Clinical audit: ER to ICU transit time

Yazhini¹, P. Saravana Kumar², V. Ramu³

¹Department of Critical care, KMC specialty hospital, Trichy Cantonment

²HOD Critical Care, KMC specialty hospital, Trichy Cantonment

³Consultant-Emergency Physician, KMC specialty hospital, Trichy Cantonment

Editor’s Note: This paper was adapted from a presentation made at a clinical meeting

Background

Several studies done in the past two decades tried to evaluate the association between prolonged ER stay and outcomes in the ICU. Reference has been made to a few of those studies like Donald B chalfin, Caroline N. L. Groenland, Muhammed Asim Rana studies.

In addition, there are studies that conclude that the transit time does not affect the outcome of the patient. However, these studies are smaller than the previously mentioned studies. Hence there seems to be controversial data existing on this subject.

We analysed the situation in our hospital and tried to compare it against the existing data.

Aim

To analyze the effect of time spent in the Emergency ward, on the outcome of ICU patients in our hospital.

Materials and Methods

Place of audit: KMC speciality hospital, cantonment
Date: July 2023 – July 2024
Done by: Department of Critical care
Methodology: Retrospective analysis of medical records of 514 patients.

Parameters

The following parameters from the medical records of 514 patients from both medical and surgical departments were collected.

APACHE 2 score at the time of arrival in ER

Transit Time Vs Mortality
Mortality ICU	APACHE	Total	%	0 -3	%	3 - 6	%	> 6	%	Others	%
Alive	0 - 10	67	18	8	2	30	8	28		1	0.3
	11 - 20	182	50	20	5	87	24	75	21
	21 - 30	112	31	13	4	53	15	46	13
	> 30	3	1			1	0.3	2	1
Alive Total	364		41	11	171	47	151	41	1	0.3
Death	0 - 10	6	4	2	1%	2	1	2	1
	11 - 20	60	40	7	5%	24	16	28	19	1	1
	21 - 30	52	35	4	3	16	11	31	21	1	1
	> 30	32	21	3	2	13	9	16	11
Death Total	150		16	11	55	37	77	51	2	1
Over All	514		57	11	226	44	228	44	3	1

Type of Illness Vs Mortality
Mortality ICU	APACHE	Total	%	Medical	%	Surgical	%
Alive	0 - 10	67	18	55	15	12	3
	11 - 20	182	50	145	40	37	10
	21 - 30	112	31	95	26	17	5
	> 30	3	1	3	1		0
Alive total	364		298	82	66	18
Death	0 - 10	6	4	4	3	2	1
	11 - 20	60	40	48	32	12	8
	21 - 30	52	35	39	26	13	9
	> 30	32	21	28	19	4	3
Death total	150		119	79	31	21
Over all	514		417	81	97	19

ICU ( 0-6HRS )
Mortality ICU	Time transfer	APACHE	Total	%	Yes	%	No	%
Alive	< 6 Hrs	0 - 10	38	19%	3	2%	35	18%
		11 - 20	102	51%	17	9%	85	43%
		21 - 30	57	29%	27	14%	30	15%
		> 30	2	1%	2	1%		0%
	< 6 Hrs Total		199		49	25%	150	75%
	> 6 Hrs	0 - 10	28	17%	1	1%	27	16%
		11 - 20	80	49%	9	5%	71	43%
		21 - 30	55	34%	22	13%	33	20%
		> 30	1	1%	1	1%		0%
	> 6 Hrs Total		164		33	20%	131	80%
	Others	0 - 10	1				1
Alive Total			364		82	23%	282	77%
Death	< 6 Hrs	0 - 10	2	2%	2	2%		0%
		11 - 20	37	38%	7	7%	30	31%
		21 - 30	38	39%	26	27%	12	12%
		> 30	21	21%	17	17%	4	4%
	< 6 Hrs Total		98		52	53%	46	47%
	> 6 Hrs	0 - 10	4	8%	1	2%	3	6%
		11 - 20	22	44%	9	18%	13	26%
		21 - 30	13	26%	11	22%	2	4%
		> 30	11	22%	5	10%	6	12%
	> 6 Hrs Total		50		26	52%	24	48%
	Others	11 - 20	1		1
	Others	21 - 30	1		1

