title: Risk factors for unplanned transfer to intensive care within 24 hours of admission from the emergency department in an integrated healthcare system.
abstract: BACKGROUND
  Emergency department (ED) ward admissions subsequently transferred to the intensive care unit (ICU) within 24 hours have higher mortality than direct ICU admissions.
  
  
  METHODS
  Describe risk factors for unplanned ICU transfer within 24 hours of ward arrival from the ED.
  
  
  METHODS
  Evaluation of 178,315 ED non-ICU admissions to 13 US community hospitals. We tabulated the outcome of unplanned ICU transfer by patient characteristics and hospital volume. We present factors associated with unplanned ICU transfer after adjusting for patient and hospital differences in a hierarchical logistic regression.
  
  
  RESULTS
  There were 4,252 (2.4%) non-ICU admissions transferred to the ICU within 24 hours. Admitting diagnoses most associated with unplanned transfer, listed by descending prevalence were: pneumonia (odds ratio [OR] 1.5; 95% confidence interval [CI] 1.2-1.9), myocardial infarction (MI) (OR 1.5; 95% CI 1.2-2.0), chronic obstructive pulmonary disease (COPD) (OR 1.4; 95% CI 1.1-1.9), sepsis (OR 2.5; 95% CI 1.9-3.3), and catastrophic conditions (OR 2.3; 95% CI 1.7-3.0). Other significant predictors included: male sex, Comorbidity Points Score >145, Laboratory Acute Physiology Score ≥7, arriving on the ward between 11 PM and 7 AM. Decreased risk was found with admission to monitored transitional care units (OR 0.83; 95% CI 0.77-0.90) and to higher volume hospitals (OR 0.94 per 1,000 additional annual ED inpatient admissions; 95% CI 0.91-0.98).
  
  
  CONCLUSIONS
  ED patients admitted with respiratory conditions, MI, or sepsis are at modestly increased risk for unplanned ICU transfer and may benefit from better triage from the ED, earlier intervention, or closer monitoring to prevent acute decompensation. More research is needed to determine how intermediate care units, hospital volume, time of day, and sex affect unplanned ICU transfer. Journal of Hospital Medicine 2013. © 2012 Society of Hospital Medicine.
authors.affiliation: Division of Emergency Medicine and the Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California., USA. kdelgado@stanford.edu
authors.forename: M Kit
authors.initials: MK
authors.lastname: Delgado
authors.forename: Vincent
authors.initials: V
authors.lastname: Liu
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Pines
authors.forename: Patricia
authors.initials: P
authors.lastname: Kipnis
authors.forename: Marla N
authors.initials: MN
authors.lastname: Gardner
authors.forename: Gabriel J
authors.initials: GJ
authors.lastname: Escobar
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000458:organization & administration / Q000706:statistics & numerical data*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000706:statistics & numerical data*; D011014:Pneumonia / Q000150:complications; D012307:Risk Factors; D018805:Sepsis / Q000150:complications; D017678:Sex Distribution; D013997:Time Factors; D014481:United States / Q000453:epidemiology