted from Number (%) Emergency Department 87 (60.4%)

Post-operative 22 (15.3%) Inpatient wards 30 (20.8%)

Fax from other peripheral hospitals 5 (3.5%) Total 144


Figure 1: Time between decision to admit and ICU arrival, for patients admitted from ED, April/2014

The median time between decision to admit and ICU arrival for those 87 patients was 100 minutes. The median time between decision to admit and ICU arrival for any single day was more than 240 minutes in two occasions. (figure 2)

Figure 2: Line graph of the median time of daily admissions from ED.

Discussion

Out of 144 patients admitted to our ICU during the month of April/ 2014. 87 patients came directly from the ED, 31 cases(35.6%) were medical and 56 cases (64.4%) were surgical or trauma patients, among the 87 patients 66 (75.9%) were intubated and mechanically ventilated.

Minutes

Days

Delay deadline (240 minutes)

Minutes

Days

Delay deadline (240 minutes)


The median time between decision to admit and ICU arrival was 100 minutes for all 87 patients, the maximum median time of any single day was 274 minutes (28/April), while the minimum median time for any single day was 69.5 minutes (12/April). Out of the 87 cases admitted from ED, 13 cases were delayed (more than 240 minutes). The longest duration taken by a delayed case to arrive to ICU was 780 minutes, whereas the shortest duration taken by a delayed case to arrive to the ICU was 245 minutes. We were able to medically justify the delay in 7 cases, whom were delayed due to: Ø Haemodynamic instability and high inotropic support (3) Ø High ventilatory settings: high FiO2, high PEEP (2) Ø Ongoing dialysis (1) Ø Requested radiological investigation prior to ICU transfer (1) However, in 6 other delayed cases we could not justify the delay medically, and the identified reasons of their delay were: Ø A very busy primary team physician, who couldn’t accompany the patient to the

ICU. Ø A single respiratory therapist covering ER alone, and can’t transfer the patient to

the ICU within the time limit. Ø Bed in ICU is not ready, because the patient already occupying it is not

discharged yet. Conclusions

On one hand the median time between decision to admit and arrival to ICU is less than the delay deadline of 240 minutes, on the other hand, we do have a percentage of about 15% of delayed cases admitted from ED, and almost have of those cases are delayed because of non-medical reasons, that involve either the lack of personnel, or poor communication and arrangement between inpatient units and the bed management.

Recommendations

Staffing: • Inadequate staffing clearly contributes to delay of admission. • It is recommended that a designee physician be available in each shift, to

transfer patients to ICU. • Respiratory therapist assigned for transfer of patients only, is also

recommended. Vacant beds: • The hospital should have an effective process to identify vacant beds, and

communicate their availability between in-patient units. • More cooperation from bed management, to evacuate beds in ICU in timely

fashion. • Availability of social workers 24/7 to solve problems of patients for transfer from

ICU, to make beds available for new admissions.


Monitoring: • Re-audit the same measure after implementation of the recommendations. • We recommend collecting data and continuous monitoring throughout the year,

or over several years, so that the results are more representative of the actual situation.

References

1. Specifications Manual for National Inpatient Hospital Quality Measures , Discharge Dates 01-01-14 (1Q14) through 12-31-14 (4Q14) v4.3b

2. Janet A Brown. The Healthcare Quality Handbook: A Professional Resource and Study Guide. ,

25th ed; 2011. 3. Derlet RW, Richards JR. Emergency department overcrowding in Floride, New York, and

Texas. South Med. J 2002; 95(8): 846-9. 4. National Quality measures clearinghouse, measure summary NQMC- 8828, Jan 2013

5. Lucienne TQ Cardoso, Cintia MC Grion*, Tiemi Matsuo, Elza HT Anami, Ivanil AM Kauss,

Ludmila Seko, Ana M Bonametti. Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study. Critical Care 2011; 15: R28.

6. Marcos I. Restrepo, MD, MSc, FCCP; Eric M. Mortensen, MD, MSc; Jordi Rello, MD, PhD; Jennifer Brody , MD; and Antonio Anzueto, MD. Late Admission to the ICU in Patients With Community-Acquired Pneumonia Is Associated With Higher Mortality. Chest 2010; 137(3): 552–557.

7. Bing-Hua YU. Delayed admission to intensive care unit for critically surgical patients is associated with increased mortality.American J Surg 2014; 208(2): 268-74.

8. Renaud B, Brun-Buisson C, Santin A, Coma E, Noyez C, Fine MJ, Yealy DM, Labarère J.. Outcomes of early, late, and no admission to the intensive care unit for patients hospitalized with community-acquired pneumonia.. Acad Emerg Med 2012; 19(3): 294-303.

9. King Saud Medical City, Riyadh, Kingdom of Saudi Arabia. Administrative Policy and Procedure: Admission of Inpatients. APP-KSMC-017 (v4). 13/May/2014.

Time between decision to admit and icu arrival of patients from emergency department

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