Identifying Infected Emergency Department Patients Admitted to the Hospital Ward at Risk of Clinical Deterioration and Intensive Care Unit Transfer |
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| Authors: | Maura Kennedy MD Nina Joyce MPH Michael D Howell MD MPH J Lawrence Mottley MD Nathan I Shapiro MD MPH |
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| Institution: | 1. From the Harvard Affiliated Emergency Medicine Residency, Department of Emergency Medicine (MK, LM, NIS);2. The Center for Vascular Biology Research (NIS);3. the Silverman Institute for Healthcare Quality and Safety (MDH);4. and the Department of Medicine, Division of Pulmonary/Critical Care (MDH), Beth Israel Deaconess Medical Center, Boston, MA. |
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| Abstract: | Objectives: An important challenge faced by emergency physicians (EPs) is determining which patients should be admitted to an intensive care unit (ICU) and which can be safely admitted to a regular ward. Understanding risk factors leading to undertriage would be useful, but these factors are not well characterized. Methods: The authors performed a secondary analysis of two prospective, observational studies of patients admitted to the hospital with clinically suspected infection from an urban university emergency department (ED). Inclusion criteria were as follows: adult ED patient (age 18 years or older), ward admission, and suspected infection. The primary outcome was transfer to an ICU within 48 hours of admission. Using multiple logistic regression, independent predictors of early ICU transfer were identified, and the area under the curve for the model was calculated. Results: Of 5,365 subjects, 93 (1.7%) were transferred to an ICU within 48 hours. Independent predictors of ICU transfer included respiratory compromise (odds ratio OR] = 2.5, 95% confidence interval CI] = 1.4 to 4.3), congestive heart failure (CHF; OR = 2.2, 95% CI = 1.4 to 3.6), peripheral vascular disease (OR = 2.0, 95% CI = 1.1 to 3.7), systolic blood pressure (sBP) < 100 mm Hg (OR = 1.9, 95% CI = 1.2 to 2.9), heart rate > 90 beats/min (OR = 1.8, 95% CI = 1.1 to 2.8), and creatinine > 2.0 (OR = 1.8, 95% CI = 1.1 to 2.8). Cellulitis was associated with a lower likelihood of ICU transfer (OR = 0.33, 95% CI = 0.15 to 0.72). The area under the curve for the model was 0.73, showing moderate discriminatory ability. Conclusions: In this preliminary study, independent predictors of ICU transfer within 48 hours of admission were identified. While somewhat intuitive, physicians should consider these factors when determining patient disposition. ACADEMIC EMERGENCY MEDICINE 2010; 17:1080–1085 © 2010 by the Society for Academic Emergency Medicine |
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| Keywords: | risk assessment triage emergency service hospital intensive care units patient transfer critical care sepsis prognosis |
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