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. 2016 Aug;31(8):895-900.
doi: 10.1007/s11606-016-3654-x. Epub 2016 Mar 11.

"Deterioration to Door Time": An Exploratory Analysis of Delays in Escalation of Care for Hospitalized Patients

Christopher B Sankey  1   2 , Gail McAvay  3 , Jonathan M Siner  4 , Carol L Barsky  5 , Sarwat I Chaudhry  6   7
Affiliations

"Deterioration to Door Time": An Exploratory Analysis of Delays in Escalation of Care for Hospitalized Patients

Christopher B Sankey et al. J Gen Intern Med. 2016 Aug.

Abstract

Background: Timely escalation of care for patients experiencing clinical deterioration in the inpatient setting is challenging. Deterioration on a general floor has been associated with an increased risk of death, and the early period of deterioration may represent a time during which admission to the intensive care unit (ICU) improves survival. Previous studies examining the association between delay from onset of clinical deterioration to ICU transfer and mortality are few in number and were conducted more than 10 years ago.

Objective: We aimed to evaluate the impact of delays in the escalation of care among clinically deteriorating patients in the current era of inpatient medicine.

Design and participants: This was a retrospective cohort study that analyzed data from 793 patients transferred from non-intensive care unit (ICU) inpatient floors to the medical intensive care unit (MICU), from 2011 to 2013 at an urban, tertiary, academic medical center.

Main measures: "Deterioration to door time (DTDT)" was defined as the time between onset of clinical deterioration (as evidenced by the presence of one or more vital sign indicators including respiratory rate, systolic blood pressure, and heart rate) and arrival in the MICU.

Key results: In our sample, 64.6 % had delays in care escalation, defined as greater than 4 h based on previous studies. Mortality was significantly increased beginning at a DTDT of 12.1 h after adjusting for age, gender, and severity of illness.

Conclusions: Delays in the escalation of care for clinically deteriorating hospitalized patients remain frequent in the current era of inpatient medicine, and are associated with increased in-hospital mortality. Development of performance measures for the care of clinically deteriorating inpatients remains essential, and timeliness of care escalation deserves further consideration.

Keywords: care escalation; care transitions; delays; inpatient clinical deterioration; timeliness.

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Conflict of interest statement

None of the authors of this manuscript have any conflicts of interest or relationships with industry. Dr. Chaudhry receives salary support from the Yale Center for Healthcare Innovation, Redesign and Learning (CHIRAL). CHIRAL is funded by a P30 grant (#1P30HS023554-01) from the Agency for Healthcare Research and Quality (AHRQ) and receives support from Yale New Haven Hospital (YNHH) and the Claude D. Pepper Older Americans Independence Center at Yale University School of Medicine (#P30AG021342 NIH/NIA). All other authors declare that they do not have a conflict of interest.

Figures

Figure 1.
Figure 1.
Patient inclusion process. Abbreviations: MICU medical intensive care unit, ER emergency room, DTDT deterioration to door time.
Figure 2
Figure 2
Severity of illness and deterioration to door time (DTDT) Categories. Rothman Index (RI) is severity of illness tool, with RI value inversely related to illness severity, and a value of 30 or less used as the cut-point for severe illness.
See this image and copyright information in PMC

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