ICU (6-12HRS )
Mortality ICU	Time Transfer	APACHE	Total	%	Yes	%	No	%
Alive	< 6 Hrs	0 - 10	38	19	7	4	31	16
		11 - 20	102	51	26	13	76	38
		21 - 30	57	29	32	16	25	13
		> 30	2	1	2	1		0
	< 6 Hrs Total		199		67	34	132	66
	> 6 Hrs	0 - 10	28	17	1	1	27	16
		11 - 20	80	49	16	10	64	39
		21 - 30	55	34	27	16	28	17
		> 30	1	1	1	1		0
	> 6 Hrs Total		164		45	27	119	73
	Others	0 - 10	1				1
	Others Total		1				1
Alive Total			364		112	31	252	69
Death	< 6 Hrs	0 - 10	2	2	2	2		0
		11 - 20	37	38	18	18	19	19
		21 - 30	38	39	31	32	7	7
		> 30	21	21	19	19	2	2
	< 6 Hrs Total		98		70	71	28	29
	> 6 Hrs	0 - 10	4	8	1	2	3	6
		11 - 20	22	44	11	22	11	22
		21 - 30	13	26	11	22	2	4
		> 30	11	22	5	10	6	12
	> 6 Hrs Total		50		28	56	22	44
	Others	11 - 20	1		1
	Others	21 - 30	1		1

Count of ICU ( 12 – 24hr)
Mortality ICU	Time Transfer	APACHE	Total	%	Yes	%	No	%
Alive	< 6 Hrs	0 - 10	38	19	10	5	28	14
		11 - 20	102	51	35	18	67	34
		21 - 30	57	29	35	18	22	11
		> 30	2	1	2	1		0
	< 6 Hrs Total		199		82	41	117	59
	> 6 Hrs	0 - 10	28	17	3	2	25	15
		11 - 20	80	49	21	13	59	36
		21 - 30	55	34	32	20	23	14
		> 30	1	1	1	1		0
	> 6 Hrs Total		164		57	35	107	65
	Others	0 - 10	1				1
	Others Total		1				1
Alive Total			364		139	38	225	62
Death	< 6 Hrs	0 - 10	2	2	2	2		0
		11 - 20	37	38	21	21	16	16
		21 - 30	38	39	33	34	5	5
		> 30	21	21	19	19	2	2
	< 6 Hrs Total		98		75	77	23	23
	> 6 Hrs	0 - 10	4	8	2	4	2	4
		11 - 20	22	44	17	34	5	10
		21 - 30	13	26	12	24	1	2
		> 30	11	22	6	12	5	10
	> 6 Hrs Total		50		37	74	13	26
	Others	11 - 20	1		1
	Others	21 - 30	1		1
	Others Total		2		2

Count of ICU (> 24 hr )
Mortality ICU	Time Transfer	APACHE	Total	%	Yes	%	No	%
Alive	< 6 Hrs	0 - 10	38	19	13	7	25	13
		11 - 20	102	51	52	26	50	25
		21 - 30	57	29	42	21	15	8
		> 30	2	1	2	1		0
	< 6 Hrs Total		199		109	55	90	45
	> 6 Hrs	0 - 10	28	17	6	4	22	13
		11 - 20	80	49	31	19	49	30
		21 - 30	55	34	41	25	14	9
		> 30	1	1	1	1		0
	> 6 Hrs Total		164		79	48	85	52
	Others	0 - 10	1		1
	Others Total		1		1
Alive Total			364		189	52	175	93
Death	< 6 Hrs	0 - 10	2	2	2	2		0
		11 - 20	37	38	36	37	1	1
		21 - 30	38	39	36	37	2	2
		> 30	21	21	21	21		0
	< 6 Hrs Total		98		95	97	3	3
	> 6 Hrs	0 - 10	4	8	4	8
		11 - 20	22	44	22	44
		21 - 30	13	26	13	26
		> 30	11	22	11	22
	> 6 Hrs Total		50		50	100
	Others	11 - 20	1		1
	Others	21 - 30	1		1
	Others Total		2		2

