TRANSFER WITHIN 12 HOURS OF HOSPITALIST ADMISSION TO THE MEDICAL INTENSIVE CARE UNIT (MICU): A LOOK AT THE HOSPITALIST, EMERGENCY DEPARTMENT AND ICU PROVIDERS PERCEPTION OF INITIAL TRIAGE

Background: Our goal was to evaluate the group of patients that are admitted to the Medicine service under the care of our hospitalist team and then transferred to the medical intensive care unit (MICU) within 12 hours of admission, to see if this was a result of incorrect triage or progression of the underlying disease process. We evaluated adult patients in a tertiary care 500+ bed hospital in an urban/suburban community.To prospectively study reasons why patients are transferred to the MICU within 12 hours of admission to the medicine service.

Methods: This was a prospective study of 50 patients over a 6-month period. Two hospitalists reviewed the MICU census daily to identify this group of patients, and then an anonymous survey via a HIPAA compliant REDCAPs server was sent out to the providers (attendings, residents and fellows) from the Emergency Department (ED), the MICU and the Hospitalist divisions. The surveys were sent to this group of people as we wanted to get the perspectives of the ED team, the hospitalist team and the MICU team to see if there was agreement on if the patient was mis-triaged or had worsening of their underlying illness. The same group of questions was asked of each provider. The answers were then compared.

Results: 105 providers responded to the survey of 12 questions. The mean age of patients admitted and reviewed was 65.9. Interestingly, the medicine and the ED called MICU consults equally. In 30% of the cases, the ICU was consulted in the ED and then rejected the patient, only to be admitted to the ICU within 12 hours. 62% of the time, the ICU attending said that bed availability did not influence their decision, whereas 38% of the time, the ICU attending said that it did. Advanced directives did not influence the requesting provider’s reason for consult in approximately 80% of the cases.66% of the providers felt that the patients were transferred to the MICU due to clinical deterioration. The ED and medicine services were equally influenced by BP values in 65% and 62% of cases, and respiratory status in 55% and 59% of cases, respectively. However, the MICU providers were influenced by respiratory status more frequently, about 80% of the time. The ED and medicine providers were also very similar in their rates of calling the ICU in instances of sepsis, substance abuse, and abnormal lab values. Interestingly, the ED providers felt that there was direct communication between the MICU and ED in 95% of the responses while medicine providers felt that MICU team communicated directly with them in 58% of the responses.

Conclusions: Although our sample size was small, we had the advantage of interviewing the ED providers, medicine providers and ICU providers on each case. The consensus is that patients who decompensate within the first 12 hours of admission to the hospitalist service are in need of ICU care due to clinical deterioration and not due to perceived errors in triage. This leads to future studies that would aim to identify this group of patients early before they decompensate.