Background: Most medical centers have limited ICU beds to directly admit high acuity patients from the emergency department. This is compounded by the trend towards increased medical acuity. Thus, rising numbers of patients with higher acuity are being admitted to general medical units and later requiring transfer to ICU. These patients have higher in-hospital mortality and are more costly to treat (1,2,3,4). Additionally, ICU capacity strains have been shown to increase mortality (5). We reviewed the clinical and non-clinical factors that are related to patient transfers from Medicine to ICU for escalation of care with the intention of mitigating these factors in the future with quality improvement efforts.
Methods: We analyzed data from our EMR (Epic) from Jan 1st, 2019, through Dec 31st, 2019, at the University of Rochester Medical Center, a tertiary care hospital. We assessed age, length of stay prior to ICU transfer, time of transfer (8am-5pm vs 5pm-8am), primary and secondary diagnosis at the time of admission, diagnosis at the time of transfer, APP (Advance Practice Practitioner) vs. resident teams, and patient outcomes – in-hospital mortality vs home vs skilled-nursing facility discharge.
Results: A total of 1225 patients were admitted to the medical floors from Jan to Dec 2019. 10.5% of these patients had unplanned transfers to ICU or intermediate care units. It took an average of 5.5 days before patients required higher level of care and ICU transfer. The most common reasons for transfer were sepsis/infection and respiratory diseases (>50%) 1.5% of all patients transferred to ICU went back a second time to ICU. Of the patients transferred to the ICU, 38% were from resident units and 62% were from APP units.Of those who died, 69.6% were of age 65 or older and 30.4% were under the age of 65. More patients died when transfer happened between 5pm and 8am (56%, n=65/115). 9% of patients died in the hospital but only 2.8% were referred to hospice.
Conclusions: The factors contributing to ICU transfer were age, time of day, number of days since admission, and diagnosis. More patients died when ICU transfer happened after hours. The most common primary diagnoses requiring transfer were sepsis or infection (47%) followed by respiratory conditions. Higher mortality was seen for patients >65 years old. We recommend increased vigilance for patients older than 65 years of age, such as afternoon re-evaluation of at-risk patients. Future PDSA cycles will include implementing strategies for triage (6), earlier intervention (and training for early recognition signs), protocols for closer monitoring to prevent acute decompensation and earlier utilization of palliative/hospice services.