Duration of mechanical ventilation
Mortality ICU	Time Transfer	APACHE	Total	%	1 - 3	%	4 - 6	%	> 7	%	No	%
Alive	< 6 Hrs	0 - 10	38	19	4	2	5	3	2	1	27	14
		11 - 20	102	51	31	16	9	5	18	9	44	22
		21 - 30	57	29	18	9	12	6	11	6	16	8
		> 30	2	1	1	1		0	1	1		0
	< 6 Hrs Total		199	100	54	27	26	13	32	16	87	44
	> 6 Hrs	0 - 10	28	17	7	4		0	1	1	20	12
		11 - 20	80	49	21	13	12	7	7	4	40	24
		21 - 30	55	34	23	14	9	5	8	5	15	9
		> 30	1	1	1	1		0		0		0
	> 6 Hrs Total		164		52	32	21	13	16	10	75	46
	Others	0 - 10	1				1
	Others Total		1				1
Alive Total			364		106	29	48	13	48	13	162	45
Death	< 6 Hrs	0 - 10	2	2	1	1		0	1	1		0
		11 - 20	37	38	22	22	5	5	4	4	6	6
		21 - 30	38	39	19	19	9	9	9	9	1	1
		> 30	21	21	14	14	2	2	3	3	2	2
	< 6 Hrs Total		98		56	57	16	16	17	17	9	9
	> 6 Hrs	0 - 10	4	8	2	4		0	1	2	1	2
		11 - 20	22	44	10	20	7	14	4	8	1	2
		21 - 30	13	26	5	10	2	4	5	10	1	2
		> 30	11	22	9	18		0	1	2	1	2
	> 6 Hrs Total		50		26	52	9	18	11	22	4	8
	Others	11 - 20	1		1
	Others	21 - 30	1		1
	Others Total		2		2

Duration of ICU stay
Mortality ICU	Time Transfer	APACHE	Total	%	0 - 3	%	4 - 6	%	> 7	%
Alive	< 6 Hrs	0 - 10	38	19	14	7	17	9	7	4
		11 - 20	102	51	38	19	33	17	31	16
		21 - 30	57	29	18	9	22	11	17	9
		> 30	2	1	1	1		0	1	1
	< 6 Hrs Total		199		71	36	72	36	56	28
	> 6 Hrs	0 - 10	28	17	15	9	10	6	3	2
		11 - 20	80	49	39	24	25	15	16	10
		21 - 30	55	34	29	18	10	6	16	10
		> 30	1	1		0	1	1		0
	> 6 Hrs Total		164		83	51	46	28	35	21
	Others	0 - 10	1				1
	Others Total		1				1
Alive Total			364		154	42	119	33	91	25
Death	< 6 Hrs	0 - 10	2	2	1	1		0	1	1
		11 - 20	37	38	14	14	6	6	17	17
		21 - 30	38	39	17	17	10	10	11	11
		> 30	21	21	13	13	5	5	3	3
	< 6 Hrs Total		98		45	46	21	21	32	33
	> 6 Hrs	0 - 10	4	8	2	4	1	2	1	2
		11 - 20	22	44	7	14	9	18	6	12
		21 - 30	13	26	4	8	4	8	5	10
		> 30	11	22	8	16	2	4	1	2
	> 6 Hrs Total		50		21	42	16	32	13	26
	Others	11 - 20	1		1
	Others	21 - 30	1		1
	Others Total		2		2

