Inpatient transfers to the intensive care unit: delays are associated with increased mortality and morbidity

Abstract

Objective: To examine if delayed transfer to the intensive care unit (ICU) after physiologic deterioration is associated with increased morbidity and mortality.

Design: Inception cohort.

Setting: Community hospital in Ogden, Utah.

Patients: Ninety-one consecutive inpatients with noncardiac diagnoses at the time of emergent transfer to the ICU. We determined the time when each patient first met any of 11 pre-specified physiologic criteria. We classified patients as "slow transfer" when patients met a physiologic criterion 4 or more hours before transfer to the ICU. Patients were followed until discharge.

Interventions: None.

Measurements: In-hospital mortality, functional status at hospital discharge, hospital resources.

Main results: At the time when the first physiologic criterion was met on the ward, slow- and rapid-transfer patients were similar in terms of age, gender, diagnosis, number of days in hospital prior to ICU transfer, prehospital functional status, and APACHE II scores. By the time slow-transfer patients were admitted to the ICU, they had significantly higher APACHE II scores (21.7 vs 16.2; P =.002) and were more likely to die in-hospital (41% vs 11%; relative risk [RR], 3.5; 95% confidence interval [95% CI], 1.4 to 9.5). Slow-transfer patients were less likely to have had their physician notified of deterioration within 2 hours of meeting physiologic criteria (59% vs 31%; P =.001) and less likely to have had a bedside physician evaluation within the first 3 hours after meeting criteria (23% vs 83%; P =.001).

Conclusions: Slow transfer to the ICU of physiologically defined high-risk hospitalized patients was associated with increased risk of death. Slow response to physiologic deterioration may explain these findings.

FIGURE 1

Study enrollment and data collection process.

FIGURE 2

Adjusted outcomes (adjusted percent dead and adjusted percent dependent calculated from logistic model using means [see reference 22]): in-hospital mortality and percentage of patients dependent at time of discharge from the hospital (adjusted for pre-ICU APACHE II score, age, and number of days in hospital pre-ICU transfer). ^‡Relative risk (RR) of functional dependence for delayed entry, 2.9; 95% confidence interval (95% CI), 1.01 to 5.4. ^§RR for death in-hospital for delayed entry, 4.9; 95% CI, 1.9 to 9.1.