Adverse outcomes of delayed intensive care unit

This prospective, cohort study performed in a tertiary academic hospital obtained data from 1913 patients admitted to the emergency room with a documented request for admission into the intensive care unit. The patients admitted directly into the medical-surgical intensive care unit (n = 209) were categorized into tertiles according to their waiting time for intensive care unit admission (Group 1: < 637 min, Group 2: 637 to 1602 min, and Group 3: > 1602 min). Patients who stayed in the intensive care unit for longer than 3.2 days (median time of intensive care unit length of stay of all patients) were considered as having a prolonged intensive care unit stay.

Results:

A total of 6,176 patients were treated in the emergency room during the study period, among whom 1,913 (31%) required a bed in the intensive care unit. The median length of stay in the emergency room was 17 hours [9 to 33 hours]. Hospitalization for infection/sepsis was an independent predictor of prolonged intensive care unit stay (OR 2.75 95%CI 1.38 - 5.48, p = 0.004), but waiting time for intensive care unit admission was not. The mortality rate was higher in Group 3 (38%) than in Group 1 (31%) but the difference was not statistically significant.

Conclusion:

Delayed admission into the intensive care unit from the emergency room did not result in an increased intensive care unit stay or mortality.

Keywords:
Length of stay; Critical care; Hospital emergency service; Hospital mortality; Patient admission

	All
Males	131 (63)
Age (years)	54 [34 - 64]
Chronic kidney dialysis	10 (5)
Neoplasia^* * 1 patient; missing data:	11 (5)
Arterial hypertension	73 (35)
Need for assistance^† † 27 patients; excluded (sedation)	31 (17)
Bedridden^† † 27 patients; excluded (sedation)	10 (5.5)
Glasgow Coma Scale^‡ ‡ 103 patients; missing data:	15 [12 - 15]
Diagnosis
Cardiovascular diseases^§ § 8 patients; missing data:	3 (1,5)
Neurological diseases^§ § 8 patients; missing data:	62 (31)
Infectious diseases^§ § 8 patients; missing data:	48 (24)
Pulmonary diseases^§ § 8 patients; missing data:	10 (5)
Kidney diseases^§ § 8 patients; missing data:	4 (2)
Other diseases^§ § 8 patients; missing data:	74 (37)
Vasoactive drugs in ICU admission
Noradrenaline	39 (19)
Dopamine^\|\| \|\| 2 patients.	7 (3)
Dobutamine^\|\| \|\| 2 patients.	6 (3)
Orotracheal intubation in ER	117 (56)
Orotracheal intubation in ICU	3 (1)
Length of stay
Length of stay in hospital (hours)	17 [9 - 33]
Group 1	65 (31)
Group 2	71 (34)
Group 3	73 (35)
Length of stay in ICU (days)	3.2 [0.5 - 8]
Length of stay in hospital above median (3.2 days)	105 (50.2)
Total length of stay in hospital (days)	13 [6 - 24]
Mortality rate	72 (34)

	Group 1	Group 2	Group 3	p value
	(n = 65)	(n = 70)	(n = 71)	p value
Clinical admission	39 (60)	41 (58)	49 (67)	0.482
Male	42 (65)	43 (61)	46 (63)	0.885
Age (years)	48 [28 - 61]	52 [31 - 60]	58 [44 - 72]	0.001
Chronic kidney dialysis	2 (3)	4 (6)	4 (5.5)	0.739
Cancer	2 (3)	2 (3)	7 (10)	0.125
Arterial hypertension	21 (32)	23 (32)	29 (40)	0.567
Need for assistance	5 (9)	9 (14.5)	17 (26)	0.038
Bedridden	2 (4)	2 (3)	6 (9)	0.256
Glasgow coma scale	15 [13 - 15]	15 [12 - 15]	14 [12 - 15]	0.585
Diagnosis
Cardiovascular diseases	1 (2)	1 (1,5)	1 (1)	0.996
Neurological diseases	18 (29)	17 (25)	27 (38)	0.245
Infectious diseases	12 (19)	19 (28)	17 (24)	0.461
Pulmonary diseases	4 (6)	4 (6)	2 (3)	0.579
Kidney diseases	1 (2)	1 (1.5)	2 (3)	0.824
Other diseases	27 (43)	25 (37)	22 (31)	0.362
Type of support at ICU admission
Noradrenaline	11 (17.5)	13 (19)	15 (21)	0.877
Dopamine	3 (5)	3 (4)	1 (1)	0.506
Dobutamine	2 (3)	2 (3)	2 (3)	0.991
Orotracheal intubation in ER	36 (55)	41 (58)	40 (55)	0.932
Orotracheal intubation in ICU	0 (0,0)	1 (1)	2 (3)	0.402
ICU renal support	4 (6)	6 (9)	5 (7)	0.700
Outcomes
Length of stay in ER (minutes)	375 [284 - 534]	973 [736 - 1229]	2693 [1930 - 4004.5]	< 0.001
Length of stay in ICU (days)	3 [0,8 - 10]	4 [0,7 - 8]	4 [0 - 9]	0.953
Prolonged hospital stay	31 (48)	37 (52)	37 (51)	0.872
Length of hospital stay (days)	10 [4 - 21]	11 [6,5 - 20]	18 [9 - 31]	0.002
ICU mortality rate	16 (25)	22 (31)	20 (27)	0,707
Hospital mortality rate	20 (31)	24 (34)	28 (38)	0,639

	Univariate			Multivariate
	OR	95%CI	p value	OR	95%CI	p value
Prolonged ICU stay
Age (years)	1.00	0.99 - 1.01	0.954
Sex (male)	0.86	0.49 - 1.51	0.604
Neurological disease	0.68	0.37 - 1.24	0.206
Infection/sepsis	2.75	1.38 - 5.48	0.004	2.75	1.38 - 5.48	0.004
Cancer	1.19	0.35 - 4.02	0.782
Arterial hypertension	0.67	0.38 - 1.19	0.176
Need for assistance	1.30	0.59 - 2.83	0.516
Chronic renal dialysis	4.21	0.87 - 20.30	0.074
Glasgow coma scale at admission	1.14	0.99 - 1.31	0.074
ER length of stay (> 17 hours)	0.98	0.57 - 1.69	0.945
In - hospital death
Age (years)	1.04	1.02 - 1.06	< 0.001	1.05	1.02 - 1.09	0.003
Sex (male)	0.90	0.50 - 1.63	0.734
Neurological disease	0.74	0.39 - 1.40	0.355
Infection/sepsis	2.26	1.16 - 4.37	0.016
Cancer	3.55	1.00 - 12.58	0.049
Arterial hypertension	2.46	1.36 - 4.47	0.003
Need for assistance	3.48	1.57 - 7.71	0.002
Chronic renal dialysis	3.02	0.82 - 11.08	0.095
Glasgow coma scale at admission	0.84	0.77 - 0.92	< 0.001	0.82	0.73 – 0.92	0.001
ER length of stay (> 17 hours)	1.20	0.68 - 2.13	0.527

Associação de Medicina Intensiva Brasileira - AMIB Rua Arminda, 93 - Vila Olímpia, CEP 04545-100 - São Paulo - SP - Brasil, Tel.: (11) 5089-2642 - São Paulo - SP - Brazil
E-mail: rbti.artigos@amib.com.br

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[1] Corresponding author: Fernanda Ribeiro Quintino Santos Hospital de Base, Faculdade de Medicina de São José do Rio Preto Av. Brigadeiro Faria Lima, 5.544 -Vila São José Zip code: 15090-000 - São José do Rio Preto (SP), Brazil E-mail: ferquintino@bol.com.br