Count of Duration of Hospital Stay
Mortality ICU	Time Transfer	APACHE	Total	%	0 - 5	%	> 6	%
Alive	< 6 Hrs	0 - 10	38	19	24	12	14	7
		11 - 20	102	51	62	31	40	20
		21 - 30	57	29	33	17	24	12
		> 30	2	1	1	1	1	1
	< 6 Hrs Total		199		120	60	79	40
	> 6 Hrs	0 - 10	28	17	24	15	4	2
		11 - 20	80	49	56	34	24	15
		21 - 30	55	34	36	22	19	12
		> 30	1	1	1	1		0
	> 6 Hrs Total		164		117	71	47	29
	Others	0 - 10	1				1
	Others Total		1				1
Alive Total			364		237	65	127	35
Death	< 6 Hrs	0 - 10	2	2	1	1	1	1
		11 - 20	37	38	17	17	20	20
		21 - 30	38	39	26	27	12	12
		> 30	21	21	17	17	4	4
	< 6 Hrs Total		98		61	62	37	38
	> 6 Hrs	0 - 10	4	8	2	4	2	4
		11 - 20	22	44	13	26	9	18
		21 - 30	13	26	7	14	6	12
		> 30	11	22	7	14	4	8
	> 6 Hrs Total		50		29	58	21	42
	Others	11 - 20	1		1
	Others	21 - 30	1		1
	Others Total		2		2

Literature Review

Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP; DELAY-ED study group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35(6):1477-1483.

Conclusions: Critically ill emergency department patients with a >or=6-hr delay in intensive care unit transfer had increased hospital length of stay and higher intensive care unit and hospital mortality. This suggests the need to identify factors associated with delayed transfer as well as specific determinants of adverse outcomes.

Groenland CNL, Termorshuizen F, Rietdijk WJR, et al. Emergency Department to ICU Time Is Associated With Hospital Mortality: A Registry Analysis of 14,788 Patients From Six University Hospitals in The Netherlands. Crit Care Med. 2019;47(11):1564-1571

Conclusions: Prolonged emergency department to ICU time (> 2.4 hr) is associated with increased hospital mortality after ICU admission, mainly driven by patients who had a higher Acute Physiology and Chronic Health Evaluation IV probability. We hereby provide evidence that rapid admission of the most critically ill patients to the ICU might reduce hospital mortality.

Muhammad Asim Rana. Association between Time Spent in Emergency Department and

Outcome of Patients Admitted to Intensive Care Unit.

Conclusion: Longer duration of time stay in emergency department before shifting to ICU (> 3.0 hours) is found to be associated with rise in mortality, especially in patients who exhibited higher acute physiology and chronic health evaluation (APACHE) IV score

Discussion

Delayed ER to ICU transit should not affect the outcome in our setup because :

Ours is a smaller hospital
There is continuous flow of work between our ER and ICU.
Also, most of our ER post graduates are exposed to ICU hence should increase ER quality.
Cross consultations are quickly and easily available in both ER and ICU.

Conclusion

Our data shows that critically ill , emergency department patients with more than or equal to 6-hr delay in intensive care unit transfer had higher clinical deterioration and higher ICU and hospital mortality.

Plan

To do a follow up audit in 2 phases

Phase1: Whatever data we presented now will be analysed by one of us and the reasons for delay in ER will be investigated .

Some of the already known factors for delay include :
Procedural delay
Delayed admission decision.
Too sick to be shifted.
Operational / administrative issues.
No or delayed availability of beds in ICU
ER being busy
Delayed opinions by doctors .

Phase 2: All factors will be addressed with proper protocols and guidelines and re-audit will be conducted.

For now dont allow patients to stay for long in ER, shift them to icu at the earliest.

Time has wonderful way of showing what really matters.

Dr. Yazhini
Department of Critical care

Dr. P. Saravana Kumar

Dr. P. Saravana Kumar
HOD Critical Care

Dr. V. Ramu
Emergency Physician

Clinical audit: ER to ICU transit time

Clinical audit: ER to ICU transit time

Yazhini1, P. Saravana Kumar2, V. Ramu3

Journals

Yazhini¹, P. Saravana Kumar², V. Ramu³