1.  Risk factors for unplanned transfer to Intensive care within 24 hours of admission from the emergency department Dr Suganthi Singaravelu SpR5 Anaesthetics Journal Club presentation -Arrowe park Hospital

2. Introduction  5% of ED admissions undergo unplanned transfer to ICU 1  Unplanned admission has a higher mortality than direct admission from ED to ICU  Better recognition and interventions in ED are needed.

3. Aim of the study  To describe the risk factors associated with unplanned transfer to ICU within 24hours of admission to the ward from ED

4. Methods- Patients identification  All adult patients admitted in ED between 2007 and 2009  Data obtained from Kaiser Permanente North California - 13 hospitals with similar patient populations.  Exclusion: Direct transfer to theatre or ICU, pregnant patients

5. Methods- Patient characteristics  Patient: Age, gender, admitting diagnosis, chronic illness burden, acute physiological derangement in the ED and hospital length of stay  Chronic illness: Comorbidity Point Score (COPS)  Acute: Laboratory Acute Physiological Score (LAPS)

6. LAPS

7. COPS

8. Statistics  Univariate analysis: ANOVA and chi square test  Multivariate logistic regression

9. Results  Total: 178,315 non ICU admission from ED  4,252 (2.4%) – admitted to ICU within 24 hours of leaving ED

10. Multivariate analysis

13. Significant Risk factors  Higher co-morbidity  More deranged physiology  Arrived overnight in the ward  More frequent in lower volume hospitals

14. Results  Respiratory conditions (COPD/ pneumonia/acute RTI) comprised nearly half (47%) of all conditions.  1 in 30 pneumonia and 1 in 33 COPD were transferred to ICU from ward  Overall 1 in 42 with respiratory condition – worse mortality

15. Respiratory problems  Tendency for rapid deterioration  ICU may accept in early stage  Applying prediction rules to identify the patients who may need ventilation  Intermediate (HDU) care for these patients

16. Discussion- Hospital size  Unplanned transfers X 2 higher in low volume centers- Reasons??? - Less resources - lower ICU capacity - less on –call intensivists - less experience with certain critical care conditions

17. Dark hours 11pm to 7 am?  Unclear why arriving overnight has higher risk  Possibilities are ED overcrowding in the evening Decreased staffing longer delays in critical diagnostic tests and interventions

18. Lesser risk of ICU admission  TCU (HDU)  Age >85 – advanced directives or patient preferences

19. Limitation of the study  Not designed to distinguish the underlying cause i.e. under recognition of illness or delays in interventions  vital signs and mental status that were not included could improve the risk adjustment.

20. Study conclusions  Unplanned admission to ICU is more likely in patients with respiratory conditions, sepsis and MI, higher co morbidity burden and grossly abnormal lab results.  Better inpatient triage, earlier interventions or closer monitoring may prevent unplanned ICU admissions.

21. How to apply in our hospital  Prediction rules can be considered for better triage  Organisational changes for night shift, more HDU beds or A&E resources  Compare data with high volume centers and regular monitoring